O c u la r flo r a in n e w b o r n s o f m o t h e r s w ith P r o lo n g e d L a b o u r a t th e U n iv e r s it y T e a c h in g H o s p ita l in L u s a k a Z a m b ia . A s tu d y c a r r i e d o u t in p a r t f u l f i l m e n t f o r t h e d e g r e e o f M a s t e r o f M e d i c i n e in O p h t h a l m o l o g y in t h e U n i v e r s i t y o f N a i r o b i , K e n y a . D r. K a s o n g o le D a v id M ay, 2010. Universit y of NAIROBI Library 0407227 8 UNIVERSITY OF NAIROBI MEDICAL LIBRARY D E C L A R A T IO N T h is d is s e r ta tio n is m y o r ig i n a l w o r k , a n d h a s n o t b e e n s u b m itte d f o r a d e g r e e in a n y o th e r u n iv e rs ity . S ig n ed : Dr. K a s o n g o le D a v id . M B .C h B ( N .N o v g o r o d ) - 2 - APPROVAL T h is d is s e r ta tio n h a s b e e n s u b m i t t e d in p a rt f u lf ilm e n t f o r th e d e g re e o f m a s t e r o f m e d ic in e in O p h th a lm o lo g y w ith o u r a p p r o v a l a s u n iv e r s ity s u p e r v is o r s . sd: [ u) f. \ ................ D ale: It) 1 D r K a riu k i M illic e n t . M B .C h B . M .M e d .O p h th ( U .o .N ) , F E A C O L e c tu re r. D e p a r tm e n t o f O p h th a lm o lo g y . U n iv e r s ity o f N a ir o b i. K e n y a . S i g n e d : ........ C \0 ..................... D a te: .. . 1 . 0 ^ I 0 D r M a rc o S h e ila , M B .C h B . M .M e d .O p h th ( U .o .N ) . F E A C O L e c tu r e r . D e p a r tm e n t o f O p h th a lm o lo g y . U n iv e rs ity o f N a ir o b i. S i g n e d : ........... " .................................................... D a te : A ^ ‘ D r K a s o n k a L a c k s o n . M B .C h B . M .M e d .O b s /G y n ( U N Z A ) H o n o ra ry L e c tu r e r . D e p a r tm e n t o f O b s te tr ic s a n d G y n a e c o lo g y . U n iv e rs ity o f Z a m b ia . - 3 - ^ D E D IC A T IO N T o m y w if e Ile ty a n d o u r li ttle b r il lia n t s ta r D a v id j u n i o r IV f o r b e a r in g w ith m e d u r in g th is Ion a b s e n c e fro m h o m e . In s o u l, to m y la te p a r e n ts D a v id s e n i o r II a n d W in n ie - F r i d a h fo r m a k in g m e w h o 1 a m to d a y . - 4 - ACKNOW LEDGEM ENT 1. D r K a riu k i. D r M a r c o a n d D r K a s o n k a . fo r th e ir a d v ic e a n d c o n s t r u c t i v e c r itic is m a s s u p e r v is o r s . 2. D r G ic h u h i S .. f o r th e v a l u a b l e c r itiq u e a n d r e v is io n o f th e d a ta . 3. M y f e l l o w c la s s m a t e s a n d f r ie n d s fo r t h e ir e s te e m e d s u p p o rt a n d e n c o u r a g e m e n t. 4. L ig h t f o r th e W o r ld ( L F T W ) . fo r o f f e r in g m e a fu ll s c h o la r s h ip s o w e ll a s f u n d in g th is s tu d y . 5. M s. M w a n a m o o n g a L . a n d M r. N g u lu b e F .. f o r t h e tir e le s s w o rk o n t h e s tu d y s p e c im e n s in th e d e p a r tm e n t o f m ic r o b io lo g y a t U T H . 6. M r. W a m b u a A .. B io s t a tis tic ia n , fo r h is a s s is ta n c e in a n a ly z in g m y d a ta . 7. D r V w a l ik a . I le a d o f D e p a r tm e n t O B S /G Y N . f o r g r a n tin g m e p e r m is s i o n to c o lle c t d a ta in th e L a b o u r w a rd . 8. C h a ir p e r s o n . U n iv e r s ity o f Z a m b ia B io m e d ic a l R e s e a r c h E t h ic s c o m m i t t e e fo r a p p r o v in g th is s tu d y . 9. D r M u m a M .. in t h e e y e c l i n i c a n d all o th e r h e a lt h p e r s o n n e l in l a b o u r w a r d f o r th e ir s u p p o rt. 10. L a s t b u t n o t le a s t, th e c a r in g m o th e rs th a t a llo w e d m e to e x a m in e t h e i r n e o n a te s . - 5 - CONTENTS PAGES D E C L A R A T I O N ............................................................................................................... 02 A P P R O V A L ....................................................................................................................... 03 D E D I C A T I O N ................................................................................................................... 0 4 A C K N O W L E D G E M E N T ............................................................................................... 05 T A B L E O F C O N T E N T S ..................................................................................................0 6 L I S T O F F I G U R E S / T A B L E S ........................................................................................ 07 L I S T O F A B B R E V I A T I O N S .......................................................................................... 08 A B S T R A C T ....................................................................................................................... 0 9 2 .0 IN T R O D U C T IO N A N D L I T E R A T U R E R E V I E W ........................................... 10 3 .0 R A T I O N A L E .......................................................................................................... 19 4 .0 O B J E C T I V E S ......................................................................................................... 2 0 5 .0 M E T H O D O L O G Y .................................................................................................21 6 .0 D A T A M A N A G E M E N T A N D A N A L Y S I S ...................................................... 2 7 7 .0 E T H IC A L C O N S I D E R A T I O N S ......................................................................... 28 8 .0 R E S U L T S ............................................................................................................... 2 9 9 .0 D I S C U S S I O N ........................................................................................................ 41 10 .0 C O N C L U S I O N .................................................................................................... 45 11.0 R E C O M M E N D A T I O N S .................................................................................... 4 6 1 2 .0 A P P E N D I C E S ........................................................................................................ 4 7 13.0 A P P E N D I X I : M A P O F Z A M B I A : L O C A T I O N O F L U S A K A ................... 4 7 14.0 A P P E N D IX I I : I N F O R M A T I O N S H E E T ......................................................... 4 8 1 5 .0 A P P E N D IX III: C O N S E N T / A G R E E M E N T F O R M ....................................... 52 1 6 .0 A P P E N D IX 111: Q U E S T I O N N A I R E ................................................................ 54 17 .0 R E F E R E N C E S ...................................................................................................... 57 - 6 - L IS T O F F I G U R E S F ig u re 1: F lo w o f p a t i e n t s ................................................................................................... 2 9 F ig u r e 2: M a te rn a l a g e d i s t r i b u t i o n ..................................................................................... 3 0 F ig u r e 3: M a te rn a l p a r i t y ...................................................................................................... 31 F ig u re 4: N e w b o r n g e s ta tio n a l a g e .................................................................................... 3 4 F ig u re 5: N e w b o r n s e x d i s t r i b u t i o n .................................................................................. 3 5 F ig u re 6: C u l t u r e re s u lts d i s t r i b u t i o n b y m a te rn a l H IV s t a t u s ....................................... 3 6 F ig u r e 7: C u ltu r e re s u lts d i s t r i b u t i o n .................................................................................3 7 F ig u r e 8: A s s o c ia tio n b e tw e e n c o l o n y c o u n t s .................................................................. 3 8 F ig u r e 9: S p e c tr u m o f m i c r o o r g a n i s m .............................................................................. 3 9 L IST O F T A B L E S T a b le 1: A n te n a ta l c lin ic p r o f i l e .......................................................................................... 3 2 T a b le 2: N e w b o r n p r o f i l e .....................................................................................................33 T a b le 3: S e n s itiv ity p a tte rn o f a n t i b i o t i c s ........................................................................ 4 0 - 7 - 1.0 L I S T O F A B B R E V I A T I O N S BA B lo o d a g a r B H 1B B ra in h e a r t i n f u s io n b ro th CA C h o c o la te a g a r CNS C oagula se n eg a tive sta phylococcus cs C a e s a r ia n s e c tio n C. tra ch o m a tis C hlam ydia tra ch o m a tis H IV H u m a n im m u n o d e f ic ie n c y v ir u s MA M ackonkey agar ON O p h th a lm ia n e o n a to r u m .X. gonococcus N eisseria g o n o co ccu s NL N o rm a l la b o u r O B S /G Y N O b s te tr ic s a n d G y n a e c o lo g y PCR P o ly m e r a s e c h a in r e a c tio n PL P r o lo n g e d la b o u r SPSS S ta tis tic a l p a c k a g e f o r s o c ia l s c ie n tis t T R IC T r a c h o m a in c lu s io n c o n ju n c tiv itis UNZA U n iv e rs ity o f Z a m b ia U .o .N U n iv e rs ity o f N a ir o b i U SA U n ite d S ta te s o f A m e r ic a U TH U n iv e rs ity T e a c h in g H o s p ita l VE V a g in a l e x a m i n a tio n - 8 - ABSTRACT T it le : O c u l a r flo r a in n e w h o r n s o f m o t h e r s w ith P r o lo n g e d L a b o u r a t t h e U n iv e r s it y T e a c h in g H o s p ita l in L u s a k a , Z a m b ia . A i m : T o c o m p a r e th e s p e c tr u m a n d q u a n tity o f o c u la r f lo r a e in n e o n a te s o f m o th e r s w ith p ro lo n g e d l a b o u r (P L ) a n d th o s e o f m o th e r s w ith n o rm a l la b o u r ( N L ) d e liv e r e d a t th e U n iv e r s ity le a c h in g H o s p ita l ( U T H ) in L u s a k a . M e t h o d s : T h i s w a s a p r o s p e c tiv e c o h o r t s tu d y w ith a s a m p l e s iz e o f 124 s u b je c ts . N e w b o r n s d e liv e r e d a n d b e fo re d is c h a r g e f r o m U T H w e re e n r o lle d in th e s tu d y . W e in c lu d e d n e o n a te s b o r n to m o th e r s w h o h a d P L . d e f in e d a s a c ti v e la b o u r o f g r e a t e r th a n 12 h o u r s a n d th o s e o f m o th e r s w h o h a d a n u n e v e n tf u l l a b o u r l a s t in g le s s th a n 12 h o u rs . C o n s e n t w a s o b ta in e d fro m th e m o th e r o r g u a rd ia n . T h e e y e s o f th e n e w b o r n s w e re e x a m in e d . A c o n ju n c t iv a s m e a r w a s ta k e n f o r m ic ro s c o p y , c u ltu r e a n d s e n s itiv ity w ith in 24 h o u r s a f t e r b ir th . R e s u l t s : W e e n ro lle d a n d a n a ly s e d 1 3 2 s u b je c ts in e q u a l a r m s o f 6 6 fo r P L a n