Models of neonatal care in the Pacific and Asia

Trevor Duke

Centre for International Child Health University of Melbourne

Royal Children’s Hospital

School of Medicine & Health Sciences

University of PNG

•  Neonatal health as a research priority •  Linking models of care with NMR •  Components of models of care •  Evidence of effectiveness •  Resources for improving neonatal care •  Sepsis: new data on antimicrobial efficacy •  The “regional action plan for neonatal

health”

Controlled trials in child health in developing countries n=1342

Year   Malaria   Nutrition   Vaccines   HIV   Diarrhoea  Pneumonia ARI   Development  

Parasitic infections  

Neonatal health   TB  

Mental health  

2003   4   15   2   1   6   3   1   4   0   1   0  

2004   18   22   7   7   8   5   5   10   3   3   0  

2005   22   17   6   7   2   5   3   4   2   1   0  

2006   31   31   8   12   11   4   3   3   2   3   0  

2007   33   40   10   13   10   7   6   8   2   1   0  

2008   40   30   15   13   11   9   3   4   9   1   2  

2009   29   29   18   11   10   11   10   11   5   0   2  

2010   51   32   23   13   14   8   7   8   7   2   6  

2011   42   39   24   21   20   12   8   11   8   4   6  

2012   44   46   32   26   21   16   9   8   11   7   1  

Total   314   301   145   124   113   80   55   71   49   23   17  

3.7% of all RCTs in child health in developing countries were on neonatal care, or included neonatal outcomes

•  Community care: – Skilled birth attendant delivery and essential

newborn care leads to 30-50% reduction in neonatal mortality in communities with very high neonatal mortality rates (e.g. >45/1000 live births)…

– Where the proportion of health facility deliveries is low…

– Where health systems are weak…

Community based neonatal health intervention trials Reference Country Baseline or control

NMR* Post Intervention NMR

Bang AT et al. Journal of Perinatology 2005; 25 Suppl 1, S92-107

India 62/1000 25/1000

Kumar V. Lancet 2008; 372:1151-1162 India 58.9-64.1/1000 41/1000 (Essential newborn care-ENC), 43.2/1000 (Essential newborn care + hypothermia indicator)

Bhutta ZA. Lancet 2011; 377:403-412 Pakistan 48/1000 live 43.0/1000

Midhet F et al. Reproductive Health 2010, 7:30. Pakistan 48/1000* 30.5-32.4/1000

Bacqui, AH. Lancet 2008; 371:1936-44 Bangladesh 46-48/1000 29.2/1000 (home care), 45.2/1000 (community- care)

Jokhio AH et al. NEJM. 2005; 252(20): 2091-9. Pakistan 46-67/1000* 33-42/1000

Gill CJ. BMJ. 2011; 342:d346 Zambia 40.4/1000* (actual numbers 59/1466)

22.8/1000 (actual numbers 43/1889)

Manandhar DS et al. Lancet. 2004; 364(9438):970-9

Nepal 36.9/1000* 26.2/1000

Azad K. Lancet.2010; 375: 1193–20 Bangladesh 36.5/1000* (cluster level mean NMR)

No significant decrease in NMR observed.

Darmstadt GL. PLoS One 2010; 5(3); e9696 Bangladesh 25.2/1000 No significant decrease in NMR observed.

Carlo WA et al. NEJM. 2010; 362(7): 614-23 6 countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan,and Zambia)

Early (<7day) NMR 23/1000 (ENC group)

No significant decrease in NMR observed.

Neonatal mortality rates for countries in the WHO South East Asian and Western Pacific Regions

Country Neonatal mortality rate per 1000 live births (NMR) 1990 2008

(WHO) 2010 * 2011

(WHO) NMR 30-40 Bangladesh 64.5 (52.1-76.4) 33 31.3 (25.4-36.9) Bhutan 63.7 (40.9-91.1) 35 30.1 (19.1-41.5) India 53.9 (43.4-64.5) 37 34.3 (27.7-40.8) Nauru 33 21.7 Niue 30 10.3 PNG 46.6 (28.6-68.0) 26 39.3 (23.4-61.1) 22.6

* Li L, et al. Lancet 2012; 379: 2151-2161

NMR 15-29 Country 1990 2008

(WHO) 2010 * 2011

(WHO) Cambodia 41.5 (32.5-51.7) 31 26.2 (18.7-35.9) 19.4 Democratic People's Republic of Korea

32.7 (21.4-41.8) 29 21.1 (13.4-27.5)

