GUEST EDITORIAL
Ebola in Pregnancy: Have We Learned Any Lessons? Deborah Money, MD, FRCSC Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
E
very few years, we seem destined to have a significant outbreak of an infectious disease that challenges the Canadian health delivery system and, more significantly, the global system as well. It is my observation that when these outbreaks occur, those who guide public health policy and practice and the implications for clinical care seldom consider the unique issues of pregnancy and the newborn until very late. We need to change this. As advocates for the safe and appropriate care of women and infants, we must push for our special populations to be considered early in the deliberations. More importantly, when the planning finally does include the specific issues of women and children, we need to gain insights for future emerging and re-emerging infectious diseases. I experienced the spread of HIV and AIDS in the early 1990s as an obstetrics and gynaecology infectious diseases specialist, at a time when this was a “gay man’s disease” in North America. The unique issues for women and pregnancy were not considered at all in the beginning; in fact, it was presumed that women never got this disease. When this possibility was finally recognized, the focus of management was strictly on the prevention of motherto-child transmission, not on the care and survival of the HIV-positive woman. In those days, AIDS was more or less a death sentence, and there was much fear of transmitting the infection to health care providers and close contacts of patients. Many health care providers declined to care for these women. Only very recently has the WHO recommended therapies for women that will result in their prolonged survival.1 It is shameful that we have taken 20 years since determining that antiretroviral therapy in pregnancy can prevent transmission of HIV from mother to infant,2 and 18 years since discovering that combination antiretroviral therapy can prolong the life of HIV positive people,3 to advocate for life-saving treatment for adult women who are HIV-positive and pregnant, regardless of the stage of disease.
In the last decade we have been faced with SARS and H1N1 outbreaks. During the early stages of the H1N1 pandemic, there were no clinical guidelines or special recommendations for pregnant women until it was recognized that pregnant women had a poorer prognosis than non-pregnant adults.4,5 However, the response to this emergency was slow and not as well coordinated as it could have been. Eventually the obstetrical care community rallied and developed guidelines, standard orders, and plans for infection control in antenatal wards and in labour and delivery units. We thought we had learned our lessons and were going to be much better prepared for the next challenge. Then came the outbreak of Ebola in late 2013. Fortunately, to date there have been no cases in Canada, but the problem remains extremely serious in Western Africa. In the three most affected countries (Guinea, Liberia, and Sierra Leone) there have been over 17 000 cases and over 6000 deaths. Understandably, the initial response to Ebola was an emergency response from local agencies, followed by international medical outreach. These efforts were focused on case identification, containment, and limited treatment. However, tragically, reports of the high fatality rates seem to have driven a fatalistic approach to management and care. Recently a number of commentaries have emphasized the high efficacy of simple supportive management approaches in the absence of specific antiviral treatment.6-8 This disease primarily appears to cause death from hypovolemic shock and consequent end organ failure, but if fluid resuscitation and basic comfort measures can be instituted early, then survival rates can be as high as 70% to 80%.9 Information about the consequences in pregnancy is limited for both maternal and fetal/newborn risk, but J Obstet Gynaecol Can 2015;37(2):105–107
FEBRUARY JOGC FÉVRIER 2015 l 105
GUEST EDITORIAL
early reports suggested very high fatality rates. This again leads to a fatalistic approach in the pregnant population.4,10 There are very worrisome reports coming from West Africa that pregnant women with suspected Ebola are being turned away from health care facilities for fear that they will contaminate others; the flawed rationale for this is that the women and their infants have a low chance of survival.11 This perspective appears to have crept into the developed world’s medical paradigm, with articles calling for limited (if any) care to be given to pregnant women with possible or proven Ebola.12 This is particularly worrying in the developed world: firstly, it is most likely that a woman with fever and symptoms compatible with Ebola has another medical condition such as malaria, gastroenteritis, or