d N L . P o s itiv e c o n ju n c tiv a c u ltu r e re s u lts w e re 2 8 .8 % in n e o n a te s o f m o th e r s w ith P L a n d 2 1 .2 % in th o s e o f m o th e r s w ith N L (p - v a lu e 0 .3 1 5 ) . N e o n a te s o f m o th e r s w ith P L w e re m o re lik e ly to p r o d u c e a p o s itiv e c u ltu r e re su lt w ith a r e l a t i v e ris k o f 1 .5 0 ( 0 .6 8 - 3 .3 3 ) . A h ig h e r c o lo n y c o u n t w a s d e m o n s tr a te d in n e o n a te s o f m o t h e r s w ith PL th o u g h n o t s ta tis tic a lly s ig n if ic a n t (p - v a lu e 0 .4 1 5 ) . T h e m o s t f r e q u e n tly i s o l a t e d o r g a n i s m s in N L w e r e C o a g u la se negative sta p h ylo co ccu s (CN S) a n d Staph a u reu s w h e re a s in P L it w a s E.coli a n d S trep virid a n s ( c o - e x is tin g ) th e n C N S. A ll th e o rg a n is m s w e r e s e n s itiv e t o C e f o t a x i m e a n d C ip r o f l o x a c in w ith a h ig h r e s is ta n c e s h o w n to C h lo ra m p h e n ic o l a n d C o - t r i m o x a z o l e . M o th e r s in P L w e r e a ls o m o re lik e ly to b e o n s y s te m ic a n tib io tic s w ith a re la tiv e ris k o f 2 .2 (0 .6 - 7 .9 ). ( o n c lu s io n : M o th e rs w ith P L i n c r e a s e d th e o c c u r r e n c e o f o c u la r o r g a n is m s in th e ir n e w b o rn s c o m p a r e d to th o s e w ith N L . H o w e v e r , th is w a s n o t s ta t is tic a lly s ig n if ic a n t. M o th e r s w ith P L w e r e o n s y s te m ic a n ti b io tic s w h ic h m a y h a v e in f lu e n c e d th e c o n ju n c tiv a l c u l t u r e re s u lt a n d o v e ra ll c o lo n y c o u n ts . T h e m o s t e f f e c t iv e a n ti b io tic s w e r e C e f o ta x i m e a n d C ip r o f l o x a c in w ith e v id e n t r e s is ta n c e to C h lo r a m p h e n ic o l a n d C o - tr i m o x a z o le . - 9 - 2 .0 I N T R O D U C T I O N A N D L I T E R A T U R E R E V I E W A s in o th e r o r g a n s a n d s y s t e m s e x p o s e d to th e e n v ir o n m e n t, th e o c u l a r s u r f a c e is c o lo n iz e d b y m ic r o b e s w h ic h a r e m a in ly c o m m e n s a l s . B a c te ria c o lo n iz in g th e c o n ju n c t iv a s a c p r o d u c e b a c te rio c in s a n d in h ib ito r y p r o d u c ts s u c h a s la c tic a n d a c e t i c a c id w h ic h o f f e r th e n e c e s s a r y c o m p e titiv e ad v a n ta g e f o r s u r v iv a l a n d p re v e n t th e e s ta b lis h m e n t o f p a th o g e n i c m ic r o ­ o rg a n is m s . T h e s e r e s id e n ts in d u c e m in im a l a c tiv a tio n o f in f la m m a tio n a n d i m m u n e r e s p o n s e s o f th e h o s t. T h e e x a c t m ic r o b ia l p o p u la tio n o f th e o c u la r s u r f a c e d e p e n d s o n th e a g e o f th e h o s t, th e g e o g ra p h ic a l lo c a tio n a n d th e c l i m a t e . 1 T h e c o n ju n c tiv a s a c is c o l o n i z e d b y b a c te ria a t b ir th a n d r e m a in s s o t h r o u g h o u t lif e w ith c h a n g e s in th e f lo r a d u e to v a r io u s f a c to r s . A v e ry s m a ll p e r c e n ta g e o f th e p o p u la tio n h a s a s te r ile c o n ju n c t iv a s ac . S ta p h s p e c i e s a n d d ip h th e r o id s a r e th e p r e d o m in a n t o r g a n is m s w ith a n a e ro b ic b a c te r ia o fte n p r e s e n t in 0 .3 3 % . a n d 3 - 1 5 % o f th e p o p u la tio n h a v e a fu n g a l flo ra . T h e m ic r o b ia l flo ra o f th e n e w b o r n c o m m o n ly c o n s is ts o f E scherichia coli. S ta p h ylo co ccu s ep id erm id is a n d S ta p h ylo co ccu s a u reu s. O th e rs in c lu d e . P ro p io n ib a cteriu m a c n e s a n d C orynehactrium s p p . It h a s b e e n n o t e d th a t w ith a d v a n c i n g a g e . g ra m n e g a ti v e b a c te ria a ls o b e c o m e p a rt o f th e flo ra . A s th e p a tte r n o f th e s e o r g a n i s m s c h a n g e s o v e r th e y e a r s , m ic r o b e s k n o w n to b e r e s id e n ts m a y b e c o m e v iru le n t. T h e risk o f c r o s s in fe c tio n to o t h e r b a b ie s e x is ts a n d s y m p to m s m a y v a n fro m m ild to s e v e r e d e b ilita tin g d i s e a s e w ith s e q u e la e o f b lin d n e s s .2 3 -1 0 - 2.1 N e o n a ta l C o n j u n c t iv it is ( O p h t h a lm ia N e o n a t o r u m ) O p h th a lm ia n e o n a to r u m ( O N ) is a n y c o n ju n c t iv itis o c c u r r i n g w ith in th e f ir s t f o u r w e e k s o f life. It h a s a n o ta b le h is to ry a n d w a s o n c e a m a jo r c a u s e o f b lin d n e s s . T h e d is e a s e h a s b e e n a ss o c ia te d w ith a n u m b e r o f o r g a n i s m s w h ic h h a v e v a r ie d in th e ir r e la tiv e im p o r ta n c e o v e r ti m e .4 f h e ey e o f a n in f a n t is m o r e s u s c e p tib le to c o n ju n c t iv itis , a n d th e d is e a s e m o r e s e r io u s , f o r a num ber o f re a s o n s :' • T h e in f a n t c o r n e a is c o m p a r a t i v e l y s o ft th u s a n a t t a c k o f c o n ju n c t iv itis is lik e ly to in fe c t a n d d a m a g e th e c o r n e a . • A n e w b o r n c h ild p r o d u c e s le s s te a r s a n d th e im m u n e r e s p o n s e s a re n o t d e v e lo p e d to a m ic a b ly f ig h t in f e c tio n . • M a n y o r g a n is m s th a t a re p a th o g e n i c to th e m o th e r s g e n ita l tr a c t a re a l s o p a th o g e n ic to th e c o n ju n c t iv a a n d t h e r e f o r e p o s e s a g r e a t ris k o f c o n ju n c t iv itis in t h e n e w b o rn . P rio r to th e 19 0 0 s . th e in c id e n c e o f b lin d n e s s a s a s e q u e la e o f o p h th a lm ia n e o n a to r u m w a s as h ig h a s 5 0 % . A s o f to d a y , w ith th e in tr o d u c tio n o f a n t i b i o t i c p r o p h y la x is , th e s itu a tio n is fa irly d iffe re n t. T h e r a te s h a v e d r o p p e d to a s lo w a s 0 .0 4 /1 0 0 0 liv e b ir th s f o r g o n o c co c a l, 4 /1 0 0 0 liv e b irth s fo r c h la m y d ia l o p h t h a l m i a n e o n a to r u m , in A s ia a n d th e W e s t fro m a s h ig h a s 1 0 % p re v io u s ly w ith A f r ic a b e i n g at 2 4 % / T h is h ig h lig h ts a n o b v io u s p ro b le m o n th e A fr ic a n c o n tin e n t. A study in K e n y a d o n e in 1 9 8 6 s h o w e d th a t N eisseria g o n o co ccu s w a s is o la te d in 4 0 % o f th e m o th e rs w h o s e n e o n a te s h a d O N . It a ls o in d ic a te d th a t N e isseria g o n o co ccu s w a s fo u n d p re s e n t at 9 .5 % a n d ( hla m yd ia tra ch o m a !is a t 2 8 % in th e b irth c a n a l o f e x p e c ta n t m o th e r s . A n o th e r s tu d y in K e n y a c o n d u c te d a t K e n y a tta N a tio n a l H o s p ita l in 1 9 8 4 s h o w e d f ig u r e s o f N eisseria gonococcus to b e 5 % a n d th a t o f C h la m yd ia tra ch o m a tis b e in g 7 .5 % o f th e s a m p l e d p re g n a n t p o p u la tio n / -1 1 - In s e v e r a l r e g io n s , o p h t h a l m i a n e o n a to r u m r e m a in s to b e o n e o f th e m o s t c o m m o n in f e c tio n s in th e firs t m o n th o f lif e a n d c a n h a v e s e r io u s s y s te m ic a s w e ll a s o c u la r m o r b i d i t y .1* T h e p r e v a le n c e o f t h i s d is e a s e a n d its s ig n i f i c a n c e a s a p u b lic h e a lt h p r o b le m in Z a m b ia is y e t to b e k n o w n . 2 .2 E tio lo g y A ll in fa n ts a r e e x p o s e d to in f e c tio u s a g e n ts in th e b irth c a n a l w h o s e d u r a tio n o f e x p o s u r e is a n im p o r ta n t f a c to r in th e d e v e l o p m e n t o f n e o n a ta l c o n j u n c t i v i t i s . 1 C a u s e s o f O p h th a lm ia n e o n a to ru m T im e o f o n s e t p o s tp a r tu m C h e m ic a l ( s i l v e r n i t r a t e ) 1-3 6 h o u r s C h la m y d ia 5 -1 4 d a y s N e is s e r ia g o n o c o c c u s 2 4 -4 8 h o u r s B a c t e r ia ( S t a p h y l o c o c c u s , s t r e p t o c o c c u s , 2 -5 d a y s H a e m o p h i l u s , E s c h e r ic h ia c o li) V i r u s (h e r p e s s im p le x t y p e 1 a n d 2 3 -1 5 d a y s T h e c a u s e o f th e c o n ju n c t iv itis is e s ta b lis h e d b y th e c lin ic a l p ic tu re , tim e c o u r s e a n d la b o ra to ry c o n f ir m a tio n . O p h th a lm ia n e o n a to r u m c a n a ls o b e c la s s i f i e d a s e ith e r c h e m i c a l o r in f e c tiv e w ith r e f e r e n c e to th e o r i g i n ." ' T h e m ic ro -o r g a n is m s o f m a jo r c o n c e r n a n d th e r e f o r e o f p u b lic h e a lt h im p o r ta n c e in c lu d e N eisseria gonococcus a n d C h la m yd ia trachom atis. T h is is d u e to th e k n o w n a s s o c ia tio n o f th e s e p a r t i c u l a r m ic ro b ia l a g e n ts w ith th e h ig h risk o f n o t o n ly p r e d is p o s in g to b l in d n e s s b u t a ls o s y s t e m i c in v o lv e m e n t th a t m a y p r o g r e s s to rh in itis , o titis m e d ia , p n e u m o n itis a n d lif e th r e a te n i n g n e o n a ta l s e p s i s . 11 G e n e r a lly th e r i s k s a re re la te d to th e l e v e l s o f m e d ic a l c a r e a t th e p r im a r y le v e l w h ic h re m a in s a r e c o g n iz a b le p r o b le m in th e d e v e lo p i n g w o r ld . - 12 - A s tu d y c o n d u c t e d in N a ir o b i b e tw e e n 2 0 0 1 - 2 0 0 2 a t th e K e n y a tta N a tio n a l h o s p ita l a n d P u m w a n i m a t e r n i t y h o s p i t a l s b y T r iv e d y et al. f o u n d C .tra ch o m a tis to b e a c o m m o n p ro b le m w ith is o la tio n o f th e a g e n t in 2 0 % o f th e c a s e s w h e r e a s N .g o n o co c c u s w a s i s o la te d in 3 .3 % .12 T h e s e fin d in g s o f C .tra c h o m a tis w e r e in k e e p in g w ith r e s u l t s o f a 1 9 8 6 s tu d y b y K la u s et al (2 4 % ) and a s t u d y b y I s e n b e r g et a l in 1 9 9 1 -1 9 9 3 ( 2 5 % ) . T h is is u n lik e in o t h e r s tu d ie s w e re Seisseria g o n o c o c c u s w a s s till a h i g h e r c h a ll e n g e th a n C .tra c h o m a tis.13 14 The m an y o t h e r d if f e r e n t i n f e c tiv e m ic r o - o r g a n is m s f o r o p h th a lm ia n e o n a to r u m n o t lis te d in th e p re v io u s ta b le i n c lu d e th e f o ll o w i n g :- Proteus species. K le b sie lla p n eu m o n ia . E nterobacter s p e c ie s a n d S e r.m a rscen s. A ra re c a u s e . Pseudom onas sp e c ie s, d e s e r v e s p a r t i c u l a r m e n tio n in t h a t in f e c tio n w ith th is o r g a n is m c a n resu lt in c o r n e a l u l c e r a t i o n a n d p e r f o r a t i o n ." - 13 - 2 .3 M o d e O f T r a n s m is s io n M o st o p h th a lm ic i n f e c t i o n s in th e n e o n a ta l p e rio d a re a c q u i r e d d u r in g v a g in a l d e liv e r ) a n d re fle c t th e s e x u a l l y t r a n s m itte d d i s e a s e s p re v a le n t in th e c o m m u n i t y .15 T h e t r a n s m i s s i o n ra te o f g o n o rrh o e a e f r o m a n in f e c te d m o t h e r to h e r n e w b o rn is 3 0 - 5 0 % .16 17 V e rtic a l tr a n s m is s io n m a y play an im p o r t a n t r o le in n e o n a ta l c o n ju n c tiv itis a s 6 7 % o f b a c te r ia fro m th e in fe c te d n e o n a te s w ere s im ila r t o th o s e d e t e c t e d in th e lo w e r g e n ita l tr a c t a n d p la c e n ta o f m o th e r s , a s s h o w n in th e S tu d y c o n d u c te d in B e i jin g b y G a o . 