Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh.

BACKGROUND: Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh. METHODS: We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs. RESULTS: Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers. CONCLUSION: Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

FACILITATING QI ACTIVITIES GLOBALLY THROUGH DIGITAL TECHNOLOGY: DECREASING SEVERE NEONATAL HYPERBILIRUBINEMIA

Purpose of Study Severe Neonatal Hyperbilirubinemia (SNH) is a major cause of neonatal mortality in Sub-Saharan Africa and can cause neurodevelopmental disability in survivors. Exchange transfusions (ET) to reduce high bilirubin levels are common in low/middle income countries (LMIC) due to late detection of jaundice. Mothers are often discharged from hospital < 24 hours after delivery. A Blended Learning Quality Improvement (QI) Program using digital technology (the in- country workshop was cancelled due to COVID 19 pandemic) was developed between Georgetown University (GU) and district hospitals in Ghana to improve quality of neonatal care (funded by GU Global Health Initiative). The objective of this program was to facilitate QI activity at a Ghana District Hospital (GDH) promoting early care seeking in mothers for neonatal jaundice so that phototherapy may be used to decrease SNH and ET. Methods Used GU faculty used Zoom and WhatsApp platforms to work with GDH staff to facilitate formation of a QI team, implement interactive health education with videos by trained midwives for antenatal/post-partum mothers, initiate daily rounds by physicians in postnatal wards, promote community health nurses to call/visit mothers postnatally at home, and maintain data on pre-defined key outcome indicators. The goal was to reduce the proportion of inborn infants ≥ 34 weeks gestational age being brought to the neonatal unit with SNH (serum bilirubin levels ≥ 340umol/L or 20 mg/dL) by 15% within 3 months. The program was exempted from review by the GU IRB. Statistical analysis: Chi- square;Fisher exact test. Summary of Results From Oct 2019 to Jan 2020, 14 (28%) of 50 discharged infants were readmitted with SNH and 7 (14%) received ET. Figure 1 shows the trend graph of infants admitted with SNH and ET each month after the initiation of the QI project in Jan 2020. Table 1 shows the decline in SNH and ET in the 3 months post intervention as well as a significant sustained decline for 16 months. There was a significant increase in infants being brought in for bilirubin levels < 255umol/L after the intervention. Conclusions Despite internet connectivity problems, this digitally mediated QI project demonstrated success in reduction of SNH and ET in a district hospital in a LMIC. Regular review of trend graphs and repeated facilitation, implemented through low-cost digital technology, are effective in promoting QI activities and can be applied regionally and globally. The increase in infants being brought in for mild jaundice points to the need for objective methods of determining bilirubin levels in the community. (Figure Presented).