chorioamnionitis, and, secondly, for such a woman to be abandoned and isolated to the point of neglect would simply be unethical. A pregnant woman in a medical facility in a developed country would have a high chance of survival with Ebola through use of standard supportive care. The survival of her infant with availability of modern medical care and support is yet to be tested. Even if an individual is deemed likely to die, compassionate palliative care would surely be the minimum that we would strive to offer. So how are these considerations balanced with the concerns and fears of health care providers about possible transmission of Ebola or indeed, in the past, fears of H1N1, SARS, and HIV transmission to attendants? Is it acceptable for maternity or neonatal care providers to refuse to provide care to persons they deem to be “too infectious”? Certainly there were many cases of HIVpositive individuals being refused care; this was more common decades ago, but examples still remain in Canada. I learned of health care providers refusing to provide care to infected or at-risk patients during the SARS outbreak. Is this an individual decision made at the time, or should this be a decision made on entering any of the health care professions? When infectious diseases were a more prominent part of medical care, and when infectious disease was the most common cause of mortality, students entering medical, midwifery, or nursing training clearly knew that there were personal risks in dealing with patients with tuberculosis, cholera, and other infectious diseases. Maternity care providers in Canada are exposed daily to blood and body fluids. Attempts to decrease the “medicalization” of birth have led to poor infection control practices, with blood, amniotic fluid, and feces contaminating the clothing and sometimes the skin of care providers. Such contaminants could contain pathogens such as Hepatitis C or HIV (or other yet to be identified agents), but there is a general lack of attention paid to having impermeable surgical scrubs, cover gowns, and eye 106 l FEBRUARY JOGC FÉVRIER 2015
protection. If we are to learn anything from the Ebola epidemic, it should be this: care providers anywhere should never be exposed to the blood or bodily fluids of the patients in their care. In our modern era, there is a perception that health care, including maternity care, can be a sterile, no risk vocation. This is untrue, and it is not likely to be true for many decades yet. New infectious agents with varying degrees of infectivity will come in outbreaks, epidemics, and pandemics, and they will not necessarily come with warnings or with full knowledge of how they are transmitted. Microbiologists must endeavour to inform public health agencies and the medical professions, and these organizations must be prepared to offer advice quickly on safe care. But practitioners also need to be reminded that they will always potentially be at some risk if they work on the “front lines” in general medical care or in maternity care. We have to learn from the excellent work that has been done in preparing for a disease that, as noted in the Committee Opinion13 in this issue, is unlikely to be seen in Canada during this pandemic. Let us learn from our colleagues who continue to fight this disease in West Africa. Let us support them as they try to rebuild their health care system after Ebola, and let us hope that women and their infants can receive the basic care they need. We must ensure that we can respond in an appropriate, safe, and compassionate way when the next infectious agent threatens to become a global pandemic. REFERENCES 1. World Health Organization (WHO). First PROMISE study results confirm WHO recommendations to treat pregnant women and reduce mother-to-child-transmission of HIV. Geneva (CH): WHO; 2014. Available at: http://www.who.int/hiv/mediacentre/news/promisestudy-result/en/#.VIjMwMd14wQ.email. Accessed December 11, 2014. 2. Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O’Sullivan MJ, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994;331:1173–80. 3. Hammer SM, Katzenstein DA, Hughes MD, Gundacker H, Schooley RT, Haubrich RH, et al. A trial comparing nucleoside monotherapy with combination therapy in HIV-infected adults with CD4 cell counts from 200 to 500 per cubic millimeter. AIDS Clinical Trials Group Study 175 Study Team. N Engl J Med 1996;335:1081–90. 4. Jamieson DJ, Uyeki TM, Callaghan WM, Meaney-Delman D, Rasmussen SA. What obstetrician-gynecologists should know about Ebola: a perspective from the Centers for Disease Control and Prevention. Obstet Gynecol 2014;124:1005–10. 5. Centers for Disease Control and Prevention. Interim guidance: considerations regarding 2009 H1N1 influenza in intrapartum and postpartum hospital settings. Atlanta (GA): CDC; 2014. Available at: http://www.cdc.gov/h1n1flu/guidance/obstetric.htm. Accessed December 11, 2014.
