|Year : 2013 | Volume
| Issue : 2 | Page : 60-65
Maternal risk factors for neonatal conjunctivitis in Aminu Kano Teaching Hospital, Kano, Nigeria
Abdulsalam Mohammed1, Mu'utassim Ibrahim1, Asani Mustafa1, Uchechukwu Ihesiulor2
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Microbiology, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||7-Dec-2013|
Department of Paediatrics Aminu Kano Teaching Hospital/ Bayero University Kano
Source of Support: None, Conflict of Interest: None
Background: Neonatal conjunctivitis remains a major cause of preventable childhood blindness in developing countries. There are maternal risk factors, which if identified can assist in its prevention. Objective: This study attempts to determine the maternal risk factors for the development of neonatal conjunctivitis among babies seen in a tertiary health facility in Kano, Nigeria. Materials and Methods: This was a cross-sectional study. Neonates from special care baby unit, postnatal ward, paediatric out-patient unit and labour room who had bilateral or unilateral eye discharge were enrolled in the study. Those neonates whose parents refused consent were excluded from the study. The questionnaire sorted for information including patients' biodata, place and mode of delivery, age at onset of eye discharge, mothers' biodata, antenatal care attendance, educational and socioeconomic status and obstetrics history. Samples were collected and Gram staining was conducted using standard technique. Chlamydial antigens were detected using a rapid immunochromatographic technique (ICT). The data were analysed using EPI INFO version 3.5.1 2002. Proportions were compared using Chi-square test of significance. A probability (P - value) of less than 0.05 was considered statistically significant. Results: A total of 175 neonates were studied. The mean age was 5.7 ± 4.6 days with a male:female ratio of 1.1:1. Low level of maternal education, lack of antenatal care attendance, prolonged rupture of amniotic membranes and low socioeconomic status were significantly associated with isolate positive neonatal conjunctivitis. Conclusion: Maternal factors including lack of antenatal care attendance and poor socioeconomic conditions are significantly associated with isolate positive neonatal conjunctivitis.
Keywords: Bacterial conjunctivitis, maternal, neonatal conjunctivitis, ophthalmic infections, ophthalmic neonatorum, purulent conjunctivitis, risk factors
|How to cite this article:|
Mohammed A, Ibrahim M, Mustafa A, Ihesiulor U. Maternal risk factors for neonatal conjunctivitis in Aminu Kano Teaching Hospital, Kano, Nigeria. Niger J Basic Clin Sci 2013;10:60-5
|How to cite this URL:|
Mohammed A, Ibrahim M, Mustafa A, Ihesiulor U. Maternal risk factors for neonatal conjunctivitis in Aminu Kano Teaching Hospital, Kano, Nigeria. Niger J Basic Clin Sci [serial online] 2013 [cited 2023 Feb 4];10:60-5. Available from: https://www.njbcs.net/text.asp?2013/10/2/60/122759
| Introduction|| |
Neonatal conjunctivitis has long been a public health problem in many countries at certain stages of their development.  Faal  noted that there was an estimated one and a half million blind children in the world in 1992 and every year about half a million more became blind. Most of these children are in Asian and African countries and neonatal conjunctivitis was responsible for blindness in majority of them. 
The major causes of neonatal conjunctivitis are bacterial and viral infections.  The association between profuse maternal leucorrhoea (vaginal discharge) and severe neonatal conjunctivitis was noted long before bacteria became known as pathogens. Gibson  in 1807 reported that babies contracted the disease when purulent secretions in the birth canal enter their eyes either intra-partum or immediately post-partum. As early as 1870 Quellmaz  noted that if the mother had gonorrhoea, the infant's eyes were usually infected; but he assumed that transmission of the disease was via bloodstream. Variation in the incidence of neonatal conjunctivitis is related to the aetiology of the disease, and its relationship with sexually transmitted infections (STI).  The incidence of neonatal conjunctivitis has also been associated with the difference in socioeconomic factors, which determine the health seeking behaviour of the individual and the community.  Most ophthalmic infections in the neonatal period are acquired during vaginal delivery and reflect the sexually transmitted diseases prevalent in the community.  In Zaria, Nigeria Bello et al.,  showed the prevalence of STI to be high. In another study, the transmission rate of gonorrhoeae from an infected mother to her newborn was reported to be 30-50% , while 67% of neonates who had conjunctivitis had isolates similar to those detected in the placentae and lower genital tract of their mothers.  This suggests that vertical transmission may play an important role in aetiology of ophthalmia neonatorum. In general, offspring of women who receive pre-natal care have a lower incidence of infectious conjunctivitis  and in the absence of maternal STIs, neonatal conjunctivitis is caused by several other agents, which are not necessarily causative agents of STI or agents of maternal vaginal flora. 
