title: Neonatal tetanus associated with topical umbilical ghee: covert role of cow dung.
abstract: BACKGROUND
  Previous studies in Pakistan have shown that ghee (clarified butter) is commonly applied to umbilical wounds of neonates, and have documented that such applications are a risk factor for neonatal tetanus (NNT). In-use contamination of ghee with Clostridium tetani has been demonstrated, but mechanisms underlying the risk of ghee have been incompletely evaluated epidemiologically.
  
  
  METHODS
  Detailed information on ghee usage, including fuels used to heat it, was obtained from cases of NNT (n = 229) and their matched controls (n = 687) from a population-based study of NNT in Punjab Province, Pakistan. Design variables were created to evaluate the impact of different fuel sources on risk of ghee applications.
  
  
  RESULTS
  Nearly one-third of all infants had ghee applied, and it was nearly always heated before application to umbilical wounds of newborns. After controlling for all factors found to be significantly associated with NNT in conditional logistic regression, only ghee that had always been heated with dried cow dung fuel was significantly associated with NNT. Topical antimicrobials and ghee were never applied together.
  
  
  CONCLUSIONS
  Ghee applications to umbilical wounds, when heated with 'clean' fuels, appear to pose no increased risk of NNT, although handling practices undoubtedly result in hazardous microbial contamination. In contrast, ghee heated with dung fuel was significantly associated with NNT. The effective promotion of topical antimicrobials might help reduce ghee use, since the intended purpose of each is to enhance healing.
authors.affiliation: Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia 30322, USA.
authors.forename: J
authors.initials: J
authors.lastname: Bennett
authors.forename: C
authors.initials: C
authors.lastname: Ma
authors.forename: H
authors.initials: H
authors.lastname: Traverso
authors.forename: S B
authors.initials: SB
authors.lastname: Agha
authors.forename: J
authors.initials: J
authors.lastname: Boring
mesh_terms: D000287:Administration, Topical; D000818:Animals; D002079:Butter / Q000009:adverse effects*; D016022:Case-Control Studies; D002417:Cattle; D005243:Feces; D005260:Female; D005579:Fossil Fuels; D006801:Humans; D006920:Hygiene / Q000592:standards*; D007231:Infant, Newborn; D008297:Male; D015999:Multivariate Analysis; D010154:Pakistan / Q000453:epidemiology; D012307:Risk Factors; D013742:Tetanus / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control; D014470:Umbilical Cord
chemical_list: D005579:Fossil Fuels; D002079:Butter