Incidence Of Neonatal Tetanus Research Articles

Neonatal Tetanus: case report in Saudi Arabia

Aims: This paper aims to investigate a case of neonatal tetanus in Saudi Arabia, studying the different factors leading to infection, role and protocols used in hospital in diagnosis and management of the case. Methods: A medical profile of neonatal case confirmed for neonatal tetanus was collected and studied, in addition to collecting literature reviews about epidemiology, diagnosis and management. Results: A newborn 7-day old girl with poor socioeconomical status and poor aseptic delivery had been admitted to hospital with symptoms of jerky repetitive movement and history of decreased feeding and poor sucking for one day. Laboratory tests, cranial computed tomography (CT) and lumbar puncture were performed, all of them with normal results. She was hospitalized on 12 November, 2019 in an environment free of sensorial stimuli in the Pediatric Intensive Care Unit (PICU), with assisted ventilation. The patient was treated with metronidazole 30mg/kg/day, ampicillin 150 mg/kg/day, and cefotaxime 150mg/kg/day. Sedation was maintained with midazolam 6mic/kg/min. Also, we started on muscle relaxation pancuronium 0.1 mg /kg/hr. and Magnesium sulfate. Besides that, we administered human immunoglobulin IM (500 IU), as well as one dose of tetanus toxoid. During hospital admission the condition of the patient was much improved. On 19 December 2019 the patient was extubated and started with baclofen and physiotherapy. Conclusion: This case indicates that non-sterile delivery by non-practical attendants are the biggest cause of neonatal tetanus along with mothers unimmunized against tetanus. However, in the rarest of incidence of neonatal tetanus, physicians should be prepared to suspect, diagnose and treat neonatal tetanus and ensure clear and clean delivery of newborns. A combination of antibiotics and muscular relaxants are used to manage neonatal tetanus. Key words: neonatal tetanus, case report, Saudi Arabia

In silicooptimization of prenatal vaccine regimens to promote early-life immunity

Abstract Newborn children are vulnerable to infection due to their dampened humoral immune response. Maternal immunoglobulin G (IgG) transferred across the placenta provides passive immunity to newborns, and prenatal vaccination to boost pathogen-specific IgG transfer successfully reduced the incidence of neonatal tetanus, diphtheria, and acellular pertussis (Tdap) infections. Despite this, higher rates of infection among premature neonates signifies a deficiency in current immunization programs. To identify regulators of IgG transfer and refine prenatal vaccine regimens, we used a novel in silico approach. To disentangle the role of placental Fc gamma receptors (FcγRs) in IgG transfer, we conducted multiplexed immunofluorescence (mIF) to measure FcγR expression in paraffin-embedded placental tissue. A mechanistic model of placental IgG transfer informed by single cell RNA sequencing and the mIF data revealed FcγRIIb as a key driver of dynamic subclass-specific IgG transcytosis in placental endothelial cells (ECs). In model simulations and experiments in vitro with human umbilical vein ECs, we found the maternal IgG profile fine-tunes antigen- and subclass-specific IgG transfer dynamics. To identify immunization windows of opportunity for maximum IgG transfer, we simulated maternal vaccination by integrating a model of B cell activation and antibody production into the mechanistic model. This revealed first trimester vaccination as a potential strategy to maximize Tdap-induced IgG transport to premature newborns. We conclude that optimal prenatal vaccine regimens depend on gestational length and that novel prenatal vaccines can leverage these determinants of IgG transport to maximize neonatal immune protection. Supported by grants from NIH (T32 GM145443) the Jeffress Trust Awards Program.