18 In th e s tu d y c a r r i e d o u t in K e n y a b y Is e n b e rg e l a l, f o u r p e r in a ta l f a c to rs w e r e in d e n tif ie d . n a m e ly :-7 1. M a te r n a l v a g in itis 2. P r e s e n c e o f m e c o n i u m a t b ir th 3. B irth in a n o n - s te r ile e n v ir o n m e n t a n d 4. P o s tn a ta l d e v e l o p m e n t o f e n d o m e tr itis A lth o u g h H I V in f e c tio n is u s u a ll y a c q u ir e d h a e m a to g e n o u s l y . th e re h a v e b e e n s u g g e s tio n s fro m th e lite ra tu re t h a t d ir e c t i n o c u l a t i o n o f th e e y e d u r in g c h i l d b ir th m a y b e a n o t h e r p o rta l o f e n try , f u r th e r m o r e , in f e c tio n m a y a ls o b e a c q u ir e d p o s tn a t a lly fr o m a n in fe c te d p a r e n t s h a n d s , a n d b y c o n v e n tio n it w ill s till b e r e f e r r e d to a s o p h th a lm ia n e o n a to r u m fo r a s lo n g a s in fe c tio n p r e s e n ts w ith in a tim e s p a c e o f 3 0 d a y s o f b i r t h . 1( B e s id e s , flic s a n d fo m ite s h a v e b e e n a s s o c ia te d w ith the tr a n s m is s io n o f m ic r o - o r g a n i s m s in a re a s w ith tr a c h o m a e n d e m i c ity .20 ( )th e r la c to rs o t n o te , s u c h a s p r e m a tu r e ru p tu r e o f m e m b r a n e s a n d p r o lo n g e d la b o u r h a v e b e e n im p lic a te d w ith re g a r d s to i n c r e a s in g th e risk o f d e v e l o p i n g o p h th a lm ia n e o n a to r u m . T h is is b a s ic a lly b a s e d o n th e u n d e r s t a n d i n g o f th e ir c lo s e a s s o c ia ti o n w ith th e in c r e a s e d d u r a tio n o f e x p o s u re o f t h e n e o n a te s e y e s to m a te r n a l v a g in a l flo ra d u r i n g p a s s a g e th r o u g h th e b irth c a n a l.21 - 14 - 2 .3 .1 P R O L O N G E D L A B O U R D y s to c ia , o n e o f th e g r e a t e s t o b s te t r ic a l p ro b le m s , is q u i t e c o m m o n . It o c c u r s f o r th e m o s t p a rt in p r im ip a r o u s w o m e n , a n d is u s u a ll y th e re s u lt o f in a d e q u a te u te rin e c o n t r a c t i o n o r s lo w c e r v ic a l d ila tio n o r b o t h . S o m e c o n d itio n s c a u s i n g th e s e d e f ic ie n c ie s a re c e p h a lo p e lv ic d is p r o p o r tio n , m u ltip le g e s t a t i o n , h y d r a m n io s . m a lp r e s e n ta tio n ( p a r tic u la r ly th e o c c ip u t - p o s t e r i o r ) , o c c lu d i n g t u m o r s , f u l l n e s s o f th e b la d d e r , c o n c e a l e d u te rin e h a e m o r r h a g e , d e la y in r u p t u r e o f m e m b r a n e s . In a d d i t i o n , a n e r v o u s , w o r r y i n g te m p e r a m e n t m a y s e r i o u s l y a ff e c t th e p r o g r e s s o f l a b o u r . " O f a ll c e p h a l i c d e liv e r ie s in t h e U n ite d S ta te s . 8 -1 1 % a re c o m p lic a te d b y a n a b n o r m a l first s ta g e o f la b o u r . D y s t o c i a o c c u r s in 1 2 % o f d e liv e rie s in w o m e n w it h o u t a h is to r y o f p r io r C a e s a r e a n d e l i v e r y a n d it m a y a c c o u n t fo r a s m a n y a s 6 0 % o f C a e s a r e a n s e c tio n s (C S ) . T h e fir s t s ta g e c o n s i s t s o f a l a te n t p h a s e a n d a n a c t i v e p h a s e . D ia g n o s is o f d y s to c ia d u r in g t h e fo r m e r p h a s e o f l a b o u r is u n c o m m o n a n d lik e ly to b e a n in c o rre c t d ia g n o s i s .23 T h e te r m p r o l o n g e d la b o u r is m a in ly a p p lie d to th e p r o lo n g a tio n o f th e firs t s ta g e o f la b o u r b e y o n d 12 h o u r s . It h a s a l s o b e e n d e f in e d a s la b o u r th a t n e e d s to b e a u g m e n t e d w ith o x y to c in d u e to p o o r p r o g r e s s o f th e firs t s ta g e . T h e p ro g r e s s io n o f la b o u r is g e n e r a lly j u d g e d b y tw o • • c riteria: I. II. ">4 25 T h e c e r v ic a l d ila ta tio n D e s c e n t o f th e p r e s e n tin g p a r t I h e lo n g e r it ta k e s fo r l a b o u r to p r o g r e s s th e lo n g e r th e f o e tu s is e x p o s e d to m a te r n a l v a g in a l flo r a a n d th is to o . is a s s o c ia te d w ith m o r e v a g in a l e x a m i n a t i o n s th a t m a y c o n ta m in a te th e fe tu s w i t h m ic ro b e s o r w o rs e e v e n b r u is e th e fa c ial s tr u c tu r e s h e n c e in c r e a s in g t h e ris k o f in fe c tio n . T h e o r g a n i s m s k n o w n to c a u s e n e o n a ta l in fe c tio n v ia th e b ir th c a n a l in c lu d e th e f o llo w in g :G r o u p B Strep, E.coli. P seu d o m o n a s aeruginosa. N eisseria gonorrhea. C h la m yd ia Trachom atis, C a n d id a a lb icans, M yco p la sm a h a rm inis a n d L isteria m o n o cyto g en es , 2h - 15 - 2 .4 C L I N I C A L P R E S E N T A T I O N I h is f o r m o f c o n ju n c t iv itis (i.e . n e o n a ta l c o n ju n c tiv itis ) , a s n o te d b y e y e lid o e d e m a , c o n ju n c t iv a in je c t i o n a n d f r e q u e n t c o n ju n c t iv a d is c h a r g e , a r is e s w ith in 2 8 -3 0 d a y s o f b ir t h . It c a n b e e ith e r u n ila te r a l o r b ila te r a l. B e c a u s e n e o n a te s d o n o t d e v e lo p fo llic le s , th e c e ll u la r m o r p h o l o g y o f th e c o n ju n c t iv a r e a c t i o n is n o t a s im p o r ta n t a s in o t h e r fo rm s o f c o n ju n c t iv itis .27 T h e c lin ic a l p r e s e n ta tio n v a r ie s w ith re s p e c t to th e c u lp r it p a th o g e n in th e g e n e r a l p o p u la tio n , h o w e v e r p r e s e n t a t i o n a lo n e d o e s n o t a llo w fo r th e e s ta b lis h m e n t o f a s p e c if ic d ia g n o s i s .5 ( i o n o c c o c a l O p h t h a l m ia N e o n a t o r u m I h i s u s u a ll y o c c u r s a s e a r ly a s 2 4 - 4 8 h o u rs p o s tp a r tu m . It is a s s o c ia te d w ith a p u r u le n t d is c h a r g e in c o p i o u s a m o u n t s , a n d r a p id c o r n e a l in v o lv e m e n t c a u s in g u lc e r a tio n in s o m e c a s e s le a d in g to c o r n e a l p e r f o r a t i o n . It is w is e to c o n s i d e r a ll p u r u le n t c o n ju n c t iv itis in th e f ir s t f e w d a y s o f life a s g o n o c c o c a l u n til p ro v e d o th e r w is e . T h e r a p id ity w ith w h ic h g o n o c o c c u s c a n p e n e tr a te th e c o r n e a h a s b e e n w e ll d o c u m e n te d , a n d g o n o c c o c a l c o n ju n c t iv itis p r e s e n ts a t r u e o p h th a lm ic e m e r g e n c y .28 C h l a m y d i a l O p h t h a l m ia N e o n a t o r u m It n o t o n ly c a u s e s o p h th a lm ia n e o n a to r u m b u t is a ls o a s s o c ia te d w ith a v a r ie ty o f lo c a l a n d s y s te m ic in f e c tio n s . In f e c tio n c o m m o n ly p r e s e n ts in th e f ir s t 5 to 14 d a y s a f t e r b ir th w ith a w a te r y d is c h a r g e th a t la te r b e c o m e s p u r u le n t th o u g h le s s c o p io u s th a n in g o n o c c o c a l o p h th a lm ia n e o n a to r u m a n d s o m e t im e s p a tie n ts m a y h a v e a p s e u d o m e m b r a n e .10 11 O t h e r O r g a n is m s S ev e ra l m ic r o - o r g a n is m s h a v e b e e n lin k e d to th e c a u s a tio n o f o p h th a lm ia n e o n a to r u m a lth o u g h th e c lin ic a l p ic tu r e is m ild e r a n d n o n - s p e c if ic w ith p a r tic u la r e x c e p tio n o f c o n ju n c t iv itis d u e to p se u d o m o n a s s p p . - 16 - C h e m i c a l c o n ju n c tiv itis A c o n j u n c t i v a r e a c tio n w ith in 2 4 h r s o f b ir th m a y re s u lt f r o m a to x ic r e a c tio n to a p ro p h y la c tic t o p i c a l a g e n t s u c h a s S ilv e r n itr a te d r o p s a n d n o t b e a t r u e in fe c tio n . R a r e ly , s i l v e r s ta in in g o f th e c o r n e a h a s b e e n s e e n .27 2 .5 P R E V E N T IO N I'h e i m p a c t o f 1 0 0 y e a r s o f p r o p h y la x is in p r e v e n tin g a n d d e c r e a s in g th e p r e v a le n c e o f th e b l i n d i n g d i s e a s e fr o m o p h th a lm ia n e o n a to r u m in n e o n a te s m u s t n o t le a d to c o m p la c e n c y . U n til p r e d i s p o s i n g c o n d i t i o n s a re e lim in a te d , th is r e m a in s a p o te n tia lly s ig n if ic a n t m e d ic a l c h a ll e n g e .2'* P r e v e n t i o n is p a r a m o u n t w ith th is d is e a s e . T h e re a re tw o la y e r s o f p r e v e n tio n a s d e p ic te d b e lo w :-30 1. D i r e c t e d t o w a r d s th e m o th e r P r o p e r p r e n a t a l c a r e w ill re v e a l a n y v a g in itis w ith r e s u lta n t tr e a tm e n t o f th e m o th e r b e fo re d e liv e r y . S t u d i e s in th e U n ite d S ta te s a n d o th e r re g io n s h a v e s h o w n a d e c r e a s e d in c id e n c e o f o p h t h a l m i a n e o n a to r u m in a r e a s o f w id e s p r e a d p re n a ta l c a r e . In terv e n tio n c a n a ls o b e in s titu te d d u r in g d e liv e r y to m o th e r s in h ig h r is k g ro u p s s u c h a s p r o lo n g e d la b o u r a n d p r e m a tu r e ru p tu r e o f m e m b r a n e s . T h e m o th e r s h o u ld a ls o g e n e r a lly b e e d u c a te d to p re s e n t f o r tr e a tm e n t i f s ig n s o f a n y g e n ita l u r in a r y tr a c t a p p e a r . 2. D ire c te d t o w a r d s th e c h ild S in c e th e 1 8 8 0 s . it h a s b e e n r e c o g n iz e d th a t a n a p p r o p r ia te a n tim ic r o b ia l e y e d r o p a p p lie d to th e e y e s h o r tly a f t e r b irth w ill d r a m a tic a lly r e d u c e th e i n c id e n c e o f o p h th a lm ia n e o n a to r u m . P r e v e n tio n c a n b e g iv e n to e ith e r a ll n e o n a te s a t d e liv e r y o r e ls e to th o s e b o m in n o n - s te r ile e n v ir o n m e n ts a n d a ls o to th o s e w ith m e c o n iu m p re s e n c e a t b irth . - 17 - 2 .6 O C U L A R P R O P H Y L A X I S In 1 8 8 0 . C r e d e in tr o d u c e d th e c o n c e p t o f w id e s p r e a d p r o p h y la x is f o r g o n o c c o c a l o p h th a lm ia n e o n a to r u m w ith 2 % s ilv e r n itr a te . T h i s m e th o d is n o t e f f e c t iv e a g a in s t T R I C a n d th e r e f o r e h a s b e e n s u p p la n te d b y a g e n ts e f f e c t iv e a g a in s t g o n o c o c c u s a n d T R I C , s u c h a s e r y th r o m y c in a n d te tr a c y c lin e o i n t m e n t s . 