(Page last updated February 26, 2014)
Welcome to the Chlorhexidine for Umbilical Cord Care Technical Resource Page. This page provides the latest information on the use of chlorhexidine for umbilical cord care—a safe and effective intervention to prevent neonatal infection. This intervention is low cost and can be integrated into existing newborn care programs or platforms.
Severe infection is one of the top three causes of newborn deaths worldwide, claiming approximately 13% of all neonatal deaths each year (Liu et al. 2012). In resource-poor, high-mortality settings, infections can account for over half of the neonatal deaths. A baby's newly cut umbilical cord can be an entry point for bacteria, which can lead to cord infection and potentially life-threatening sepsis. Poor hygiene and lack of antisepsis at birth and in the first week of life increases the risk of deadly but preventable infections.
Evidence supports 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) for cord cleansing as an efficacious, acceptable, feasible and cost-effective strategy to reduce neonatal mortality in settings where poor hygiene and high neonatal mortality are issues.
The following information is aimed to support program managers, policymakers and stakeholders in countries where early implementation is possible. For questions or information not found on this resource page, please email the Chlorhexidine Working Group at firstname.lastname@example.org.
- Overview & Advocacy Documents
- Policy & Guidelines
- Research & Evidence
- Product Supply
- Programmatic Experience
- Chlorhexidine Working Group Terms of Reference (June 2013)
- Chlorhexidine Technical Brief
- English: Umbilical Cord Cleansing Saves Newborn Lives (Updated February 2014)
- Français: La chlorhexidine pour les soins du cordon ombilical: Une nouvelle intervention à faible coût pour réduire la mortalité néonatale (Updated February 2014)
- Frequently Asked Questions About Chlorhexidine (Updated June 2013)
- Summary of the Evidence, Policy, Product Availability, and Global Introduction Efforts (Updated November 2013).
- Chlorhexidine for umbilical cord care: a game-changer for newborn survival? Global Health: Science and Practice (March 2013).
- Chlorhexidine for umbilical cord care - report prepared for the UN Commission on Life-Saving Commodities for Women and Children (July 2012).
- Evidence Base and the Way Forward: Regional dissemination meeting in Nepalgunj, Nepal, 2011. Read the meeting report (PDF).
- Scaling Up Lifesaving Commodities for Women, Children and Newborns: An Advocacy Toolkit (December 2013).
Use of 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) for cord care is compatible with World Health Organization (WHO) guidelines. Since 1998, the WHO has recommended the use of an antiseptic such as chlorhexidine for umbilical cord care in settings where the risk of bacterial infection is high.
Since 2007, members of the Chlorhexidine Working Group (CWG) have advocated for revision of the cord care guidelines to be more inclusive of effective topical antiseptics such as chlorhexidine. In September 2012, WHO convened an expert consultation to review evidence for postnatal care. The consultative meeting participants reviewed the evidence for chlorhexidine cord care and made a recommendation which was recently adopted by the WHO. In January 2014, the WHO published the Recommendations on Postnatal Care of the Mother and Newborn, which contains formal guidance on the use of 7.1% chlorhexidine digluconate for cord care.
Since 2007, members of the CWG have also advocated for inclusion of 7.1% chlorhexidine digluconate in the WHO Model List of Essential Medicines for Children (EMLc), and to this end submitted a formal application in 2008. While the review committee agreed that there was sufficient evidence on the effectiveness of 7.1% chlorhexidine digluconate, they declined to replace bulk 20% chlorhexidine digluconate with 7.1% chlorhexidine digluconate due to perceived lack of commercially available 7.1% chlorhexidine digluconate product. In 2009 and 2010, members of the CWG responded to the WHO EMLc review with supporting letters and request letters updating WHO on research and manufacturing developments. In November 2012, members of the CWG submitted a revised application with updated information on programmatic research and commercial availability of 7.1% chlorhexidine digluconate products. The WHO’s 19th Expert Committee on the Selection and Use of Medicines reviewed and approved the revised application and subsequently, 7.1% chlorhexidine digluconate for umbilical cord care was included in the July 2013 publication of the EMLc.
- WHO Recommendations on Postnatal Care of the Mother and Newborn (January 2014).