Elimination of Neonatal Tetanus in Rural Central African Republic: Issues and Challenges

Like other countries in the world, the Central African Republic is committed to the fight against the elimination of neonatal tetanus (NNT). Despite the efforts made, the number of NNT cases continues to grow. The objective of this work was to describe the epidemiological profile and identify the risk factors for the occurrence of NNT in rural Central African areas in order to improve control strategies in this context. This was a case-control study of newborns with tetanus (case) or not (controls), conducted between 2014 and 2019 at the Gazi Secondary Health Center. A questionnaire collected socio-demographic and clinical data that were entered and analyzed using the Epi info 7 software. Multiple logistic regression used to establish the relationship between the occurrence of tetanus and the characteristics of the mother and the newborn, through the ORs and their 95% CI. A total of 332 newborns were included, including 166 cases of NNT and 166 controls. The average age was 7.8 ±3.6 days. The incidence of NNT was 2.7 and 5.2 cases per 1000 live births in 2014 and 2019 respectively. The main risk factors for NNT were new males (p=0.04), low maternal education (p=0.001), separation from health care (p=0.006), primiparity (p<0.001), low number of antenatal visits (p<0.003) and low tetanus vaccine coverage (p<0.001). According to newborn care practices: home birth (p=0.002), delivery by unskilled personnel (p<0.001), umbilical cord septic section (p<0.001), no cord dressing (p<0.001) and septic dressing (p=0.012) were statistically associated with the occurrence of NNT in our context. In rural Central African Africa, the incidence of neonatal tetanus remains high and the risk factors are multiple. Effective health promotion measures can contribute to the elimination of this disease.

Toxin-associated infectious diseases: tetanus, botulism and diphtheria.

The incidence rates of the toxin-related infectious diseases, tetanus, diphtheria and botulism declined dramatically over the past decades mainly because of the implementation of immunization programs also in low-and-middle-income countries (LAMICs) and by improving hygiene conditions. But still, single cases occur, and they need fastest possible recognition and management. Over the past 20 years, the incidence of neonatal tetanus has declined by more than 90%. This success was achieved by immunizing women in reproductive age in areas of high risk as sub-Saharan Africa and parts of Asia. Larger regional outbreaks of diphtheria have been reported from the former Soviet Union in the 1990s and from India in 2017. Botulism is still rare, mainly seen in infants and, in recent years, in intravenous drug abusers. Tetanus, diphtheria and botulism are rarities in high-income countries (HICs) with unlimited access to immunization programs and standard hygiene procedures. The diagnosis of all three diseases is still, even in the 21st century, based upon patient's history and clinical signs and symptoms. Neither biochemical bedside tests nor neuroradiological investigations help to confirm the diagnosis in an emergency situation.

English

Neonatal tetanus, a completely preventable disease, still contributes to morbidity and mortality in Akwa Ibom State, despite the fact that there should have been a global eradication many years back. It therefore still constitutes a public health problem. The aim of this work is to highlight the importance of continuous educational actions for pregnant women, mother and midwives with a view to preventing neonatal tetanus and promoting the improvement of the quality of life and health of the mother-child binomial, family members and other care givers. This work is a review of delivery practices and intervention measures in a traditional birth attendant’s home where four babies delivered at the home presented at the University of Uyo Teaching Hospital with features of neonatal tetanus within a three week period between late June 2005 and July 2005. The intervention measures which included teaching clean delivery practices, proper cord care, involvement of the TBA in counseling sessions and postnatal checks eliminated the incidence of neonatal tetanus in the home. These interventions, when applied to other TBAs will help eliminate neonatal tetanus. Key words: Cluster, Lay mid wife, newborn, tetanus.

Knowledge, attitudes and practices related to tetanus toxoid vaccination in women of childbearing age: A cross-sectional study in peri-urban settlements of Karachi, Pakistan.