A study from Ilorin found the pre-disposing factors to neonatal conjunctivitis to include antenatal maternal vaginal discharge, low social class and maternal age less than 20 years. Other factors include un-booked maternal status, babies requiring aggressive resuscitation at birth, low gestational age and padding of the eyes during phototherapy.  A case control study of neonatal conjunctivitis in Kaduna, Northern Nigeria, by Olatunji  found the main risk factors in the development of neonatal conjunctivitis to be maternal vaginal discharge during pregnancy, place of delivery and prolonged rupture of amniotic membranes. In a study carried out in Kenya, four peri-natal factors, namely maternal vaginitis, presence of meconium in the eyes of the newborn at birth, birth in unsterile environment and post-natal development of endometritis were identified as risk factor for the development of neonatal conjunctivitis.  This study attempts to determine the maternal risk factors for the development of neonatal conjunctivitis and provide essential steps for its subsequent prevention.
| Materials and Methods|| |
This was a cross-sectional study. The inclusion criteria involves all babies within the age of 0-28 days presenting at special care baby unit, paediatric outpatient unit, the post-natal ward and labour ward of Aminu Kano Teaching Hospital (AKTH) with discharge from one or both eyes. These neonates were enrolled in to the study. Exclusion criteria included parents refusal of consent. The World Health Organisation's Working Group on Neonatal Conjunctivitis defined it as any conjunctivitis with discharge occurring during the first 28 days of life. 
Approval was obtained from the Ethics Committee of AKTH. Informed and written consent of the primary care givers was obtained after explanation of the nature and objectives of the study. The sample size of 175 was determined based on the highest prevalence of positive bacterial isolates of 13.15% reported from Ilorin.  A pre-tested questionnaire was administered by face-to-face interview to the care giver. Information obtained included patients biodata, place and mode of delivery, birth weight (where possible) and age at onset of eye discharge. Others include mother's biodata, educational and socioeconomic status, paternal biodata, educational and socioeconomic status. Obstetrics history including antenatal care attendance, prolonged rupture of amniotic membranes, vaginal discharge, duration of labour, place and mode of delivery were also obtained.
General condition of the babies was assessed followed by thorough physical examination. The investigator's hands and those of his assistants were thoroughly washed using soap and water and sterile gloves worn. The conjunctivae were exposed by gentle traction on the eyelids and specimens taken. A sterile cotton-tipped applicator was used to obtain a swab of the palpebral and bulbar conjunctiva of the affected eye when unilateral or the worse eye when bilateral. Two swab specimens were taken from each patient using two different swab sticks; one for chlamydia immunochromatographic test and the other for bacterial Gram stain and culture. Swabs were not taken while a baby was crying to avoid the bactericidal effects of lysosome in tears on the bacteria present in the discharge. Eye swabs were taken to the microbiology laboratory by the investigator with assistance of the two research assistants immediately after collection and nutrient broth was used as transport medium. Samples were immersed in the broth in universal bottles and transported to the laboratory within 30 minutes to one hour.
The broth consisted of peptone, beef extracts and sodium chloride, which served as nutrients for the pathologic organisms.
Gram staining of slides was by standard technique.  The Mckonky and Chocolate agar plates on which the samples were inoculated were incubated for 24-48 hours at 37°C. The aerobic isolates were identified by the standard methods of Cowan.  Anaerobes were not studied due to lack of facilities. Chlamydial antigen was detected using rapid immunochromatographic technique (ICT). This test was carried out for the detection of Chlamydial antigens using a rapid ICT. It is sensitive and specific, simple to perform and read with built in controls.  Using the Chlamydia STAT-PAK the antigen was extracted from the eye discharge specimen at room temperature. Three to five millilitres of reagent A were dispensed into the extraction tube. The swab was extracted by rotating the swab stick inside reagent A for 15 times and allowed to stand for 2 minutes. A quantitative pipette was filled to the mark line with reagent B and then added to the extraction tube. The resultant solution turned cloudy. The swab was extracted again by rotating the swab stick at the bottom of the tube until the solution turned clear or blue tint. The extraction tube was then covered and allowed to stand for 1 minute. Two to three drops of the prepared suspension were added into the kits and allowed to stand for 20 minutes. The appearance of two red lines indicates a positive result while one red line indicates a negative result.  This rapid method recognises markers from the bacteria in specimens that may be self-collected swabs or swabs collected by healthcare providers. 
