Neural tube defects as a cause of death among stillbirths, infants, and children younger than 5 years in sub-Saharan Africa and southeast Asia: an analysis of the CHAMPS network.

BACKGROUND: Neural tube defects are common birth defects resulting in severe morbidity and mortality; they can largely be prevented with periconceptional maternal intake of folic acid. Understanding the occurrence of neural tube defects and their contribution to mortality in settings where their burden is highest could inform prevention and health-care policy. We aimed to estimate the mortality attributed to neural tube defects in seven countries in sub-Saharan Africa and southeast Asia. METHODS: This analysis used data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network and health and demographic surveillance systems from South Africa, Mozambique, Bangladesh, Kenya, Mali, Ethiopia, and Sierra Leone. All stillbirths and infants and children younger than 5 years who died, who were enrolled in CHAMPS, whose families consented to post-mortem minimally invasive tissue sampling (MITS) between Jan 1, 2017, and Dec 31, 2021, and who were assigned a cause of death by a determination of cause of death panel as of May 24, 2022, were included in this analysis, regardless the cause of death. MITS and advanced diagnostic methods were used to describe the frequency and characteristics of neural tube defects among eligible deaths, identify risk factors, and estimate the mortality fraction and mortality rate (per 10 000 births) by CHAMPS site. FINDINGS: Causes of death were determined for 3232 stillbirths, infants, and children younger than 5 years, of whom 69 (2%) died with a neural tube defect. Most deaths with a neural tube defect were stillbirths (51 [74%]); 46 (67%) were neural tube defects incompatible with life (ie, anencephaly, craniorachischisis, or iniencephaly) and 22 (32%) were spina bifida. Deaths with a neural tube defect were more common in Ethiopia (adjusted odds ratio 8·09 [95% CI 2·84-23·02]), among female individuals (4·40 [2·44-7·93]), and among those whose mothers had no antenatal care (2·48 [1·12-5·51]). Ethiopia had the highest adjusted mortality fraction of deaths with neural tube defects (7·5% [6·7-8·4]) and the highest adjusted mortality rate attributed to neural tube defects (104·0 per 10 000 births [92·9-116·4]), 4-23 times greater than in any other site. INTERPRETATION: CHAMPS identified neural tube defects, a largely preventable condition, as a common cause of death among stillbirths and neonatal deaths, especially in Ethiopia. Implementing interventions such as mandatory folic acid fortification could reduce mortality due to neural tube defects. FUNDING: Bill & Melinda Gates Foundation.

Causes of death identified in neonates enrolled through Child Health and Mortality Prevention Surveillance (CHAMPS), December 2016 -December 2021.

Each year, 2.4 million children die within their first month of life. Child Health and Mortality Prevention Surveillance (CHAMPS) established in 7 countries aims to generate accurate data on why such deaths occur and inform prevention strategies. Neonatal deaths that occurred between December 2016 and December 2021 were investigated with MITS within 24-72 hours of death. Testing included blood, cerebrospinal fluid and lung cultures, multi-pathogen PCR on blood, CSF, nasopharyngeal swabs and lung tissue, and histopathology examination of lung, liver and brain. Data collection included clinical record review and family interview using standardized verbal autopsy. The full set of data was reviewed by local experts using a standardized process (Determination of Cause of Death) to identify all relevant conditions leading to death (causal chain), per WHO recommendations. For analysis we stratified neonatal death into 24-hours of birth, early (1-<7 days) and late (7-<28 days) neonatal deaths. We analyzed 1458 deaths, 41% occurring within 24-hours, 41% early and 18% late neonatal deaths. Leading underlying causes of death were complications of intrapartum events (31%), complications of prematurity (28%), infections (17%), respiratory disorders (11%), and congenital malformations (8%). In addition to the underlying cause, 62% of deaths had additional conditions and 14% had ≥3 other conditions in the causal chain. The most common causes considering the whole causal chain were infection (40%), prematurity (32%) and respiratory distress syndrome (28%). Common maternal conditions linked to neonatal death were maternal hypertension (10%), labour and delivery complications (8%), multiple gestation (7%), placental complications (6%) obstructed labour and chorioamnionitis (5%, each). CHAMPS' findings showing the full causal chain of events that lead to death, in addition to maternal factors, highlights the complexities involved in each death along with the multiple opportunities for prevention. Highlighting improvements to prenatal and obstetric care and infection prevention are urgently needed in high-mortality settings.

Reduction in Central Line-Associated Bloodstream Infection Rates After Implementations of Infection Control Measures at a Level 3 Neonatal Intensive Care Unit.

