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

CDC

 

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

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.


The global supply of oral cholera vaccines is set to double after WHO approved a third producer from S. Korea

WHO

Cholera vaccine supply set to double, easing global shortage


8 January 2016

The global supply of oral cholera vaccines is set to double after WHO approved a third producer, helping to address global shortages and expand access in more countries.

Oral Cholera Vaccination Campaign in Southern Malawi, 2015

Oral Cholera Vaccination Campaign in Southern Malawi, 2015
WHO/L. Pezzoli

Globally, OCV production is low, with demands currently exceeding supply. Sudan and Haiti last year made requests to WHO for supplies of vaccines to conduct pre-emptive vaccination campaigns that could not be filled because of the global shortage.

The vaccine producer, a South Korean company, is the latest oral cholera vaccine (OCV) manufacturer to be approved under the WHO’s pre-qualification programme, which ensures that drugs and vaccines bought by countries and international procurement agencies such as the United Nations Children’s Fund (UNICEF) meet acceptable standards of quality, safety and efficacy.

The addition of an additional pre-qualified vaccine producer is expected to double global supply to 6 million doses for 2016, with the potential for further increased production in the future. This additional capacity will contribute to reversing a vicious cycle of low demand, low production, high price and inequitable distribution, to a virtuous cycle of increased demand, increased production, reduced price and greater equity of access.

Cholera is an acute diarrhoeal disease that can kill within hours if left untreated. There are between 1.4 million and 4.3 million cases a year, and as many as 142 000 deaths. Cholera is endemic in more than 50 countries, but usually only garners international attention during humanitarian emergencies, such as the outbreak among refugees in Goma, Democratic Republic of the Congo, in 1994 that killed tens of thousands. Climate change and El Niño may also be contributing to more frequent cholera outbreaks.

Oral cholera vaccines have been used in mass vaccination campaigns in response to humanitarian emergencies since 1997. But because the disease disproportionately affects poor communities who are often unaware that the vaccines exist, there has historically been little demand for the products.

In 2013 the WHO created the world’s first OCV stockpile, undertaking to buy and use 2 million doses a year in order to stabilize and create demand for the vaccines.

Vaccination requires 2 doses per person, meaning the stockpile is sufficient to cover 1 million people.

Access to OCV has been further improved by a commitment of US$115 million over 5 years from Gavi, the Vaccine Alliance, to expand availability and the use of vaccine in countries with endemic cholera. Since the OCV stockpile was created more vaccines have been distributed and used than in the previous 15 years. A total of 21 OCV deployments of about 4 million doses to 11 countries have been used in various contexts: humanitarian crises in Cameroon, Haiti, Iraq, Nepal, South Sudan, and United Republic of Tanzania; outbreaks in Guinea and Malawi; and in endemic hotspots such as Bangladesh and Democratic Republic of the Congo.

The creation of the stockpile and pre-qualification of a new vaccine producer highlights the success of an international joint effort through public-private partnership, including governments, non-profit organizations, manufacturers, donors and research organizations. Accompanying the use of stockpile vaccine, many donors and partners have worked together within the framework of the Global Task Force on Cholera Control (GTFCC) to demonstrate the public health potential of this vaccine when used in mass vaccination campaigns. The evidence is contributing to a body of work which will inform larger investments on the further production and use of this vaccine.


Cholera in the Democratic Republic of the Congo: Nearly 20 000 cases in 2015

WHO

Disease Outbreak News
15 December 2015

The Ministry of Health of the Democratic Republic of the Congo (DRC) has notified WHO of ongoing outbreaks of cholera across the country. Although the overall trend is decreasing, there are still areas reporting a high number of cases.

Democratic Republic of the Congo

Since the beginning of the year, 19,705 cases have been reported in DRC. As of 29 November, the following provinces had reported cases: South Kivu (4,906), ex-Katanga (4,565), Maniema (3,971), North Kivu (3,294) and ex-Oriental (2,969). A high number of cases are still reported in the province of South Kivu where the situation is particularly worrying because of the presence of camps hosting refugees from Burundi. Furthermore, there are concerns that the epidemic in Maniema could spread to other provinces of the country as observed during the 2011 cholera epidemic when areas of Kinshasa were also affected.

Public health response

In response to the outbreaks, the government of DRC, together with WHO and partner organizations, has intensified surveillance, case management and health promotion activities in the affected areas. Moreover, cholera treatment centres have been strengthened at selected sites.

Water sanitation and hygiene activities, such as water chlorination, are being implemented. Communication and health education activities are also continuing.

The MoH and WHO conducted joint risk assessment missions in South Kivu, Maniema and Kisangani. Following their recommendations, an updated control and response plan was developed. WHO also provided technical support and coordination for the implementation of prevention and control measures. The implementation of oral cholera vaccine campaigns is being discussed with national authorities.

WHO advice

WHO does not recommend any travel or trade restriction to DRC based on the current information available.


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