A higher incidence of neonatal tetanus implies failure of the vaccination program in Pakistan. The objective of this study was to assess knowledge, attitudes and practices related to tetanus toxoid (TT) vaccine in women of childbearing age. We performed a cross-sectional survey in peri-urban Karachi, Pakistan, among women of childbearing age, stratified into three mutually exclusive groups as: married pregnant; married non-pregnant; and unmarried. Descriptive and inferential analyses were performed to estimate vaccine coverage and knowledge attributes. A total of 450 women participated, of which the largest proportion were married and non-pregnant (n = 185/450, 41%). Over 50% of women (n = 258/450) had not received TT vaccine. Most unmarried women (n = 139, 97%) were unvaccinated. Non-vaccination predictors included: women aged <25 years without any formal education (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0-4.4), lack of knowledge about free vaccination (adjusted OR, 4.0; 95% CI, 1.64-10.20), poor knowledge of tetanus disease/vaccination (adjusted OR, 4.6; 95%, 2.2-9.6), living with extended family (adjusted OR, 2.0; 95% CI, 1.04-3.96); family non-supporting vaccination (adjusted OR, 5.7; 95% CI, 2.3-13.9); and husband/other family member deciding upon issues related to women's health (adjusted OR, 2.9; 95% CI, 1.3-6.6). Low coverage of TT vaccine is largely influenced by poor knowledge, family structure and family decision-making in the local communities of Pakistan.

Morbidité et mortalité du tétanos des nouveau-nés et des enfants dans les Centres hospitaliers universitaires d’Abidjan, Côte d’Ivoire (2001-2010)

The lack of data on neonatal tetanus and children in university hospitals (UH) in Abidjan for over a decade has motivated the realization of this study. The objective of this study is to evaluate the morbidity and mortality related to neonatal tetanus (NT) and child tetanus (CT) in Abidjan University Hospital from 2001 to 2010. It is a retrospective study, multicenter analysis with records of newborns and children suffering from tetanus in the three UH of Abidjan. The collection and analysis of data were made by the SPHINX 4.5 and EPI.INFO 6.0 software. In ten years, 242 cases of tetanus (53 NT cases and 189 CT cases) were collected with a predominance of cases after the fifth year of life (59.5%). The incidence rate of NT was less than 1 case per 1,000 live births. All mothers of the newborns were inhabiting the city of Abidjan. Their median age was 19 years [16-32] and 64% were teenagers. Gateways were dominated by umbilical wounds (77.3%) in the NTand skin wounds (59%) in CT. The cure rate was 30.2% in the NT and 60% in the CT. Lethality was 60% for NT and 22% for CT with a positive correlation with young age (neonates: p = 4.10-7, age <5 years: p = 0.01), lack of intraspinal injection of tetanus serum (p = 8.10-6), the absence of conventional antibiotic therapy (p = 0.023), the existence of metabolic complications (p = 2.10-5), the score of ≥ 4 Dakar (p = 0.005). Tetanus remains a real morbidly cause among children in Abidjan University Hospital with high lethality. However, the incidence of NT seems consistent with the incidence threshold desired by WHO.

Incidence of neonatal tetanus in a Nigerian State Hospital, Benin, Nigeria

Aim: The study was aimed at determining the incidence of neonatal tetanus (NT) in Stella Obasanjo State Hospital, Benin City over a period of 5 years. Settings and Design: Retrospective design was used where past records were reviewed from January 2008 to June 2013 and analyzed. Materials and Methods: An observational checklist was developed for manual collection of secondary data from the case notes and the neonatal ward register (the admission and discharge records of patients). The checklist includes information on the following; age at birth, age at discharge, duration of hospitalization, date of manifestation of the disease, entry point of the disease, mother's immunization, place of birth, treatment modality, and outcome of treatment. Statistical Analysis: Descriptive statistics was used which involves the use of simple percentage and bar chart to analyze the data. Results and Conclusions: The result of findings shows that 5 cases were admitted in 2008 and 2010 and the age at manifestation of disease range from 3 to 15 days old while age at admission ranges from 5 to 17 days old. The highest number of days infants stayed in the hospital is 44 days while the least was 2 days whereas the age at discharge ranges between 7 and 52 days. The result further revealed that 60% of the cases were born in the hospital, 26.6% were born out of the hospital while 13.3% gave were born in traditional birth attendant quarters. Finally, this study showed that the percentage of unimmunized mothers outweighs that of immunized mothers. NT is a key cause of neonatal mortality even though it is preventable and it was recommended that all babies born on the floor, roadside, or in a motor vehicle due to precipitated labor should be given injection ATS 4 units/kg before the disease appears.