- WHO Model List of Essential Medicines for Children (July 2013).
- Topical umbilical cord care at birth: RHL Commentary - Capurro. H. Topical umbilical cord care at birth: RHL commentary. The WHO Reproductive Health Library; Geneva: World Health Organization. (last revised 30 September, 2004)
Chlorhexidine is a well-known antiseptic with an excellent safety record. Since its introduction in the 1950s, chlorhexidine has been used regularly as a pre-surgical scrub and skin antiseptic and carefully studied for safety and efficacy. The Chlorhexidine Working Group has compiled a Chlorhexidine Bibliography that lists the evidence supporting chlorhexidine digluconate for cord care.
Chlorhexidine for Umbilical Cord Care: Selected Bibliography (Updated February 2014)
CHLORHEXIDINE PRODUCTS AND USES IN HEALTH CARE
- Chlorhexidine Products and Uses in Health Care (February 2014)
COMMUNITY-BASED RANDOMIZED TRIALS
Recent community‐based randomized trials in rural areas in Bangladesh, Nepal, and Pakistan confirm that applying 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) to the umbilical cord prevents infection and saves newborn lives. The results of these trials showed a reduction of neonatal mortality from 20% to 38%, and eliminates up to three-quarters of serious umbilical infections (omphalitis). Additionally, operational studies in Bangladesh and Nepal demonstrated that both liquid and gel forms of 7.1% chlorhexidine digluconate were acceptable to families, and that families were typically able to use the product as recommended. (Lancet registration required for full access)
- Nepal: 24% reduction in newborn mortality when community health workers applied 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) to the cord during home visits. Cord cleansing with 7.1% chlorhexidine digluconate can be successfully incorporated into maternal and newborn care programs using existing cadre of female community health volunteers.
- Pakistan: When 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) was recommended and provided by traditional birth attendants to families, risk of newborn infection dropped 42%, and neonatal mortality reduced by nearly 40%.
- Bangladesh: 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) cord cleansing on the first day of birth reduced newborn death by as much as 20%, but continuing the treatment for 7 days, although showing fewer signs of infection when compared to dry cord care, did not see a significant reduction in newborn mortality.
- Safety and Impact of Chlorhexidine Antisepsis Interventions for Improving Neonatal Health in Developing Countries. LC Mullany, GL Darmstadt, JM Tielsch. The Pediatric Infectious Disease Journal, August 2006.
- Chlorhexidine Gel Versus Aqueous for Preventive Use on Umbilical Stump: A Randomized Noninferiority Trial. S Hodgins, K Thapa, L Khanal, et al. The Pediatric Infectious Disease Journal, November 2010.
At this time, there are two sources for purchase of 7.1% chlorhexidine digluconate for umbilical cord care:
- Gel: Lomus Pharmaceuticals in Nepal. Lomus requires a minimum lead time of 25 days.
- Liquid: UNICEF Supply Division catalogue, product number S1531515.
EXPLORING LOCAL PRODUCTION
The CWG believes that local production is one of the production strategies for producing chlorhexidine for cord care - locally owned manufacturers, multi-national companies based in low-resource countries, or regional manufacturers, as appropriate. 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) is relatively easy to manufacture and local production allows low-resource countries to build local drug production capacity.
- Production Strategy (2013):
- Market Sizing Tool (2012): This tool is available in two versions. Version 1 utilizes available market data for selected countries based primarily on Demographic and Health Survey (DHS) data. Version 2 utilizes defined user inputs which allows users to adjust variable values to estimate market size.
Step-by-step guidance for health professionals to make 7.1% chlorhexidine digluconate liquid from 20% chlorhexidine digluconate.
- Dilution Instructions (January 2014)
EXAMPLES OF PRODUCT PACKAGING
In addition to large-scale clinical effectiveness trials, extensive formative research and programmatic piloting has been conducted to establish and confirm the acceptability, feasibility, impact, and cost‐effectiveness of introducing a 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) product for umbilical cord care. In order to provide an overview of programmatic experiences to date, we have created a summary of chlorhexidine for umbilical cord care implementation in five countries.