1132 A s tu d y d o n e in K e n y a in 1 9 9 5 s h o w e d th a t 2 .5 % P o v id o n e - io d in e o p h th a lm ic s o lu tio n is m o r e e ff e c tiv e th a n S i l v e r n itr a te o r E r y th r o m y c in e y e o i n t m e n t a n d it is le s s to x ic a n d f a r le ss e x p e n s iv e .3^ In a m o re r e c e n t s tu d y in K e n y a c o n d u c t e d a t K ik u y u E y e C lin ic . I s e n b e r g e t a / tr ie d to c o m p a r e th e d o u b le a p p l i c a t i o n o f 2 .5 % P o v id o n e - io d in e w ith in t h e first p o s tn a ta l d a y w ith a s in g le d ro p a p p lie d a t b ir th . H o w e v e r th e re s u lts re v e a le d n o d i f f e r e n c e . 4 - 18 - 3 .0 R A T I O N A L E R e g a rd le s s o f o u r k n o w le d g e th a t o p h t h a l m i a n e o n a to r u m is o n e o f th e m o s t c o m m o n in f e c tio n s o f th e n e w b o r n , m a n y q u e s t i o n s s till r e m a in a s to w h e n , w h o m an d h o w to a d m i n i s t e r o c u la r p ro p h y la x is . It h a s b e e n e s t a b l i s h e d th a t o c u la r f l o r a e o f th e n e o n a te v a r i e s fro m o n e g e o g r a p h ic a l re g io n to the n e x t a n d f r o m tim e to t i m e to o . a s d o th e m ic r o - o r g a n is m s im p lic a te d in O N . T h is le a d s to the n e e d f o r a n u n d e r s ta n d in g o f o c u l a r s u r f a c e flo ra e in r e a lis i n g w h e th e r to in s titu te o c u la r p r o p h y la x is o r n o t. b a s e d o n th e p a th o g e n i c ity o f th e m ic r o - o r g a n is m s . There a re n o s t u d i e s c o n d u c te d in Z a m b i a to d e te r m in e th e n a tu r e o f th is f lo r a e a n d th e a s s o c ia te d p e r in a ta l ris k s f a c to r s s u c h a s p r o lo n g e d la b o u r . In a d d itio n , o c u la r p r o p h y la x is o f a n y fo rm is n o t r o u ti n e ly p e r f o r m e d in h o s p ita ls in Z a m b ia . It is w ith th is in m in d th a t th is s tu d y has b e e n d e s i g n e d in a n a tt e m p t to d e te r m in e w h e th e r th e o c u l a r flo r a e o f n e o n a te s b o rn to m o th e rs w ith p r o lo n g e d l a b o u r d i f f e r s , a n d to w h a t d e g r e e fr o m th a t o f m o th e r s w ith u n e v e n tf u l d e liv e rie s. th is d a ta w ill b e u s e d fo r a d v o c a c y a n d s e n s itiz a tio n o f p o lic y m a k e r s , h e a lt h p e rs o n n e l a n d th e p u b lic o n th e n e e d t o r s e le c tiv e o r w h e r e p o s s ib le c o m p u ls o r y o c u la r p r o p h y la x is . T h e r e s u lts w ill a ls o p r o v id e a b a s e lin e f o r f u tu r e re s e a rc h w o rk s . - 19 - 4 .0 O B J E C T I V E S 4.1 M a in f o c o m p a r e th e s p e c tr u m a n d q u a n tity o f o c u la r f l o r a e in n e o n a te s b o m fr o m m o th e r s w ith p r o lo n g e d l a b o u r a n d th o s e f r o m m o th e r s w ith u n e v e n tf u l d e liv e ry . 4.2 S p e c if ic 1. T o c o m p a r e th e n u m b e r o f c o l o n i e s o f o c u l a r f l o r a e in n e o n a te s o f m o t h e r s w ith p r o lo n g e d la b o u r w ith th a t o f n e o n a te s o f m o th e r s w i t h u n e v e n tf u l la b o u r . 2. T o d e t e r m i n e th e s p e c tr u m o f o r g a n is m s in n e o n a te s o f m o th e r s w ith p r o lo n g e d la b o u r a n d t h o s e o f m o th e r s w ith u n e v e n tf u l la b o u r. 3. f o d e t e r m i n e th e d r u g s e n s itiv ity o f th e c o m m o n ly o c c u r r in g o c u la r s u r f a c e m ic r o ­ o r g a n is m s in n e o n a te s o f m o th e r s w ith p r o lo n g e d la b o u r . -2 0 - 5 .0 M ETHODOLOGY 5 .1 M e th o d s 5 .1 .1 S tu d y d e s ig n P r o s p e c t i v e C o h o r t c a s e s tu d y 5 .1 .2 S t u d y P o p u la tio n 1 N e o n a t e s o f m o th e r s w h o h a d p r o lo n g e d la b o u r 2. N e o n a t e s o f m o th e r s w h o h a d a n u n e v e n tf u l d e liv e r y 5 .1 .3 S t u d y d u r a tio n T h e s t u d y w a s c a r r i e d o u t o v e r a p e r io d o f 4 m o n th s in th e y e a r 2 0 1 0 • D a ta c o l l e c t e d o v e r th r e e m o n th s • D a ta a n a l y s i s a n d p r e s e n ta tio n d u r in g o n e m o n th 5 .1 .4 S t u d y S e t tin g T h is s tu d y w a s d o n e a t th e U n iv e r s ity T e a c h in g H o s p ita l ( U T H ) in L u s a k a th e c a p it a l c ity o f Z a m b i a w h o s e p o p u la tio n is a p p r o x im a te ly 1 .0 8 4 .7 0 3 ( c e n s u s 2 0 0 0 ) . It is t h e b ig g e s t h o s p ita l in t h e c o u n try ' lo c a te d a p p r o x im a te ly 4 k m e a s t o f th e c ity c e n tr e in L u s a k a . T h e h o s p ita l is a n a c a d e m i c m e d ic a l c e n tr e /u n iv e r s ity h o s p ita l w ith a p p r o x im a te ly 1 .8 4 6 b e d s a n d 2 5 0 b a b y c o ts . It p r o v i d e s a fu ll r a n g e o f p r im a r y , s e c o n d a r y a n d te r tia r y h e a lt h a n d m e d ic a l s e r v i c e s o n a n in p a t i e n t a n d o u tp a tie n t b a s is . In a d d itio n , it a ls o s e r v e s a s th e c o u n tr y ’s s p e c ia lis t c e n tr e r e c e i v i n g r e f e r r a ls fro m all o v e r th e c o u n t r y . The h o s p ita l s u p p o r ts th e m is s io n o f th e s c h o o l o f m e d ic in e in Z a m b ia w h ic h p r im a r ily f o c u s e s o n te a c h in g a n d re s e a rc h . It a ls o s u p p o r ts th e -2 1 - s c h o o l o f n u r s in g a n d o th e r te a c h in g p r o g r a m s in a n u m b e r o f te c h n ic a l fie ld s . A m o n g th e s e v e ra l d e p a r tm e n t s th a t th e in s titu tio n h o u s e s is th e d e p a r t m e n t o f O b s t e tr ic s a n d G y n a e c o lo g y ' O liS G Y N ) th r o u g h w h ic h t h is s tu d y w a s c o n d u c te d . T h e d e p a r tm e n t p r o v id e s s e r v ic e s fo r b o th lo w c o s t a n d h ig h c o s t r e p r o d u c tiv e h e a lt h s e r v ic e s . T h e O b s te tr ic s w i n g h a s 6 la b o u r w a r d s a n d r e c e iv e s a n e s tim a te o f 1 8 0 0 a d m is s io n s p e r m o n t h w ith 1 2 0 0 d e liv e r ie s . - 22 - 5 .1 .5 C a s e d e f in itio n N e w b o r n s o f m o th e r s a d m itte d to th e U n iv e r s ity T e a c h in g H o s p ita l in L u s a k a . P r o lo n g e d la b o u r N e o n a t e s b o m to m o th e r s h a v in g a d ia g n o s i s o f p r o lo n g e d la b o u r, d e f in e d a s a c ti v e la b o u r o f g r e a t e r t h a n 12 h o u rs . N o r m a l la b o u r N e o n a t e s b o m to m o th e r s w ith a l a b o u r d u r a tio n le s s th a n 12 h o u r s a n d u n e v e n tf u l. 5 .1 .6 I n c lu s io n c r it e r ia 1. N e o n a t e s o f m o th e r s d ia g n o s e d w ith p ro lo n g e d la b o u r. 2. N e o n a t e s b o m to m o th e r s w i t h u n e v e n tf u l la b o u r. 3 . W r itte n c o n s e n t fro m th e m o t h e r o r g u a rd ia n . 5 .1 .7 E x c lu s io n c r it e r ia 1. V e r y s i c k p a tie n ts 2. N e o n a t e s n o t d e liv e r e d at th e U n iv e r s ity T e a c h in g H o s p ita l in L u s a k a 3. L a c k o f c o n s e n t fro m e i t h e r m o t h e r o r g u a r d ia n 4. N e o n a te s m o r e th a n 2 4 h o u r s o ld 5. N e o n a te s th a t h a d le f t th e h o s p i t a l a re a o f th e s tu d y a t a n y o n e tim e p r i o r to r e c r u itm e n t tim e . 6. N e o n a te s w ith m a n if e s t o c u l a r a n o m a lie s - 23 - 5 .1 .8 S a m p le s iz e R a n d o m iz e d s a m p l in g m e th o d w a s d o n e . E v e r )' s e c o n d e x p e c t a n t m o th e r a n d h e r n e o n a te w e re e n r o lle d . W e u s e d th e fo r m u la b e lo w f o r u n m a tc h e d s tu d ie s to c a lc u la te th e s a m p l e . th e n s im p lif ie d t o n — 2 \P Q /(p \ - po)^ W h ere; n = th e r e q u ir e d s a m p l e s iz e Pi = p „ R / | l + p 0( R - l )] P = ,/ * (p i+ P o ) , Q = 1 -P p 0 P r o p o r tio n e x p o s e d ( 5 7 % ) 1 R d e n o te d th e R e l a t i v e R is k c o r r e s p o n d i n g to th e s m a l le r i n c r e a s e in th e ris k o f in te re s t. ( 1 .5 ) •Za a n d Z fi a r e t h e c u t o il p o in ts a lo n g th e X a x is o f d ie n o rm a l p ro b ab ility d istrib u tio n th a t r e p r e s e n ts p r o b a b i l i t y m a tc h in g th e 9 5 % c o n f id e n c e in te r v a l ( 1 .9 6 ) a n d th e s ta t is tic a l p o w e r o f 8 0 % ( 0 .8 4 2 ) . T h e re fo re , n = 1 2 3 .6 7 ~ 1 2 4 s tu d y T h e re fo re , a to ta l o f A r m P L = 6 2 a n d A r m N L = 6 2 . - 24 - 5 .1 .9 R e s o u r c e p e r s o n n e l H ie f o ll o w i n g w e r e in v o lv e d a t v a r io u s le v e ls o f th e s tu d y :• O p h th a lm o lo g is t • O b s te tric ia n • M id w if e • M i c r o b io lo g is t • I .a b o r a t o r y te c h n ic ia n • E p i d e m io l o g is t/ B io - s ta tis tic ia n 5.2 S T l D Y M A T E R I A L S • Q u e s tio n n a ire • P a tie n t in f o r m a t io n s h e e t a n d C o n s e n t f o r m s • P e n s, p e n c ils a n d e ra se rs • P e n to r c h • S te r ile d i s p o s a b l e g lo v e s • S te r ile d i s p o s a b l e s w a b s tic k s • M ic r o b io lo g y g la s s s lid e s • B ra in h e a r t in f u s io n b r o t h ( B H l B ) • P e tri d is h a g a r ( C h o c o la te . B lo o d . M a c k o n k e y ) • T e tr a c y c li n e e y e o in tm e n t - 25 - 5 .3 P R O C E D U R E \ f t e r e x p l a i n i n g th e p u r p o s e o f th e s t u d y to th e m o th e r o r g u a r d ia n , a n i n f o r m e d c o n s e n t w a s o b ta in e d . D e m o g r a p h ic d a ta a n d o th e r r e le v a n t d e ta i ls w e r e o b ta in e d u s in g a s tr u c tu r e d q u e s t i o n n a i r e ( a p p e n d i x III). T h e e y e s o f th e n e w b o rn w e r e e x a m in e d w ith in 2 4 h rs p o s tp a r tu m , a n d a t t h e s a m e s e t t i n g a c o n ju n c tiv a l s m e a r w a s ta k e n . S p e c im e n C o lle c t io n A s t e r i l e c o t t o n s w a b s tic k s o a k e d in b r a in h e a r t in f u s io n ( B 1 I I ) w a s u s e d to c o l l e c t th e s a m p le p rio r to a n y m e d i c a t i o n b e in g in s tille d i f n e c e s s a ry . T h e l o w e r e y e lid w a s e v e r t e d to e x p o s e th e fo r n ix t h e n th e s w a b w a s ro lle d in a m e d ia l to la te ra l d ir e c tio n . A s a b e d s id e p r o c e d u r e , th e i n o c u l a t i o n s / s m e a r s w e r e d o n e b y th e p r in c ip a l in v e s tig a to r . G la s s s lid e s w e re u s e d to m a k e th in film s f o r m i c r o s c o p y i.e . P o ta s s iu m h y d r o x id e ( K O H ) . G r a m a n d G ie m s a s ta in . A d if f e r e n t c o tto n s w a b w a s u s e d f o r in o c u la tio n o n to th e p r e p a r e d c u l t u r e m e d ia o f C h o c o l a te a g a r ( C A ) , B lo o d a g a r ( B A ) a n d M a c k o n k e y a g a r ( M A ) . T h e c u l t u r e m e d i a w a s in c u b a te d fo r 2 4 h o u