Incidence and Risk Factors for Neonatal Tetanus in Admissions to Kilifi County Hospital, Kenya

BackgroundNeonatal Tetanus (NT) is a preventable cause of mortality and neurological sequelae that occurs at higher incidence in resource-poor countries, presumably because of low maternal immunisation rates and unhygienic cord care practices. We aimed to determine changes in the incidence of NT, characterize and investigate the associated risk factors and mortality in a prospective cohort study including all admissions over a 15-year period at a County hospital on the Kenyan coast, a region with relatively high historical NT rates within Kenya.MethodsWe assessed all neonatal admissions to Kilifi County Hospital in Kenya (1999–2013) and identified cases of NT (standard clinical case definition) admitted during this time. Poisson regression was used to examine change in incidence of NT using accurate denominator data from an area of active demographic surveillance. Logistic regression was used to investigate the risk factors for NT and factors associated with mortality in NT amongst neonatal admissions. A subset of sera from mothers (n = 61) and neonates (n = 47) were tested for anti-tetanus antibodies.ResultsThere were 191 NT admissions, of whom 187 (98%) were home deliveries. Incidence of NT declined significantly (Incidence Rate Ratio: 0.85 (95% Confidence interval 0.81–0.89), P<0.001) but the case fatality (62%) did not change over the study period (P = 0.536). Younger infant age at admission (P = 0.001) was the only independent predictor of mortality. Compared to neonatal hospital admittee controls, the proportion of home births was higher among the cases. Sera tested for antitetanus antibodies showed most mothers (50/61, 82%) had undetectable levels of antitetanus antibodies, and most (8/9, 89%) mothers with detectable antibodies had a neonate without protective levels.ConclusionsIncidence of NT in Kilifi County has significantly reduced, with reductions following immunisation campaigns. Our results suggest immunisation efforts are effective if sustained and efforts should continue to expand coverage.

Neonatal tetanus in Kano: A ten-year review

Background: Neonatal tetanus (NNT) is one of the childhood's preventable diseases and a leading cause of neonatal death especially in developing countries. It is entirely preventable through effective immunisation of women of child-bearing age, and through simple and basic precautionary measures in child delivery. Objective: This study highlighted the burden of neonatal tetanus in Kano over a period of ten years. Materials and Methods: We retrospectively studied the case notes of neonatal tetanus admitted over a ten-year period (2000-2009). The records of neonates admitted as cases of neonatal tetanus into the special care baby unit of Aminu Kano Teaching Hospital, a tertiary health facility in Kano, northern Nigeria, over a ten-year period were reviewed. Data on age at presentation, local government area from which the neonates presented, antenatal history, maternal immunisation status, clinical feature, complications and the outcome were noted. Results : Majority of the cases (74%) were concentrated in the cosmopolitan areas of Kano. Only 33% of the mothers had antenatal care (ANC) while only 18 (24%) of the mothers received immunisation against tetanus. In all, 76% of the mothers delivered outside the medical facility. The umbilical cord was the route of infection in 52.7% of cases. The case-specific fatality rate was 51.4%. Conclusion: The incidence of NNT is still very high in Kano and this scourge can be tackled through improved quality and accessibility of ANC services and tetanus toxoid (TT) vaccination, provision of skilled attendants at delivery under hygienic conditions and avoidance of harmful traditional practices.

HE BURDEN AND CHALLENGES OF NEONATAL TETANUS IN KILIFI DISTRICT, KENYA--2004-7.

