Correction: Early warning for healthcare acquired infections in neonatal care units in a low-resource setting using routinely collected hospital data: The experience from Haiti, 2014-2018.

[This corrects the article DOI: 10.1371/journal.pone.0269385.].

Early warning for healthcare acquired infections in neonatal care units in a low-resource setting using routinely collected hospital data: The experience from Haiti, 2014-2018.

In low-resource settings, detection of healthcare-acquired outbreaks in neonatal units relies on astute clinical staff to observe unusual morbidity or mortality from sepsis as microbiological diagnostics are often absent. We aimed to generate reliable (and automated) early warnings for potential clusters of neonatal late onset sepsis using retrospective data that could signal the start of an outbreak in an NCU in Port au Prince, Haiti, using routinely collected data on neonatal admissions. We constructed smoothed time series for late onset sepsis cases, late onset sepsis rates, neonatal care unit (NCU) mortality, maternal admissions, neonatal admissions and neonatal antibiotic consumption. An outbreak was defined as a statistical increase in any of these time series indicators. We created three outbreak alarm classes: 1) thresholds: weeks in which the late onset sepsis cases exceeded four, the late onset sepsis rates exceeded 10% of total NCU admissions and the NCU mortality exceeded 15%; 2) differential: late onset sepsis rates and NCU mortality were double the previous week; and 3) aberration: using the improved Farrington model for late onset sepsis rates and NCU mortality. We validated pairs of alarms by calculating the sensitivity and specificity of the weeks in which each alarm was launched and comparing each alarm to the weeks in which a single GNB positive blood culture was reported from a neonate. The threshold and aberration alarms were the strongest predictors for current and future NCU mortality and current LOS rates (p<0.0002). The aberration alarms were also those with the highest sensitivity, specificity, negative predictive value, and positive predictive value. Without microbiological diagnostics in NCUs in low-resource settings, applying these simple algorithms to routinely collected data show great potential to facilitate early warning for possible healthcare-acquired outbreaks of LOS in neonates. The methods used in this study require validation across other low-resource settings.

Risk factors for adverse outcomes in women with high-risk pregnancy and their neonates, Haiti.

OBJECTIVES: To determine the prevalence of maternal death, stillbirth and low birthweight in women with (pre-)eclampsia and complicated pregnancies or deliveries in Centre de Références des Urgences Obstétricales, an obstetric emergency hospital in Port-au-Prince, Haiti, and to identify the main risk factors for these adverse pregnancy outcomes. METHODS: We conducted a retrospective cohort study of pregnant women admitted to Centre de Référence des Urgences Obstétricales between 2013 and 2018 using hospital records. Risk factors investigated were age group, type of pregnancy (singleton, multiple), type of delivery and use of antenatal care services. RESULTS: A total of 31 509 women and 24 983 deliveries were included in the analysis. Among these, 204 (0.6%) maternal deaths (648 per 100 000 women giving birth), 1962 (7.9%) stillbirths and 11 008 (44.1%) low birthweight neonates were identified. Of all admissions, 10 991 (34.9%) were women with (pre-)eclampsia. Caesarean section significantly increased the risk of maternal death in the women with a complicated pregnancy and women with (pre-)eclampsia, but reduced the risk of stillbirth in such women. Not attending antenatal care was associated with a significantly higher risk of stillbirth (odds ratio (OR) 4.82; 95% confidence interval (CI) 3.55-6.55) and low birthweight (OR 1.40; 95% CI 1.05-1.86) for women with complicated pregnancies. CONCLUSION: To prevent and treat pregnancy complications as early as possible, antenatal care attendance is crucial. Improving the quality of and access to antenatal care services and providing it free to all pregnant women in Haiti is recommended.

Risk factors for adverse outcomes in women with high-risk pregnancy and their neonates, Haiti

[ABSTRACT]. Objectives. To determine the prevalence of maternal death, stillbirth and low birthweight in women with (pre-) eclampsia and complicated pregnancies or deliveries in Centre de Références des Urgences Obstétricales, an obstetric emergency hospital in Port-au-Prince, Haiti, and to identify the main risk factors for these adverse pregnancy outcomes. Methods. We conducted a retrospective cohort study of pregnant women admitted to Centre de Référence des Urgences Obstétricales between 2013 and 2018 using hospital records. Risk factors investigated were age group, type of pregnancy (singleton, multiple), type of delivery and use of antenatal care services. Results. A total of 31 509 women and 24 983 deliveries were included in the analysis. Among these, 204 (0.6%) maternal deaths (648 per 100 000 women giving birth), 1962 (7.9%) stillbirths and 11 008 (44.1%) low birthweight neonates were identified. Of all admissions, 10 991 (34.9%) were women with (pre-)eclampsia. Caesarean section significantly increased the risk of maternal death in the women with a complicated pregnancy and women with (pre-)eclampsia, but reduced the risk of stillbirth in such women. Not attending antenatal care was associated with a significantly higher risk of stillbirth (odds ratio (OR) 4.82; 95% confidence interval (CI) 3.55–6.55) and low birthweight (OR 1.40; 95% CI 1.05–1.86) for women with complicated pregnancies. Conclusion. To prevent and treat pregnancy complications as early as possible, antenatal care attendance is crucial. Improving the quality of and access to antenatal care services and providing it free to all pregnant women in Haiti is recommended.