r s fo r e n r ic h e d a n d d if f e r e n tia l m e d ia . I f n o g r o w th w a s o b t a i n e d a t 2 4 h o u r s th e s a m p le w a s r e - in c u b a te d fo r u p to 4 8 h o u rs th e n o th e r w is e d is c a r d e d . A p o s i t i v e c u ltu r e w a s d e f in e d a s g r o w th o n a n y o f th e m e d ia th a t w a s u s e d . T h e c o lo n ie s w e r e c o u n t e d m a n u a lly th e n g r a d e d a s h e a v y ( > 1 0 0 ) . m o d e r a te ( 5 0 - 1 0 0 ) , lig h t ( 1 - 5 0 ) an d n o g r o w th . T h e c o m m o n ly o c c u r r in g o r g a n is m s in th e n e w b o r n s o f m o th e r s w ith PL w e re id e n tif ie d a n d s u b j e c t e d to te s t s fo r d r u g s e n s itiv ity . - 26 - 6 .0 D A T A M A N A G E M E N T A N D A N A L Y S IS D u rin g t h e s tu d y , d a ta w a s c o lle c te d u s i n g a s tr u c tu r e d d a t a c o lle c tio n to o l. D a ta e n tr y a n d a n a ly s is w a s d o n e b y a s ta tis tic ia n u s in g M ic r o s o f t E x c e l 2 0 0 7 v e r s io n a n d th e s ta tis tic a l p a c k a g e to r s o c ia l s c ie n tis t ( S P S S ) v e rs io n 17 f o r M ic r o s o f t W in d o w s r e s p e c tiv e ly . I h e r e s u l t s a r e illu s tr a te d /p r e s e n te d in th e fo r m o f flo w c h a r t s , ta b le s , h is to g r a m s , b a r c h a r ts , p ie c h a r ts , r a tio s a n d p r o p o r tio n s w e re a p p r o p r ia te . A p - v a lu e o f le s s th a n 0 .0 5 w a s c o n s id e r e d to b e s t a t i s t i c a l l y s ig n if ic a n t w ith 95 % C l. - 27 - 7 .0 E T H I C A L C O N S I D E R A T I O N S 7.1 E t h ic a l A p p r o v a l P r io r to th e c o m m e n c e m e n t o f th is s t u d y , e th ic a l a p p r o v a l w a s s o u g h t f r o m th e U n iv e r s ity o f Z a m b ia B io m e d ic a l R e s e a r c h E th ic s c o m m itte e . In d e e d , p e r m is s i o n w a s a ls o s o u g h t fro m th e l d i v e r s ity T e a c h i n g H o s p ita l to a c c e s s p a tie n ts . 7 .2 C o u n s e l l i n g 1 h e m o t h e r g u a r d i a n w a s in f o r m e d th a t n o in v a s iv e p r o c e d u r e s w e re to b e c a r r i e d o u t o n th e n e o n a te . R e l e v a n t in f o r m a tio n w a s a ls o p ro v id e d to th e m o th e r /g u a r d ia n r e g a r d in g th e ris k s o f n e o n a ta l o c u l a r i n f e c tio n s . T h e m e d ic a tio n s (e y e d r o p s o r o in t m e n t ) th a t w e re u s e d in th is s tu d y are r e g i s t e r e d in Z a m b i a . S in g le u s e d is p o s a b le s w a b s w e r e u tiliz e d . 7 .3 C o n s e n t In f o r m e d c o n s e n t w a s ta k e n f r o m e i t h e r th e m o th e r o r g u a r d ia n b e fo re r e c r u i t m e n t in to th e s tu d y . C o n s e n t w a s a l s o s o u g h t fo r a n y r e le v a n t p h o to - d o c u m e n ta tio n . P a tie n ts w e re in f o r m e d th a t th e y w e re f r e e to d is c o n t i n u e th e ir p a r tic ip a tio n in th e s tu d y a t a n y tim e i f th e y s o w is h e d . 7 .4 D a ta C o n f id e n t i a lit y I he i n f o r m a t i o n c o l l e c t e d fr o m th e p a tie n ts r e c o rd s , in c lu d in g th e la b o ra to ry t e s t r e s u lts w a s k e p t c o n f id e n tia l th r o u g h o u t th e s tu d y p e r io d . - 28 - 8 .0 R E S U L T S F ig u r e 1: F lo w c h a r t o f p a r t ic ip a n t s A to ta l o f l 3 2 m o t h e r a n d b a b y p a irs w e r e e lig ib le a n d e n r o l l e d in to th e tw o s t u d y a r m s a s illu s tra te d a b o v e . - 29 - F i g u r e 2 : M a t e r n a l a g e d is t r ib u t io n (n = 1 3 2 ) < 20 20-29 30-39 £40 Age (Years) T h e m e a n a g e w a s f o u n d to b e 2 2 .5 y e a r s f o r P L a n d 2 7 .5 y e a r s fo r N L . T h is w a s s ta tis tic a lly s ig n if ic a n t ( p - v a l u e o f < 0 .0 0 1 ). T h e m e d i a n a g e w a s 2 0 .5 a n d 2 7 .0 y e a r s r e s p e c tiv e ly . - 30 - F ig u r e 3 : P a r it y a m o n g m o t h e r s ( n = 1 3 2 ) P ro lo n g ed L a b o u r N o rm al L ab o u r G roups A m o n g t h e m o t h e r s w ith P L 4 8 .5 % w e r e p r im ip a r o u s . w h e r e a s th o s e fro m th e N L g ro u p w e re 15.2 % . T h e m e a n p a r ity w a s 1.1 a n d 2 .2 re s p e c tiv e ly w ith a s ta tis tic a l s ig n if ic a n c e o f < 0 .0 0 1 . T h e m e d i a n p a r ity w a s fo u n d to b e 1 .0 a n d 2 .0 re s p e c tiv e ly . - 31 - T a b le 1: A n t e n a t a l a n d L a b o u r p r o f ile ( n = 1 3 2 ) P r o lo n g e d la b o u r N o r m a l la b o u r n=66 n=66 R R (9 5 % C l) p - v a lu e N um ber o f V E M ean 4 .2 2.1 M e d ia n 4 .0 2 .0 1-2 0 5 3 ( 8 0 .3 ) 3 -4 4 6 ( 6 9 .7 ) 1 3 ( 1 9 .7 ) >5 2 0 ( 3 0 .3 ) A n t ib io t ic s in - < 0 .0 0 1 0 1 0 ( 1 5 .6 ) 5 (7 .6 ) 2 .2 ( 0 . 6 - 7 . 9 ) 0 .1 5 1 8 ( 1 2 .1 ) 2 7 (4 0 .9 ) 0 .2 (0 .1 - 0 . 5 ) < 0 .0 0 1 last tw o w e e k s H IV +Ve M o th e r s w h o h a d p r o lo n g e d la b o u r h a d m o r e v a g in a l e x a m i n a tio n s ( V E ) th a n t h o s e w h o h a d n o rm a l la b o u r . T h e y w e r e a ls o o n s y s te m ic a n tib io tic s a lth o u g h th is w a s n o t s ta t is tic a lly s ig n if ic a n t. O f th e m o th e r s w ith n o rm a l la b o u r 4 0 .9 % w e r e fo u n d to b e H IV p o s itiv e a s o p p o s e d to 12.1 % fo u n d in th e g r o u p th a t h a d p r o lo n g e d la b o u r. - 32 - T a b le 2 : N e w b o r n p r o f ile (n = 1 3 2 ) P r o lo n g e d N o r m a l la b o u r RR la b o u r n = 6 6 n=66 95 % C l p -v a lu e A g e (H rs) M ean 10.6 9.5 M e d ia n 10.0 9 .0 - < 1 5 ( 7 .6 ) 5 (7 .6 ) 1-9 2 5 ( 3 7 .9 ) 3 2 ( 4 8 .5 ) 1 0-19 2 9 ( 4 3 .9 ) 23 ( 3 4 .8 ) >20 7 ( 1 0 .6 ) 6 (9 .1 ) SV D 6 4 ( 9 7 .0 ) 6 6 ( 100.0 ) c/s 2 (3 .0 ) 0 0 .6 5 3 M o d e o f D e liv e r y M e c o n iu m 2 - 0 .4 8 ( 0 .0 9 - 2 .7 4 ) 4 0 .1 5 4 0 .3 4 0 The m e an a g e at th e tim e o f co n ju n ctiv al s m e a r w ere 10.6 h o u rs fo r PL and 9.5 h o u rs fo r N L but w a s not statistically s ig n ific a n t (p -v alu e 0 .65 3 ). In th e PL group, all but tw o patien ts d eliv ered b y sp o n tan eo u s vaginal d e liv e ry . M e c o n iu m stain w as o b se rv e d m ore in n e w b o rn s o f m o th ers w ith N L b u t th is w as not statistically s ig n ific a n t (p -v alu e 0 .3 4 0 ). - 33 - F ig u r e 4 : N e w b o r n g e s t a t io n a l a g e ( n = 1 3 2 ) O u t o f t h e 1 0 5 t e r m d e liv e r ie s 5 7 w e re f r o m m o th e r s w h o h a d p r o lo n g e d la b o u r a n d 4 8 fro m th o s e t h a t h a d n o r m a l la b o u r ( p - v a lu e 0 .0 5 2 ) . O f t h o s e t h a t w e r e p r e - te r m . 9 w e re b o r n to m o th e r s w ith p r o lo n g e d l a b o u r a n d 18 fro m m o th e r s w ho h a d n o rm a l la b o u r. - 34- F i g u r e 5 : S e x d is t r ib u t io n o f th e N e w B o r n (n = 1 3 2 ) T he m a le to f e m a le r a tio w a s 1 :1 .2 O ut o f th e 7 2 m a le n e o n a te s 2 7 w e re f r o m m o th e rs w h o h a d p r o lo n g e d la b o u r a n d 4 5 fro m th o s e that h a d n o rm a l l a b o u r . T h e p - v a lu e w a s s ta tis tic a lly s i g n i f i c a n t a t 0 .0 0 2 . - 35 - UNIVERSITY OF NAIROBI MEDICAL LJBHAfly F i g u r e 6 : D is t r ib u t io n o f C u l t u r e r e su lts b y H I V s t a t u s ( n = 1 3 2 ) □ HIV Positive ■ HIV Negative N o n e o f th e n e o n a t e s b o m to m o th e r s w h o h a d p r o lo n g e d l a b o u r w ith a p o s itiv e H IV te s t h a d a p o s itiv e c o n j u n c t i v a . T h e p - v a lu e w a s 0 .0 0 2 - 36- F i g u r e 7 : D is t r ib u t io n o f C u l t u r e r e s u lts ( n = 1 3 2 ) ■ +VE ■-VE 52 (78.8) 0 ---------------------------------Prolonged labour Normal labour G roups P -v alu e = 0 .3 1 5 . RR = 1 .5 0 . 9 5 % C l ( 0 .6 8 - 3 .3 3 ) N e w b o rn s o f m o t h e r s w ith P L h a d m o r e p o s itiv e c u ltu r e r e s u l t s in c o m p a r is o n t o th o s e o f n e o n a te s fr o m m o t h e r s w h o h a d n o rm a l la b o u r , a lth o u g h t h e p - v a lu e w a s n o t s ta t is tic a lly s ig n ific a n t. - 37- F ig u r e 8 : A s s o c ia t io n b e tw e e n C o l o n y in te n s it y ( n = 3 3 ) ■ Normal □ Prolonged N e w b o rn C o u n t 30 T h e re w a s n o s t a t i s t i c a l s ig n if ic a n c e e x h i b i t e d b e tw e e n th e n e w b o r n s o f th e tw o s e ts o f m o th e rs ( p - v a lu e 0 .4 1 5 ) . - 38- F i g u r e 9 : S p e c t r u m o f m ic r o o r g a n is m s ( n = 3 3 ) T h e re w a s n o s t a t i s t i c a l s ig n if ic a n c e in th e s p e c tr u m o f o r g a n i s m s b e tw e e n n e o n a te s o f m o th e rs w h o h a d p r o l o n g e d a n d th o s e w h o h a d n o r m a l la b o u r ( p - v a lu e 0 .0 8 8 ). V ir u le n t o r g a n is m s w e re also i s o l a t e d in c o n j u n c t i v a s m e a r s o f n e o n a t e s o f m o th e r s w h o h a d p r o lo n g e d la b o u r . - 39 - T a b l e 3 : S e n s it iv ity p a tt e r n o f a n t ib io t ic s C o m m o n l y o c c u r r i n g o r g a n i s m s a m o n g n e o n a t e s o f m o t h e r s w it h p r o lo n g e d la b o u r ( n = 1 7 ) )ru g s S t r e p . V ir id a n s (n = 6) S ta p h . A u r e u s E s c h e r ic h ia C o l i CNS (n = 6) (n = 3) (n = 2) R S R s R 0 6 0 0 2 ♦ * * * * * 0 * * 6 0 3 0 0 2 2 0 2 2 1 2 C o -iri m o x a z o le 0 3 * * 0 4 0 1 E r y th ro m y c in * * * * * * 1 2 A m p ic illin 4 0 * * 6 0 * * P en icillin * * * * * * 0 2 S R C e fo ta x im e 6 0 fle n ta m y c in 2 0 C ip ro fl o x a c in 6 C h lo ra m p h e n ic o l S O r g a n is m s w e r e m o s t s e n s itiv e to C e f o ta x i m e a n d C ip r o f l o x a c in . T h e re w a s a h ig h r e s is ta n c e p a tte rn t o C h lo r a m p h e n i c o l a n d C o - tr im o x a z o le . in ) n u m b e r o f i s o l a t e s te s te d f o r th e d r u g is) n u m b e r o f s e n s i t i v e is o la te s ( R ) n u m b e r o f r e s i s t a n t is o la te s * A n tib io tic d is c n o t u s e d o n p a r tic u la r o r g a n is m f o r s e n s itiv ity te s t. - 40 - 9.0 D I S C U S S I O N This s t u d y w a s c a r r i e d o u t in th e la b o u r w a r d a t th e la r g e s t t e r t i a r y h o s p ita l in Z a m b i a , th e U n iv e rs ity T e a c h i n g H o s p ita l s itu a te d in th e c a p ita l c ity L u s a k a . In th is s t u d y , w e s o u g h t to c o m p a r e th e s p e c tr u m a n d q u a n tity o f o c u la r flo ra in n e w b o r n s o f m o th e r s w h o h a d P L a n d th o s e o f m o t h e r s w h o h a d h a d u n e v e n tf u l d e liv e r y . A to ta l o f 132 s u b je c ts w e r e e n r o l l e d w h o w e r e th e n d i v i d e d in to tw o r e s p e c t i v e a rm s o f 66 p a i r s e a c h ( m o th e r an d b a b y ) a s d e p i c t e d in th e flo w c h a r t ( F i g u r e 1). T h e m e a n a g e o f t h e m o th e r s w a s 2 2 .5 y e a r s fo r P L a n d 2 7 .5 y e a r s fo r N L ( F ig u r e 2 ). T h e m e d ia n a g e w a s 2 0 .5 y e a r s a n d 2 7 .0 y e a r s r e s p e c tiv e ly . T h i s w a s e x p e c te d a s p r im ip a r o u s w o m e n a r e y o u n g e r a n d a re m o r e lik e ly to h a v e P L ( p - v a lu e 0 .0 0 2 ) . A m o n g t h o s e th a t w e re p r i m i g r a v i d a ( F i g u r e 3 ). 