loving the older people in times of cholera
DESCRIPTION
Research by Jonathan Kwok, Todd Swarthout, Pascale Fritsch, Abid Raza and Melanie NewportTRANSCRIPT
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
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
Conclusions
• Older pa1ents present no later than others – Age is only weakly correlated with delays in Hme from
first symptoms to presentaHon at a CTC
• Older pa1ents present with worse dehydra1on – 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
• Older pa1ents are not more likely to receive ac1ve treatment – Age is not correlated with acHve treatment
(either ORS, iv Ringers, or a combinaHon of both)
• Older pa1ents are more likely to die – 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
(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
Similar presentaHon pa3ern, over Hme, for all age groups
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>80yo
60-‐79yo
25-‐59yo
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Children
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>80yo
60-‐79yo
Number of paHents admi3ed to CTC by age group
• Very weak correlaHon between Age and Time to presentaHon
Older persons present with worse dehydraHon
DehydraHon status of older paHents on arrival at CTC
ProporHon of older (>60yo) versus adults
presenHng with severe dehydraHon
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)
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
– 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
Jonathan Kwok Brighton & Sussex Medical School
Todd Swarthout MSF-‐OCA
Pascale Fritsch Help Age InternaHonal
Melanie Newport Brighton & Sussex Medical School
Abid Raza InsHtute of Postgraduate Medicine
Results
1 Background
• WHO es1mates 2.8 million cases of cholera annually worldwide – 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
• First Hai1an case of cholera in more than a century, confirmed 20th October 2010
• 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)
• MSF-‐OCA has operated cholera treatment centres at six loca1ons – 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)
• MSF doctors and nurses have become concerned about outcomes for their older pa1ents – Belief that older paHents have been more likely to die – Desire to idenHfy potenHal protocol improvements
HaïH
Dominican Republic
Cuba
Map data © OpenStreetMap contributors, CC BY-‐SA
CumulaHve cholera deaths (4)
(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
MSF-‐OCG MSF-‐OCP
MSF-‐OCBA MSF-‐OCB
MSF-‐OCA MSF-‐OCG MSF-‐OCBA
MSF-‐OCA
2 Methodology
• MSF clinical teams collected pa1ent data using an internal “linelist” data tool – 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 – Older pa1ents present later – Older pa1ents present worse – Older pa1ents suffer worse outcomes
• 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
3
4 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
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% Adult (25-‐59 yo)
% Old (>60 yo)
• Poor Dehydra1on Status is associated with Age – For Moderate dehydraHon vs Mild, at presentaHon to CTC
• 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)
DehydraHon is strongly associated with mortality
• For Moderate dehydra1on versus Mild – 10.2x odds of death (p<0.001, 95% CI 4.5-‐23.3)
• For Severe dehydra1on versus Mild – 57.8x odds of death (p<0.001, 95% CI 26-‐128)