Neonatal deaths account for almost 44% of global under-5 child deaths.1 Three South Asian countries (Bangladesh, India and Pakistan) account for more than one third of all global neonatal deaths, the majority of which occur at home.2–6 The World Health Organization (WHO) estimates that 26% of these deaths are because of infection.7 Neonatal mortality rates differ across settings and are higher where the neonatal infection rate is very high.3,8 Inherent difficulties in collecting and processing specimens from young infants are one of the main barriers to understanding the etiology of infections in neonates in low-income countries. Current evidence on neonatal infection etiology is based on the predominantly hospital-based studies that identified bacterial pathogens by blood culture from only 5%–10% of neonates with suspected serious infection.9–12 Limited knowledge in this area is a major impediment to designing effective programs for successful prevention and management of neonatal infections.13 We are conducting the Aetiology of Neonatal Infection in South Asia (ANISA) study at 5 population-based sites in Bangladesh, India and Pakistan to provide information on incidence, etiology and risk factors for community-acquired neonatal infections. This study also enrolls young infants aged 28–59 days as they have a high risk of infection.14–16 We instituted pregnancy and birth surveillance to capture births in the catchment areas and record young infant infections. This article describes various aspects of the pregnancy and infection surveillance activities carried out at ANISA study sites.
PROJECT GOAL AND OBJECTIVES
The goal of the ANISA study is to provide data to design appropriate treatment regimens and strategies for reducing serious bacterial and viral infections in young infants. The study has 4 primary objectives: (1) to establish community-based surveillance to identify cases of possible serious bacterial infection among infants aged 0–59 days and collect specimens for etiologic evaluation; (2) to determine community-acquired etiology-specific incidence of bacterial and viral infections among infants by using standard and molecular diagnostic tools; (3) to identify the risk factors for community-acquired serious bacterial and viral infections in young infants and (4) to identify clinical features predictive of invasive viral and bacterial infections among ill-appearing young infants in the community.
STUDY DURATION AND TIMELINE
We intend to collect data in a similar manner at all study sites to minimize reporting bias and allow pooled analysis. This requires developing the protocol and standard operating procedures, designing data collection forms, recruiting and training staff and arranging study logistics in a standardized manner, as well as harmonizing the processes across the field sites, study hospitals and site laboratories. Each site has gone through a pilot phase to adapt the protocol to its particular setting. The duration of this phase for individual sites varied based on the achievement of benchmark targets set at the beginning of the project.17 Once a site achieved these targets, it started enrolling study participants in the main study. At least 2 years of surveillance time has been scheduled for each site. We believe that this duration will permit us to understand the impact of seasonal variation on the types of pathogens isolated from enrolled cases. As different study sites have ended their pilot phases at different times, the start date of the main study varies by site. Start and end dates of surveillance activities at ANISA study sites are listed in Table 1.
ANISA STUDY SITES
Collecting specimens from neonates at the community level is difficult in South Asia because caregivers are not able to bring their newborns to health care facilities given a variety of sociocultural barriers.18 We selected 5 sites where the investigators had good records of working in the communities and had a thorough understanding of the local cultures in the expectation that these existing relationships would encourage caregivers to overcome barriers and bring their newborns to health care facilities for assessment, care and specimen collection. Among the sites, 4 are rural communities and 1 is peri-urban (Fig. 1). All the study sites have recently completed a population census, which provides baseline data on neonatal mortality rates. The sites also possess adequate laboratory facilities for performing microbiological and molecular analysis of clinical specimens. The notable features and expected number of clinical specimens to be collected at each site are listed in Table 2.
