Bundling, a newly identified risk factor for neonatal tetanus: Implications for global control

Background. Bundling, which consists of wrapping an infant for prolonged periods in a sheepskin cover after dried cow dung is applied, is a common and apparently unique practice limited to the rural, mountainous regions of Northern Pakistan. The practice is initiated at various ages during the neonatal period. Its potential contribution to neonatal tetanus (NNT) had not been evaluated. Methods. A population-based, matched, case-control study was undertaken to assess bundling and other factors potentially related to NNT in rural parts of the Northern Areas, Pakistan. Results. Bundling instituted within the first 3 days of life 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 application of ghee to the mothers. Handwashing by the delivery attendant and use of a new razor to cut the umbilical cord were protective. Conclusions. Bundling is a significant risk factor for NNT in the mountainous regions of Northern Pakistan. While this practice is seemingly limited to these remote areas, the findings have broad implications since they indicate that NNT can derive from exposures of the umbilical wound at any time during the first several days of life. Thus, clean cord care at delivery is not itself sufficient to prevent NNT and control programmes need to address post-delivery sources of NNT.