Maria W. Steenland

Cholera Surveillance during the Haiti Epidemic — The First 2 Years

BACKGROUND In October 2010, nearly 10 months after a devastating earthquake, Haiti was stricken by epidemic cholera. Within days after detection, the Ministry of Public Health and Population established a National Cholera Surveillance System (NCSS). METHODS The NCSS used a modified World Health Organization case definition for cholera that included acute watery diarrhea, with or without vomiting, in persons of all ages residing in an area in which at least one case of Vibrio cholerae O1 infection had been confirmed by culture. RESULTS Within 29 days after the first report, cases of V. cholerae O1 (serotype Ogawa, biotype El Tor) were confirmed in all 10 administrative departments (similar to states or provinces) in Haiti. Through October 20, 2012, the public health ministry reported 604,634 cases of infection, 329,697 hospitalizations, and 7436 deaths from cholera and isolated V. cholerae O1 from 1675 of 2703 stool specimens tested (62.0%). The cumulative attack rate was 5.1% at the end of the first year and 6.1% at the end of the second year. The cumulative case fatality rate consistently trended downward, reaching 1.2% at the close of year 2, with departmental cumulative rates ranging from 0.6% to 4.6% (median, 1.4%). Within 3 months after the start of the epidemic, the rolling 14-day case fatality rate was 1.0% and remained at or below this level with few, brief exceptions. Overall, the cholera epidemic in Haiti accounted for 57% of all cholera cases and 53% of all cholera deaths reported to the World Health Organization in 2010 and 58% of all cholera cases and 37% of all cholera deaths in 2011. CONCLUSIONS A review of NCSS data shows that during the first 2 years of the cholera epidemic in Haiti, the cumulative attack rate was 6.1%, with cases reported in all 10 departments. Within 3 months after the first case was reported, there was a downward trend in mortality, with a 14-day case fatality rate of 1.0% or less in most areas.

Pregnancy outcomes with an IUD in situ: a systematic review

BACKGROUND While intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an IUD in situ. METHODS We searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-releasing (LNG) IUDs. RESULTS Nine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions. CONCLUSION Pregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal appeared to improve outcomes but did not entirely eliminate risks.

Intrauterine contraceptive insertion postabortion: a systematic review☆

BACKGROUND This review was conducted to evaluate the evidence regarding the safety and effectiveness of intrauterine device (IUD) insertion immediately following spontaneous or induced abortion. STUDY DESIGN We searched MEDLINE databases for all articles (in all languages) published in peer-reviewed journals from January 1966 through March 2010 for evidence comparing immediate postabortion IUD insertion with either no IUD insertion, insertion at a different time, insertion following first-trimester compared with second-trimester abortion or copper IUD insertion compared with hormone-releasing IUD insertion postabortion. We used standard abstraction forms to summarize and assess the quality of the evidence. RESULTS The search strategy identified a total of 990 articles, of which 19 met our inclusion criteria for this review. Studies comparing immediate postabortion IUD insertion with no IUD insertion found that both groups experienced similar rates of pain and infection and a similar number of bleeding days, but one study reported that women with copper IUD insertion experienced a greater amount of bleeding than women without IUD insertion after abortion. Results from studies comparing immediate postabortion IUD insertion and insertion at a time not associated with pregnancy did not report differences between the two groups in the duration of bleeding, pain, expulsions or pelvic inflammatory disease (PID). One study however reported a greater amount of bleeding and another reported more removals for medical reasons among women with postabortion IUD insertion. Evidence from studies that examined immediate vs. delayed postabortion insertion reported minimal differences in bleeding, pain, expulsion and PID between groups. Studies comparing immediate IUD insertion after first- vs. second-trimester abortion reported no difference in removals for pain and bleeding, and an increased risk of expulsion among those women who had insertions after second-trimester abortion. In addition, women with insertions immediately after abortions occurring later in the first trimester had higher expulsion rates than those with insertions after early first-trimester abortions. Studies examining women using a copper IUD compared with a hormone-releasing IUD reported inconsistent results, with one paper reporting more bleeding days in the copper IUD group and another finding higher rates of removal for bleeding in the progesterone-releasing IUD group. CONCLUSION Intrauterine device insertion immediately after abortion is not associated with an increased risk of adverse outcomes compared with use of other contraceptive methods or with no IUD insertion after abortion and compared with IUD insertion at times other than immediately after abortion. Intrauterine device expulsion rates, while generally low, were higher with insertions that occurred after later first-trimester abortion compared with after early first-trimester abortion and higher with IUD insertion after second-trimester abortion compared with after first-trimester abortion.