To describe the incidence of neonatal tetanus (NNT) and to describe the trends between 2004 and 2007; to show the geographical distribution of NNT in Kilifi district and to describe routine immunisation coverage, catch-up campaigns and mop-ups. Retrospective study Kilifi district, Coastal Kenya Children diagnosed with Neonatal Tetanus (NNT) attending Health facilities in the District. The incidence of NNT in Kilifi increased from 0.6 in 2004 to 1.0 per 1000 live births in 2007. Over 50% of Kilifi district was a high risk area for NNT. It was a public health problem (> 1 per 1000 live births) in 19/36 locations. Immunisation (TT2+) increased from 4% in 2004 to 17% in 2007 for women of childbearing age and from 22% to 98% for pregnant women in the same period. All cases of NNT were delivered at home. 83% of NNT cases had potentially infectious materials applied to their cords. Neonatal tetanus was an increasing problem in Kilifi district in the period 2004-2007. Immunisation coverage was low for women of childbearing age. TT immunisation data capture was a mix-up (pregnant women andwomen of childbearing age) at various health facilities and was a challenge to accurate estimates of TT2+ immunisation coverage.

Elimination of maternal and neonatal tetanus in Senegal: evolution of survey indicators of 2003-2009

This study aimed to estimate the evolution of the maternal and neonatal tetanus in Senegal from the tetanus vaccination coverage among pregnant women, the proportion of deliveries attended by trained medical personnel and the number of cases of tetanus declared by respective districts, helping to identify districts at high risk of neonatal tetanus (NNT). Data analysis of the epidemiological surveillance realized from 2003 to 2009 in 65 districts of Senegal. Data were collected from the reports of vaccination usage and from the Statistical Directories of the National Health Information Services of the Ministry of Health & Prevention. A district is at high risk when the incidence of NNT is ≥1 case per 1 000 Live births (LB). There were 153 reported cases of NNT in Senegal between 2003 and 2009. National incidence decreased from 0.08 to 0.03 case per 1 000 LB (p = 0,0008). The vaccination coverage of the pregnant women by at least two doses of tetanus vaccine (VAT2+) increased from 66% in 2003 to 78% in 2009. The percentage of districts that had reached a vaccination coverage ≥80% was 20% in 2003 compared to 60% in 2009 (p = 0.009). The proportion of deliveries attended by qualified medical staff evolved from 53% in 2003 to 67% in 2009 (p = 0,02). By 2009, the incidence of NNT was less than 1 case per 1,000 LBs in all districts. Assessing the elimination of maternal and neonatal tetanus in Senegal shows that progress has been made from 2003 to 2009. This was made possible through the organization of vaccination campaigns for women of childbearing age and the improvements in the conditions of deliveries.

Completeness of reporting and case ascertainment for neonatal tetanus in rural Pakistan

The objectives of this study were to assess the case ascertainment and completeness of neonatal tetanus (NT) reporting and to estimate the incidence of NT in Dadu District, Pakistan. We conducted active surveillance and hospital record reviews for suspected NT cases. We compared the cases of NT reported to the routine surveillance system with the cases identified through the hospital record reviews for 1993 through 2003. The two-source capture-recapture method was used to evaluate case ascertainment in the routine surveillance system and to estimate the incidence of cases of NT. Active surveillance and hospital record reviews identified 134 cases in addition to 274 cases in the routine surveillance system. The two-source capture-recapture method indicated that there would have been 463 cases during this period (95% confidence interval (CI)=418-508), representing an average annual incidence of 0.62 per 1000 live-births. The overall completeness of routine reporting was 59.2%. The proportions of cases reported were 68.1% for government hospitals and 53.8% for private reporting sites. Reporting of NT cases is incomplete. Active promotion of private sector participation, community involvement, and strengthening of the government sector as a way of improving NT reporting and surveillance is strongly suggested.

Neonatal tetanus incidence in Dadu District, Pakistan, 1993–2003

The study objective was to assess the incidence of neonatal tetanus (NT) in Dadu District, Pakistan. We analyzed the NT surveillance data for the period 1993-2003 in order to determine the NT incidence. We identified unreported NT cases retrospectively in 2005, by active surveillance and hospital record reviews. The 2-source capture-recapture method was used to estimate the incidence of NT cases. Active methods identified 134 cases in addition to 274 cases in the routine surveillance system. The average annual incidence in routine surveillance was 0.55 per 1000 live-births (LB). Based on an estimated 463 NT cases during this period (95% confidence interval (CI) 425-509), the average annual incidence (capture-recapture) was 0.62 per 1000 LB. Through routine immunization and supplementary immunization activities, NT incidence declined from 0.87 per 1000 LB in 1994 to 0.18 per 1000 LB in 2003. Males had higher incidence rates than females. Both of the average annual incidence rates (by routine surveillance and capture-recapture method) are below the World Health Organization global elimination goal. Enhanced case-based investigation, targeted tetanus toxoid immunization of women of childbearing age, community-based NT reporting, immediate reporting and active surveillance are critical to sustain the ongoing decline in NT incidence.

