BUNDLING, A NEWLY IDENTIFIED RISK FACTOR FOR NEONATAL TETANUS - IMPLICATIONS FOR GLOBAL CONTROL

Background. Bundling, which consists of wrapping an infant for prolong ed periods in a sheepskin cover after dried cow dung is applied, is a common and apparently unique practice limited to the rural, mountainou s regions of Northern Pakistan. The practice is initiated at various a ges during the neonatal period. Its potential contribution to neonatal tetanus (NNT) had not been evaluated. Methods. A population-based, ma tched, case-control study was undertaken to assess bundling and other factors potentially related to NNT in rural parts of the Northern Area s, Pakistan. Results. Bundling instituted within the first 3 days of l ife was a substantial risk factor for NNT (odds ratio [OR] = 2.5, 95% confidence interval [Cl] : 1.3-4.9). Other factors found risky for NNT were delivery on a straw surface and pre-delivery intravaginal applic ation of ghee to the mothers. Handwashing by the delivery attendant an d use of a new razor to cut the umbilical cord were protective. Conclu sions. Bundling is a significant risk factor for NNT in the mountainou s regions of Northern Pakistan. While this practice is seemingly limit ed to these remote areas, the findings have broad implications since t hey indicate that NNT can derive from exposures of the umbilical wound at any time during the first several days of life. Thus, clean cord c are at delivery is not itself sufficient to prevent NNT and control pr ogrammes need to address post-delivery sources of NNT.