Loving the Older People in 1mes of Cholera Preliminary findings from a 2008-‐12 study to analyse care and outcomes for cholera pa1ents treated by MSF-‐OCA in Haï1 and Zimbabwe Jonathan Kwok
Todd Swarthout
j.kwok1@uni.bsms.ac.uk
toddswarth@yahoo.com
Brighton & Sussex Medical School
1
Pascale Fritsch
MSF-‐OCA
2
Conclusions
3
Background
– Officially reported cases represent 5-‐10% of the actual total 1.2-‐4.3 million cases; 28,000 to 142,000 deaths (1) – There is a lack of published material invesHgaHng the cholera epidemiology of old people, and their specific outcome risk factors
– Age is significantly associated with poor dehydraHon status on arrival (2-‐3x odds for >60yo vs adults)
• Dehydra1on status at presenta1on is strongly associated with mortality – 58x odds of death for Severe versus Mild
• First Hai1an case of cholera in more than a century, confirmed 20th October 2010
• Older pa1ents are not more likely to receive ac1ve treatment
• More than half a million people affected by cholera in Haï1 since (to 20th April 2012) – 536,943 cases noHfied – 288,839 paHents hospitalised – 7,112 deaths (1.3% CFR) (2)
– Age is not correlated with acHve treatment (either ORS, iv Ringers, or a combinaHon of both)
• Older pa1ents are more likely to die
– Belief that older paHents have been more likely to die – Desire to idenHfy potenHal protocol improvements
Older persons present with worse dehydraHon DehydraHon status of older paHents on arrival at CTC
250 C (severe, iv) B (moderate, ORS) A (mild)
50
1,000
% Old (>60 yo) 10%
Jul'11
Nov'11
Jun'11
Oct'11
Sep'11
Aug'11
May'11
Jan'11
Apr'11
Feb'11
Dec'10
Nov'10
Mar'11
Jul'11
Nov'11
Jun'11
Oct'11
Sep'11
Aug'11
May'11
Jan'11
Apr'11
Feb'11
Dec'10
15-‐24yo Children Infants
0
• Poor Dehydra1on Status is associated with Age
No v'1 De 0 c'1 Ja 0 n'1 Fe 1 b'1 M 1 ar' 1 Ap 1 r'1 M 1 ay '1 Ju 1 n'1 1 Ju l'1 Au 1 g'1 Se 1 p'1 Oc 1 t'1 No 1 v'1 1
– For Moderate dehydraHon vs Mild, at presentaHon to CTC
350 300 250 200 150
>80yo
100
60-‐79yo
• 1.4x odds raHo for 60-‐79yo (versus adult, p<0.001, 95% CI 1.23-‐1.67) 1.9x odds raHo for >80yo (p<0.001, 95% CI 1.31-‐2.83) – For Severe dehydra1on vs Mild • 1.9x odds ra1o for 60-‐79yo (versus adult, p<0.001, 95% CI 1.64-‐2.20), 2.9x odds ra1o for >80yo (p<0.001, 95% CI 2.01-‐4.18) • Males enjoy independent protecHve effect of 0.91 odds raHo (p=0.002, 95% CI 0.85-‐0.97)
• For Moderate dehydra1on versus Mild
Age is weakly correlated with acHve treatment • Either ORS, iv Ringers or both during inpa1ent stay
– InvesHgated by creaHng a new variable for treatment, to run bivariate correlaHon
50
No v'1 De 0 c'1 0 Ja n'1 Fe 1 b'1 M 1 ar' 1 Ap 1 r'1 M 1 ay '1 Ju 1 n'1 1 Ju l'1 Au 1 g'1 Se 1 p'1 Oc 1 t'1 No 1 v'1 1
0
• Very weak correlaHon between Age and Time to presentaHon
• Ethical approvals were not required for this retrospecHve secondary data analysis
– The project is staffed with full Hme research from Brighton & Sussex Medical School, part Hme voluntary support from Todd Swarthout, part Hme technical advice from Help Age InternaHonal and MSF-‐OCA, and administraHve support from Kathrin Go3wald
(4) Pan American Health OrganizaHon. Atlas of cholera outbreak in La Hispaniola, 2010-‐12. Washington DC; 2012. Available at h3p://new.paho.org/hq/images/Atlas_IHR/ CholeraHispaniola/atlas.html
% Adult (25-‐59 yo)
20%
0%
Nov'10
0
Mar'11
2,000
25-‐59yo
Map data © OpenStreetMap contributors, CC BY-‐SA
– 57.8x odds of death (p<0.001, 95% CI 26-‐128)
30%
200
100
60-‐79yo
CumulaHve cholera deaths (4)
• For Severe dehydra1on versus Mild
40%
150
>80yo
– Older pa1ents present later – Older pa1ents present worse – Older pa1ents suffer worse outcomes
– 10.2x odds of death (p<0.001, 95% CI 4.5-‐23.3)
50%
Age (years) Sex (M or F) District and ward Days since first symptoms DehydraHon status at presentaHon Treatments (ORS or iv Ringers in litres) Outcome (Cured, Transferred, Lost to Follow Up, Died) Dates of admission and discharge