Upsurge in neonatal tetanus in Benin City, Nigeria

Neonatal tetanus was on the decline from mid 1970's to mid 1990's due to the various efforts by many governments of the developing countries and such agencies as World Health Organisation (WHO) and United Nation's Children's Fund (UNICEF). However recently there appear to be an increase in neonatal tetanus despite these interventions leading to increasing neonatal morbidity and mortality. To study the upsurge in neonatal tetanus despite the various interventions, examine possible causes responsible for it and proffer suggestions for eliminating neonatal tetanus by new target date of 2005 set by World Health Organisation. A prospective study. The study was done at the University of Benin Teaching Hospital, Benin city and Modic Medical Centre, a private paediatric hospital in Benin City, Nigeria between January 1997 to December 2001. In 1996, it was noticed that cases of neonatal tetanus had increased suddenly among the total admissions. Morbidity and mortality among the under six months children had also increased and about ten percent of it was due to neonatal tetanus. It became imperative therefore to determine the magnitude of this problem. Consequently, cases of neonatal tetanus admitted to Special Care Baby Unit (SCBU) of the University of Benin Teaching Hospital and the Intensive Care Unit (ICU) of the Modic Medical Centre, a private paediatric hospital in Benin over a five year period January 1997 to December 2001 were examined. One hundred and fifty three tetanus cases were recorded during the period comprising 87 (56.9%) males and 66 (43.1%) females. The annual incidence in UBTH was 6.9% (99/1425) and 5.3% (54/1021) in Modic Centre. Forty three point eight percent (67/153) survived while 56.2% (86/153) died. There was a yearly increase in incidence of neonatal tetanus of total neonatal admissions. Average age on admission was 8.8 days and incubation period was 5-22 days. Only 40 (26.1%) did not have any antenatal care. Eighteen of the 40 (45%) mothers who had antenatal care had two doses of tetanus toxoid only. Many of the mothers were ignorant about immunisation, feared about the consequences of immunisation, some got disenchanted with it because of the out of stock syndromes associated with the vaccines whenever they visited the health centres. Some of them did not even know about antenatal care. Problem identified included lack of awareness of antenatal services among the target population, under utilisation of antenatal service, non immunisation with tetanus toxoid vaccines, negative cultural beliefs, primordial cord care, lack of economic and decision making empowerment of the target population and lack of government commitment towards elimination of neonatal tetanus. The following recommendations which may lead to elimination of Neonatal Tetanus were made: Strengthening school health programmes, intensive mobilisation and advocacy, regular availability of tetanus toxoid vaccines, empowerment of the target population, training and retraining personnel including Traditional Birth Attendants and increasing commitment by various tiers of government.

Epidemiological Analysis on Neonatal Tetanus Cases from 1999 through 2004 in Shaoxing City

Objective This analysis was conducted to better understand the epidemiological characteristics of neonatal tetanus(NT)in Shaoxing city in order to provide background information for the formulation of strategies to control and eradicate the disease. Methods Descriptive study was used to statistically analyze the data collected from the NT-specific reporting system and case study from 1999 to 2004. Results Statistics showed that the incidence of NT fluctuated between 0.15‰ and 0.65‰,exhibiting a general tendency of increasing. There were 2 counties (districts) where the incidence was equal to or more than 1‰. The mortality of NT ranged from 11.11% to 37.50%。It was observed that Yuecheng district and Shaoxing county where economics were relatively developed were dominated by the disease, with no seasonal. Of the 78 cases diagnosed, floating population accounted for 89.74% and males were more affected than females, with the ratio being 2.12:1. Most cases developed clinical manifestations 5-8 days after birth. 83.33% of the cases were infants delivered at home with the help of an untrained midwife. And all the mothers had no definite inoculation history of tetanus toxoid. Conclusion The dominant factors contributing to NT involve old midwifery, lack of tetanus toxoid injection before labor and delivery, and population floating. It is believed that eradication of NT can be achieved through improving self-care among pregnant women, promoting hospital delivery, inoculating high risk groups with TT and strengthening training of new midwifery.