Timor-Leste 36.2 (21.4-57.2) 43 26.8 (15.6-42.3) Indonesia 27.5 (21.5-33.8) 19 17.8 (14.0-22.2) Kiribati 36.6 (21.8-51.9) 17 23.8 (13.5-35.0) 19.1 Lao PDR 44.8 (26.8-71.2) 20 28.3 (15.8-46.5) 17.5 Marshall Islands 25.6 (15.1-37.2) 15 23.8 (13.5-35.0) 11.7 Mongolia 33.0 (19.5-53.6) 14 16.7 (9.5-24.8) 11.7 Myanmar 40.5 (23.3-62.9) 48 24.4 (14.4-38.5) Nepal 59.1 (47.2-71.5) 31 25.4 (20.5-30.9) Solomon Islands 20.0 (11.8-28.8) 14 15.8 (8.9-23.0) 10.5

* Li L, et al. Lancet 2012; 379: 2151-2161

When mortality less than 25-30 per 1000 live births

•  Community care still important –  inequity

•  Models of care needed at all levels of health service •  Questions •  What services are needed at

–  health clinic –  district hospital –  referral hospital… –  to establish minimal standard of neonatal care

•  What current capacity exists? •  What human resources are needed? •  What technical resources are needed (physical facility

space, medications, equipment, guidelines, training)? •  What are the appropriate referral criteria and

mechanisms?

Community based public health, sanitation, education, maternal nutrition

Facility-based obstetric and neonatal care, improved access to antibiotics, attention to thermal care, infant

nutrition and care of LBW and prematurity

Neonatal intensive care

Historical evidence

Models of care

•  WHO/UNICEF Regional Action Plan for Neonatal Care

•  Modelled on “The First Embrace” •  Philippines hospital survey Sobel HL et al. Acta Paed. 2011

–  51 hospitals, obstetric and immediate newborn care –  Widespread gaps in implementation of essential

newborn care (e.g. skin-skin contact, drying, thermal care)

–  Unhelpful interventions common (early separation, suctioning)

Regional Action Plan 2013-2020

Goals 1.  To reduce national NMR 10 per 1000 or less in all member states 2.  To reduce sub-national NMR 10 per 1000 or less

Models of care

•  Quality improvement approach •  What services are needed at

–  health clinic –  district hospital –  referral hospital… –  to establish a minimal standard of neonatal care

•  What current capacity exists? •  What human resources are needed? •  What technical resources are needed (physical facility

space, medications, equipment, guidelines, training)? •  What are the appropriate referral criteria and

mechanisms?

Models of care: Health clinics •  Newborn resuscitation •  Support for breastfeeding •  Thermal protection, skin-to-skin contact •  Infection prevention: general hygiene, hand washing, cord care •  Eye infection prophylaxis •  Immunization and Vitamin K prophylaxis •  Identification, treatment or referral of signs of severe illness, injury or

malformation (IMCI, referral guidelines) •  Birth registration •  Counseling regarding newborn care, care-seeking, health promotion

including immunizations and avoidance of indoor air pollution •  Developmental care including newborn stimulation and play •  Follow up visits for vaccines, growth monitoring •  Family planning

Models of care: District and provincial hospitals

•  All interventions at the clinic level, plus… •  A special care / high dependency nursery •  Management of a newborn with serious illness:

–  Oxygen and oximetry –  Apnoea: monitoring and prevention –  Warming (includes KMC) –  Breast feeding and prevention of hypoglycaemia –  Safe administration of intravenous fluids –  Standard antibiotics

•  Guidelines for management and referral of common conditions: –  Preterm and VLBW babies –  Severe respiratory distress –  Severe infection –  Severe birth asphyxia –  Severe jaundice - phototherapy –  Malformations and common surgical conditions

•  Audit •  Prevention of nosocomial infection

Models of care: Referral hospitals

•  All interventions at the clinic and district hospital level, plus…

•  Respiratory distress: –  CPAP / high flow nasal prong oxygen

therapy •  Surgical services for neonates •  Care for the VLBW baby (weight for

referral depending on access and capacity at district / provincial hospital)

•  Exchange transfusion for severe jaundice

Effect of minimal standards of neonatal care

Admit Deaths Mortality (%)

Relative risk (95% CI)

p value

Total admissions A B

1167 1247

205 122

17.5 9.8

0.56 (0.45-0.69)

<0.0001

RR adjusted for higher number of neonates <2kg in ‘95-97 0.59 (0.48-0.74) <0.0001 Birth weight <1000g A B