• Data were cleaned up and charted in Microsoq Excel (MS Excel for Mac 2008 v12.1.5) and then exported to IBM SPSS StaHsHcs (v19) for staHsHcal invesHgaHon of the following hypotheses
Dominican Republic
MSF-‐OCA MSF-‐OCG MSF-‐OCBA
DehydraHon is strongly associated with mortality
ProporHon of older (>60yo) versus adults presenHng with severe dehydraHon
350 300
3,000
MSF-‐OCG
MSF-‐OCBA MSF-‐OCB
• MSF doctors and nurses have become concerned about outcomes for their older pa1ents
Results
4,000
MSF-‐OCP
HaïH MSF-‐OCA
– La Saline, Delmas, Carrefour (urban districts N, E & W of Port au Prince) – Barradères, Bonne Fin, Plaisance du Sud (rural southwest) – Treated >26,881 paHents (3)
(1) Ali M et al. The global burden of cholera. Bull World Health Organ 2012; 90: 209-‐218A (2) Ministère de la Santé Publique et de la PopulaHon, HaïH. Rapports journaliers du MSPP sur l'évoluHon du choléra en HaïH. Port au Prince; 2012. Available at h3p://www.mspp.gouv.ht/site/downloads/Rapport %20journalier%20MSPP%20du%2023%20avril%202012.pdf (3) Médicins Sans FronHères. MSF-‐OCA linelist data to April 12th, 2012
5,000
Cuba
• MSF-‐OCA has operated cholera treatment centres at six loca1ons
– Age is significantly associated with mortality outcome, controlled for sex, dehydraHon status at presentaHon, duraHon and type of treatment, experience and acHvity levels of the CTC
6,000
Methodology – – – – – – – –
• WHO es1mates 2.8 million cases of cholera annually worldwide
• Older pa1ents present with worse dehydra1on
Number of paHents admi3ed to CTC by age group
Melanie Newport
Brighton & Sussex Medical School
• MSF clinical teams collected pa1ent data using an internal “linelist” data tool
– Age is only weakly correlated with delays in Hme from first symptoms to presentaHon at a CTC
Similar presentaHon pa3ern, over Hme, for all age groups
InsHtute of Postgraduate Medicine
pfritsch@helpage.org
• Older pa1ents present no later than others
4
Abid Raza
Help Age InternaHonal
– However, we are cauHous of the accuracy of the ORS and iv Ringers observaHons in our linelist data tool
• >20% of pa1ents presen1ng with Mild dehydra1on go on to receive iv fluids
– Half of the Moderate, and four fiqhs of the Severe dehydraHon paHents received both ORS and iv Ringers – We believe paHents receiving only iv Ringers died early before switching to oral soluHons
Age is associated with greater risk of mortality • Pa1ents who died have a higher mean age (38 yo, SD 29) versus those who recovered (23yo, SD 18) p<0.001
Regression Model • Binary logisHc regression on Outcome – Controlled for sex, age group, CTC experience (admission month), duraHon of care, dehydraHon status on presentaHon, type of treatment, and acHvity levels of the CTC (paHents per week)
• Age 60-‐79yo associated with 3.97x odds of death (95% CI 2.29-‐6.90, p<0.001) – Age >80yo associated with 11.4x odds for death 95% CI 5.13-‐25.44, p<0.001
• Male sex associated with 0.62 odds protec1ve effect (95% CI 0.41-‐0.94, p=0.025) – Longer dura1on of care was associated with a significant protecHve effect (odds 0.54, 95% CI 0.46-‐0.62, p<0.001) – “Busy” ness or ac1vity levels of the CTC had no significant associaHon with outcome (odds 0.999)
5
Next steps • Sta1s1cal inves1ga1on of addi1onal pa1ent data from con1nuing epidemic in Haï1 – Latest updates (Nov’11 to Apr’12)
• A3empt to idenHfy and control for addiHonal confounders, eg. – Socioeconomic status – NutriHonal status – Co-‐morbidiHes
• Deeper analysis of idenHfied subgroups, eg.
– Subset of severely dehydrated paHents appear to die quickly, before ORS is started • InvesHgaHon of paHent characterisHcs? Treatment profiles? Time pa3ern to mortality?
• Examine data from MSF-‐OCA mission to Zimbabwe – Comparison with HaïH • Poten1al discussions with previous and current MSF field teams • PotenHal contribuHon to ongoing MSF review of Cholera Guidelines – AnHcipated Dec’12
With thanks to Leslie Shanks and Kathrin Go3wald, Emanuele Sozzi, MSF’s country teams, Muna Aljawad, the Royal Sussex County Hospital and the people of HaïH and Zimbabwe