[RESUMEN]. Objetivos. Determinar la prevalencia de la muerte materna, la mortinatalidad y el peso bajo al nacer en mujeres con eclampsia o preeclampsia y embarazos o partos complicados en el Centre de Références des Urgences Obstétricales, un hospital de urgencia obstétrica en Puerto Príncipe (Haití), e identificar los principales factores de riesgo de estos resultados adversos del embarazo. Métodos. Se llevó a cabo un estudio de cohortes retrospectivo con embarazadas ingresadas en el Centre de Références des Urgences Obstétricales entre el año 2013 y el 2018 empleando los registros del hospital. Se investigaron como factores de riesgo el grupo etario, el tipo de embarazo (único o múltiple), el tipo de parto y el uso de los servicios de atención prenatal. Resultados. Se incluyó en el análisis un total de 31 509 mujeres y 24 983 partos. De estos, se documentaron 204 (0,6 %) muertes maternas (648 de cada 100 000 mujeres que dan a luz), 1962 (7,9 %) mortinatos y 11 008 (44,1%) recién nacidos con peso bajo al nacer. De todos los ingresos, 10 991 (34,9 %) fueron mujeres con eclampsia y preeclampsia. La cesárea aumentó significativamente el riesgo de muerte materna en mujeres con un embarazo complicado y mujeres con eclampsia y preeclampsia, si bien redujo el riesgo de mortinatalidad en estas mujeres. No asistir a la atención prenatal se asoció con un riesgo significativamente mayor de mortinatalidad (razón de posibilidades [OR] 4,82; intervalo de confianza [IC] de 95 % 3,55-6,55) y peso bajo al nacer (OR 1,40; IC de 95 % 1,05-1,86) en mujeres con embarazos complicados. Conclusiones. Para prevenir y tratar las complicaciones del embarazo lo antes posible, es crucial asistir a la atención prenatal. Se recomienda mejorar el acceso a servicios de atención prenatal de buena calidad y ofrecerlos de manera gratuita a todas las embarazadas en Haití.

[RESUMO]. Objetivos. Determinar a prevalência de mortalidade materna, natimortos e baixo peso ao nascer em mulheres em pré-eclâmpsia, ou gravidez ou partos com complicações no Centre de Références des Urgences Obstétricales, um hospital de emergência obstétrica em Porto Príncipe, no Haiti, e identificar os principais fatores de risco para esses desfechos adversos na gravidez. Métodos. Realizamos um estudo de coorte retrospectivo de gestantes admitidas no Centre de Références des Urgences Obstétricales entre 2013 e 2018, utilizando os prontuários do hospital. Os fatores de risco estudados foram: faixa etária, tipo de gravidez (feto único ou múltiplo), tipo de parto e uso de serviços de atendimento pré-natal. Resultados. A análise incluiu um total de 31.509 mulheres e 24.983 partos. Entre eles, 204 (0,6%) mortes maternas (648 por 100.000 mulheres que deram à luz), 1.962 (7,9%) natimortos e 11.008 (44,1%) recém-nascidos com baixo peso ao nascer estavam documentados. De todas as internações, 10.991 (34,9%) eram de mulheres em pré-eclâmpsia. Parto cesariana aumentou significativamente o risco de mortalidade materna nas mulheres com complicações na gravidez e com pré-eclâmpsia, mas reduziu o risco de natimorto nessas mulheres. Não fazer acompanhamento pré-natal foi associado a risco significativamente maior de natimorto (razão de chances (OR) 4,82; intervalo de confiança de 95% (IC) 3,55-6,55) e baixo peso ao nascer (OR 1,40; IC de 95% 1,05-1,86) para as mulheres com complicações na gravidez. Conclusões. Para prevenir e tratar as complicações da gravidez o mais precocemente possível, o acompanhamento pré-natal é crucial. Recomenda-se o aprimoramento do acesso a serviços de atendimento pré-natal de qualidade e oferecidos gratuitamente a todas as gestantes do Haiti.

Growth and neurodevelopment in low birth weight versus normal birth weight infants from birth to 24 months, born in an obstetric emergency hospital in Haiti, a prospective cohort study.