Effect of missed combined hormonal contraceptives on contraceptive effectiveness: a systematic review.

BACKGROUND Combined hormonal contraceptives (CHCs) are popular methods of reversible contraception in the United States, but adherence remains an issue as reflected in their lower rates of typical use effectiveness. The objective of this systematic review was to evaluate evidence on the effect of missed CHCs on pregnancy rates as well as surrogate measures of contraceptive effectiveness (e.g., ovulation, follicular development, changes in hormone levels, cervical mucus quality). STUDY DESIGN We searched the PubMed database for peer-reviewed articles published in any language from database inception through April 2012. We included studies that examined measures of contraceptive effectiveness during cycles with extended hormone-free intervals or nonadherence (e.g., omission of pills, delayed patch replacement) on days not adjacent to the hormone-free interval. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS The search strategy identified 1387 articles, of which 26 met our study selection criteria. There is wide variability in the amount of follicular development and risk of ovulation among women who extended the pill-free interval to 8-14 days; in general, the risk of ovulation was low, and among women who did ovulate, cycles were usually abnormal (i.e., low progesterone levels, small follicles and/or poor cervical mucus) (Level I, good, indirect to Level II-3, fair, indirect). Studies of women who missed one to four consecutive pills or 1-3 consecutive days of delay before patch replacement at times other than adjacent to the hormone-free interval reported little follicular activity and low risk of ovulation (Level I, fair, indirect to Level II-3, poor, indirect). Studies comparing 30 mcg versus 20 mcg mc ethinyl estradiol pills showed more follicular activity when 20 mcg ethinyl estradiol pills were missed (Level I, good, indirect). CONCLUSION Most of the studies in this evidence base relied on surrogate measures of pregnancy risk and ranged in quality. For studies providing indirect evidence on the effects of missed CHCs, it is unclear how differences in surrogate measures correspond to pregnancy risk. Fewer studies examined the transdermal patch and vaginal ring than combined oral contraceptives.

Laboratory-Confirmed Cholera and Rotavirus among Patients with Acute Diarrhea in Four Hospitals in Haiti, 2012–2013

An outbreak of cholera began in Haiti in October of 2010. To understand the progression of epidemic cholera in Haiti, in April of 2012, we initiated laboratory-enhanced surveillance for diarrheal disease in four Haitian hospitals in three departments. At each site, we sampled up to 10 hospitalized patients each week with acute watery diarrhea. We tested 1,616 specimens collected from April 2, 2012 to March 28, 2013; 1,030 (63.7%) specimens yielded Vibrio cholerae, 13 (0.8%) specimens yielded Shigella, 6 (0.4%) specimens yielded Salmonella, and 63 (3.9%) specimens tested positive for rotavirus. Additionally, 13.5% of children < 5 years old tested positive for rotavirus. Of 1,030 V. cholerae isolates, 1,020 (99.0%) isolates were serotype Ogawa, 9 (0.9%) isolates were serotype Inaba, and 1 isolate was non-toxigenic V. cholerae O139. During 1 year of surveillance, toxigenic cholera continued to be the main cause of acute diarrhea in hospitalized patients, and rotavirus was an important cause of diarrhea-related hospitalizations in children.