Advances in neonatology led to survival of micro-preemies, who need central lines. Central line-associated bloodstream infection (CLABSI) causes prolonged hospitalization, morbidities, and mortality. Health care team education decreases CLABSIs. The objective was to decrease CLABSIs using evidence-based measures. The retrospective review compared CLABSI incidence during and after changes in catheter care. In April 2011, intravenous (IV) tubing changed from Interlink to Clearlink; IV tubing changing interval increased from 24 to 72 hours. CLABSIs increased. The following measures were implemented: July 2011, reeducation of neonatal intensive care staff on Clearlink; August 2011, IV tubing changing interval returned to 24 hours; September 2011, changed from Clearlink back to Interlink; November 2011, review of entire IV process and in-service on hand hygiene; December 2011, competencies on IV access for all nurses. CLABSIs were compared during and after interventions. Means were compared using the t test and ratios using the χ2 test; P <.05. CLABSIs decreased from 4.4/1000 to 0/1000 catheter-days; P < .05. Evidence-based interventions reduced CLABSIs.

Reduction in Central Line-Associated Bloodstream Infection Rates After Implementations of Infection Control Measures at a Level 3 Neonatal Intensive Care Unit.

Advances in neonatology led to survival of micro-preemies, who need central lines. Central line-associated bloodstream infection (CLABSI) causes prolonged hospitalization, morbidities, and mortality. Health care team education decreases CLABSIs. The objective was to decrease CLABSIs using evidence-based measures. The retrospective review compared CLABSI incidence during and after changes in catheter care. In April 2011, intravenous (IV) tubing changed from Interlink to Clearlink; IV tubing changing interval increased from 24 to 72 hours. CLABSIs increased. The following measures were implemented: July 2011, reeducation of neonatal intensive care staff on Clearlink; August 2011, IV tubing changing interval returned to 24 hours; September 2011, changed from Clearlink back to Interlink; November 2011, review of entire IV process and in-service on hand hygiene; December 2011, competencies on IV access for all nurses. CLABSIs were compared during and after interventions. Means were compared using the t test and ratios using the χ(2) test; P <.05. CLABSIs decreased from 4.4/1000 to 0/1000 catheter-days; P < .05. Evidence-based interventions reduced CLABSIs.

The effect of comprehensive infection control measures on the rate of late-onset bloodstream infections in very low-birth-weight infants.

Late-onset bloodstream infection (LOBI) is a significant problem in very low-birth-weight (VLBW) infants and can lead to increased mortality and morbidity. The incidence of LOBI in VLBW infants in our unit was >35% before 2004, much higher than 20% reported in other studies. A comprehensive infection control measure was introduced in our unit in 2005. Here we report the effects of comprehensive infection control measures on the rate of LOBI in VLBW infants. Infants in the preintervention group (born 2001 to 2004) were compared with the intervention group (born 2005 to 2008) for baseline demographics, risk factors for infection, and the rate of LOBI. LOBI was defined as a positive blood and/or cerebrospinal fluid culture after 3 days of life. Three hundred thirty-four VLBW infants were admitted to our unit during the preintervention period and 303 during the intervention period. There was no significant difference in baseline demographics and risk factors for LOBI between the two groups. The incidence of LOBI was significantly reduced from 38% before intervention to 23% after intervention ( P < 0.001). Comprehensive infection control measures significantly reduced the rate of LOBI in VLBW infants.

Twice-weekly fluconazole prophylaxis in premature infants: association with cholestasis.

BACKGROUND: Fluconazole prophylaxis is effective in preventing invasive candidiasis in extremely low-birthweight (ELBW) infants. The authors previously reported an increased incidence of cholestasis with fluconazole prophylaxis in ELBW infants, which led to fluconazole prophylaxis being changed to a less frequent dosing (LFD) schedule of twice a week at their institution. The purpose of the present study was therefore to evaluate the effectiveness and safety of LFD fluconazole prophylaxis in preventing invasive candidiasis in ELBW infants. METHODS: ELBW infants who received the LFD regimen of fluconazole (twice a week for up to 6 weeks) were compared with infants who received the frequent dosing (FD) schedule (every 72 h for first 2 weeks, every 48 h for next 2 weeks and every 24 h for the final 2 weeks). The two groups were compared for baseline demographics, risk factors for candidiasis, the rate of invasive fungal infection and the incidence and severity of cholestasis. RESULTS: There was no significant difference in the incidence of invasive candidiasis in infants who received the LFD (2/104, 2%) compared to FD (0/140, 0%; P= 0.4) fluconazole prophylaxis. The severity of cholestasis was lower and a trend towards decreased incidence of cholestasis was observed on the LFD schedule. CONCLUSION: The LFD regimen of fluconazole prophylaxis is effective in preventing invasive fungal infection in ELBW infants. The severity of cholestasis was decreased with the LFD schedule.

A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection.