COMMUNITY-BASED ACTIVE SURVEILLANCE FOR INFECTION IN NEWBORNS
Community-based active surveillance for infection cases includes (1) registering married women of reproductive age (MWRA) in the target communities; (2) identifying pregnancies; (3) identifying live births as soon as possible after delivery; (4) identifying suspected infections among young infants in the community; (5) referring cases of suspected infection to study hospitals and (6) enrolling healthy controls. A group of project staff performs each activity. The key components of ANISA surveillance and laboratory activities are depicted in Table 3. To harmonize the study protocol across sites and train project staff in a similar manner, a 2-stage training program was conducted. In the first stage, experts from WHO trained supervisory staff from the sites and provided them with training guides, videos and booklets. These trained personnel then trained community health workers (CHWs) from their respective sites for 15–21 days, with the length depending on the experience of the CHWs, local procedures and capacity.19,20
REGISTERING MARRIED WOMEN AND PREGNANCY SURVEILLANCE
The study area of each site is subdivided into clusters and blocks. One CHW is responsible for conducting surveillance in a particular area (1–3 blocks). A CHW makes bimonthly household visits to identify and register MWRA (13–49 years) in her area for the study. Unmarried women are excluded, as the possibility of finding a premarital pregnancy is remote given the cultural settings of the study sites. During MWRA surveillance, CHWs maintain individual planners for making household visits in each block and visit every house at least once every 2 months. During the visits, CHWs ask MWRAs for the date of their last menstrual period. An MWRA is considered to be pregnant if 2 months have passed since her last menstrual period.21,22 Pregnant women who provide verbal consent for themselves and their newborns for participation in the study are registered and tracked until their deliveries take place. Figure 2 shows the pregnancy and birth surveillance scheme of the ANISA study.
FOLLOW-UP OF PREGNANT WOMEN
Once a CHW identifies a pregnancy, she places the pregnant woman on a roster and schedules 2 visits to that household during the pregnancy. The first visit is immediately after pregnancy identification, during which the CHW counsels the pregnant woman about the importance of seeking routine antenatal care from a trained health worker. The CHW also collects demographic, educational and previous pregnancy-related information about the woman and her family members to determine the risk factors for young infant infections. The CHW conducts the second antenatal visit in the 29th week of pregnancy, during which she provides information to the pregnant woman and her family members related to the health care of mothers and neonates. These visits help a CHW build rapport with families, which in turn helps early notification of births to the CHW and referral compliance if she suspects infection in a young infant under observation. The CHW provides her mobile phone number to family members so that they can inform her about the delivery. Study site personnel reimburse mobile phone call costs to the family to encourage early birth notification. The CHW also phones the family every other day starting in the 37th week of pregnancy to inquire whether the mother has delivered.
ANISA sites hire CHWs locally, so that they are familiar with traditional and other skilled birth attendants in the surveillance area and maintain contact with them to increase the likelihood of early birth notification.
NEWBORN REGISTRATION IN THE STUDY
The ANISA study tries to identify and register each newborn in the study area as soon as possible after birth to capture early neonatal infection cases. However, a CHW can register a newborn in the study up to 7 days after birth. At the time of registration, the CHW administers 2 separate sets of questionnaires for recording the newborn’s health status and delivery history to capture the most likely risk factors for neonatal infection. We have described the detailed questionnaires elsewhere in this supplement. A CHW also makes a visit plan to keep the newborn under continuous follow-up until the age of 59 days.
IDENTIFYING SUSPECTED INFECTION CASES
ANISA is using CHWs to identify suspected infection cases because previous studies have shown that trained CHWs can effectively identify suspected neonatal sepsis cases among young infants in a community setting using Integrated Management of Childhood Illness guidelines.8,23,24 We designed the pregnancy and suspected infection surveillance to minimize the impact of a CHW’s visit on the natural burden of infection and yet capture all the suspected infection cases. CHWs visit each newborn on days 0, 2, 6, 13, 20, 27, 34, 41, 48 and 59. During these visits, they assess the newborns based on the clinical variables listed in Table 4.
SUSPECTED INFECTION CASE REFERRAL
If a CHW finds any of the signs from Table 4 in a newborn during follow-up visits, she refers the newborn to a study-designated health care facility. Whenever necessary, a CHW accompanies the mother and newborn to the facility. The CHW visits that household again the next day to reinforce referral if the family members have not complied. In the health care facility, a study physician reexamines the newborn to confirm the presence of any sign of infection. In Matiari, Pakistan, there is no study-designated health care facility for ANISA, so study physicians work with CHWs as mobile teams and reassess newborns with sign(s) of suspected infection.