Retention of intrauterine devices in women who acquire pelvic inflammatory disease: a systematic review☆

BACKGROUND Women using intrauterine devices (IUDs) are not protected against acquiring pelvic inflammatory disease (PID). If a woman has an IUD in place when she is diagnosed with PID, there is a theoretical concern that presence of an IUD might impact the course of treatment. This review was conducted to evaluate the evidence regarding whether an IUD should be retained or removed if a woman develops PID. STUDY DESIGN The PubMed database was searched from database inception through April 2012 for all peer-reviewed articles in any language concerning PID in women using IUDs. Articles were included if they examined women with IUDs who developed PID and compared the clinical course of women in whom the IUD was retained versus women in whom the IUD was removed. Articles were excluded if the infection was diagnosed before or at the time of IUD insertion. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS Four fair-quality studies met inclusion criteria for this review. One randomized controlled trial showed that women with IUDs removed had longer hospitalizations than those with IUD retention (15% versus 4%, p<.01), although there were no differences in PID recurrences or subsequent pregnancies. Another randomized controlled trial showed no differences in laboratory parameters among women who retained the IUD when compared with women in whom the IUD was removed. One prospective cohort study showed that there were no differences in clinical or laboratory parameters during hospitalization; however, the IUD removal group had a higher proportion hospitalized for more than 2 weeks compared with the IUD retention group (33% versus 19%, p<.05). One randomized controlled trial showed that women who had the IUD removed experienced improved recovery in most clinical signs and symptoms compared with women who retained the IUD. CONCLUSIONS Three fair-quality studies showed no difference in clinical or laboratory outcomes among women who retained IUDs when compared with women who had IUDs removed, and two of these studies showed that women who had IUDs removed had longer hospitalizations. In contrast, one fair quality study showed improved clinical signs and symptoms among women who had IUDs removed. Overall, women who retained their IUDs had similar or better outcomes than women who had their IUDs removed.

Appropriate follow up to detect potential adverse events after initiation of select contraceptive methods: a systematic review

BACKGROUND After a woman initiates certain methods of contraception [e.g., hormonal methods, intrauterine devices (IUDs)], she is generally asked to return at some interval for a follow-up visit; however, is it unclear whether follow up is needed, what an appropriate follow-up schedule is and what should be done at follow-up visits. METHODS We conducted four separate searches in the PubMed database for all peer-reviewed articles in any language published from database inception through April 2012 that examined the following health outcomes for combined hormonal contraceptives (CHCs), IUDs or medroxyprogesterone acetate (DMPA): (a) incidence of hypertension among women who began using a CHC compared to women not using a CHC; (b) incidence of migraine among women who began using a CHC compared to women not using a CHC; (c) incidence of pelvic inflammatory disease (PID) among women who began using an IUD compared to women who started another form or used no method of contraception or examined incidence of PID at two or more time periods after IUD insertion and (d) whether initial weight gain predicts future weight gain among women who began using DMPA. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS A total of 15 studies met our inclusion criteria: 5 examined hypertension and combined oral contraceptive (COC) use, 7 examined PID and IUD use and 3 examined weight gain after DMPA initiation. No studies that examined migraine after CHC initiation met our inclusion criteria. Few women developed hypertension after initiating COCs, and studies examining increases in blood pressure after COC initiation found mixed results (Level I, fair to II-2, fair). Among women who had a copper IUD inserted, there was little difference in incidence of PID, or IUD removal for PID, compared with women who initiated DMPA, a hormone-releasing IUD, or COCs (Level I, good to Level II-2, fair). Studies that examined when women were diagnosed with PID after IUD insertion found mixed results. The study with the largest sample size found a much greater incidence of PID in the first 20 days after insertion, with very low rates of PID up to 8 years postinsertion (Level I, good to Level II-3, poor). Studies that examined weight gain after DMPA initiation found that weight gain >5% of baseline weight at 6 months was associated with greater mean change in weight and greater mean change in body mass index at follow-up times ranging from 12 to 36 months (Level II-2, fair to Level II-3, fair). CONCLUSIONS Evidence on select adverse events associated with initiation of contraceptive use is limited but does not suggest increased risk of hypertension among COC users or increased risk of PID among IUD users. DMPA users who gain >5% of baseline body weight may be at increased risk of future weight gain.

