|Year : 2014 | Volume
| Issue : 3 | Page : 240-243
Maternal and neonatal risk factors associated with vertical transmission of ophthalmia neonatorum in neonates receiving health care in Blantyre, Malawi
Roshni Ranjit1, Lynette Menezes2, Mitchell Drucker1, Gerald Msukwa3, Nkume Batumba3
1 Department of Ophthalmology, University of South Florida Eye Institute, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, Florida, USA
2 Department of International Medicine, University of South Florida Eye Institute, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, Florida, USA
3 Department of Ophthalmology, University of Malawi College of Medicine, Lilongwe, Malawi
|Date of Web Publication||19-Jun-2014|
Dr. Roshni Ranjit
12901 Bruce B. Downs Blvd, Tampa, Florida 33612
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Neonatal conjunctivitis is associated with poor prenatal care worldwide.
Purpose: Data on neonatal conjunctivitis is scarce in Malawi. This study describes risk factors associated with conjunctivitis in neonates born in a large tertiary care hospital in Blantyre, Malawi.
Materials and Methods: Medical records of a retrospective cohort of 231 neonates diagnosed with conjunctivitis from January 2006 to December 2009 at a large tertiary hospital in Malawi were reviewed. All subjects were clinically diagnosed with ophthalmia neonatorum. Data were collected on patient demographics and clinical features. The frequencies were calculated of various risk factors in neonates with ophthalmia neonatorum and their mothers as well as the treatments administered.
Results: Mean age of the mother was 23.45 years (range, 15-40 years), and the mean number of previous deliveries was 2.3 (range, 1-7) children. Nearly, 80% of mothers delivered preterm infants via spontaneous vaginal delivery. The mean birth weight of neonates was 2869.6 grams (1100-5000 grams). Among mothers, premature rupture of membranes was the leading risk factor (24%) followed by sepsis during labor (9%), and history of sexually transmitted infections (STI) (7%). Neonates presented with low Apgar scores (19%), fever (8%), and/or meconium aspiration (5%). Providers treated patients empirically with a varied combination of benzyl penicillin, gentamicin, tetracycline eye ointment, and saline eye wash. Tetracycline with a saline eyewash was used frequently (34%) compared with combinations of benzyl penicillin and gentamicin.
Conclusions: Improving prenatal care to reduce sepsis, traumatic deliveries, and early diagnosis of STI with appropriate treatment may potentially reduce vertical transmission of neonatal conjunctivitis in this understudied population.
Keywords: Neonatal Conjunctivitis, Ophthalmia Neonatorum, Prenatal Care, Risk Factors, Vertical Transmission
|How to cite this article:|
Ranjit R, Menezes L, Drucker M, Msukwa G, Batumba N. Maternal and neonatal risk factors associated with vertical transmission of ophthalmia neonatorum in neonates receiving health care in Blantyre, Malawi. Middle East Afr J Ophthalmol 2014;21:240-3
|How to cite this URL:|
Ranjit R, Menezes L, Drucker M, Msukwa G, Batumba N. Maternal and neonatal risk factors associated with vertical transmission of ophthalmia neonatorum in neonates receiving health care in Blantyre, Malawi. Middle East Afr J Ophthalmol [serial online] 2014 [cited 2021 Oct 24];21:240-3. Available from: http://www.meajo.org/text.asp?2014/21/3/240/134684
| Introduction|| |
Neonatal conjunctivitis is the most common ocular disease in neonates worldwide.  Neonatal ocular infections have been largely associated with various factors including premature rupture of membranes in preterm mothers, subclinical infections of the lower female genital tract during birth, and nutritional deficiency during pregnancy-prevalent mostly in developing countries. , Preterm pregnancy is defined as delivery before 37 weeks of gestation. It is well-known that early contractions and delivery affect the transmission of the infectious agent. Several studies support the idea that antibiotics are essential in preventing maternal and neonate infection in patients with prelabor membrane rupture during the preterm period.  Poor perinatal outcomes such as respiratory failure, compromised immunity due to premature birth, neonatal sepsis from an ascending maternal infection, premature rupture of membranes, placental abruption, postpartum sepsis, and maternal anemia are some of the possible outcomes that can affect the mother and the neonate.  Additionally, maternal sepsis and intrauterine growth retardation of the fetus are suspected to be consequences of ascending maternal infections. 