Ebola in Pregnancy: Have We Learned Any Lessons?
6. Boseley S, O’Carroll L. Number of Ebola deaths could be cut by use of basic measures, say experts. Guardian; 2014. Available at: http://www.theguardian.com/world/2014/dec/05/ebola-deathsbasic-medical-measures-lancet. Accessed December 11, 2014. 7. Lamontagne F, Clément C, Fletcher T, Jacob ST, Fischer WA 2nd, Fowler RA. Doing today’s work superbly well—treating Ebola with current tools. N Engl J Med 2014;1565–6. doi:10.1056/ NEJMp1411310.
10. Mupapa K, Mukundu W, Bwaka MA, Kipasa M, De Roo A, Kuvula K, et al. Ebola hemorrhagic fever and pregnancy. J Infect Dis 2000;179:22–3. 11. Lang J. Ebola in the maternity ward. New Yorker; 2014. Available at: http://www.newyorker.com/tech/elements/ebola-maternity-ward. Accessed December 11, 2014.
8. Chertow DS, Kleine C, Edwards JK, Scaini R, Giuliani R, Sprecher A. Ebola virus disease in West Africa—clinical manifestations and management. N Engl J Med 2014;371:2054–7.
12. Public Health England. Ebola in pregnancy: information for healthcare workers Ebola transmission Ebola risk and healthcare workers. London: Public Health England; 2014. Available at: https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/377176/ Ebola_in_pregnancy_information_for_healthcare_workers.pdf. Accessed December 11, 2014.
9. World Health Organization (WHO). Ebola response roadmap situation report. Geneva (CH): WHO; 2014. Available at: http://apps.who.int/iris/ bitstream/10665/144806/1/roadmapsitrep_3Dec2014_eng.pdf ?ua=1. Accessed December 3, 2014.
13. Money D; SOGC Infectious Disease Committee. SOGC committee opinion on the management of a pregnant woman exposed or infected with Ebola virus disease in Canada. SOGC Committee Opinion no. 319, February 2015. J Obstet Gynaecol Can 2015;37:183–90.
ERRATA
Singh SS, Scott S, Bougie O, Leyland N; SOGC Clinical Practice–Gynaecology Committee; GOC Executive Committee. Technical Update on Tissue Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy. SOGC Technical Update, No. 317, J Obstet Gynaecol Can 2015;37(1):68–78. This technical update was a joint effort by both the Society of Obstetrics and Gynaecology and the Society of Gynecologic Oncology of Canada. This should have been reflected in a main header titled SOGC Joint Technical Update, which should also replace the element SOGC Technical Update in citations. The GOC shares copyright in this update; none of its contents may be reproduced in any form without prior written permission of both the SOGC and the GOC. The Journal of Obstetrics and Gynaecology Canada regrets the errors and any inconvenience they may have caused.
Singh SS, Scott S, Bougie O, Leyland N; comité de pratique clinique-gynécologie de la SOGC; comité exécutif de la GOC. Mise à jour technique sur le morcellement tissulaire dans le cadre d’une chirurgie gynécologique : Son utilisation, ses complications et les risques liés à la présence insoupçonnée de tumeurs malignes. Mise à jour technique de la SOGC, n° 317. J Obstet Gynaecol Can 2015;37(1):79–81. Cette mise à jour technique a été le fruit d’efforts déployés conjointement par la Société de gynéco-oncologie du Canada et la Société des obstétriciens et gynécologues du Canada. Le titre aurait donc dû être rédigé comme suit dans la vedette principale et les citations : Mise à jour technique commune SOGC/GOC. La GOC partage les droits d’auteur liés à cette mise à jour; ainsi, aucune partie de ce document ne peut être reproduite sous quelque forme que ce soit sans l’obtention au préalable d’une permission écrite de la part tant de la SOGC que de la GOC. Le Journal d’obstétrique et gynécologie du Canada regrette cette erreur, ainsi que toute confusion que cela a pu causer.
