CNN

A mother of twins, a law student and a government worker were among the 31 people killed in Brussels.

The victims span 40 nationalities.

LA Times

“……Less than a week ago, the most wanted suspect in November’s Paris attacks was arrested in a shootout with police in the Belgian capital. Salah Abdeslam was considered a suspect after his older brother, Brahim, blew himself up at a bar as part of a series of coordinated attacks that killed 130 people.

Said and Cherif Kouachi…….were identified as being responsible for the Charlie Hebdo massacre in Paris in January 2015 that left 12 people dead.

Dzhokhar and Tamerlan Tsarnaev……bombed the Boston Marathon in 2013, killing three people and leaving more than 260 wounded……”

Med-Xpres

**  a 21-year-old Havana woman who had not traveled outside Cuba was diagnosed with the virus after suffering headaches, fatigue and other symptoms.

**  Cuba has thrown more than 9,000 soldiers, police and university students into an effort to fumigate for mosquitoes, wipe out the standing water where they breed and prevent a Zika epidemic.

NBC

WHO

Risk-commication

CDC

Factors Related to Fetal Death in Pregnant Women with Cholera, Haiti, 2011–2014

 

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Factors Related to Fetal Death in Pregnant Women with Cholera, Haiti, 2011–2014

[Announcer] This program is presented by the Centers for Disease Control and Prevention.

[Reginald Tucker] Cholera infections during pregnancy are associated with high rates of fetal death, especially when women are severely dehydrated. In Haiti in 2011, pregnant women with clinical signs of cholera who sought treatment from Médecins Sans Frontières, or MSF, in Port-au-Prince, were sent to a general cholera treatment center, or CTC. In April 2012, MSF established a CTC to improve fetal outcomes in pregnant women by facilitating intensive follow-up for dehydration and rapid access to obstetric and neonatal services. In June 2013, a more aggressive rehydration protocol was implemented. To assess the effects of cholera infection, establishment of a specialized CTC, and the new rehydration protocol, the authors conducted a retrospective cohort analysis of pregnant women with suspected cholera admitted to MSF’s CTC during September 1, 2011 through December 31, 2014.

This study was approved by the National Bioethical Committee of the Ministry of Public Health and Population of Haiti. A cholera case patient was defined as someone who passed about 3 liquid stools with or without vomiting or dehydration in the previous 24 hours or within 6 hours of seeking treatment. Women of childbearing age were asked whether they were pregnant. Urine dipstick tests were conducted in cases of uncertainty or early stages of pregnancy. Gestational age was determined by the date of the woman’s last menstruation, uterine height, or ultrasound. Fetal status was assessed at admission and hourly by using fetal stethoscope or ultrasonic fetal Doppler. Women who had a miscarriage at home and were not bleeding at admission were not classified as pregnant. Dehydration status was determined according to World Health Organization categories. The authors assigned women into 3 treatment groups, or TGs, according to whether they were treated in the general or specialized CTC and whether they were given the original or new protocol.

During September 1, 2011 through December 31, 2014, a total of 936 pregnant women were admitted. Thirty-six were excluded from analysis: 33 lacked fetal outcome data and 3 died. Of the remaining 900, mean age was 26.7 years; 168 were in their first trimester, 303 second trimester, and 416 third trimester. Trimester was unknown for 13. A total of 444 sought treatment within 24 hours of symptom development.

Fetal death occurred in 141 of the 900 analyzed pregnancies, more often in women less than 20 years of age, in their third trimester, seeking treatment more than 24 hours after symptom onset, with severe dehydration or who vomited. A total of 64 fetal deaths occurred before admission.

Women who experienced preadmission or postadmission fetal death did not differ by age or clinical presentation. However, preadmission fetal death was more likely in women who arrived more than 24 hours after symptom onset or were severely dehydrated. In unadjusted analysis, postadmission fetal death was associated with moderate dehydration and vomiting. Of 836 women with viable fetus at admission, 120 were in TG1, 399 in TG2, and 317 in TG3.

There was no modification effect of TG in postadmission fetal death. Weak evidence of a difference in effect of severe dehydration and postadmission fetal death between TGs was potentially due to a lower rate among severely dehydrated women in TG2. However, there was insufficient power to detect these differences, and the final model did not require adjustment. Although the proportion of postadmission fetal deaths within a TG decreased with each protocol change, the proportion in TG3 was not different from TG1 or TG2.

Fetal death occurred in 141 of 900 pregnancies. Risk factors were third trimester, younger maternal age, severe dehydration, and vomiting.