BACKGROUND: This study was conducted to investigate decreases in catheter-related bloodstream infections (CRBSIs) through an evidence-based multimodal intervention. METHODS: This was a prospective interventional study of neonates with a central venous catheter (CVC) from a neonatal intensive care unit database, involving implementation of a multimodal approach to central venous catheter hub care using 2% chlorhexidine in 70% isopropyl alcohol and education of medical staff by audiovisual presentations. CRBSI rates in the pre-intervention period and postintervention period were compared. RESULTS: A total of 373 patients with a CVC (163 in the preintervention period and 210 in the postintervention period) were studied. Patient demographic and clinical characteristics were similar in the 2 periods. Extremely low birth weight infants constituted 40% of the cohort in the preintervention period and 38% of the cohort in the postintervention period. The CRBSI rate in patients with a umbilical artery catheter and an umbilical vein catheter decreased from 15/1000 catheter-days to 10/1000 catheter-days (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.17-0.91). The CRBSI rate in patients with a peripherally inserted central catheter decreased from 23/1000 catheter-days to 10/1000 catheter-days (OR, 0.33; 95% CI, 0.12-0.91). These decreased CRBSI rates were sustained despite high device utilization. The incidence of gram-negative septicemia also decreased. Ten CRBSIs were prevented by this multimodal approach, representing significant health care cost savings. CONCLUSION: This study demonstrates significant decreases in CRBSI rate for all catheter types and birth weight categories associated with the multimodal intervention. Audiovisual education is an effective tool for practice change. Reeducation and compliance monitoring should be part of all nosocomial infection prevention strategies, resulting in significant savings in health care costs.

Cystic hygroma and potential airway obstruction in a newborn: a case report and review of the literature.

BACKGROUND: Cervical cystic hygroma is a benign congenital malformation of the lymphatic system. Incidence of cystic hygroma is 1/6000 live births. We present a case of right neck mass with potential respiratory compromise in a newborn. CASE PRESENTATION: The patient was a full term baby girl with an incidental finding of right neck mass which was described on ultrasound and magnetic resonance imaging as a cystic lesion in the nasopharynx and right neck which inferiorly followed the course of the right carotid artery, consistent with cystic hygroma. She started with respiratory compromise, and a follow-up magnetic resonance imaging showed increased size of the cystic hygroma. Dexamethasone was started to reduce fluid build up in the mass. When the cystic hygroma was found to be inseparable from the right half of the thyroid gland, the otolaryngologist performed hemithyroidectomy. CONCLUSION: The patient had neuropraxia involving the marginal mandibular branch of the facial nerve, which was expected to correct with time. Large cervical cystic hygromas may surround or displace neurovascular structures making their identification quite challenging intraoperatively. A team of experienced surgeons will help to ensure a successful surgical outcome.

Efficacy of the Community Reinvestment Act in promoting lead abatement.

The efficacy of the Community Reinvestment Act (CRA) in assisting homeowners or landlords in urban areas of New Jersey to finance lead abatement was evaluated in the study reported here, as was the effectiveness of the abatement. The study involved working with homeowners, banks, local health departments, and communities to facilitate financing for lead abatement, and collecting environmental-dust specimens from some of the participants' homes before and after abatement. Of the 113 interested subjects, 59 (52 percent) completed abatement of their homes. Of the 58 who applied for CRA loans, 21 received approvals and had the work completed. Thirty-nine of the homeowners found alternate means of financing abatement. The environmental data showed a significant decrease on the windowsills in the 4aated homes, but not on the floors. In conclusion, one-on-one counseling of homeowners about funding was associated with more than 50 percent success in completing abatement, The CRA loans' accounted for about one-third of the abated units. The lead abatement was effective in removing lead paint from the windows, but not in reducing dust lead levels on the floors.

Evaluation of cleaning methods applied in home environments after renovation and remodeling activities.

We conducted a cleaning trial in 40 northern New Jersey homes where home renovation and remodeling (R&R) activities were undertaken. Two cleaning protocols were used in the study: a specific method recommended by the US Department of Housing and Urban Development (HUD), in the 1995 "Guidelines for the Evaluation and Control of Lead-Based Paint Hazards in Housing," using a high-efficiency particulate air (HEPA)-filtered vacuum cleaner and a tri-sodium phosphate solution (TSP); and an alternative method using a household vacuum cleaner and a household detergent. Eligible homes were built before the 1970s with potential lead-based paint and had recent R&R activities without thorough cleaning. The two cleaning protocols were randomly assigned to the participants' homes and followed the HUD-recommended three-step procedure: vacuuming, wet washing, and repeat vacuuming. Wipe sampling was conducted on floor surfaces or windowsills before and after cleaning to evaluate the efficacy. All floor and windowsill data indicated that both methods (TSP/HEPA and non-TSP/non-HEPA) were effective in reducing lead loading on the surfaces (P < 0.001). When cleaning was applied to surfaces with initial lead loading above the clearance standards, the reductions were even greater, above 95% for either cleaning method. The mixed-effect model analysis showed no significant difference between the two methods. Baseline lead loading was found to be associated with lead loading reduction significantly on floors (P < 0.001) and marginally on windowsills (P = 0.077). Such relations were different between the two cleaning methods significantly on floors (P < 0.001) and marginally on windowsills (P = 0.066), with the TSP/HEPA method being favored for higher baseline levels and the non-TSP/non-HEPA method for lower baseline levels. For the 10 homes with lead abatement, almost all post-cleaning lead loadings were below the standards using either cleaning method. Based on our results, we recommend that contractors or homeowners can use a household vacuum cleaner and a household detergent to clean lead-contaminated environments after R&R activities when HUD-recommended equipment is not available.