4 8 .5 % h a d P L a n d 15.2 % o f th e m o t h e r s h a d N L . 1 h e m e a n p a rity w as 1.1 a n d 2.2 w h i c h w a s s ta tis tic a lly s ig n if ic a n t ( p - v a lu e 0 . 001 ) a n d is c o m p a r a b le to o th e r s tu d ie s .1 M o th e r s w h o h a d P L h a d m o re v a g in a l e x a m i n a tio n s (V E ) in tr a - p a r tu m th a n t h o s e w h o h a d N L w ith r e s p e c t to t h e d u r a tio n o f la b o u r ( p - v a l u e = < 0 .0 0 1 ). M o s t o f th e m o th e r s w h o h a d P L w e re on s y s t e m i c a n t i b i o t i c s a t le a s t in th e la s t tw o w e e k s p r io r t o th is s tu d y . M a jo r ity w e r e b e in g tre a te d f o r u r in a r y tr a c t in f e c tio n s ( U T T s ) . A lth o u g h th is r e s u l t w a s f o u n d n o t to b e s ta tis tic a lly s ig n if ic a n t it w a s o f c lin ic a l s ig n if ic a n c e . D u rin g r o u t i n e s c r e e n i n g a h ig h p r e v a le n c e o f H IV r e a c tiv e m o th e r s w a s o b s e r v e d in th e N L g ro u p c o m p a r e d t o th o s e w h o h a d P L ( 4 0 .9 % a n d 12.1 % r e s p e c tiv e ly , p - v a lu e = < 0 .0 0 1 ). (h o u g h th is f in d i n g w a s s ta tis tic a lly s ig n if ic a n t, it c o u ld h a v e b e e n in f lu e n c e d b y th e a g e a t first - 41- c h ild b irth , a n d / o r a g e a t fir s t s e x u a l in te r c o u r s e . A s m o s t o f t h e m o th e r s in th e N L g r o u p w e re o ld er t h is m a y a ls o m e a n th a t th e y h a d a s t r o n g e r h is to ry o f s e x u a l e x p o s u r e th a n m o th e r s in th e PL g ro u p ( T a b l e 1 ). In th is s t u d y ( T a b l e 2 ) , th e m e a n a g e a t t h e tim e o f c o n j u n c t i v a s m e a r f o r th e n e o n a t e s w a s 10.6 h o u r s ( P L ) a n d 9 .5 h o u rs ( N L ) r e s p e c tiv e ly . T h i s is u n l i k e in m o s t s tu d ie s w e r e th e a v e r a g e ag e at ti m e o f s m e a r w a s b e tw e e n 2 4 a n d 4 8 h o u r s .1 ' A ll w e r e d e liv e r e d b y s p o n ta n e o u s v a g in a l d e liv e ry e x c e p t f o r t w o a m o n g th e m o t h e r s in th e P L g r o u p . M e c o n iu m s ta in w a s o b s e r v e d m o r e in b a b ie s o f m o t h e r s w ith N L b u t w a s n e i t h e r s ta tis tic a lly s i g n i f i c a n t n o r a s s o c i a t e d w ith a p o s itiv e c u l t u r e r e s u lt. A la rg e r p r o p o r t i o n o f b a b ie s w e r e b o m a t te rm (7 9 .5 % ) in c o n t r a s t to th o s e b o m b e fo re te r m (2 0 .5 % ) . a l t h o u g h t h i s w a s n o t s ta t is tic a lly s ig n if ic a n t ( F i g u r e 4 ). O f th o s e th a t w e r e p r e - te r m . 9 w ere b o m t o m o t h e r s w ith P L a n d th e r e m a i n i n g 18 to m o t h e r s w ith N L . I h e m a l e to fe m a le ratio w a s f o u n d to b e 1: 1. 2 . T h is s tu d y i l l u s t r a t e d ( F ig u r e 6 ) m o re p o s i t i v e c o n ju n c t iv a c u l t u r e re s u lts in b a b i e s w h o w e re b o m to m o t h e r s w i t h N L a n d h a v in g a p o s i t i v e re tr o - v ir a l t e s t d u r in g s c r e e n in g , in c o n tr a s t to th o se in t h e P L g r o u p ( p - v a lu e 0 .0 0 2 ) . T h i s m ig h t h a v e b e e n a r e s u lt o f th e h i g h e r p r e v a le n c e o f H IV (4 0 .9 % ) a m o n g th e m o th e r s w h o h a d N L . In a re c e n t s t u d y b y G ic h u h i el a l c a r rie d o u t in K e n y a, n e o n a ta l c o n j u n c t i v i t i s w a s f r e q u e n tly d ia g n o s e d in i n f a n ts b o m to m o th e r s w ith H IV -1 in fe c tio n s u g g e s t i n g a n in c re a s e d v i g ila n c e in th is g r o u p .3' B ab ies b o m to m o t h e r s w ith P L h a d a h i g h e r o c c u r r e n c e o f p o s itiv e c u ltu r e r e s u l t s in c o m p a ris o n to t h o s e o f m o th e r s w h o h a d N L (R R 1 .5 0 ). A s in o th e r s tu d ie s , t h i s w a s - 42 - a ttrib u te d t o th e lo n g d u r a t i o n o f e x p o s u r e in th e b ir th c a n a l a n d h ig h n u m b e r o f V E .26 The tw o w h o w e r e b o m b y C S h a d a s t e r i l e c o n ju n c tiv a l s a c . In a s tu d y b y I s e n b e r g el al. s te r ile c o n ju n c tiv a l c u l t u r e s w e r e m o re f r e q u e n t in n e o n a te s d e l i v e r e d b y C S (66 % ) t h a n in n e o n a te s d e liv e re d v a g i n a l l y ( 2 0 %) . 36 T h e n u m b e r o f p o s itiv e c u ltu r e c o u n t s w e re lo w e r in th is s tu d y ( F ig u r e 7 ) a t 2 8 .8 % in P L a n d 2 1 .2 % in N L u n lik e in o th e r s tu d ie s . T h i s m a y b e d u e to th e fa c t that a g e a t c o n j u n c t i v a s m e a r in t h is s tu d y w a s o n a v e r a g e l e s s th a n 10 h o u r s . M u n d i a e l al is o la te d 6 3 % o f p o s i t i v e c u ltu r e s in P L a n d 51 % in N L . a n d a ls o s h o w e d th a t c o lo n iz a tio n in c re a s e d s t e a d i l y w i t h a g e .1J a f f e i ji el a l. is o la te d 4 3 .9 4 % o f c u ltu r e p o s itiv e r e s u l t s fro m th e n o rm a l c o n j u n c t i v e f l o r a in a K e n y a n p o p u la tio n w h o s e m e d i a n a g e w a s 4 6 .5 y e a r s . In a m o r e r e c e n t s t u d y b y Z o g a el al. a h i g h e r p o s itiv e c u l t u r e c o u n t o f 5 8 .7 % w a s is o la te d in a s a m p le d p o p u l a t i o n w h o s e m e d ia n a g e w a s 7 0 y e a r s . N ot o n l y w e r e m o r e o r g a n is m s is o la te d in th e c o n ju n c tiv a o f b a b i e s fro m m o th e r s w h o h a d P L but a ls o a h i g h e r c o l o n y c o u n t w a s o b s e r v e d in th e m ( F ig u r e 8 ). A m o d e r a te to h e a v y g ro w th p a t t e r n w a s e v i d e n t in n e o n a te s ( 1 0 .5 % ) o f m o th e r s w ith P L th a n in t h o s e w ith N L (7.1 % ) . p - v a l u e 0 .4 1 5 . D e s p ite n o s t a t i s t i c a l s ig n if ic a n c e ( p - v a lu e 0 .0 8 8 ) in th e s p e c tr u m o f o r g a n is m s , v ir u le n t o r g a n is m s w e r e s e e n in th e flo ra o f b a b i e s o f m o th e r s w ith P L . N o n - p a th o g e n ic o r g a n is m s w e re m o s tly s e e n in th e c o n ju n c t iv a f lo r a o f i n f a n t s o f m o th e r s w h o h a d N L . C o a g u la se negative sta p h ylo co ccu s ( 3 5 .7 % ) . a n d S ta p h y lo c o cc u s a u reu s (2 8 .5 % ) w e r e f r e q u e n tly is o la te d in b a b ie s from th e N L g r o u p . S tre p viridans a n d E .c o li (in c o - e x is te n c e , 2 1 .1 % ) , a n d C N S (2 6 .3 % ) w e re the m o s t is o la te d o r g a n is m s in th e flo r a o f b a b ie s in th e P L g r o u p . A m o n g th e in v a s i v e o r g a n is m s . C a n d id a w a s fo u n d in 10 % o f th e n e o n a te s o f m o t h e r s w h o h a d P L . In th e s tu d y b y M u n d ia e l al. S ta p h aureus. S ta p h e p id erm id is a n d E .coli w e r e fr e q u e n tly is o la te d in th e -43- c o n ju n c tiv a o f n e w b o r n s o f m o th e r s w ith e i t h e r N L o r P L .1 P r e n ti c e et a l h a d s i m i l a r f in d in g s with th e m o s t is o l a t e d o r g a n is m s b e in g S ta p h a u reu s (8 % ) . S tr e p virid a n s ( 1 6 % ) a n d E .coli 15.4% ). T h i s w a s in a s t u d y in w h ic h th e in c id e n c e o f O N w a s f o u n d to b e 8 .2 %. 39 In a d d itio n . Isen b erg et a l a ls o i l l u s t r a t e d th e c o n ju n c t iv a l flo ra o f b a b ie s b o m b y S V D to b e m a in ly C N S 120% ) fo llo w e d b y E .c o li a n d S ta p h a u re u s (1 % e a c h ). '6 M ic r o o rg a n is m s is o l a t e d s h o w e d r e s is ta n c e to C h lo r a m p h e n ic o l a n d C o - t r i m o x a z o l e b u t w e re m ore s e n s itiv e to C e f o t a x i m e a n d C ip r o f l o x a c in ( T a b le 3 ). T h e c o m m o n ly u s e d to p ic a l d ru g s b y g en eral p r a c t i t i o n e r s a t U T H a s firs t lin e i n c lu d e G e n ta m y c in a n d P e n ic illin ( f o r tif ie d ) . T h e s e w ere n o t w i d e l y u s e d f o r r o u tin e s e n s itiv ity te s t s in th is s tu d y w i t h re g a rd to t h e i r re s is ta n c e . J afferji et al. d e m o n s t r a t e d th a t C e p h a l o s p o r i n 's h a d g o o d s e n s i t i v i t y w h e r e a s G e n ta m y c in a n d A m p ic illin h a d a h i g h r e s i s t a n c e .’7 M u n d ia et a l a ls o d e m o n s t r a t e d a s im ila r r e s is ta n c e p a tte r n .1 This s tu d y h a d s e v e r a l s tr e n g th s a n d lim it a ti o n s . T h e s t r e n g t h s in c lu d e d th e p r o s p e c tiv e m e th o d o f d a ta c o l l e c t i o n , a b i l i t y to p e rf o rm m ic r o b io lo g i c a l s tu d ie s o n th e s a m p le s in ti m e s o w e ll a s to d e te rm in e th e s e n s itiv ity p a tte r n . U n f o r t u n a te ly , w e w e r e u n a b le to c a r r y o u t P C R f o r a c c u r a te iso la tio n o f o r g a n i s m s s u c h a s C h la m yd ia o r G onococcus. C o l o n i e s w o u ld h a v e a l s o b e e n p re fe ra b ly c o u n te d u s i n g a n a u to m a te d m a c h i n e r a th e r th a n t h e m a n u a l m e th o d t h a t w a s a d o p te d . W e w e r e n o t a b le to c o lle c t in f o r m a tio n o n th e tim e o f r u p tu r e o f m e m b r a n e s in m o th e r s w ith e ith e r P L o r N L . -44- 10. C O N C L U S I O N 1. P r o l o n g e d l a b o u r d id n o t r e s u lt in h ig h c o lo n y c o u n ts . 2. M o t h e r s w ith P L w e r e o n s y s te m ic a n tib io tic s w h ic h m a y h a v e in f lu e n c e d th e o v e ra ll c o l o n y c o u n t. 3. A h i g h e r s p e c t r u m o f o r g a n is m s w a s is o la te d in b a b ie s o f m o th e r s w ith P L in c o n tr a s t to n e o n a t e s o f m o t h e r s w ith N L . P L a l s o in c r e a s e d th e o c c u r r e n c e o l p a th o g e n i c o r g a n is m s in t h e flo r a o f t h e b a b ie s . 4. C e f o t a x i m e & C ip r o f l o x a c i n w e re m o s t s e n s itiv e to th e o r g a n is m s is o la te d w ith C h l o r a m p h e n i c o l a n d C o - tr i m o x a z o l e b e in g m o s t r e s is ta n t. -45- 11. R E C O M M E N D A T I O N S 1. F o ll o w u p s t u d y o f n e o n a te s b o rn t o m o th e r s w ith P L in f ir s t m o n th o f lif e i s n e e d e d . T h is is to a s c e r t a i n th e o c c u r r e n c e o f O N a n d th e c a u s a t i v e m ic r o b ia l s p e c tr u m , a n d to s e e i f th e p a t t e r n is s im ila r o r n o t t o th a t is o la te d w ith in 2 4 h o u rs p o s tp a r tu m . 