Severe dehydration at admission increased risk of fetal death. Fetal death may occur due to fetal hypoxia and acidosis resulting from excessive maternal dehydration. The proportion of fetal deaths was higher than that previously recorded in Haiti but close to that of the 2006 Senegal cholera outbreak. Earlier studies in India, Nigeria, and Pakistan found higher proportions.

Women less than 20 years of age were twice as likely as older women to experience fetal death. Although the relationship between fetal death and maternal age during cholera has not been documented, younger age is associated with increased risk for other adverse pregnancy outcomes. The risk for fetal death was highest in the third trimester, even after controlling for maternal age, dehydration level, and vomiting. The relationship between fetal death and trimester of pregnancy is unclear.

Determination of dehydration status of pregnant women is difficult in later stages of pregnancy. Misclassification of dehydration status could affect fetal outcome due to placement of patients under the wrong treatment protocol. In addition, increased placental blood flow with gestational age may increase the effect of dehydration. Even after the authors controlled for dehydration level, they determined that fetal death was twice as likely in women experiencing vomiting, potentially due to electrolyte changes in amniotic fluid.

Lack of effect of a specialized CTC on fetal death could result from a detection bias in the establishment of the specialized CTC that led to an increased likelihood of detection of fetal deaths. In addition, 45 percent of fetal deaths occurred before women sought treatment. Fetal death may occur early in a pregnant woman’s illness with cholera, and more than half the women sought treatment more than 24 hours after symptom onset, likely contributing to poor fetal outcomes. Likewise, the effect of the new treatment protocol may have been limited by fetal death occurring before the women sought treatment or by women assigned the incorrect protocol due to difficulty in determining dehydration status.

Limitations include lack of laboratory-confirmed diagnoses. Data were collected for programmatic rather than research purposes and lack electrolyte levels, amniotic fluid composition, maternal blood group, and fetal cause of death. Some first-trimester pregnancies may have been missed. Pregnancies in women who completed miscarriage at home were not counted, potentially underestimating overall risk of fetal death. Because there was no follow-up of women after discharge, some early-term fetal deaths might have been missed. In addition, the long-term effect of treatment on fetal well-being could not be determined. TG outcomes also may have been affected by differences in factors, such as women’s access to health services over time.

Although the implementation of a specialized CTC did not decrease fetal deaths, specialized CTCs play a vital role in preserving patient dignity and providing patient-centered care. Determining the mechanism of fetal death in cholera infection would enable development of evidence-based treatment protocols. Because many fetal deaths occurred before women sought treatment, the importance of cholera prevention and the risk of poor fetal outcomes should be emphasized.

I’ve been reading Factors Related to Fetal Death in Pregnant Women with Cholera, Haiti, 2011 through 2014, online in the January 2016 issue of Emerging Infectious Diseases at www.cdc.gov/eid.

I’m Reginald Tucker for Emerging Infectious Diseases.

[Announcer] For the most accurate health information, visit www.cdc.gov or call 1-800-CDC-INFO.

