Reducing Sepsis Deaths in Newborns Through Home Visitation and Active Case Detection: Is it Realistic?

THE ISSUE OF SERIOUS NEWBORN INFECTION

Serious bacterial infection remains 1 of the 3 leading causes of newborn deaths globally¹ and in some high-burden settings accounts for more than a third of such deaths. Reducing this burden requires strategies that result in more timely case identification and initiation of suitable antibiotic treatment. In many low-income, high-burden settings, achieving such improvements requires services to be pushed out more peripherally to make them more easily accessible. This is particularly challenging in places where much of the population does not currently have easy access to hospital-based care.

EARLIER LANDMARK STUDIES

Bang et al. (1999)²—working in a poorly served, comparatively remote area of India—piloted an approach to reduce newborn mortality that relied on community health workers (CHWs) to provide postnatal home visits, with an intensive, closely monitored, 7-visit schedule over the first month of life. These CHWs were to identify and treat cases of possible sepsis, using oral cotrimoxazole and intramuscular gentamicin. The package also included having the CHWs assist traditional birth attendants at childbirth, resuscitating any newborns not spontaneously initiating breathing at birth. This quasi-experimental study achieved greater than 60% reduction in newborn deaths. These findings challenged a fatalistic attitude then widespread in the global health community, which assumed that important progress in reducing newborn mortality would not be possible without wide access to sophisticated hospital-based services.

Almost a decade later, in 2008 Baqui and colleagues published the results of a comparably important study,³ testing a similar approach in rural Bangladesh, using a cluster-randomized control trial (RCT) design with a much larger sample than in the Bang study. Like the earlier study, this trial recruited and trained its own CHWs to provide this package of services, and in addition to active case detection and treatment of possible sepsis, the intervention included CHW counseling for women and household members on essential newborn care and danger signs. It also included a community mobilization component. However, the package of interventions did not include resuscitation of non-breathing newborns. The schedule of home visits was less intensive than in the Bang study (2 visits during pregnancy, 3 in the first week of life), and the trial was implemented in a less isolated setting, where treatment services were more readily available than in the Bang study setting. The Baqui trial achieved 34% lower mortality in the intervention than the comparison arm. The findings of this study drew considerable attention, including its recognition as the Lancet “paper of the year” in 2008.

WHO/UNICEF RECOMMENDATION

On the strength of these 2 studies, along with several others that didn't include a sepsis treatment component, in 2009 the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) issued a joint statement recommending introduction of postnatal home visitation by health professionals or CHWs, with assessment for danger signs and counseling on essential newborn care practices.⁴ More recently published papers^5,6 report on a similar approach entailing active detection of cases of possible sepsis, through an intensive schedule of home visits with referral to the most peripheral level of the primary health care system for outpatient antibiotic treatment for cases for which hospital referral is not feasible. These studies demonstrated equivalent outcomes for simplified antibiotic regimens, in comparison with 7 days of injections of procaine penicillin and gentamicin, given on an outpatient basis.

THE CURRENT STUDY

The study by Hailegebriel and colleagues, reported in this issue of GHSP,⁷ is a useful additional piece of evidence that can inform the development of more effective strategies to reduce the population burden of preventable infection deaths among newborns. In this cluster RCT, home visitation (3 visits during pregnancy and 5 postnatally) was introduced in both intervention and control arms. One of the pregnancy visits and 2 of the postnatal visits were to be done by paid, government health auxiliaries (Health Extension Workers, or HEWs); the remainder of the visits were to be done by community volunteers, 3,500 of whom were recruited and trained for the trial. Home visits were to focus on counseling on essential newborn care practices and assessment for danger signs. Any identified cases of possible sepsis were to be referred. In the intervention arm, outpatient antibiotic treatment was made available at the health post level, provided by HEWs, if caregivers of the sick newborn were unable or unwilling to go to a higher-level facility. The intervention also included monthly review meetings with HEWs.