Blood pressure measurement prior to initiating hormonal contraception: a systematic review ☆

BACKGROUND Women with hypertension who use hormonal methods of contraception may have an increased risk for cardiovascular events. This review was conducted to evaluate the evidence regarding whether blood pressure should be measured prior to initiating hormonal contraceptives. STUDY DESIGN The PubMed database was searched from database inception through March 2012 for all peer-reviewed articles in any language concerning blood pressure measurement prior to initiation of hormonal contraceptives. Articles were included if they reported on women with and without blood pressure measurement prior to current hormonal contraceptive usage and assessed cardiovascular outcomes. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS Six fair-quality articles from three studies met inclusion criteria for this review. Three case-control studies showed that women who did not have blood pressure measurement prior to initiating combined oral contraceptives (COCs) had a higher risk for acute myocardial infarction (AMI) than women who did have blood pressure measurement. Two case-control studies showed that women who did not have blood pressure measurement prior to initiating COCs had a higher risk for ischemic stroke than women who did have blood pressure measurement. One case-control study showed no difference in the risk for hemorrhagic stroke among women who initiated COCs based on whether or not blood pressure was measured. CONCLUSIONS Fair-quality evidence from five reports showed that women who did not have blood pressure measurement prior to COC initiation had a higher risk for AMI and ischemic stroke than women who did have blood pressure measurement. One fair-quality study showed no increased risk for hemorrhagic stroke based on whether or not blood pressure was measured. Studies that examined hormonal contraceptive methods other than COCs were not identified.

How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review

BACKGROUND The review was conducted to examine studies that assess whether the number of pill packs dispensed, or prescribed, affects method continuation and other measures of use. STUDY DESIGN PubMed database was searched from inception through March 2012 for all peer-reviewed articles, in any language, that examined the effect of the number of oral contraceptive pill packs dispensed on method continuation, and other measures of use. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS Four studies met the inclusion criteria for this review. Studies that compared 1 vs. 12, 1 vs. 12-13, or 3 vs. 7 packs found increased method continuation. However, one study that examined the difference between providing one and then three packs versus providing four packs all at once did not find a difference in continuation. In addition to continuation, evidence from the individual studies included found that a greater number of pill packs was associated with fewer pregnancy tests, fewer pregnancies and less cost per client. A greater number of pill packs was, however, also associated with increased pill wastage. CONCLUSIONS A small body of evidence suggests that dispensing a greater number of oral contraceptive pill packs may increase continuation of use.

The effect of follow-up visits or contacts after contraceptive initiation on method continuation and correct use.

BACKGROUND We conducted a systematic review to assess whether follow-up visits or contacts after a woman begins using contraception improve method continuation and correct use. STUDY DESIGN We searched the PubMed database for all peer-reviewed articles in any language published from database inception through May 2012 that examined the effect of a structured follow-up schedule of visits or contacts on contraceptive use. We included studies that compared women who initiated a method of contraception with a certain follow-up schedule compared to women with a different follow-up schedule or no follow-up at all. To be included, studies must have compared groups on a measure of contraceptive use (e.g., pregnancy, correct use, consistent use, method discontinuation including expulsion). Though not ideally suited to answer our review question, studies in which women used a variety of contraceptive methods but results were not stratified by method type were included. RESULTS Four studies met our inclusion criteria (Level I, poor to II-2, poor). Two studies examined the effect of a specific follow-up visit schedule on intrauterine device (IUD) continuation: one examining frequency of visits and one examining the timing of the first follow-up visit. Women with more frequent follow-up visits did not have a statistically significant difference in proportion of removals for medical reasons compared with women who had fewer follow-up visits; among women who had their IUDs removed for medical reasons, those who had more frequent follow-up visits had a longer mean time of use prior to removal. The other study found more removals and shorter continuation among women with a follow-up visit at 1 week compared to women with a follow-up visit at 1 month after IUD insertion (no statistical tests reported). Two studies examined the effect of follow-up phone calls compared to no follow-up phone calls after an initial family planning visit among adolescents initiating a variety of contraceptive methods. Neither of the two studies found any differences in method continuation or correct use between study groups. CONCLUSIONS It is difficult to determine what effect, if any, follow-up visits or contacts have on contraceptive method continuation or correct use. Few studies were identified, and those that were identified were mostly of poor quality, were not method specific and had either poor patient compliance with follow-up visits or poor phone contact completion rates.