Asia-UK Maternal-neonatal Infection and Immunity Network (AMMUNet)

Maternal and neonatal health

The health of women during pregnancy, delivery and postpartum period is referred to as maternal health. Direct causes like excessive

bleeding, infections, high blood pressure, unsafe abortion, obstructed labor and indirect causes like malaria, anemia and heart diseases are the most common cause of maternal mortality. Timely management by skilled health workers can prevent the maternal deaths. [1]

Neonate is a baby within the first 28 days of life. During this period neonate are at highest risk of morbidity and mortality. Preterm birth, birth asphyxia, infections and congenital abnormalities are the major causes of neonatal death. [2]

Maternal and neonatal mortality

Maternal mortality: In 2023, globally, more than 700 women died each day from pregnancy and childbirth related causes that could have been prevented. On average, a maternal death was recorded nearly every two-minute throughout the year. About 260,000 women died during and following pregnancy and childbirth in that year. About 92% of all maternal deaths happened in low and lower middle-income countries (LMICs). [3]

In Nepal 190 maternal deaths were reported in fiscal year 2080/2081 B.S. (2023/24). [4]

Neonatal mortality: In 2022, globally, around 2.3 million infants died worldwide within first 28 days of life. The highest neonatal mortality rate was reported in Sub Saharan Africa (22 deaths per 1000 live births) in 2022, followed by Central and Southern Asia (21 deaths per 1000 live births).[5] Over 550,000 newborn deaths occur each year because of neonatal infections.[6]

In Nepal, out of 1,907 perinatal deaths in fiscal year 2080/2081 B.S (2023/24), 58% were antepartum still births.[7]

Perinatal infections and immunity:

During pregnancy, woman goes through various physiological and immunological changes that supports healthy pregnancy. Sometimes these changes may make women more sensitive to infections. Bacterial, viral, parasitic or fungal maternal infections can occur at any stage of pregnancy. TORCH pathogens: Toxoplasma gondii; others (syphilis, varicella zoster, parvovirus b19), Rubella, cytomegalovirus, Herpes simplex virus) causes congenital infections.[8]

On the other hand, infants and neonates are known to have underdeveloped and ineffective immune system. They are more susceptible to particular pathogens that leads to infection. [9] Risk of infection is increased due to both genetic and environmental factors. Neonatal infections are the most common cause of mortality. [10] In utero infection includes spontaneous abortion, intra-uterine growth retardation (IUGR), preterm birth, still birth, congenital infections (Rubella) and symptomatic(toxoplasmosis). During intra-partum period, infection is transmitted to fetus in utero as in cases of pre-labor rupture of membrane. Postpartum infections include TB (infected maternal tissue and body fluids) and acquired through breastfeeding (HIV, CMV). [11]

Vaccines preventable maternal and neonatal infections

Maternal immunization prevents perinatal infections and, thus, decreases morbidity and mortality in neonates. [12] 

Among the routine vaccines: COVID-19 vaccine is recommended during pregnancy; Hepatitis A is recommended if the pregnant woman is at risk; Hepatitis B is recommended if not already vaccinated; Influenza (inactivated) is recommended seasonally, while the live nasal spray form (LAIV) is contraindicated. 

TDaP is recommended during each pregnancy, ideally between 27–36 weeks; alternatively, TD should be used if otherwise indicated; RSV (Pfizer Abrysvo) is recommended between 32–36 weeks.

While MMR and Varicella are contraindicated during pregnancy, Mpox, polio (IPV) and meningococcal B vaccines should be considered only if the benefit outweighs the risk (Meningococcal ACWY may be used if indicated). There is no recommendation for HPV, Hib, pneumococcal conjugate (PCV), pneumococcal polysaccharide (PPSV23), or the zoster (RZV) vaccine (consider delaying RZV until after pregnancy).[13]

Hepatitis B vaccine, BCG (Bacille Calmette-Guérin) and polio vaccine are recommended for neonates to reduce the risk of infection and promote wellbeing. [14]

According to Nepal Government guidelines, a child is considered fully immunized if they receive all vaccines as outlined in the National immunization schedule. Full immunization rate reached 96% in FY 2080/81 B.S. (2023/24). [15]

Objective of AMMUNet network

Asia-UK Maternal-neonatal infection and iMmunity Network has five key objectives listed below:

1. Bring together international expert groups to strengthen research on maternal and neonatal infections and immunity in Nepal and South Asia
2. Strengthening the clinical and laboratory research capacities in Nepal to enable the country for large clinical trials
3. Initiate collaboration for writing larger research grants on maternal and neonatal infection and immunity fostering Asia-UK academic partnership
4. Support early career clinical researchers of Nepal and neighboring countries through longitudinal mentorship opportunities
5. Aid to the country and regional initiatives towards meeting the United Nations Sustainable Development Goals, particularly SDG 3 – Good Health and Wellbeing

AMMUNet network activities

• Collaborative research projects
• Knowledge exchange and networking
• Workshops, symposia and training programmes
• Community and stakeholder engagement and involvement
• Scientific publications and global dissemination
• Policy briefs and advisory to national health sector programmes

Network partners

• National and subnational government units, non-government partners
• Academic institutions
• Research groups
• Early career researchers

References:

[1] https://www.who.int/health-topics/maternal-health#tab=tab_1

[2] https://www.who.int/westernpacific/health-topics/newborn-health#tab=tab_1

[3] https://www.who.int/news-room/fact-sheets/detail/maternal-mortality

[4] [7][15] https://hmis.gov.np/media/40/Annual-Health-Report-208081_compressed.pdf

[5] https://www.who.int/news-room/fact-sheets/detail/newborn-mortality

[6] https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/newborn-health/newborn-infections

[8] https://pmc.ncbi.nlm.nih.gov/articles/PMC9217740/#s5

[9] https://pmc.ncbi.nlm.nih.gov/articles/PMC10301501/

[10] https://pmc.ncbi.nlm.nih.gov/articles/PMC3959733/

[11] https://www.msdmanuals.com/professional/pediatrics/infections-in-neonates/overview-of-neonatal-infections

[12] https://pmc.ncbi.nlm.nih.gov/articles/PMC4001569/

[13] https://www.cdc.gov/vaccines-pregnancy/hcp/vaccination-guidelines/index.html

[14] Neonatal Immunization and the Prevention of Vaccine-Preventable D 

(Compiled by Dr. Dilip Aryal, Research Intern, GlohMed)