Incremental cost-effectiveness of supplementary immunization activities to prevent neonatal tetanus in Pakistan.

This study aimed to estimate the incremental cost-effectiveness of supplementary immunization activities to prevent neonatal tetanus in the Loralai district of Pakistan. The supplemental immunization activities were carried out in two phases during 2001-03. A state-transition model was used to estimate the effect of routine vaccination with tetanus toxoid as well as vaccination with tetanus toxoid during supplementary immunization activities. The model follows each woman in the target population from birth until the end of her childbearing years, using age-specific fertility data and vaccination history to determine the number of births at risk for neonatal tetanus. Recently published data on the incidence of neonatal tetanus from Loralai were used to determine the number of cases occurring with and without supplementary immunization activities. Data on the costs of the activities were collected from the UNICEF office in Balochistan and from the Provincial Health Department. Using base-case assumptions we estimated that the supplementary immunization activities would prevent 280 cases of neonatal tetanus and 224 deaths from neonatal tetanus between 2001 and 2034. Implementation of the supplementary activities was relatively inexpensive. The cost per tetanus toxoid dose delivered was 0.40 U.S. dollars. In the base-case analysis the cost per death averted was 117.00 U.S. dollars (95% confidence interval (CI) = 78-205 U.S. dollars) and the cost per disability-adjusted life year (DALY) averted was 3.61 U.S. dollars (95% Cl = 2.43-6.39 U.S. dollars). Compared with similar analyses of other interventions, the cost per DALY averted is a favourable cost-effectiveness ratio. However, if routine diphtheria-tetanus-pertussis vaccination coverage in the Loralai district had been higher (at a coverage rate of about 80%) the cost-effectiveness of the intervention would have been even more favourable, at 2.65 U.S. dollars per DALY averted.

Management of the Umbilical Cord

After completing this article, readers should be able to: 1. Describe the most serious infection that may result from inappropriate management of the umbilical cord and potential sources. 2. Describe the relationship between infant bacterial colonization and postpartum infection. 3. List the most common neonatal staphylococcal infections. 4. List the factors that affect the timing of cord separation. 5. Delineate the probable causes of drainage from the umbilical stump. This review addresses several aspects of the care of the umbilical cord: how to ligate and cut it, what (if anything) to apply to it, the problems that may be associated with ligation and cutting, and the natural history of cord separation. The traditional method of ligating the umbilical cord was to use string or twine to tie the cord before cutting it. In Southern Sudan, fine stringlike roots are used to tie the cord. More recently in the United States, special cotton tape (umbilical tape) was used and still is found on most trays used for insertion of catheters into umbilical blood vessels. Because the umbilical cord tends to shrink after birth, these types of ligature proved somewhat unreliable in preventing hemorrhage. Although the umbilical arteries tend to constrict rapidly after birth because of the muscular walls, this does not occur with the umbilical vein. Consequently, more efficient and effective methods of ligation were sought in the middle of the 20th century. The first method was to use constricting rubber bands, which were effective, but somewhat difficult to apply. This method recently found favor in a developing country (Ethiopia). However, the more usual method in developed countries currently is plastic or metal clamps, which produce safe, reliable constriction. In particular, the plastic Hollister® clamp (Double-Grip Umbilical Cord Clamp, Hollister, Libertyville, IL) has been very successful in preventing bleeding from the cord. These devices are removed …

