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Incidence and Risk Factors for Newborn Umbilical Cord Infections on Pemba Island, Zanzibar, Tanzania

Mullany, Luke C. PhD, MHS*; Faillace, Silvana MD, MPH*; Tielsch, James M. PhD*; Stoltzfus, Rebecca J. PhD; Nygaard, Kara E. MPH*; Kavle, Justine A. PhD*; Farag, Tamer H. PhD*; Haji, Hamad J. MSc; Khalfan, Sabra S. MPS; Ali, Nadra S. BSc; Omar, Rahila S.; Darmstadt, Gary L. MD*

The Pediatric Infectious Disease Journal: June 2009 - Volume 28 - Issue 6 - p 503-509
doi: 10.1097/INF.0b013e3181950910
Original Studies

Background: Few community-based data exist on the frequency of cord infection signs in low resource settings, especially in Sub-Saharan Africa. We developed simple sign-based definitions of omphalitis and estimated incidence and risk factors for infection over a range of severity among neonates in Pemba, Zanzibar, Tanzania.

Methods: Infants’ umbilical stump was assessed on days 1, 3, 5, 7, 10, and 14 after birth for presence of pus, redness, swelling, and foul odor. Infection incidence and proportion of affected infants was estimated for 6 separate combinations of these signs. Two definitions were examined for associations between infection and selected potential risk factors using multivariate analysis.

Results: Nine thousand five hundred fifty cord assessments (in 1653 infants) were conducted. The proportion of affected infants ranged from 16 (1.0%, moderate to severe redness with pus discharge) to 199 (12.0%, pus and foul odor), while single signs were observed in >20% of infants. Median time to onset of infection was 3 to 4 days; 90% of infections occurred by age 7 days. Breast-feeding within the first hour after birth was associated with lower risk of infection in multivariate analyses, while other maternal, and infant and care practices were generally not associated.

Conclusions: Signs of omphalitis occur frequently and predominately in the first week of life among newborns in Pemba, Tanzania. Infection definitions relying on single signs without classifying severity level may overestimate burden. Redness with pus or redness at the moderate or severe level if pus is absent is more appropriate for estimating burden or during evaluation of interventions to reduce infection.


From the *Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; †Division of Nutritional Sciences, Cornell University, Ithaca, New York; and ‡Public Health Laboratory-Ivo de Carneri, Pemba Island, Zanzibar, Tanzania.

Accepted for publication November 13, 2008.

This research was funded by a grant from the Bill and Melinda Gates Foundation (810-2054). The funding sources played no role in the study design, collection, data analysis, writing of the report, or decision to submit the article for publication.

Address for correspondence: Luke C. Mullany, PhD, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Suite E8646, Baltimore, MD 21211. E-mail:

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© 2009 Lippincott Williams & Wilkins, Inc.