The most common microbial agents responsible for causing neonatal conjunctivitis world-wide are Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae. Since the development and widespread use of the Crede's silver nitrate eye drops as prophylaxis for newborns at birth, the incidence of gonorrheal conjunctivitis has significantly decreased.  However, C. trachomatis is not affected by Crede's silver nitrate prophylaxis, and it has become a major cause of neonatal conjunctivitis, also known as inclusion blennorrhea, in the developing world. , Tetracycline or erythromycin ointment immediately after birth has largely replaced Crede's prophylaxis against neonatal conjunctivitis because of its efficacy against Chlamydia and gonorrheal pathogens and its low incidence of causing a chemical conjunctivitis.  Prophylactic regimens using 1.0% tetracycline, 0.5% erythromycin ophthalmic ointment, or 2.5% povidone iodine solution are considered equally effective in the prevention of gonococcal ophthalmia globally; however, the only drug approved by the U.S. Food and Drug Administration for this indication is 0.5% erythromycin ophthalmic ointment. 
C. trachomatis is primarily transmitted to newborns vaginally by mothers with untreated genital C. trachomatis infections and 15-20% are at risk for developing nasopharyngeal infections, 3-18% are at risk for developing pneumonia, and 18-50% are at risk of developing conjunctivitis.  The World Health Organization Global Incidence report in 1999 found that globally, female adolescents had the highest rate of C. trachomatis ranging from 24.1% to 27% percent, and that 70-75% of women infected worldwide were asymptomatic. 
Given the scarcity of published data and research in Malawi, the purpose of this study is to describe the maternal and neonatal risk factors associated with the vertical transmission of neonatal conjunctivitis as well as examine treatment for neonates with this infection. By describing the key factors associated with neonatal conjunctivitis, interventions can be designed to reduce vertical transmission of this preventable condition.
| Materials and Methods|| |
A retrospective chart review was performed of infants born between January 2006 and December 2009 at a large referral hospital in Blantyre, Malawi. Approval was obtained from the University of South Florida Institutional Review Board and the Research Ethics Committee from the University of Malawi College of Medicine. A thorough chart review was performed of neonates born from January 2006 to December 2009 and those clinically diagnosed with ophthalmia neonatorum by the physicians in the maternity ward were further reviewed and descriptive data was catalogued. The diagnosis of ophthalmia neonatorum was made clinically by the physicians at the maternity ward at Queen Elizabeth Central Hospital and the same physicians provided treatment plans for the neonates. Identifying information was removed during data collection. Data were collected on socio-demographic variables such as age of mother, age of neonate when diagnosed, weight of neonate (grams), number of deliveries, type of delivery, maternal risk factors, treatment, and treatment response. Data were entered into an Excel (Microsoft Corp., Redmond, WA, USA) database. Data were analyzed using SAS 9.2 (SAS Institute Inc., Cary, NC, USA). The proportion of mothers and infants with a risk factor was estimated using frequency distribution. The frequencies of risk factors were not mutually exclusive. An infant or their mother could have more than one risk factor and the frequency distribution could total more than 100%. Lastly, we computed the proportion of the type of treatment received by infants with neonatal conjunctivitis.
| Results|| |
Data were collected from 231 patient charts out of 12,249 maternal/neonate admissions. Demographic data are presented in [Table 1]. The majority of mothers (55%) had one risk factor [Table 2]. The most common maternal risk factors included premature rupture of membranes (24%), sepsis during birth (9%), and sexually transmitted infections (STIs) (7%) [Table 3]. Other maternal risk factors noted by physicians included Venereal Disease Research Laboratory (VDLR) positive, HIV positive, staphylococcus infections during pregnancy, and/or chorioamnionitis. The most common risk factors for the neonates were a low Apgar score (19%) fever (8%), and meconium aspiration (5%) [Table 3]. Other neonatal risk factors (51%) included sepsis, jaundice, and respiratory distress [Table 3].
|Table 1: Selected characteristics of neonates with ophthalmia neonatorum and their mothers|
Click here to view
Neonates were treated with benzyl penicillin, gentamicin, saline eye-wash, and tetracycline eye ointment [Table 4]. A combination of saline eye-wash with tetracycline eye ointment was the most common treatment provided to the neonates (34%), and a combination benzyl penicillin, gentamicin, and saline eye-wash was the second most common treatment in 25% of the neonates [Table 4].