CIDRAP

Details of the cases

• A 24-year-old, non-national male from Buraidah city developed symptoms on 19 February and, on the same day, was admitted to the hospital where the current MERS-CoV outbreak is occurring. While hospitalized, he developed further symptoms on 5 March. The patient, who has no comorbidities, tested positive for MERS-CoV on 7 March. Currently, he is in critical condition in ICU. Investigation of epidemiological link with MERS-CoV cases admitted to this hospital or with shared health care workers is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 56-year-old, non-national male from Buraidah city developed symptoms on 6 February and, on the same day, was admitted to the hospital where the current MERS-CoV outbreak is occurring. While hospitalized, the patient developed further symptoms on 7 March. He was admitted to ICU and passed away on the same day. The patient, who had comorbidities, tested positive for MERS-CoV on 8 March. Investigation of epidemiological links with MERS-CoV cases admitted to this hospital or with shared health care workers is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 68-year-old female from Buraidah city developed symptoms on 2 March and, on 5 March, was admitted to the hospital where the current MERS-CoV outbreak is occurring. The patient, who has comorbidities, tested positive for MERS-CoV on 7 March. Currently, the patient is in stable condition in a negative pressure isolation room. Investigation of exposure to the known risk factor in the 14 days prior to the onset of symptoms is ongoing.
• A 41-year-old male from Alzulfi city developed symptoms on 25 February and, on 4 March, was admitted to hospital. The patient, who has no comorbidities, tested positive for MERS-CoV on 6 March. Currently, he is in stable condition in a negative pressure isolation room. Investigation of exposure to the known risk factor in the 14 days prior to the onset of symptoms is ongoing.
• An 81-year-old male from Buraidah city was first admitted to the hospital where the current MERS-CoV outbreak is occurring, between 5 and 28 February. After discharge, he developed further symptoms on 1 March and was readmitted to the same hospital on 4 March. The patient, who has comorbidities, tested positive for MERS-CoV on 6 March. Currently, he is in critical condition in ICU. Investigation of epidemiological links with MERS-CoV cases admitted to this hospital or with shared health care workers is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 42-year-old male from Buraidah city developed symptoms on 26 February and, on 4 March, was admitted to the hospital where the current MERS outbreak is occurring. The patient, who has no comorbidities, tested positive for MERS-CoV on 6 March. Currently, the patient is in stable condition in a negative pressure isolation room. The patient has a history of frequent contact with camels and consumption of their raw milk. He has no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms. The Ministry of Agriculture was notified and is now conducting investigations.
• A 36-year-old, non-national male from Buraidah city (working at the hospital where the current MERS-CoV outbreak is occurring) developed symptoms on 28 February and, on 4 March, was admitted to the same hospital. The patient, who has no comorbidities, tested positive for MERS-CoV on 6 March. Currently, he is in stable condition in a negative pressure isolation room. Investigation of epidemiological links with MERS-CoV cases admitted to this hospital is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 68-year-old male from Alrass city developed symptoms on 3 March and, on 5 March, was admitted to hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 7 March. Currently, he is in stable condition in a negative pressure isolation room. The patient has a history of frequent contact with camels and consumption of their raw milk. He has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms. The Ministry of Agriculture was notified and is now conducting investigations.
• A 76-year-old male from Buraidah city was admitted to the hospital where the current MERS-CoV outbreak is occurring on 4 February, due to his chronic comorbid conditions. While hospitalized, he developed further symptoms on 3 March. The patient tested positive for MERS-CoV on 5 March. Currently, he is in stable condition in a negative pressure isolation room. Investigation of epidemiological links with MERS-CoV cases admitted to this hospital or with shared health care workers is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 62-year-old, non-national male from Buraidah city, working as a physician in the hospital where the current MERS-CoV outbreak is occurring, developed symptoms on 3 March and, on 4 March, was admitted to the same hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 5 March. Currently, he is in stable condition in a negative pressure isolation room. Investigation of epidemiological links with MERS-CoV cases hospitalized in this hospital is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 49-year-old male from Riyadh city developed symptoms on 1 March and, on 5 March, was admitted to the hospital. The patient, who has no comorbidities, tested positive for MERS-CoV on 6 March. Currently, he is in stable condition in a negative pressure isolation room. The patient has a history of frequent contact with camels and consumption of their raw milk. He has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms. The Ministry of Agriculture was notified and is now conducting investigations.
• A 70-year-old male from Buraidah city developed symptoms on 10 February and, on 17 February, was admitted to the hospital where the current MERS outbreak is occurring. The patient, who has comorbidities, first tested negative for MERS-CoV on 20 February, but later tested positive on 4 March after worsening of symptoms. Currently, he is in stable condition in a negative pressure isolation room. Investigation of epidemiological links with MERS-CoV cases hospitalized in this hospital or with shared health care workers is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 82-year-old male from Hail city developed symptoms on 10 February and, on 22 February, was admitted to the hospital where the current MERS outbreak is occurring. The patient, who has comorbidities, first tested negative for MERS-CoV on 24 February, but later tested positive on 4 March after worsening of symptoms. Currently, he is in critical condition in ICU. Investigation of epidemiological link with MERS-CoV cases hospitalized in this hospital or with shared health care workers is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 23-year-old male from Buraidah city was admitted to the hospital where the current MERS outbreak is occurring on 15 February, due to a chronic comorbid condition. On 2 March, while hospitalized, he developed further symptoms, and tested positive for MERS-CoV on 4 March. Currently, the patient is in critical condition in ICU, but not on mechanical ventilation. Investigation of epidemiological link with MERS-CoV cases admitted to this hospital or with shared health care workers is ongoing. The patient has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 49-year-old male from Jeddah city, working as a physician in a hospital, developed symptoms on 26 February and, on 2 March, was admitted to the same hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 4 March. Currently, he is in stable condition in a negative pressure isolation room. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing.