2. U s e o f C i p r o f l o x a c i n o r C e f o ta x i m e in O N a s s e n s itiv ity re s u lts a r e a w a ite d , o r w h e re m i c r o b i o l o g i c a l f a c ilitie s a r e n o t a v a il a b le . . C o n t i n u e d t e s t i n g o f a n tib io tic s f o r c h a n g in g s e n s itiv ity p a tte r n in Z a m b ia - 46 - 12.0 A P P E N D I C E S 12.1 A p p e n d i x I: M a p o f Z a m b ia ; L o c a ti o n o f L u s a k a ^TANZANIA > N OR t H ER N ANGOLA - 'NORTH- \ EA STERN WESTERN . MOZAMBI SO U TH ERN BOTSWANA 47 - 12.2 A p p e n d ix II ( E n g lis h ) : P a t ie n t I n fo r m a t io n s h e e t T itle o f s t u d y : O c u l a r f l o r a in n e w b o r n s o f m o t h e r s w it h p r o l o n g e d la b o u r a t t h e U n i v e r s i t y T e a c h i n g H o s p i t a l in L u s a k a . Z a m b i a . P r i n c i p a l I n v e s t i g a t o r : D r K a s o n g o le D a v i d , M B .C h B ( N .N o v g o r o d ) . M .M e d ( O p h t h ) re s id e n t l n i v e r s ity o f N a i r o b i . K e n y a . In tro d u c tio n Y o u a r e b e i n g in v ite d t o p a r tic ip a te in t h i s a lo r e m e n t io n e d s tu d y . T h e p u r p o s e o f o u r s tu d y is to d e te r m in e t h e s p e c t r u m , a n d q u a n tity o f o c u l a r tlo r a is o la te d f r o m n e o n a te s o l m o t h e r s w h o h a d p r o lo n g e d l a b o u r a n d c o m p a r e w ith th a t o f n e o n a te s o f m o th e r s w ith n o rm a l la b o u r . L x p la n a tio n o f p r o c e d u r e O n c e th e O n c e y o u a c c e p t to h a v e y o u r b a b y ta k e p a rt in th is s tu d y y o u ( m o t h e r o r g u a r d ia n ) w ill h e in te rv ie w e d u s in g a la id o u t s e t o f q u e s t i o n s . T h e b a b y s e y e s a n d o c u l a r a d n e x a w ill th e n be e x a m in e d a f te r w h ic h a c o n ju n c t iv a l s m e a r w ill b e ta k e n u s i n g a s ta n d a r d d is p o s a b le s w a b s tic k . The s p e c im e n s o b t a i n e d w ill i m m e d ia te ly b e s e n t to th e m i c r o b io lo g y la b o r a to r y lo r s p e c if ic e x a m in a tio n . R is k s a n d d i s c o m f o r t s The p ro c e d u re s to b e e n c o u n te r e d a re n o n - in v a s iv e . a n d t h e r e f o r e m in im a l s id e e f f e c t s are e x p e c te d i f a n y a t a ll. T h e b a b y is n o t e x p e c t e d to e x p e r ie n c e p a in a s th e s m e a r is ta k e n . - 48 - B e n e f its \n v o c u la r i n f e c t i o n s o r a b n o r m a litie s p r e s e n t s h a ll b e a d d r e s s e d o r o th e r w is e r e l e v a n t r e te r r a l >r s p e c ia lis t c a r e w i l l b e m a d e . Y o u w ill a l s o b e m a k in g a m a j o r c o n tr ib u tio n to t h e in f o r m a tio n >n o c u la r f l o r a a n d in p a r t i c u l a r p r o lo n g e d l a b o u r a s a ris k f a c t o r o f o p h th a lm ia n e o n a to r u m . C o n fid e n tia lity ' \11 i n f o r m a t i o n g a t h e r e d fro m th e s tu d y a n d y o u r id e n tity w ill re m a in c o n f id e n tia l th r o u g h o u t the p ro c e ss. The re s u lts m ay be p u b lis h e d fo r p la n n in g and a w are n e ss to o th e rs . W i t h d r a w a l w i t h o u t P r e j u d ic e l.n r o llm e n t in to t h is s t u d y is v o lu n ta ry a n d th e r e f o r e r e f u s a l t o p a r tic ip a te w ill a t t r a c t n o p e n a lty . Y ou a r e f r e e to w ith d r a w c o n s e n t a n d d is c o n t i n u e p a r tic ip a tio n in th e p r o je c t a t a n y tim e w ith o u t p re ju d ic e f r o m th is in s titu tio n . C o s ts a n d / o r P a y m e n t s to S u b j e c t fo r P a r t ic ip a t io n in R e s e a r c h P a rtic ip a n ts w ill n o t b e p a id to p a r tic ip a te in th is re s e a rc h p r o je c t. Q u e s tio n s If c a s e o f a n y p r o b l e m o r q u e s ti o n s c o n c e r n i n g th is s tu d y , y o u r rig h ts a s a p a r tic ip a n t, o r a b o u t any r e s e a r c h r e la te d i n ju r y , c o n ta c t th e p r in c ip a l in v e s tig a to r o f th is s tu d y : D r K a s o n g o l e D a v id I e le p h o n e n u m b e r : + 2 6 0 - 9 7 9 - 1 5 6 8 5 4 o r v i a E - m a il: k a v d e e 1 3 3 @ y a h o o .c o .u k or rite C h a ir m a n o f th e R e s e a r c h a n d E th ic s C o m m itte e : I e le p h o n e n u m b e r : + 2 6 0 - 1 - 2 5 6 0 6 7 , E - m a i l: u n z arec Y / u n z a .z m Postal a d d r e s s : R id g e w a y C a m p u s . P .O . B o x 5 0 1 1 0 . L u s a k a . Z a m b ia - 49 - 1 2 .2 .1 A p p e n d ix II ( N y a n j a ) : k u d w a l a m a s o k w a a n a a c h i c h e p c l e c h i f u k w a c h a k u c h e d w a k u b e le k a k w a a / i m a i a w o p a h i p a t a l a c h a U n i v e r s i t y t e a c h i n g H o s p i t a l L u s a k a Z a m b ia . k k u l u a z o f u f u z a : D r K a s o n g o le D a v id , M B .C h B ( N .N o v g o r o d ) . M .M e d ( O p h th ) r e s id e n t. U n iv e rs ity o f N a ir o b i. K e n y a . M au o u n ik ila /a m k a t i M w a ita n id w a k u te n g a k o m b a li k u m a p u n z i r o a m e n e a c h u lin d w a p a m w a m b a . C h o lin g a c h a m a p u n z ir o a w a n d i k u p e z a n g ir a n d i m u y e s o w a k u d w a la m a s o k u s iy a n is a p a li a z im a i o e h e d w a k u b a la n d i a z i m a i o b a la p a n ta w i y a k e . Kumasulira k w a m undondom eko :n u k a \ o m e r e z a k u ti m w a n a w a n u a te n g e k o m b a li k u m a p u n z i r o a tu (a m a i o s u n g a m w a n a ) m u z a f u n s in d w a m a f u n s o k u lin g a n a n d i m u n d o n d o m e k o w a m a t u n s o m a n s o a m w a n a n di k u te n g a m o m a n to g o y a m e n e tiz a p e le k a k u m a k in a y o p im ir a n d i k u y a p im a m a n to g o . C h iy o p w e z o n d i k u s o w a m u te d e r e M u n d o n d o m e k o w a k u p u n z i r a k w a tu k u l i b e c h o ip a c h ilic h o n s e c h in g a c h itik e n d i p o n s o m w a n a w a n u s a z a \ e r a z o w a w a z iliz o n s e p o ta n g a m a n to n g o . P in d u N g a ti m a s o v a m w a n a y a li n a m a te n d a y a m a s o o lo m u lik a lik o n s e k a m e n e s i k a t u n i k a k u k a la m o . m w a n a a z a o n e d w a n d i a d o to lo a m a s o . M u z a ta n d iz i r a p a k u p e l e k a u te g a w a k u d w a la m a s o k w a ana c h if u k w a c h a k u c h e d w a k w a k u b e l e k a k w a a m a i a w o . K u s u n g a c h is in s i / a m e n e z iz a k a m b id w e n d i zi z in d ik ilo z a n u z iz a n k a la c h is in s i k u y a m b a n i k u s i l i z a k w a m a p u n ziro v a th u . Z o t u l u k a z iz a u lu s id w e n d i k u k o n z e d w a k u p u n z is i la m o a z m a i e n a . -50- _ u te n g a k o m b a l i s i k w a c h i k a k a m i z o n d ip o n g a ti si m u f u n a k u te n g a k o m b a li s i tiz a k u le se n i a u g a le k e p o m w e m w a f u n i r a . *■ lu tt-n g o / M a l i p i l o p o t e n g a k n m b a li m u k u f u f u z a k w a tu > ten g ak o m b a l i s a z a l i p i l a n d a la m a p a c h i f u f u z o c h a tu . v la fu n s o ■'vgati p a li z o v u i a n d i m a f u n s o y o k u z a m a p u n z i r o y a tu . U f u lu w a n u o te n g a k o m b a li. o lo n g a ti - .w a p e z e k a z i l o n d a . Z i b i s a n i o f u f u z a p a z a m a p u n z ir o a d o to lo K a s o n g o l e D a v id -«a n a m b a l a i y i : + 2 6 0 - 0 9 7 9 - 1 5 6 8 5 4 o lo p a e - m a i l : k a v d e e l 3 3 v a h o o .c o .u k O lo A k u lu a z o f u f u z a Pa n a m b a l a : + 2 6 0 - 1 - 2 5 6 0 6 7 . E - m a il: u n z a r e c @ ,u n z a .z m C a re ra : R i d g e w a y C a m p u s . P . 0 B o x 5 0 1 1 0 L u sa k a . Z a m b i a . - 51 - 1 2 .3 A p p e n d i x 111 ( E n g lis h ) : C o n s e n t /A g r e e m e n t fo r m K in d ly p r in t in b lo ck le tte rs in the sp a ces g iv e n below. Y o u r s ig n a tu r e on th is fo rm im p lies th a t you u n d erstan d th e in fo rm atio n p resen ted , and th a t y o u accep t to h a \ e y o u r c h ild e n ro lle d in th e stu d y . Y ou u n d erstan d th at p a rtic ip a tio n is voluntary', an d you may u ith d ra w fro m th e s tu d y a t a n y tim e. • I h a v e r e a d th e in f o r m a tio n s h e e t c o n c e r n i n g th is s tu d y , ( o r h a v e u n d e r s to o d th e v e rb a l e x p la n a tio n ) . • M y q u e s tio n s h a v e b e e n a n s w e re d b y D r K a s o n g o le D a v id • I u n d e r s ta n d th a t a t a n y tim e I m a y w i t h d r a w fro m th is s t u d y w ith o u t g iv in g a re a s o n a n d w ith o u t it a f f e c t in g m y c h i l d 's c a r e a n d m a n a g e m e n t. • I a g r e e to h a v e m y c h ild ta k e p a rt in t h i s s tu d y . S ig n a tu r e o f m o t h e r / g u a r d i a n ............................................. D a t e : ..................... O r T h u m b P r in t: N a m e o f P a r t i c i p a n t ...................................................................... S ig n a tu r e o f W i t n e s s ...................................................... D a te : S ig n a tu r e o f R e s e a r c h e r ...................................................... D a te : - 52 - 1 2 .3 .1 A p p e n d i x 111 ( N y a n j a ) : L e m b a n i m u m a n u m b e r a y a k u lu p a n s i a p o . k u s a i n a k w a n u k u s u n v e z a k u ti m w a n v e s e s a n d i z o m w e m w a u z id w a . n d i k u ti m w a v o m e r e z a k u li m w a n a w a n u a o n e d w e rn a so . M w a n v e s e s a k u ti k u te n g a k o m b a l u m u m a p u n z ir o n i k u f u n a k w a n u n d i k u ti m u n g a le k e p a n ta w i iliy o n s e . • N a b e l e n g a z o n e s z a m a p u n z ir o a y a ( n a n v e s e s a m a u y a p a k a m w a ) . • M a f u n s o y a n g a y a v a n k id w a n d i a d o t o l o K a s o n g o le D a v id • N a n v e s e s a k u ti n ig a le k e m a p u n z ir o n ta w i iliy o n s e . P o p a n d a k u p a s a lin g o n d i p o s ic h iz a s o k o n e z a k u su n g a m w an a w anga. • N d a v o m e r a k u t i m w a n a w a n g a a te n g e k o m b a li m u p u n z i r o ili. s ik u K u s a in a k w a m a i / o s u n g a m w a n a O lo c h i d i n d o l ) / i n a y a o d w a l a .............................................................. k u s a i n a k w a m b o n i ..................................... s ik u : k u s a i n a o f u f u z a ........................................ s ik u : - 53- 1 2 .4 A p p e n d i x IV : Q u e s t io n n a i r e O c u l a r F lo r a O f N e w b o r n s F r o m M o t h e r s W ith P r o lo n g e d L a b o u r A t I he U n i v e r s i t y T e a c h i n g H o s p it a l In L u s a k a 8 .3 .1 M a t e r n a l P r o f ile T ick lu in d ic a te o p tio n o f ch o ice o th erw ise p r in t in b lock letters. 