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Effectiveness of Home-Based Management of Newborn Infections by Community Health Workers in Rural Bangladesh

Baqui, Abdullah H. MBBS, MPH, DrPH*†; Arifeen, Shams E. MBBS, PhD†; Williams, Emma K. MHS*; Ahmed, Saifuddin MBBS, PhD‡; Mannan, Ishtiaq MBBS, MSc†; Rahman, Syed M. MBBS, DCH, MSc†; Begum, Nazma MA, DCS†; Seraji, Habibur R. MBBS, MSc§; Winch, Peter J. MD, MPH*; Santosham, Mathuram MD, MPH*; Black, Robert E. MD, MPH¶; Darmstadt, Gary L. MS, MD*

Pediatric Infectious Disease Journal: April 2009 - Volume 28 - Issue 4 - pp 304-310
doi: 10.1097/INF.0b013e31819069e8
Original Studies

Background: Infections account for about half of neonatal deaths in low-resource settings. Limited evidence supports home-based treatment of newborn infections by community health workers (CHW).

Methods: In one study arm of a cluster randomized controlled trial, CHWs assessed neonates at home, using a 20-sign clinical algorithm and classified sick neonates as having very severe disease or possible very severe disease. Over a 2-year period, 10,585 live births were recorded in the study area. CHWs assessed 8474 (80%) of the neonates within the first week of life and referred neonates with signs of severe disease. If referral failed but parents consented to home treatment, CHWs treated neonates with very severe disease or possible very severe disease with multiple signs, using injectable antibiotics.

Results: For very severe disease, referral compliance was 34% (162/478 cases), and home treatment acceptance was 43% (204/478 cases). The case fatality rate was 4.4% (9/204) for CHW treatment, 14.2% (23/162) for treatment by qualified medical providers, and 28.5% (32/112) for those who received no treatment or who were treated by other unqualified providers. After controlling for differences in background characteristics and illness signs among treatment groups, newborns treated by CHWs had a hazard ratio of 0.22 (95% confidence interval [CI] = 0.07–0.71) for death during the neonatal period and those treated by qualified providers had a hazard ratio of 0.61 (95% CI = 0.37–0.99), compared with newborns who received no treatment or were treated by untrained providers. Significantly increased hazards ratios of death were observed for neonates with convulsions (hazard ratio [HR] = 6.54; 95% CI = 3.98–10.76), chest in-drawing (HR = 2.38, 95% CI = 1.29–4.39), temperature <35.3°C (HR = 3.47, 95% CI = 1.30–9.24), and unconsciousness (HR = 7.92, 95% CI = 3.13–20.04).

Conclusions: Home treatment of very severe disease in neonates by CHWs was effective and acceptable in a low-resource setting in Bangladesh.

From the *International Center for Advancing Neonatal Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; †the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh; ‡Department of Population and Family Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; §the South Australia Community Health Research Unit, Department of Public Health, Flinders, Adelaide, Australia; and ¶Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Accepted for publication October 7, 2008.

Supported by the United States Agency for International Development (USAID), through cooperative agreements with the Johns Hopkins Bloomberg School of Public Health and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) (Grant Number GHS-A-00-03-00019-00), and by the Saving Newborn Lives program of Save the Children-US through a grant from the Bill & Melinda Gates Foundation.

The project team comprised the ICDDR,B; the Bangladesh government's Ministry of Health and Family Welfare; Bangladeshi nongovernmental organizations, including Shimantik, Save the Children-US, Dhaka Shishu Hospital and the Institute of Child and Mother Health; and the Johns Hopkins Bloomberg School of Public Health.

Address for correspondence: Abdullah H. Baqui, MBBS, MPH, DrPH, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Suite: E-8138, 615 N. Wolfe St., Baltimore, MD 21205. E-mail: abaqui@jhsph.edu.

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© 2009 Lippincott Williams & Wilkins, Inc.