A young infant is deemed eligible for enrollment as a case of suspected infection if a study physician identifies any 1 of the 7 signs listed in Table 5 and none of the exclusion criteria (Table 5) are met. The exclusion criteria are intended to ensure that the case is not nosocomial in nature and that each reported episode is an isolated event.25 The study team requests the family’s consent for blood and nasopharyngeal-oropharyngeal swab specimen collection from the enrolled newborn. The team also aims to collect cerebrospinal fluid in suspected cases of meningitis (patients with history of irritability, convulsions, high-pitched cry and full, bulging anterior fontanelle) if the family provides written consent.26 A flow diagram of the newborn registration, follow-up visits, case enrollments and specimen collections are shown in Figure 3.
PASSIVE SURVEILLANCE FOR INFECTION CASES
As CHWs visit the young infants on a fixed schedule, there is a possibility of missing some infection cases between visits. To capture those cases, CHWs teach household members how to identify signs of infection in a young infant (Table 4) and requests family members to take the infant to a study-designated health care facility if they observe any of these signs. In the study-designated hospitals, a study physician and other study staff assess a self-referred newborn for signs of infection and enroll the infant in ANISA if he/she meets the enrollment criteria (Table 5).
Mothers and other family members are encouraged to hospitalize their ill-appearing newborns so that a study physician can confirm any of the 7 clinical signs of suspected infection. The hospital manages the admitted young infants according to the hospital policy. If caregivers refuse to hospitalize their sick young infants, study physicians provide standard outpatient care for the illness. A combination of penicillin and aminoglycoside (penicillin/ampicillin and gentamicin) is typically used to treat suspected infection.2,27–31 For meningitis, a third-generation cephalosporin (ceftriaxone/cefotaxime) is used with or without an aminoglycoside. The results of blood and cerebrospinal fluid cultures are provided to treating physicians.
Supervisory staff members conduct a complete verbal autopsy for each young infant who dies within the follow-up period (0–59 days),32–37 using validated WHO Verbal Autopsy Forms.37 Two physicians then independently review the completed forms. If the physicians do not concur, a third physician reviews the information and makes a conclusion on the cause of death.
Consent is requested from parents or caregivers at 2 points. Informed verbal consent is taken at the time of registering a pregnant woman in the study. Informed written consent is requested at the time of collecting specimens from a sick young infant with suspected infection. We obtained ethical clearance for the study from the ethical review committees or internal review boards of all the organizations involved in this study, and they have reviewed and approved the study protocol and consent and data collection forms. These organizations include the Bangladesh Institute of Child Health, WHO, Johns Hopkins Bloomberg School of Public Health, Aga Khan University, International Centre for Diarrhoeal Disease Research, Bangladesh, Christian Medical College and the Asian Institute of Public Health.
The ANISA infection surveillance protocol is designed to capture the population-based incidence, etiology and risk factors for community-acquired neonatal infections in South Asia. We expect that through this study we will able to report the etiology of young infant infections in South Asia to guide the future treatment policy for this group and help to develop strategies to reduce the burden of young infant infections across the world. We believe that the methodology described in this article will also be useful to design future population-based studies in resource-poor areas.
The authors thank the experts who provided their valuable thoughts in designing this protocol, the families who participated in this study and the project staff who are contributed their time, experience and hard work to make the study successful.
ANISA Methods Group: A. S. M. Nawshad Uddin Ahmed, FCPS, Belal Hossian, MSc, Maksuda Islam, BA, Tanvir Hossain, MSc, Qazi Sadeq-ur Rahman, MSc, Maureen Helen Diaz, PhD, Jonas Winchell, PhD, Nong Shang, PhD, Derrick Crook, MRCP, Vishawjeet Kumar, MPH, Aarti Kumar, MS, Stephen P. Luby, MD, Luke Mullany, PhD, Mathuram Santosham, MD, Yoonjoung Choi, PhD, Shahida M Qureshi, MSc, Imran Ahmed, MSc, Sheraz Ahmed, MBBS, Arif Mahmud, MBBS, Nazma Begum, MA, and Stephanie J. Schrag, DPhil.
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