Chlorhexidine gel versus aqueous for preventive use on umbilical stump: a randomized noninferiority trial.

BACKGROUND: Recent trials of chlorhexidine cord cleansing have employed aqueous solution applied with cotton swabs. Care-takers may prefer gel, resulting in better compliance when implemented at large scale. We examined whether a guar-gum-thickened formulation was at least as efficacious as aqueous in reducing periumbilical flora. METHODS: Newborns (n = 694) from normal deliveries at a hospital in Kathmandu were randomly allocated to cord cleansing with either gel or aqueous chlorhexidine, applied by finger. Immediately before and 24 hours after cleansing, periumbilical swabs were collected and cultured. The primary outcome was periumbilical colonization at 24 hours. Household-level acceptability and ease of use in a rural setting where most deliveries are not attended by health workers were assessed by providing 61 women with either gel or aqueous formulations and following up on their experience using the products. RESULTS: Babies allocated to gel and aqueous chlorhexidine were comparable on a range of variables measured at baseline. At 24 hours postapplication, 4.6% (15 of 327) of cultures were positive in the gel group and 10.7% (35 of 326) in the aqueous group. The absolute difference in rates (gel minus aqueous) was -6.1% (95% CI: -10.2%, -2.1%). The acceptability study found that satisfaction and compliance were high for both; use of either largely displaced the traditional use of oil-based mixtures. Overall, there was a preference for gel. CONCLUSIONS: The gel formulation was not inferior to aqueous and gel reduced bacterial colonization to a greater degree. A gel formulation might be considered in future research or program settings where chlorhexidine cleansing of the cord is being evaluated or promoted.

Process of neonatal tetanus elimination in Nepal.

BACKGROUND: In late 2005, Nepal demonstrated through surveys that it had reached the World Health Organization criterion for having eliminated neonatal tetanus (NT), i.e. NT cases occurred at a rate of less than 1 per 1000 live births in every district. This paper summarizes how a combination of strategies contributed to this success. METHODS: For each of the 4 strategies (clean delivery, routine immunization, supplemental immunization campaigns, and surveillance) activities before and after 2000 are described and achievements are summarized using published and unpublished data. RESULTS: Through routine immunization of pregnant women with tetanus toxoid (TT), NT cases had decreased substantially by 1999, but the final push was provided through the national TT supplemental immunization activities in 2000-2004, which raised the proportion of children protected at birth against tetanus to above 80%. Fewer than 20% of deliveries take place with trained assistance. Although NT surveillance has improved since the extensive Acute Flaccid Paralysis/Polio surveillance infrastructure in Nepal was made available for the NT elimination initiative, it is likely that a number of cases still occur without being reported, particularly in rural areas. CONCLUSIONS: NT elimination was achieved in 2005 in Nepal, but activities must continue and be strengthened to ensure that NT incidence will not increase in the future. The introduction and further expansion of school-based immunization will, in combination with diphtheria-tetanus-pertussis vaccine given in infancy, reduce the need for future cohorts of childbearing age women to be immunized at every pregnancy. However, booster doses will still need to be given in early adulthood to ensure ongoing protection.