Risk factors for neonatal tetanus in Ibadan, Nigeria

This case-control study identified risk factors for neonatal tetanus in this population and indicates that the problem has not yet received adequate attention. The incidence of neonatal tetanus can be greatly reduced by providing the masses with appropriate health education as well as formal education especially at the grass roots level; ensuring access to antenatal services, improving the quality of such services, and extending efforts to provide tetanus immunisation to mothers. Tetanus, listed among the major causes of neonatal death in many tropical countries including Nigeria, is a major public health problem. Although neonatal tetanus (NNT) death toll has reduced by a third in the last decade worldwide, there is a noticeable surge in deaths from this killer disease in Nigeria, giving the country the largest absolute increase worldwide, up by 62% [5,6]. This study sought to obtain more recent information on major risk factors associated with NNT in this community and to make suggestions for reducing its incidence. The study was conducted in all secondary and tertiary hospitals in Ibadan, Nigeria, a city with a projected population of over 4 million [1]. All NNT cases diagnosed by standard criteria were admitted into the study until the total required sample size was met and matched 1:1 with controls. The minimum sample size was calculated after correcting for design effect. The instrument used was a pre-tested structured questionnaire administered to mothers of cases and controls. Subjects enrolled in the study were140 cases and 140 controls with a male/female ratio of 1.4:1 and 1.1:1 respectively. All 19 neonates with onset of illness within the first 4 days of life died, giving a case fatality of 100%. The younger the babies at onset of illness the more likely they were to die (x 2 =41.7, P <0.0001). The overall case fatality rate was 79.4% with a male/female death ratio of 1.3:1. Teenage mothers, fathers with no education, primiparity, low socio-economic class, late antenatal (ANC) booking, none/incomplete maternal tetanus immunisation, delivery outside the health facility, untrained personnel at delivery, use of non-sterile cord-cutting tool, and the presence of animals within the residence were significantly associated with NNT (Table 1). ANC was attended by 86.4% of mothers of cases but only 25.6% of these mothers received full immunisation. Three out of four mothers of cases who attended ANC did so with a frequency of 5 to 20 times indicating missed opportunities for immunisation. The main reason for failure to receive full immunisation was ignorance on the mothers’ part, which reflects inadequate health education by the system. The study identified major risk factors associated with the occurrence of NNT in Ibadan and the surrounding district and indicated that NNT continues to be a common and serious problem in this community because NNT constituted more than one third (38.5%) of the total neonatal admissions in the study sites during the study period. In this study, 40% of the NNT cases were delivered in health facilities in contrast to Tompkins series in which none was delivered in a health facility [4]. The NNT rate in facility delivery is, however, higher than the 15% reported by Grange [2]. Though health facility delivery was associated with significantly lower risk for NNT, the risk was not totally absent suggesting that there is need to look more critically at the role the health facilities play in the transmission of NNT.

A method for adjusting gender bias in neonatal tetanus reports in Egypt 1991.

Reports of neonatal tetanus (NT) disease, common in developing countries, often suffers from gender bias because male infants are brought to health facilities while females are attended at home. Using existing health data we applied reasonable assumptions to estimate the true incidence of NT economically. To adjust for gender disparities in national reporting, we ignored the number of female NT cases and doubled the number for males. Governorates with similar demographic risk profiles for NT were assigned to one of six groups. The highest incidence rate within the group was determined and applied to the number of live births represented by the group. Other internal data comparisons were done to support our estimate that the male:female ratio of NT incidence was far less than the reported 412:1. In 1991, the male: female ratio of NT cases was 4.12:1. Decreasing the male: female ratio to 1:1 decreased sensitivity to a 62% estimate. Further adjusting for assumed under-reporting by governorates based on population profiles yielded a reporting sensitivity of 40%. Estimated male and female age-specific NT mortality rates from available data supported the assumption that NT mortality ratios are less than 4.12:1. This report, therefore, describes a unique, economical method to estimate the incidence of a disease assumed to be affected by gender biases in the reporting system. The method relies on two assumptions: that the true NT male:female ratio is close to 1:1 and that populations with similar demographics within a country should have similar incidence rates of NT.