The data generated were entered into a Microsoft Excel spreadsheet and analysed using EPI INFO version 3.5.1 2002.  Continuous variables were summarised using means, medians and ranges as appropriate. Frequency tables were generated and cross tabulation to observe the relationship between categorical variables were done. Proportions were compared using Chi-square test of significance. A probability (P-value) of less than 0.05 was considered statistically significant.
| Results|| |
A total of 175 neonates were studied. The age range of subjects at presentation was 1-24 days with the mean age of 5.7 ± 4.6 days. Ninety-one (52%) neonates were males while 84 (48%) were females with a male:female ratio of 1.1:1. Of those who had their birth weight recorded, the birth weight ranged from 1200-4200 g with a mean of 3000 g. The birth weights of 94 neonates were not recorded because they were either born at home or in private clinics where the birth weights were not recorded. Fourteen (8%) neonates had low birth weight (<2500 g) of whom 10 were pre-term. Fifty-four (31%) of the neonates were delivered in AKTH while 56 (32%) were delivered in other hospitals. Sixty-five (37%) of the neonates studied were delivered at home.
A total number of 1602 neonates were seen in AKTH during the period of the study, thus giving an incidence of neonatal conjunctivitis of 60.5 per 1000 live births. [Table 1] shows the distribution of weights of neonates with conjunctivitis on presentation. Most of the neonates (73.7%) were within normal weight range of 2500-3999 g. Only 15 (8.6%) had weight of 4000 g and above.
|Table 1: Distribution of weight on presentation of 175 neonates with conjunctivitis|
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A total of 97 (55.4%) neonates had positive isolates while the remaining yielded no growth [Table 2].
|Table 2: Age at onset of symptoms, bacterial isolates and Chlamydial antigens positivity in neonates with conjunctivitis|
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Staphylococcus aureus (29.7%) was the most frequently isolated organism while Klebsiella specie and Neisseria More Details gonorrhoea were the least isolated organisms accounting for 1.7% each.
Sixty-nine (39.4%) bacterial agents were isolated in babies with conjunctivitis in early neonatal period, whereas 28 (16.0%) bacteria were isolated in those with conjunctivitis in late neonatal period [Table 2].
The maternal factors associated with neonatal conjunctivitis are shown in [Table 3]
Low level of maternal education, lack of antenatal care attendance, prolonged rupture of amniotic membranes and low socioeconomic status were significantly associated with isolate positive neonatal conjunctivitis (P < 0.05).
|Table 3: Maternal factors and bacterial isolates in neonates with conjunctivitis|
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Is the abnormal exudation of watery or creamy substance per vaginum
Prolonged rupture of amniotic membranes for more than 18 hours.
Is the number of times a woman has given birth to live children counting multiple birth as one.
Mode of delivery
Is the route through which a baby is delivered from the mother, most commonly through the birth canal (spontaneous vaginal delivery [SVD]) or through the abdominal wall via caesarean section (CS).
Is the ability of a pregnant woman to access and utilise the care provided by obstetricians or skilled birth attendants at least four times during pregnancy to improve her health and that of her baby.
Is a combined total measure of a person's work experience and of an individual's or family's economic and social position in relation to others, based on income, education and occupation.
Low education status
Parents with informal education or those who only attended primary school.
| Discussion|| |
The mean age at presentation of 5.7 days ± 4.6 in neonates with neonatal conjunctivitis in this study is lower than the mean age of 12.9 days documented by Ugbode  in Zaria in 1991 and Olatunji.  The mean age was, however, slightly higher than 5 days reported by Abdulkadir from Zaria  in 2008. It was also close to 4.6 days recorded by Ibekwe  from Abakaliki. This younger age at presentation may be due to self-referral system of attending tertiary health centres as suggested by Ibekwe et al.,  The male to female ratio of 1.1:1 in this study differs from that reported by Olatunji  and Mohile et al.,  It was, however, in keeping with the study by Ibekwe  from Abakiliki who reported a male:female ratio of 1.2:1. Ugbode  from Zaria also recorded M:F ratio of 1.5:1. Males have approximately 2-fold higher incidence of infections than females suggesting the possibility of a sex-linked factor in host susceptibility to infection. 