• A 67-year-old female from Buraidah city developed symptoms on 28 February and, on 1 March, was admitted to the hospital where the current MERS outbreak is occurring. The patient, who had comorbidities, tested positive for MERS-CoV on 3 March. She was in critical condition in ICU but not on mechanical ventilation, and passed away on 6 March. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing.
• A 52-year-old female from Riyadh city developed symptoms on 22 February and, on 25 February, was admitted to hospital. The patient, who has comorbidities, first tested negative for MERS-COV on 27 February, but later tested positive on 3 March after worsening of symptoms. Currently, she is in critical condition in ICU but not on mechanical ventilation. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing.
• A 40-year-old male from Buraidah city first developed symptoms on 22 February and, on the same day was admitted to the hospital where the current MERS outbreak is occurring. While hospitalized, he developed further symptoms on 28 February. The patient, who had comorbidities, tested positive for MERS-CoV on 1 March. He was in critical condition in ICU, and passed away on 4 March. Investigation of epidemiological link with MERS-CoV cases admitted to this hospital or with shared health care workers is ongoing. The case had no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms.
• A 30-year-old, non-national male from Riyadh city developed symptoms on 26 February and, on 27 February, was admitted to hospital. The patient, who has no comorbidities, tested positive for MERS-CoV on 28 February. The patient has a history of contact with two MERS-CoV cases (see DON published on 10 March – case no. 6, and case no. 22 below). He has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms. Currently, he is in stable condition in a negative pressure isolation room.
• A 68-year-old male from Shaqra city developed symptoms on 15 February and, on 25 February, was admitted to the hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 27 and 28 February (a second sample was tested for further confirmation). Currently, he is in stable condition in a negative pressure isolation room. He has a history of frequent contact with camels and consumption of their raw milk. He has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms. The Ministry of Agriculture was notified and is now conducting investigations.
• A 72-year-old male from Al Artawiyah city developed symptoms on 23 February and, on 27 February, was admitted to hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 28 February. Currently, he is in stable condition in a negative pressure isolation room. He has a history of frequent contact with camels and consumption of their raw milk. He has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms. The Ministry of Agriculture was notified and is now conducting investigations.
• A 30-year-old, non-national male from Riyadh city developed symptoms on 19 February and, on 20 February, was admitted to hospital. The patient, who has comorbidities, first tested negative for MERS-CoV on 21 and 24 February, but after worsening of symptoms, tested positive on 27 February. The patient has a history of contact with a MERS-CoV case (see DON published on 10 March – case no. 6 ). He has no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms. Currently, he is in critical condition in ICU.
• A 50-year-old male from Muhayil city developed symptoms on 19 February and, on 25 February, was admitted to hospital. The patient, who had comorbidities, tested positive for MERS-CoV on 27 February. The patient was in critical condition in ICU, and passed away on 26 February. He had a history of frequent contact with camels and consumption of their raw milk. He had no history of exposure to the other known risk factors in the 14 days prior to the onset of symptoms. The Ministry of Agriculture was notified and is now conducting investigations.
• A 68-year-old male from Riyadh city developed symptoms on 15 February and, on 23 February, was admitted to hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 25 February. Currently, he is in stable condition in a negative pressure isolation room. Investigation of history of exposure to any of the known risk factors in the 14 days prior to the onset of symptoms is ongoing.
• A 72-year-old male from Arruwaidhah city developed symptoms on 17 February and, on 23 February, was admitted to hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 25 February. Currently, he is in critical condition in ICU, but not on mechanical ventilation. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing.

Contact tracing of household and healthcare contacts is ongoing for these cases.

WHO

WHO Vector Control Advisory Group emergency meeting deliberates vector control tools
14 March 2016 | Geneva −− A two-day emergency meeting of the Vector Control Advisory Group (VCAG) got underway today to discuss the use of new vector control tools. Experts are reviewing available evidence on proposed vector control tools and identify potential gaps that might limit the roll-out of these methods.

Besides deliberating on existing vector control tools and their potential, discussions will focus on evidence gathered so far on the use of some new tools including:

• Wolbachia
• Transgenic mosquitoes ‘Oxitec OX513A
• Sterile Insect Technique (SIT)
• Vector traps
• Attractive Toxic Sugar Baits (ATSB)

The two-day meeting in Geneva, Switzerland also brings together innovators who are scheduled to provide evidence gathered from diverse conditions. Assessment of each method will be done along with the feasibility of the intervention and its resource implications.

At the end of the meeting a position statement is expected on existing and new vector control tools for use in Zika emergency response.

VCAG is a joint programme of WHO’s Global Malaria Programme (GMP) and NTD.

NY Times

CNN