17 10

15 7

88.2 70.0

0.79 (0.51-1.23)

0.32

Birth weight 1000-1499g A B

90 71

60 21

66.7 29.6

0.44 (0.30-0.65)

<0.0001

Birth weight 1500-2000g A B

134 120

31 14

23.1 11.7

0.50 (0.28-0.90)

0.02

Septicaemia or pneumonia A B

341 224

47 11

13.8 4.9

0.36 (0.19-0.67)

0.0006

Birth asphyxia or meconium aspiration A B

135 137

30 18

22.2 13.1

0.59 (0.35-1.01)

0.057

Models of care: referral criteria Indications for referring newborns to hospital • Birth-weight between 1-1.5 kg • Birth-weight between 1.5–2.0 kg if:

¨ Respiratory distress or apnoea ¨ Signs of sepsis

• Birth asphyxia • Severe respiratory distress • Severe infection

¨ Sepsis ¨ Meningitis ¨ Osteomyelitis / septic arthritis

• Any infection that does not improve after 48 hours of appropriate treatment • Severe abdominal distension • Signs of shock (>3 seconds for capillary refill, weak pulse, cold hands) • Congenital abnormalities:

¨ Suspected congenital heart ¨ Open abdominal lesions ¨ Ambiguous genitalia ¨ Imperforate anus ¨ Bile (green) stained vomiting ¨ Frequent vomiting and lots of saliva in the first few hours of life ¨ Pain and swelling of the testes or the inguinal area

• Recurrent apnoeas (>3 periods of no breathing for longer than 20 seconds per day) • Coma and / or convulsions • Uncontrolled bleeding despite Vitamin K injection • Pallor • Severe jaundice or jaundice that lasts longer than 2 weeks • Unexplained poor weight gain for more than 2 weeks after birth Call or radio National Referral Hospital or provincial hospital

Models of care: referral mechanisms

•  Communication •  Transport •  Funding •  The model in Fiji

Other resources

•  Training on the WHO Pocket Book of Hospital Care – Training in care of the neonate with LBW,

sepsis, birth asphyxia •  Assessment tools for neonatal care standards at

hospitals •  Appropriate technology •  Posters •  Simple standardized data reporting system

Training strategies •  Training CD-ROM

NEONATAL RESUSCITATION

Neonatal resuscitation can be highly effective even without oxygen using a self-inflating resuscitation bag & mask All newborn babies should be given their first dose of BCG and Hepatitis B vaccines and a dose of vitamin K Babies should be breast-fed within the first hour of birth

Produced by the Paediatric Society of PNG and the World Health Organization 2008

Systematic approach to the use of oxygen

•  Concentrators •  Oximetry •  Bubble-CPAP

Simple systems of data for surveillance

Simple standardised outcome reporting

Simple standardised outcome reporting

2010 2011 Diagnoses Admit Deaths CFR Admit Deaths CFR All neonatal 2752 335 12.3 4180 480 11.5 Neonatal sepsis 592 37 6.3 2124 152 7.1 Asphyxia 467 54 11.6 1219 165 13.5 VLBW 106 32 30.2 518 169 32.6

Sepsis

•  Half a million neonatal deaths each year •  WHO recommends treatment with

penicillin / ampicillin and gentamicin •  Many countries use third-generation

cephalosporins to treat neonatal sepsis

•  19 studies, 13 countries, >4000 cases of bacteraemia •  Staph aureus, Klebsiella spp. and E. coli accounted for

55% (39–70%) •  Penicillin/gentamicin had comparable in vitro coverage to

third-generation cephalosporins (57% vs 56%) •  Resistance to the combination of penicillin and

gentamicin and to third-generation cephalosporins occurs in more than 40% of cases

Implications •  How to determine criteria for second-line therapy that are

implementable in resource-limited settings •  How to ensure recommendations are effective but

minimise the development of further resistance •  How to make available more expensive or higher-

generation antibiotics in resource-limited developing countries but ensure their use is based on evidence

•  How to address the poor state of bacteriology services in most developing countries and improve local surveillance data

Summary

•  Models of care at primary, district, referral level •  It can be done…and saves lives •  Tools available •  Implementation science •  Monitor neonatal outcomes – it can be done •  Antibiotic stewardship needed

How to start •  What services are needed at

–  health clinic –  district hospital –  referral hospital… –  to establish a minimal standard of neonatal care

•  What current capacity exists? •  What human resources are needed? •  What technical resources are needed (physical facility

space, medications, equipment, guidelines, training)? •  What are the appropriate referral criteria and

mechanisms?