Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh.

There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6 . Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019.

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.

Community health worker-led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol.

Background: Extreme hyperbilirubinemia leading to neurologic disability and death is disproportionately higher in low- and middle-income countries (LMIC) such as Bangladesh, and is largely preventable through timely treatment. In LMICs, an estimated half of all newborns are born at home and few receive screening or treatment for hyperbilirubinemia, leading to 6 million newborns per year who need phototherapy treatment for hyperbilirubinemia but are untreated. Household screening and treatment for neonatal hyperbilirubinemia with phototherapy administered by a trained community health worker (CHW) may increase indicated treatment for neonatal hyperbilirubinemia in comparison to the existing care system in Bangladesh. Methods: 530 Bangladeshi women in their second or third trimester of pregnancy from the rural community of Sakhipur, Bangladesh will be recruited for a cluster randomized trial and randomized to the intervention arm - home screening and treatment for neonatal hyperbilirubinemia - or the comparison arm to receive usual care. In the intervention arm, CHWs will provide mothers with two prenatal visits, visit newborns by 2 days of age and then daily for 3 days to measure transcutaneous bilirubin (TcB) and monitor for clinical danger signs. Newborns without danger signs but with a TcB above the treatment threshold, but >15 mg/dL will be treated with light-emitting diode (LED) phototherapy at home. Newborns with danger signs or TcB ≥15 mg/dL will be referred to a hospital for treatment. Treatment rates for neonatal hyperbilirubinemia in each arm will be compared. Conclusion: This study will evaluate the effectiveness of CHW-led home phototherapy to increase neonatal hyperbilirubinemia treatment rates in rural Bangladesh. LMICs are expanding access to postnatal care by using CHWs, and our work will give CHWs a curative treatment option for neonatal hyperbilirubinemia. Similar projects in other LMICs can be pursued to dramatically extend healthcare access to vulnerable newborns with hyperbilirubinemia.

Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh.

BACKGROUND: In low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have the potential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment. METHODS: In this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48 h of birth and then consecutively for three days. A physician repeated 20% (n = 148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician's danger sign identification and referral decision as the gold standard to validate CHWs' identification of danger signs and referral decisions. RESULTS: The referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K = 0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7-100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50-100%) and excellent negative predictive value (NPV) (99-100%). Specificity was high (99-100%) for all ten danger signs. CONCLUSION: CHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities. TRIAL REGISTRATION: clinicaltrials.gov NCT03933423 , January 05, 2019.

Metal-free C-H amination of unactivated hydrocarbons with sulfonylimino-λ(3)-bromanes generated in situ from (diacetoxybromo)benzene.

A simple method for direct metal-free C-H amination of unactivated hydrocarbons using easy-handling diacetoxy-λ(3)-bromane and triflylamide or sulfamate esters was developed. The high 2°/3° regioselectivities and deuterium isotope effects suggest a concerted organonitrenoid transition state, analogous to C-H amination with N-triflylimino-λ(3)-bromane.

Reductive detriflylation of N-triflylamides with Red-Al.

Reduction of cis-N-triflylaziridines with 10 equiv of Red-Al in toluene at -40 to 0 °C selectively afforded corresponding deprotected parent aziridines in good to high yields. N,N-Dialkyltriflylamides were also successfully cleaved under similar reaction conditions.

Metal-free α-CH amination of ethers with hypervalent sulfonylimino-λ3-bromane that acts as an active nitrenoid.

Hypervalent N-triflylimino-λ(3)-bromane undergoes direct and regioselective α-C-H amination of ethers at room temperature under transition metal-free conditions. Kinetic results, substituent and deuterium isotope effects suggest an asynchronous concerted organonitrenoid transition state with some hydride transfer character, analogous to that for alkane C-H insertions.

Synthesis and structure of hypervalent diacetoxybromobenzene and aziridination of olefins with imino-λ3-bromane generated in situ under metal-free conditions.

Ligand exchange of p-CF(3)C(6)H(4)BrF(2) with acetoxy groups using AcOH and Ac(2)O affords (diacetoxybromo)benzene in a high yield, which undergoes aziridination of alkenes in the presence of TfNH(2) and sulfamate esters in one pot under mild conditions. The aziridination with TfNH(2) proceeds stereospecifically with retention of stereochemistry of olefins at room temperature using limiting amounts of olefins under transition-metal-free conditions. The one-pot aziridination procedure using sulfamate esters can be applied to the intramolecular versions.

Oxidation of primary aliphatic and aromatic aldehydes with difluoro(aryl)-λ3-bromane.

Oxidation of primary aliphatic aldehydes with p-trifluoromethylphenyl(difluoro)-λ(3)-bromane in dichloromethane at 0 °C afforded acid fluorides selectively in good yields, while that of aromatic aldehydes in chloroform at room temperature produced aryl difluoromethyl ethers. A larger migratory aptitude of aryl groups compared to primary alkyl groups during a 1,2-shift from carbon to an electron-deficient oxygen atom in bromane(III) Criegee-type intermediates will result in these differences in the reaction courses.

Septicemic neonates without lumbar puncture: what are we missing?

Meningitis is a serious problem in newborn infants and has high mortality and frequent neurological sequelae. In neonates, signs and symptoms of serious infections are often obscure and clinical examination cannot distinguish septicemic babies with or without meningitis. Therefore, lumbar puncture is often not done in time and thus diagnosis of meningitis is missed. This study aimed to discover the prevalence of meningitis among these cases based on laboratory investigation. We prospectively enrolled the blood culture positive septicaemia cases which were not labeled as cases of meningitis during routine clinical evaluation. Out of 30 septicemic cases, eight (26.7%) had abnormal CSF cytology and biochemistry suggestive of meningitis. Among these eight cases, four had positive CSF culture; [Klebsiella pneumoniae (n = 3) and Pseudomonas aeruginosa (n = 1)], which were similar to the blood isolate of the respective patient. The clinical manifestations were similar in both septicemia and meningitis cases. Mortality was high among the meningitis cases compared with those having septicemia alone (37.5% vs. 13.3%), indicating the need for early diagnosis of this disease. Our data confirmed that it is important to do a lumbar puncture, along with blood culture, for all suspected septicemia cases.