- Summary of Chlorhexidine for Umbilical Cord Care:
- English: Summary of Chlorhexidine for Umbilical Cord Care in Selected Countries (Updated May 2013)
- Français: Résumé concernant la chlorhexidine destinée aux soins du cordon ombilical dans les pays sélectionnés (June 2013)
- Formative Research: Operations Research Draft Report and Presentation (2010)
- Chlorhexidine Product Attribute Study (2008)
- Operations Research Phase II Instructions for Use (2009)
Democratic Republic of the Congo:
- Infection Ombilicale
- Résumé sur les évidences scientifiques de l’utilisation de la Chlorhexidine digluconate 7,1%
- Présentation du produit: Chlorhexidine Digluconate à 7,1 %
- Élaboration d’une politique nationale concernant l’introduction de la chlorhexidine à 7,1 % pour les soins du cordon ombilical
- Outline of group structure and work to introduce chlorhexidine for umbilical cord care in the Democratic Republic of the Congo
- Investiguer les pratiques courantes et les perceptions autor du soin du cordon obilical et l'acceptabilite de AroFoitra par les cibles
- Strategie de Communication 2013
Programme introductive de prevention de l’infection du nouveau–ne par la chlorhexidine 7,1% pommade – Formation des agents de sante
AroFoitra poster (Malagasy)
AroFoitra flyer (Malagasy)
- Chlorhexidine in Nepal: A Public-Private Partnership Case Study (July 2013)
- Video! Nepal: Reducing Newborn Death Through Better Cord Care (November 2012)
- Better Cord Care Saves Babies' Lives in Nepal: Presentation to UNCoLSC in Abuja, Nigeria (October 2012)
- Video! Better Cord Care Saves Babies' Lives (August 2012)
- A Study on Cord Care Practices in Bardiya District (April 2007)
- Survey tools
- Semi Structured Interview with Recently Delivered Women
- Semi Structured Interview with Mothers in Law
- Semi Structured Interview with TBAs/FCHVs
- Semi Structured Interview with Cord Cutting Occupational Groups
- Focus Group Discussion with Recently Delivered Women
- Focus Group Discussion with Mothers in Law
- Focus Group Discussion with Ocuupational Castes
Access additional resources and coverage on chlorhexidine for umbilical cord care:
We can save thousands
For less than US$0.50 a dose, chlorhexidine could save an estimated 422,000 babies over the next five years.
Chlorhexidine Working Group (CWG)
The Chlorhexidine Working Group (CWG) is an international collaboration of organizations committed to advancing the use of 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) for umbilical cord care through advocacy and technical assistance.
PATH is the Secretariat for the CWG. Participants include individuals representing:
- Bill & Melinda Gates Foundation
- Boston University
- Clinton Health Access Initiative
- John Snow, Inc. (JSI)
- Johns Hopkins Bloomberg School of Public Health
- Lomus Pharmaceuticals Pvt. Ltd.
- Maternal and Child Health Integrated Program (MCHIP)
- Promoting the Quality of Medicines Program/United States Pharmacopeial Convention (PQM/USP)
- Population Services International (PSI)
- Save the Children/Saving Newborn Lives program
- Systems for Improved Access to Pharmaceuticals and Services Program/Management Sciences for Health (SIAPS/MSH)
- United Nations Children’s Fund Programme Division
- United Nations Children’s Fund Supply Division
- United States Agency for International Development (USAID)
- Venture Strategies Innovations
- World Health Organization (WHO)
For more information, please contact email@example.com.
Leading experts from the Chlorhexidine Working Group representing JSI, PATH and Save the Children held a discussion on chlorhexidine programming in Madagascar, Nepal and Nigeria. Watch the video to get an overview of the event, held in Washington, DC in January. >> Watch the Video
Chlorhexidine Use in Nepal
As part of a research trial in Nepal’s Banke district, Female Community Health Volunteers (FCHVs) are trained to educate mothers and caregivers about the dangers of cord infection and to apply chlorhexidine to the cord immediately after cutting. Follow two dedicated FCHVs as they counsel women and teach them to use chlorhexidine on their newborn's umbilical cords.
>> Launch photo gallery