1) D a t e : ................................... 2) I P n u m b e r : .............................. 3) A g e : ................ 6) P ro lo n g e d 7) D u ra tio n o f la b o u r > 1 2 h o u rs . 8) N u m b e r o f V a g i n a l e x a m s ........................................... 9) M e d ic a tio n s la b o u r 5 ) P a r i t y ............................... CD o r N o r m a l la b o u r Y es EH or EH N o EH P e s s a ry /s y s te m ic a n tib io tic th e ra p y ta k e n 2 w e e k s p rio r to d e liv e ry , Y es EH o r I f y e s s p e c i f y ........................................................................................................................................... 10) H is to ry o f a n te n a ta l v a g in a l d is c h a r g e . Y e s 1 1 ) A n te n a ta l s c r e e n in g te s t r e s u lts EH or N o D ( i f a v a ila b le in d ic a te b e lo w ) H I V ........................................ S T I (note ty p e ) .................... -54- N o EH 1 2 .3 .2 N e w b o r n P r o f ile T ic k to in d ic a te o p tio n o f ch o ice o th e rw ise p rin t in blo ck letters. 1) D a t e .............................. 2 ) IP n u m b e r ..................... 2 ) A g e in h o u r s ................. 3) Sex 4) 5 ) I i m e ............................... D a t e o f d e l i v e r y ................... M D or F d l 6 ) M o d e o f d e liv e ry SV D CH C /S Q A s s is te d 7 ) M e c o n iu m p re s e n c e . Y es D □ or N o □ 7 ) G e s ta tio n a l A g e T e rm ( > 3 7 w k ) □ P r e te rm ( < 3 7 w k ) □ 8 ) D a t e c o n j u n c t i v a s w a b t a k e n ............................................... 9 ) O c u l a r m e d i c a t i o n s g iv e n b e fo re t a k in g s w a b . Y e s CH o r N o CH I f y e s s p e c i f y .............................................................................................. 10) O c u l a r s ig n s o f C o n j u n c t i v i t i s . Y e s D or No D I f y e s lic k b e l o w a p p r o p r ia te ly O L id o e d e m a /s w e ll in g O C o n ju n c tiv a re d n e ss O C o n ju n c tiv a c h e m o s is O D is c h a r g e (p u r u le n t, m u c o i d , w a te r y ) O O th e r s ( s p e c if y ) - 55 - 1 2 .3 .3 L a b o ra to ry W ork U p o f N ew born D a t e .............................. O c u la r a) IP n u m b e r . P r o file M ic r o s c o p y fin d in g s b) Culture (tic k in the relevant box) T im e ( h o u r s ) +Ve CH or -V e EH 4 8 ho u rs 2 4 h o u rs .N? c o lo n ie s O r g a n is m is o la te d S e n s itiv ity pattern - 56 - 1 3 .0 R E F E R E N C E S M u n d i a . D . G . , M a s i n d e . M .S .. I la k o . D .R : P u b lis h e d M M E D d is s e r ta tio n . R isk o f d e v e lo p in g n e o n a ta l c o n ju n c tiv itis in n e w b o rn o f m o th ers w ith p r o lo n g e d la b o u r. E A J O : 2 0 0 8 : T h e r e s a . K . L . . M a d h a v a n . H .N : M ic ro b io lo g ic a l p ro c e d u res f o r d ia g n o sis o f o c u la r in fectio n s. L & T M i c r o b i o l o g y R e s e a r c h c e n t r e v is io n R e s e a r c h fo u n d a tio n . E d e r. M ., F a r i n a . N . , S a n a b r i a . R ., T a . C .. K o s s . M .. S a m u d io . M .. et ah N o rm a l o c u la r flo ra in n e w b o r n s d e liv e r e d at tw o h o sp ita l cen ters in P a ra g u a y & A rgentina. G r a e f e s a r c h iv e f o r c l i n i c a l & e x p e r i m e n t a l o p h th a lm o lo g y . 2 0 0 5 ; 2 4 o ( 1 1 ); 1 0 9 8 -1 0 7 . A r m s tr o n g . J . . F a c a r i a s . F .. R e in . M ; O p h th a lm ia n eo n a to ru m : A c h a r t r e v ie w . P a e d ia tric s . 1 9 7 6 ; 5 7 : 8 8 4 - 9 2 . 5 J o h n . S .S : E ye D is e a s e s in hot clim a tes. E ls e v ie r p u b lic a tio n . In d ia . 2 0 0 6 : 4 th e d itio n . 6 A le x a n d e r. A .B .. K l a u s . P .S : N eo n a ta l o p h th a lm ia in tro p ica l countries. T r o p ic a l in fe c tio u s d is e a s e s o f th e e y e ; 6 4 6 Is e n b e rg . S ., A p t. L .. W o o d . M : The in flu en ce o f p e rin a ta l in fective fa cto rs on o p h th a lm ia N eonatorum : J o u r n a l o t P a e d . O p h th a n d S tr a b is m u s . 1 9 9 6 . 3 o ( o ) . 1 8 5 -8 8 * O rw e n y o . E .A ; A s tu d y o f cerv ica l in fectio n s w ith N. g o n o rrh ea . C. tra ch o m a tis a n d H erpes sim plex viru s d u r in g 111 T rim ester at K e n y a tta N a tio n a l H ospital: U n p u b lis h e d M M E D d is s e r ta tio n . 1 9 8 4 . * D a tta. P .. F r o s t, E .. P e e lin g . R .. M a s in d e . S ., D e s la n d e s . S ., E c h e lu . C . et al: O ph th a lm ia neonato rum in tra c h o m a en d em ic u rea . J o u r n a l o i S e x u a lly 1 ra n s m itte d d is e a s e s (U S A ). 1 9 9 4 ;2 1 ( 1 ) : 1 - 4 M y ro n . Y .. J a y . S : O phth alm olo gy>, s e c o n d e d itio n . 2 0 0 6 : V o l . l : 4 0 3 - 4 0 4 -57- K a n s k i . J .J : C lin ic a l O p h th a lm o lo g y : A s y s t e m i c a p p r o a c h . E l s e v i e r p u b lic a tio n . In d ia . 2 0 0 7 : 6 th e d i t i o n : 2 2 3 - 2 2 4 T r i v e d y . J . , I la k o D ., R e v a t h i G : E tio lo g y a m i p a tte rn o f n e o n a ta l co n ju n ctivitis in X a ir o b i. M M E D D is s e r t a t i o n . 2 0 0 3 . 13 L a g a . M .. P l u m m e r . F .. P io t . P .. D a tta . P .. N a m a a r a . W .. N z a n z e . H . et a l: P r o p h y la x i s o f G o n o c o c c a l a n d C h l a m y d i a l O p h th a lm ia n e o n a to r u m . A co m p a riso n o f S ilver n itra te anil T e tr a c y c lin e : N E J M , Vol. 3 IS: 653 -6 5 ". 1988 14 C h a n d l e r . J . . A l e x a n d e r . E .. P h e if f e r , T .. W a n g , S .. H o lm e s . K .. E n g lis h . M : O p h th a lm ia n e o n a to r u m a sso c ia te d w ith m a tern a l C h la m y d ia l infections. T r a n s S e c t O p h t h a l m o l A m A c a d O p h th a lm o l O to la r y n g o l. 1 9 7 7 M a r - A p r : 8 3 (2 ): j 15 F r a n s o n . L . , K l a u s s . V : 02-8. N e o n a ta l o p h t h a l m i a in th e d e v e l o p i n g c o u n tr ie s . E pidem io lo gy, m a n a g e m e n t a n d C o n tro l. J in t e c t d is . 1 9 8 6 ; 1 1 :1 8 9 - 9 6 . h O h a ra . M . A . O p h th a lm ia neonatorum : P e d ia tr c lin N o r th A m 1 9 9 3 : 4 0 ( 4 ) : 7 1 5 - 2 5 . 17 H a m m e r s c h l o g . M : N e o n a ta l c o n ju n ctivitis. P a e d ia tric A n n a ls 1 9 9 3 : 2 2 ( 6 ) : 3 4 6 - 3 5 1 . G a o . Y .N : B a c te r ia l co n d itio n o f the lo w e r g en ita l t r a d o f p re g n a n t w om en a n d neonatal Infection. C h u n g H u a F u C han K o I s a C hih 1 9 9 3 ; 2 8 ( 1 2 ) 7 1 7 - 9 .7 5 9 . B a s ic a n d c lin ic a l s c i e n c e c o u r s e : A m e rica n A c a d em y o f o p h th a lm o lo g y . s e c tio n 13. 2 0 0 3 - 2 0 0 4 e d itio n . W H O : C o n j u n c t i v i t i s o f th e n e w b o r n : P reven tio n a n d trea tm en t at th e p r im a ry ca re level. P P l - 3 .G e n e v a . S w i t z e r l a n d , w o r ld h e a lth o r g a n iz a ti o n . 1 9 8 6 . S te in f ie ld . J .. L e n k o s k i. C .. L e r e r . T .. W a x . J .. In g a rd ia . C : N eo n a ta l m o rb id ity a t 3 4 -3 7 Weeks, th e role o f ru p tu re d m em branes. O b s . G y n a e c o lo g y . J u ly 1 9 9 9 ; 9 4 1: 1 2 0 -3 P h ilip . H .A : S a n F r a n c is c o . P ro lo n g e d la b o r. V o l .7 6 ; N o .l - 58 - S a ju . J . . S c o t t . P .. L y o n , D : e M e d i c i n e O b s /C iy n . A b n o rm a l la b o u r : u p d a te d 2 0 0 8 E I - M o w a f i . D . M : O b ste tr ic s sim p lified . P u b li s h e d by th e a u th o r . 1 9 9 7 ; 1 e d itio n . R o o s e m a le n . J .V : M a te r n a l h eig h t a n d p r o lo n g e d la b o u r in r u r a l Tanzania. J o u r n a l o f O B S / G Y N . o f E a s t e r n & C e n tr a l A f r ic a . 1 9 9 1 ; 9 2 : 1 2 3 4 V aughan. A: G e n e r a l O p h th a lm o lo g y. L a n g e 1 9 8 0 ; 1 0 lh e d i t i o n : 331 C h a n d l e r . J . W . . R a p o z a . P .A : O p h th a lm ia n eo n a to ru m . Int O p h th a lm o l C lin . 1 9 9 0 :3 0 :3 6 - 3 8 . ‘ P a v a n . D .L : M a n u a l o f o c u la r d ia g n o sis a n d th erapy. 2 0 0 2 ; 5 e d itio n N H e r tle . R . W . . S c h a f f e r . D .B ., F o s te r . J .A : P ediatric eye d isea se color a tla s & sy n o p sis. 2 0 0 2 : 1 :3 -4 30 I s e n b e r g . S . . A p t , L .. W o o d . M : The in flu en ce o f p e rin a ta l in fe c tive fa c to r s on o p h th a lm ia n e o n a to r u m : J o u r n a l o f P a e d . O p h th & S tr a b is m u s . 1 9 9 6 : j 3 ( 3 ) . 1 8 3 -1 8 8 H o lla n d . G . N . . I s e n b e r g . S .J : In fectio u s diseases. In : I s e n b e r g S .J . e d . T h e e y e in m ia n c y . 2nd e d . S t L o u i s : M o s b y : 1 9 9 4 :4 9 3 - 5 0 4 : O 'H a r a . M . A : O p h th a lm ia neo n a to ru m : P e d ia tr C lin N o rth A m . 1 9 9 3 : 4 0 . 7 1 5 - 7 2 5 - | Se n b e r g . S . , A p t. L .. W o o d . M : C o n tro lle d Trial o f P o vid o n e-Io d in e a s p r o p h y la x is against 0 . n e o n a to r u m : N E J M . 1 9 9 5 : V o l.3 3 2 : 5 6 2 - 5 6 6 4 I s e n b e r g . S ., A p t. L .. D e l S ig n o e .. M .. G i c h u h i . S .. B e r m a n . N : A dou b le a p p lica tio n A p p ro a c h to o p h th a lm ia n eo n a to ru m p ro p h yla xis: B r. J. O p h th a lm o l. 2 0 0 3 ; V o l.8 7 : 1 4 4 9 1452 G ic h u h i. S .. B o s ir e . R .. M b o r i- G a n c h a . D .. G ic h u h i. C .. W a m w a la . D „ M a le c h e - O b im b o . E. e t a l: R is k fa c to r s f o r n eo n a ta l c o n ju n ctivitis in babies o f m o th e rs w ith U IV -1 in fe c te d m o th ers: O p h th a lm ic e p id e m io lo g y . 2 0 0 9 : V 0 I . I 6 .N 0 .6 ; 3 o 7 -:> 4 5 - 59 - I s e n b e r g . S . . A p t . L .. Y o s h i m o r i . R ., M c C a r ty . J .. A lv a r e z . S : Source o f th e c o n ju n ctiva l b a c te r ia l fl o r a a t b irth a n d im p lic a tio n s f o r o p h th a lm ia n e o n a to ru m p ro p h yla xis; A m J O p h t h a l m o l . 1 9 8 8 O c t 1 5 :1 0 6 ( 4 ) :4 5 8 - 6 2 . 37 J a f f e i j i . S .. l l a k o . D .. K o l l m a n n . M .. K a r iu k i. M : A n tib io tic s e n s itiv ity p a tte rn o f s ta p h y lo c o c c u s a u r e u s ; E A J O . 2 0 0 8 ; 14: 2 9 - 3 7 . a Z „ g a . O .. N j u g u n a . M „ G i c h u h i . S .. T r i v e d y . J : M .M e d d i s s e r t a t i o n ; E ffect co n ju n ctiva fo r n i x ir r ig a tio n w ith l i d sc ru b s a s a c a ta ra c t su rg e ry -A r a n d o m iz e d c o n tro lle d tr ia l o f th e effe ct 5 % P o vid o n e io d in e on the on n o rm a l flora o f th e o c u la r a d n exa . 2 0 0 9 —3 . » P rentice. M .. H u t c h i n s o n . G .. T a y l o r - R o b i n s o n . D : A m ic ro b io lo g ica l stu d y o f n e o n a ta l c o n ju n c tiv a e a n d c o n ju n c tiv itis: B r . J . O p h th a lm o . 1 9 7 7 .6 1 .6 0 1 y - • 'i i m r a s i T v - 60' 0F fjA in p p r M E D IC A L L I B R A R Y %