Lessons from implementation research on community management of Possible Serious Bacterial Infection (PSBI) in young infants (0-59 days), when the referral is not feasible in Palwal district of Haryana, India

Abstract

Background Neonatal sepsis is a major cause of death in India, which needs hospital management but many families cannot access hospitals. The World Health Organization and the Government of India developed a guideline to manage possible serious bacterial infection (PSBI) when a referral is not feasible. We implemented this guideline to achieve high coverage of treatment of PSBI with low mortality. Methodology The implementation research study was conducted in over 50 villages of Palwal district, Haryana during August 2017-March 2019 and covered a population of 199143. Policy dialogue with central, state and district health authorities was held before initiation of the study. A baseline assessment of the barriers in the implementation of the PSBI intervention was conducted. The intervention was implemented in the program setting. The research team collected data throughout and also co-participated in the implementation of the intervention for the first six months to identify bottlenecks in the health system and at the community level. RE-AIM framework was utilized to document implementation strategies of PSBI management guideline. Implementation strategies by the district technical support unit (TSU) included: (i) empower mothers and families through social mobilization to improve care-seeking of sick young infants 0–59 days of age, (ii) build capacity through training and build confidence through technical support of health staff at primary health centers (PHC), community health centers (CHC) and sub-centers to manage young infants with PSBI signs and (iii) improve performance of accredited social health activists (ASHAs). Findings A total of 370 young infants with signs of PSBI were identified and managed in 5270 live births. Treatment coverage was 70% assuming that 10% of live births would have PSBI within the first two months of life. Mothers identified 87.6% (324/370) of PSBI cases. PHCs and CHCs became functional and managed 150 (40%) sick young infants with PSBI. Twenty four young infants (7-59days) who had only fast breathing were treated with oral amoxicillin without a referral. Referral to a hospital was refused by 126 (84%); 119 had clinical severe infection (CSI), one 0–6 days old had fast breathing and six had critical illness (CI). Of 119 CSI cases managed on outpatient injection gentamicin and oral amoxicillin, 116 (96.7%) recovered, 55 (45.8%) received all seven gentamicin injections and only one died. All 7–59 day old infants with fast breathing recovered, 23 on outpatient oral amoxicillin treatment; and 19 (79%) received all doses. Of 65 infants managed at either district or tertiary hospital, two (3.1%) died, rest recovered. Private providers managed 155 (41.9%) PSBI cases, all except one recovered, but sub-classification and treatment were unknown. Sub-centers could not be activated to manage PSBI. Conclusion The study demonstrated resolution of implementation bottlenecks with existing resources, activated PHCs and CHCs to manage CSI and fast breathers (7–59 day old) on an outpatient basis with low mortality when a referral was not feasible. TSU was instrumental in these achievements. We established the effectiveness of oral amoxicillin alone in 7–59 days old fast breathers and recommend a review of the current national policy.

A multi-country implementation research initiative to jump-start scale-up of outpatient management of possible serious bacterial infections (PSBI) when a referral is not feasible: Summary findings and implications for programs

“…Six sites reporting referral acceptance rates of <20% [ 17 , 20 – 24 ] were similar to those reported earlier from several African and Asian countries [ 5 , 6 , 8 – 11 ]. The highest referral acceptance rate in Pune, India, was due to an effective referral system, good communication between the care providers and families and awareness among families about the seriousness of illness [ 19 ].…”

“…Of the 7972 young infants identified with signs of PSBI (whether living inside or outside the study catchment area), 7484 young infants were sub-classified (333 infants at Tigray, Ethiopia [ 16 ] and 155 at Haryana, India [ 17 ] were not sub-classified into critical illness or clinical severe infection). There were 2898 (38.7%) 7–59 days old infants with only fast breathing, 4037 (53.9%) 0–59 days old infants with signs of clinical severe infection (including 988, 0–6 days old infants with only fast breathing) and 549 (7.3%) 0–59 days old infants with signs of critical illness.…”

“…Only one study from India [ 18 ] reported two deaths among 7–59 days old infants with only fast breathing leading to CFR of 0.1% (0.01% to 0.2%), (2841 cases and 2 deaths). Among those who were not sub-classified to critical illness or clinical severe infection and received inpatient treatment, thus not included in CFR by sub-group, there were 28 deaths among 333 infants in Tigray, Ethiopia [ 16 ], and no death among 155 infants in Haryana, India [ 17 ].…”

“…They were also important for empowering mothers and family members through counselling and teaching them about the PSBI signs and where and when to seek care. Despite these efforts, the identification of young infants with fast breathing was substantially lower than expected in a few sites [ 17 – 20 ].…”

“…Implementation research studies were carried out from October 2015 to March 2019 in 11 sites in six African and Asian countries, i.e., in Bominenge and Karawa Health Zones in North and South Ubangi (Equateur province) in DR Congo [ 14 ], Jimma (Oromia Region) [ 15 ] and Mekelle (Tigray Region) [ 16 ] in Ethiopia, Palwal (Haryana) [ 17 ], Sirmaur (Himachal Pradesh) [ 18 ], Pune (Maharashtra) [ 19 ] and Lucknow (Uttar Pradesh) [ 20 ] in India, Ntechu (Central Region), Malawi [ 21 ], and Zaria (Kaduna) [ 22 ] and Ibadan (Oyo) [ 23 ] in Nigeria and Thatta (Sindh), Pakistan [ 24 ]. Each study site had a population of 100,000 to 300,000, with a combined population of over 2.5 million.…”