| Discussion|| |
To our knowledge, this is the first study that has examined maternal and neonate risk factors among neonates diagnosed with ophthalmia neonatorum at a tertiary hospital in Malawi. The leading maternal risk factor was premature rupture of membranes, probably due to an infection commonly passed during the 28 th week of gestation.  Ophthalmia neonatorum is one of the most preventable causes of blindness in neonates, in addition to cortical impairment from birth asphyxia and retinopathy of prematurity worldwide.  Close to 80% of neonates in this study were born preterm thus increasing their risk for ophthalmia neonatorum if the mother had an STI. Both premature rupture of membranes (24%) and sepsis during birth (9%) can be closely monitored and prevented with proper prenatal and perinatal care. Furthermore, more than half (55%) of the mothers had at least one risk factor which contributed to the transmission of infection to the fetus and/or neonate.
The leading risk factor for the neonates was a low Apgar score (19%) followed by fever (8%) possibly because of maternal sepsis and unprotected environmental exposure due to premature rupture of maternal membranes. Close monitoring to prevent vertical transmission is crucial and important to recognize, as early fetal immunocompetence in the second and the third trimesters of pregnancy could lead to devastating perinatal effects. 
Of interest, the revival of Fusidic acid as a promising therapy in ocular infections is important due to its natural bacteriostatic protein synthesis inhibitory action against both gram-positive and several gram-negative microbes including C. trachomatis and N. gonnorhea.  Isenberg et al. demonstrated that 2.5% povidone iodine was most effective at reducing ophthalmia neonatorum in Kenya because it protected against bacterial and viral agents.  Furthermore, the use of 2.5% povidone iodine resulted in fewer cases of ophthalmia neonatorum, and fewer cases of C. trachomatis conjunctivitis when compared to both erythromycin and silver nitrate prophylaxis given within the first hours after birth.  In addition to its effective prophylactic capabilities and affordability, the solution turns the surface of the eye brown which provides visual evidence that the medication was administered properly. For these reasons, povidone iodine may serve as an alternative to erythromycin and/or tetracycline as prophylaxis and can become the new standard of care as prophylaxis in developing countries. 
There is a critical need for the development of tailor made programs which encompass the issues of the target population in developing nations. Efficacy can only be achieved with a multi-disciplinary approach, and our hope with this paper was to bring to light the efforts that should be undertaken to prevent the transmission of ophthalmia neonatorum to decrease blindness and visual impairment among the children of Malawi.
| References|| |
|1.||Kakar S, Bhalla P, Maria A, Rana M, Chawla R, Mathur NB. Chlamydia trachomatis causing neonatal conjunctivitis in a tertiary care center. Indian J Med Microbiol 2010;28:45-7. |
|2.||Bergstrom S. Infection-related morbidities in the mother, fetus and neonate. J Nutr 2003;133 (5 Suppl 2):1656S-60. |
|3.||Locksmith G, Duff P. Infection, antibiotics, and preterm delivery. Semin Perinatol 2001;25:295-309. |
|4.||Bell TA, Stamm WE, Kuo CC, Wang SP, Holmes KK, Grayston JT. Risk of perinatal transmission of Chlamydia trachomatis by mode of delivery. J Infect 1994;29:165-9. |
|5.||Rogers LK,Baker CJ, Kimberlin DW, Long SS. Red Book 2009 Report of the Committee on Infectious Diseases. 28 th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. p. 827-9. |
|6.||World Health Organization. Global prevalence and incidence of selected curable sexually transmitted diseases: Overview and estimates. Geneva: World Health Organization; 1999. |
|7.||World Health Organization. Malawi: Country Cooperation Strategy; 2013. |
|8.||Gogate P, Gilbert C, Zin A. Severe visual impairment and blindness in infants: Causes and opportunities for control. Middle East Afr J Ophthalmol 2011;18:109-14. |
|9.||Zuppa AA, D'Andrea V, Catenazzi P, Scorrano A, Romagnoli C. Ophthalmia neonatorum: What kind of prophylaxis? J Matern Fetal Neonatal Med 2011;24:769-73. |
|10.||Isenberg SJ, Apt L, Del Signore M, Gichuhi S, Berman NG. A double application approach to ophthalmia neonatorum prophylaxis. Br J Ophthalmol 2003;87:1449-52. |
[Table 1], [Table 2], [Table 3], [Table 4]