ORIGINAL ARTICLE

Development of clinical sign based algorithms for community based assessment of omphalitis

L C Mullany¹, G L Darmstadt¹, J Katz¹, S K Khatry², S C LeClerq¹, R K Adhikari³ and J M Tielsch¹

¹ Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
² Nepal Nutrition Intervention Project, Sarlahi (NNIPS), Kathmandu, Nepal
³ Institute of Medicine, Tribhuvan University, Kathmandu

Correspondence to:
Correspondence to:
Dr Mullany
Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Suite W5021, Baltimore, MD 21211, USA; lmullany{at}jhsph.edu

Background: In developing countries, newborn omphalitis contributes significantly to morbidity and mortality. Community based identification and management of omphalitis will require standardised clinical sign based definitions.

View larger version (116K): [in this window] [in a new window]   Figure 1  Images of umbilical cord of infants in Sarlahi, Nepal: (A) mild redness, four days after birth; (B) pus, moderate redness, six days after birth; (C) moderate swelling, four days after birth; (D) severe redness, three days after birth; (E) pus, moderate redness, three days after birth; (F) pus, severe redness, moderate swelling, three days after birth. Parental consent was obtained for publication of this figure.

Objective: To identify optimal sign based algorithms to define omphalitis in the community and to evaluate the reliability and validity of cord assessments by non-specialist health workers for clinical signs of omphalitis.

Design: Within a trial of the impact of topical antiseptics on umbilical cord infection in rural Nepal, digital images of the umbilical cord were collected. Workers responsible for in-home examinations of the umbilical cord evaluated the images for signs of infection (pus, redness, swelling). Intraworker and interworker agreement was evaluated, and sensitivity and specificity compared with a physician generated gold standard ranking were estimated.

Results: Sensitivity and specificity of worker evaluations were high for pus (90% and 96% respectively) and moderate for redness (57% and 95% respectively). Swelling was the least reliably identified sign. Measures of observer agreement were similar to that previously recorded between experts evaluating subjective skin conditions. A composite definition for omphalitis that combined pus and redness without regard to swelling was the most sensitive and specific.

Conclusions: Two sign based algorithms for defining omphalitis are recommended for use in the community. Focusing on redness extending to the skin around the base of the stump will identify cases of moderate and high severity. Requiring both the presence of pus and redness will result in a definition with very high specificity and moderate to high sensitivity.

Keywords: omphalitis; infection; umbilical cord infection; validation; Nepal

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This article has been cited by other articles:

• Mullany, L. C., Darmstadt, G. L., Katz, J., Khatry, S. K., LeClerq, S. C., Adhikari, R. K., Tielsch, J. M. (2007). Risk Factors for Umbilical Cord Infection among Newborns of Southern Nepal. Am J Epidemiol 165: 203-211 [Abstract] [Full Text]  
• Mullany, L. C., Darmstadt, G. L., Khatry, S. K., LeClerq, S. C., Katz, J., Tielsch, J. M. (2006). Impact of Umbilical Cord Cleansing With 4.0% Chlorhexidine on Time to Cord Separation Among Newborns in Southern Nepal: A Cluster-Randomized, Community-Based Trial. Pediatrics 118: 1864-1871 [Abstract] [Full Text]