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Early implementation of guidelines for managing young infants with possible serious bacterial infection in Bangladesh
  1. Jennifer A Applegate1,
  2. Sabbir Ahmed2,
  3. Marufa Aziz Khan2,
  4. Sanjida Alam2,
  5. Nazmul Kabir2,
  6. Munia Islam2,
  7. Mamun Bhuiyan2,
  8. Jahurul Islam3,
  9. Iftekhar Rashid4,
  10. Steve Wall5,
  11. Joseph de Graft-Johnson5,
  12. Abdullah H Baqui1,
  13. Joby George2
  1. 1International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
  3. 3National Newborn Health Program, Government of Bangladesh Ministry of Health and Family Welfare, Dhaka, Dhaka District, Bangladesh
  4. 4United States Agency for International Development, Dhaka, Bangladesh
  5. 5Save the Children, Washington, ‎District of Columbia, USA
  1. Correspondence to Dr Abdullah H Baqui; abaqui{at}


Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0–59 days) with simpler antibiotic regimens if hospital referral is not feasible. Bangladesh was one of the first countries to adapt WHO guidance into national guidelines for implementation in primary healthcare facilities. Early implementation was led by the Ministry of Health and Family Welfare (MOHFW) in 10 subdistricts of Bangladesh with support from USAID’s MaMoni Health System Strengthening project. This mixed methods implementation research case study explores programme feasibility and acceptability through analysis of service delivery data from 4590 sick young infants over a 15-month period, qualitative interviews with providers and MOHFW managers and documentation by project staff. Multistakeholder collaboration was key to ensuring facility readiness and feasibility of programme delivery. For the 514 (11%) infants classified as PSBI, provider adherence to prereferral treatment and follow-up varied across infection subcategories. Many clinical severe infection cases for whom referral was not feasible received the recommended two doses of injectable gentamicin and follow-up, suggesting delivery of simplified antibiotic treatment is feasible. However, prereferral antibiotic treatment was low for infants whose families accepted hospital referral, which highlights the need for additional focus on managing these cases in training and supervision. Systems for tracking sick infants that accept hospital referral are needed, and follow-up of all PSBI cases requires strengthening to ensure sick infants receive the recommended treatment, to monitor outcomes and assess the effectiveness of the programme. Only 11.2% (95% CI 10.3 to 12.1) of the expected PSBI cases sought care from the selected service delivery points in the programme period. However, increasing trends in utilisation suggest improved awareness and acceptability of services among families of young infants as the programme matured. Future programme activities should include interviews with caregivers to explore the complexities around referral feasibility and acceptability of simplified antibiotic treatment.

  • health services research
  • child health

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  • Handling editor Seye Abimbola

  • Contributors JG led the MaMoni HSS project in Bangladesh with technical support from SabA, MAK, JI, MB, IR and SanA to implement program activities and collect data. JG, JAA, IR and SabA conceptualised the manuscript. JA, SabA, SanA, MI and MAK generated the qualitative reports. JAA conducted the analysis, created the tables and figures, was the principal author and managed all revisions of the drafts of the paper. NK, SanA and SabA managed the program database and assisted with data analysis. JG and AB provided guidance to the analysis and drafts of the paper. JJ, SW, IR and JI provided comments on the intellectual content for the paper. All authors approved the final draft of the manuscript.

  • Funding This manuscript is made possible by the support of the American people through the United States Agency for International Development (USAID); Associate Cooperative Agreement no. AID-338-LA-13–00004 - MaMoni Health Systems Strengthening (MaMoni HSS). The contents are the sole responsibility of USAID’s MaMoni HSS Project and do not necessarily reflect the views of USAID or the United States Government.

  • Disclaimer The contents are the sole responsibility of USAID’s MaMoni HSS Project and do not necessarily reflect the views of USAID or the US Government.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The data presented in this paper are from program monitoring and were used by the MaMoni HSS team for quality improvement efforts. At the time of manuscript development, this project was reviewed by the Johns Hopkins School of Public Health (JHSPH) Institutional Review Board who granted a waiver and made the determination that JHSPH and its faculty, staff and students are ‘not engaged in human subjects research’ for this project.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No additional data are available.

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