Feasibility of implementing the World Health Organization case management guideline for possible serious bacterial infection among young infants in Ntcheu district, Malawi

Abstract

Background Neonatal sepsis is a leading cause of mortality, yet the recommended inpatient treatment options are inaccessible to most families in low-income settings. In 2015, the World Health Organization released a guideline for outpatient treatment of young infants (0-59 days of age) with possible serious bacterial infection (PSBI) with simplified antibiotic regimens when referral was not feasible. If implemented widely, this guideline could prevent many deaths. Our implementation research evaluated the feasibility and acceptability of implementing the WHO guideline through the existing health system in Malawi. Methods A prospective cohort study was conducted in 12 first-level health facilities in Ntcheu district. Trained health workers identified and treated young infants with PSBI signs with injection gentamicin for 2 days and oral amoxicillin for 7 days, whereas those with only fast breathing were treated with oral amoxicillin for 7 days. Health Surveillance Assistants (HSAs) were trained to promote care-seeking and to conduct home visits on day 3 and 6 to assess infants under treatment, encourage treatment adherence and remind the caregiver to return for facility follow up. Infants receiving outpatient treatment were followed up at health facility on day 4 and 8. The primary outcome was proportion of outpatient cases completing treatment per protocol. Findings A total of 358 infants received outpatient treatment (202 clinical severe infection, 156 only fast breathing) from February to September 2017. Of these, 92.7% (332/358) met criteria for

Feasibility of implementation of simplified management of young infants with possible serious bacterial infection when referral is not feasible in tribal areas of Pune district, Maharashtra, India

“…We had reasonable treatment coverage of approximately 60% in our study. Similar implementation research studies on PSBI in young infants from African and Asian countries reported variable treatment coverages of 16.3% in Sylhet and Chittagong in Bangladesh [24], 50% in Ethiopia [25], 42% in Kushtia district, Bangladesh [26], 63.8% in Malawi [27] and 95% in Nigeria [28]. Thus, except for the Nigeria study, our coverage proportions were comparable with other reported coverages.…”

“…This aspect needs further investigation and we agree that the private health sector, where available, can play a valuable role in managing sick young infants. Our referral refusal proportion differs considerably from other similar studies, with referral refusal as high as 83% in Bangladesh, 90% in Malawi and 97% in Nigeria {24, 27,28]. The high acceptance of referral in our study could limit generalizability of this study to settings where such high referral is not possible.…”

“…In any case, this finding enables the public health system to effectively triage such cases and avoid referring them unnecessarily to tertiary care centres, thus reducing the workload at these centres as well as reducing the exposure of these young infants to higher-level anti-microbials. In the Malawi study, out of 150 young infants with FB, cure rate was achieved in 96% infants [ 27 ]. The study in Kushtia, Bangladesh reported that among 475 young infants with FB, approximately 80% of caregivers reported that their infant had received oral amoxicillin for five days and 74% for seven days and the treatment failure rate was approximately 5% [ 26 ].…”

Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India

“…When compared with other PSBI implementation research studies, our treatment failure rate for CSI was 7% compared to 10.9% in Pune [ 25 ] and 5.8% in Lucknow, India [ 26 ], 3.5% in Malawi [ 24 ], 1.3% in Zaria, Nigeria [ 23 ]. However, our treatment failure rate for pneumonia patients (15%) was higher than that reported by Lucknow, India (4.8%) [ 26 ] and Malawi (2.2%) [ 24 ] and none in Pune, India [ 25 ] and Zaria, Nigeria [ 23 ].…”

“…A large proportion of PSBI cases can be identified if families and community workers are taught to recognise illness and seek care early from an appropriate source; 80% of the estimated PSBI cases in the study area were identified, assuming 10% of infants would have sepsis [ 22 ]. Our 21% proportion of fast breathing pneumonia in 7–59 day-old infants was lower compared to 87% in Kushtia, Bangladesh [ 27 ], 49% in Pune, India [ 25 ], 27% in MaMoni project, Bangladesh [ 29 ], 28% in Malawi [ 24 ], 22% in Zaria, Nigeria [ 23 ] and higher compared to 13.3% in Lucknow, India [ 26 ]. Though it is possible that some cases of PSBI were missed, however, an examination of the deaths reported in the state government portal, showed that of the 69 deaths among infants aged 0–59 days reported during the study period ~14 were due to probable sepsis.…”