Cost and consequences of using 7.1 % chlorhexidine gel for newborn umbilical cord care in Kenya.

BACKGROUND: Omphalitis is an important contributor to neonatal mortality in Kenya. Chlorhexidine digluconate 7.1 % w/w (CHX; equivalent to 4 % w/w chlorhexidine) was identified as a life-saving commodity for newborn cord care by the United Nations and is included on World Health Organization and Kenyan Essential Medicines Lists. This pilot study assessed the potential resource savings and breakeven price of implementing CHX for neonatal umbilical cord care versus dry cord care (DCC) in Kenya. METHODS: We employed a cost-consequence model in a Kenyan birth cohort. Firstly, the number of omphalitis cases and cases avoided by healthcare sector were estimated. Incidence rates and treatment effect inputs were calculated from a Cochrane meta-analysis of randomised clinical trials (RCTs) (base case) and 2 other RCTs. Economic outcomes associated with omphalitis cases avoided were determined, including direct, indirect and total cost of care associated with omphalitis, resource use (outpatient visits and bed days) and societal impact (caregiver workdays lost). Costs and other inputs were sourced from literature and supplemented by expert clinical opinion/informed inputs, making necessary assumptions. RESULTS: The model estimated that, over 1 year, ~ 23,000 omphalitis cases per 500,000 births could be avoided through CHX application versus DCC, circumventing ~ 13,000 outpatient visits, ~ 43,000 bed days and preserving ~ 114,000 workdays. CHX was associated with annual direct cost savings of ~ 590,000 US dollars (USD) versus DCC (not including drug-acquisition cost), increasing to ~ 2.5 million USD after including indirect costs (productivity, notional salary loss). The most-influential model parameter was relative risk of omphalitis with CHX versus DCC. Breakeven analysis identified a budget-neutral price for CHX use of 1.18 USD/course when accounting for direct cost savings only, and 5.43 USD/course when including indirect cost savings. The estimated breakeven price was robust to parameter input changes. DCC does not necessarily represent standard of care in Kenya; other, potentially harmful, approaches may be used, meaning cost savings may be understated. CONCLUSIONS: Estimated healthcare cost savings and potential health benefits provide compelling evidence to implement CHX for umbilical cord care in Kenya. We encourage comprehensive data collection to make future models and estimates of impacts of upscaling CHX use more robust.

Loss of Malar Bags in Lower Eyelid in Orbital Blow Out Fracture Reconstruction Following Pre- or Retro-Septal Transconjunctival Incision.

An isolated orbital blow out fracture may require surgical correction by accessing the infraorbital rim through a transconjunctival incision and inserting an orbital plate. The risk for aesthetic complications due to the incision has previously been well described. Sixty patients surgically treated using pre- or retro-septal transconjunctival incisions for isolated orbital blow out fractures were recruited and examined with regards to lower eyelid asymmetry. Forty-seven controls with conservative treatment were recruited and underwent a similar examination. A grading system for malar bags in the lower eyelids was set up to compare the 2 groups. All patients with moderate or severe malar bags on the nonoperated eyelid lost the malar bags on the operated side and developed asymmetry in the lower eyelids. No difference was found between the pre- and retro-septal approach. In this study we describe a new complication related to the transconjunctival incision and highlight the importance of informing patients in need of reconstruction of the orbital walls about the risk of postoperative asymmetry in the lower eyelids.