Chlorhexidine

On September 15–16, 2011, in Nepalgunj, Nepal, over 70 participants from governments and nongovernmental organizations in Nepal, Bangladesh, Cambodia, India, Indonesia, Pakistan, and the United States joined to hear the results of clinical trials conducted in Nepal, Bangladesh, and Pakistan on the application of chlorhexidine to the newborn cord during the first week of life. Results from operational studies in Bangladesh and Nepal were also presented as well as the policy considerations on the use of this intervention. The meeting was hosted by the Ministry of Health and Population of Nepal, with support from the United States Agency for International Development, PATH, Save the Children's Saving Newborn Lives program, the Maternal and Child Health Integrated Program (MCHIP), and Johns Hopkins Bloomberg School of Public Health.

Primary meeting objectives:

•   Present evidence from recent research relating to the efficacy and programmatic outcomes of using a 4% chlorhexidine product for umbilical cord care from Bangladesh, Nepal, and Pakistan.

•   Assist country policymakers to identify next steps for introduction of chlorhexidine for umbilical cord care, as warranted.

Prior to the meeting, participants also had the opportunity to visit the pilot study sites in the district of Banke, Nepal, to observe how female community health volunteers are mobilized to use chlorhexidine in the context of a maternal and newborn program. Following the presentations, country delegations met and outlined the next steps for moving ahead with chlorhexidine work in their countries.

Main Conclusions:

Introduction of 4% chlorhexidine for cord care is compatible with the World Health Organization’s 1998 recommendations. According to these recommendations clean and dry cord care practices are preferred; however, in settings where the risk of bacterial infection is high, it may be prudent to use an antiseptic (such as chlorhexidine) per local preference. This report notes that more research is needed for optimal guidelines for high-risk settings.

•  Chlorhexidine is a well-known antiseptic. It is commonly found in products for oral rinse and presurgical hand washing and has an excellent safety record. The WHO Model List of Essential Medicine for Children includes chlorhexidine bulk (20% chlorhexidine gluconate) with the instruction to dilute for umbilical cord care.

•  There is sufficient evidence to recommend inclusion of 4% chlorhexidine cord cleansing as a strategy to reduce neonatal mortality in settings where poor hygiene and high neonatal mortality are issues. The results from the clinical trials in the three countries showed a reduction of neonatal mortality from 20% to 38%, with reduction in omphalitis from 24% to 75%.

•  These trials also indicated that applying 4% chlorhexidine immediately after cord cutting was critical to reduce omphalitis and neonatal mortality. If feasible, 4% chlorhexidine can be applied once daily through the first week of life or until the cord separates, whichever occurs earlier, for additional benefits including reduced local infection or improved hygiene practices. 

•  Operational studies in Bangladesh and Nepal demonstrated that both liquid and gel forms of 4% chlorhexidine were acceptable by users.

•  The pilot project in the district of Banke, Nepal, demonstrated that cord cleansing with 4% chlorhexidine can be successfully incorporated in maternal and newborn care programs using existing cadre of female community health volunteers.

A full report from this meeting is available on this website. The results of the Nepal study have been published in the Lancet, and results of the recent trials from Bangladesh and Pakistan are expected to be published in the next several months.

Acknowledgement: This collaborative effort was made possible by the generous support of the American people through the United States Agency for International Development, the Bill & Melinda Gates Foundation, and the Government of Nepal.