BACKGROUND: Low birthweight (LBW) infants are at higher risk of mortality and morbidity (growth, chronic disease and neurological problems) during their life. Due to the high incidence of (pre-) eclampsia in Haiti, LBW infants are common. We assessed the anthropometric growth (weight and length) and neurodevelopmental delay in LBW and normal birthweight (NBW) infants born at an obstetric emergency hospital in Port au Prince, Haiti, between 2014 and 2017. METHODS: Infants were followed at discharge and 3, 6, 12, 15, 18, 21 and 24 months of corrected gestational age. At each visit they underwent a physical checkup (weight, length, physical abnormalities, identification of morbidities). At 6, 12, 18 and 24 months they underwent a neurodevelopmental assessment using the Bayley Scale III (motor, cognitive and communication skills). We modelled the trajectories between birth and 24 months of age of NBW compared to LBW infants for weight, length, and raw scores for Bayley III assessments using mixed linear models. RESULTS: In total 500 LBW and 210 NBW infants were recruited of which 333 (46.7%) were followed up for 24 months (127 NBW; 60.5% and 206 LBW; 41.2%) and 150 died (LBW = 137 and NBW = 13). LBW and NBW babies gained a mean 15.8 g and 11.4 g per kg of weight from discharge per day respectively. The speed of weight gain decreased rapidly after 3 months in both groups. Both groups grow rapidly up to 6 months of age. LBW grew more than the NBW group during this period (22.8 cm vs. 21.1 cm). Both groups had WHZ scores <- 2 up to 15 months. At 24 months NBW babies scored significantly higher on the Bayley scales for gross motor, cognitive and receptive and expressive communication skills. There was no difference between the groups for fine motor skills. CONCLUSION: LBW babies that survive neonatal care in urban Haiti and live up to 24 months of age, perform similar to their NBW for weight, length and fine motor skills. LBW babies are delayed in gross motor, cognitive and communication skills development. Further research on the clinical significance of these findings and long term implications of this neurodevelopmental delay is needed.

High prevalence of ESBL-positive bacteria in an obstetrics emergency hospital and neonatal care unit-Haiti, 2016.

A point-prevalence survey of mothers and neonates admitted to an obstetrics emergency hospital in Port-au-Prince, Haiti, revealed that 13 of 127 gram-negative bacteria isolates (10%) from rectal swabs were ESBL-positive in women and 30 of 59 gram-negative bacteria isolates (51%) from rectal swabs were ESBL-positive in neonates. Length of hospital stay and antibiotic consumption were risk factors for ESBL colonization.

A Nosocomial Outbreak of Clinical Sepsis in a Neonatal Care Unit (NCU) in Port-Au-Prince Haiti, July 2014 - September 2015.

INTRODUCTION: Between July 2014 and September 2015, a neonatal care unit (NCU) in Port Au Prince, Haiti, experienced an outbreak of sepsis, most probably due to nosocomial transmission of Extended Beta Lactamase (ESBL) producing gram negative bacteria, included Klebsiella pneumoniae. METHODS: We describe the epidemiological and microbiological activities performed as part of the outbreak investigation and the control measures implemented throughout this period. RESULTS: During the study period 257 cases of sepsis were reported, of which 191 died. The case fatality decreased from 100% in July 2014 to 24% in September 2015 and could be attributed to an improvement in clinical management and strengthened infection prevention and control measures. Risk factors identified to be associated with having late onset sepsis (sepsis onset >48 hours after birth)(n=205/257, 79. included: all categories of birthweight lower than <2500g (p=<0.0001) and all categories of gestational age younger than 36 weeks (p=0.0002). Microbiological investigations confirmed that out of 32 isolates (N=55; 58%) that were positive for gram negative bacteria, 27 (89%) were due to K. pneumoniae and most of these were from single MLST type (ST37). DISCUSSION: This outbreak highlighted the importance of epidemiological and microbiological surveillance during an outbreak of sepsis in a NCU in a low resource setting, including regular point prevalence surveys.

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

We assessed risk factors for fetal death during cholera infection and effect of treatment changes on these deaths. Third trimester gestation, younger maternal age, severe dehydration, and vomiting were risk factors. Changes in treatment had limited effects on fetal death, highlighting the need for prevention and evidence-based treatment.

Field evaluation of three plant-based insect repellents against malaria vectors in Vaca Diez Province, the Bolivian Amazon.

The efficacy of repellents against Anopheles darlingi, the main malaria vector in Bolivia, was evaluated. This mosquito has a peak in biting activity early in the evening. Three natural repellents (1 eucalyptus based, 1 neem based, and 1 containing several repellent essential oils) were tested in comparison with 15% deet in human landing catches in Bolivia. The eucalyptus-based repellent containing 30% p-menthane-diol applied at a dose similar to those used in practice gave 96.89% protection for 4 h. Deet gave 84.81% protection. The other 2 products did not provide significant protection from mosquito bites.