Staphylococcus aureus was the most commonly isolated bacteria in this study. This was in keeping with the finding of Amoni  and Ugbode  from Zaria who documented S. aureus as the most common organism of neonatal conjunctivitis. It was also in keeping with the report of Iyamu and Enabule  in Benin City where S. aureus was also the most prevalent organism. It was also in keeping with the finding of Ibekwe et al.,  Studies from USA  and UAE  also showed S. aureus as the most common organism causing neonatal conjunctivitis. However, these results differed from that of Kolade  who recorded Chlamydia trachomatis as the predominant organism of neonatal conjunctivitis in Ilorin. The predominance of S. aureus in this study may suggest that most of the cases of neonatal conjunctivitis are post-natally acquired probably due to low levels of hygiene rather than during passage through the birth canal as suggested by Vedanthan  in explaining the implication of S. aureus as aetiological agent of neonatal conjunctivitis.
Low rate of Neisseria gonorrhoea neonatal conjunctivitis was found in this study. This was similar to the finding of Iyamu  from Benin but higher than the report by Kolade  from Ilorin. However, Amoni  in 1979 in Zaria found N. gonorrhoea and S. aureus as the most implicated organisms of neonatal conjunctivitis. Two decades later, Ugbode  from the same centre showed a lower prevalence of N. gonorrhoea neonatal conjunctivitis. Similarly, Abdulkadir  in 2008 from the same centre in Zaria did not isolate N. gonorrhoea in neonatal conjunctivitis. These observations suggest reducing importance of N. gonorrhoea as a cause of neonatal conjunctivitis. It may be suggested that the low rate of N. gonorrhoea isolation may be due to availability of health facilities, improved health habits and improved antenatal care attendance as observed in this study. Other reasons could be improved awareness and actual improvement in managing cases of gonorrhoea.
The differences in isolated organisms from different centres may be a reflection of the socioeconomic status, personal hygiene of the individuals and predominant agents in the newborn environment, which may differ from centre to centre. Laboratory factors, fastidious nature of some of the organisms, the objective of the studies, locally available expertise and high ethical laboratory standards all may play a role. It may also be due to variation in the aetiological agents of STIs and maternal genital flora in various centres. However, maternal genital flora was not examined in this study as it was not part of the objectives of the study.
Low level of maternal formal education, lack of antenatal care attendance and low social class were found to be statistically, significantly associated with isolate positive neonatal conjunctivitis. This was in keeping with other studies by Kolade  and Adeyantso et al.,  Kolade  identified low maternal education and lack of antenatal care and prolonged rupture of membranes (PROM) as some of the factors significantly associated with positive bacterial isolates in neonatal conjunctivitis. Education enables one to utilise the available health facilities and also promotes good health habits of individuals. Also antenatal care in a good centre for antenatal care can lead to staying healthy through disease surveillance, early detection and institution of appropriate treatment for mothers and prophylaxis or treatment for newborns.  PROM was found to be associated with isolate positive neonatal conjunctivitis, which is in keeping with other studies. , Rupture of amniotic membranes breaches the protective barrier of the amniotic membranes, which protect the foetus in utero from infective micro-organisms.  PROM also makes it conducive for thriving pathogens, which increases the risks of easy colonisation of the foetus even before delivery through ascending infection.  Maternal vaginal discharge was not significantly associated with isolate positive neonatal conjunctivitis, and this contrast with the reports of Ernest et al.,  and Abdulkadir  who found it to be statistically significant.
| Conclusion|| |
Neonatal conjunctivitis was mainly infective and the organisms isolated were mostly non-gonococcal in nature. Low maternal education, lack of antenatal care attendance, prolonged rupture of amniotic membranes and low socioeconomic status were the factors significantly associated with isolate positive neonatal conjunctivitis.
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[Table 1], [Table 2], [Table 3]