FEBRUARY JOGC FÉVRIER 2015 l 107
Ebola in Pregnancy: Have We Learned Any Lessons? Deborah Money, MD, FRCSC Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
E
very few years, we seem destined to have a significant outbreak of an infectious disease that challenges the Canadian health delivery system and, more significantly, the global system as well. It is my observation that when these outbreaks occur, those who guide public health policy and practice and the implications for clinical care seldom consider the unique issues of pregnancy and the newborn until very late. We need to change this. As advocates for the safe and appropriate care of women and infants, we must push for our special populations to be considered early in the deliberations. More importantly, when the planning finally does include the specific issues of women and children, we need to gain insights for future emerging and re-emerging infectious diseases. I experienced the spread of HIV and AIDS in the early 1990s as an obstetrics and gynaecology infectious diseases specialist, at a time when this was a “gay man’s disease” in North America. The unique issues for women and pregnancy were not considered at all in the beginning; in fact, it was presumed that women never got this disease. When this possibility was finally recognized, the focus of management was strictly on the prevention of motherto-child transmission, not on the care and survival of the HIV-positive woman. In those days, AIDS was more or less a death sentence, and there was much fear of transmitting the infection to health care providers and close contacts of patients. Many health care providers declined to care for these women. Only very recently has the WHO recommended therapies for women that will result in their prolonged survival.1 It is shameful that we have taken 20 years since determining that antiretroviral therapy in pregnancy can prevent transmission of HIV from mother to infant,2 and 18 years since discovering that combination antiretroviral therapy can prolong the life of HIV positive people,3 to advocate for life-saving treatment for adult women who are HIV-positive and pregnant, regardless of the stage of disease.
In the last decade we have been faced with SARS and H1N1 outbreaks. During the early stages of the H1N1 pandemic, there were no clinical guidelines or special recommendations for pregnant women until it was recognized that pregnant women had a poorer prognosis than non-pregnant adults.4,5 However, the response to this emergency was slow and not as well coordinated as it could have been. Eventually the obstetrical care community rallied and developed guidelines, standard orders, and plans for infection control in antenatal wards and in labour and delivery units. We thought we had learned our lessons and were going to be much better prepared for the next challenge. Then came the outbreak of Ebola in late 2013. Fortunately, to date there have been no cases in Canada, but the problem remains extremely serious in Western Africa. In the three most affected countries (Guinea, Liberia, and Sierra Leone) there have been over 17 000 cases and over 6000 deaths. Understandably, the initial response to Ebola was an emergency response from local agencies, followed by international medical outreach. These efforts were focused on case identification, containment, and limited treatment. However, tragically, reports of the high fatality rates seem to have driven a fatalistic approach to management and care. Recently a number of commentaries have emphasized the high efficacy of simple supportive management approaches in the absence of specific antiviral treatment.6-8 This disease primarily appears to cause death from hypovolemic shock and consequent end organ failure, but if fluid resuscitation and basic comfort measures can be instituted early, then survival rates can be as high as 70% to 80%.9 Information about the consequences in pregnancy is limited for both maternal and fetal/newborn risk, but J Obstet Gynaecol Can 2015;37(2):105–107
FEBRUARY JOGC FÉVRIER 2015 l 105
GUEST EDITORIAL
early reports suggested very high fatality rates. This again leads to a fatalistic approach in the pregnant population.4,10 There are very worrisome reports coming from West Africa that pregnant women with suspected Ebola are being turned away from health care facilities for fear that they will contaminate others; the flawed rationale for this is that the women and their infants have a low chance of survival.11 This perspective appears to have crept into the developed world’s medical paradigm, with articles calling for limited (if any) care to be given to pregnant women with possible or proven Ebola.12 This is particularly worrying in the developed world: firstly, it is most likely that a woman with fever and symptoms compatible with Ebola has another medical condition such as malaria, gastroenteritis, or chorioamnionitis, and, secondly, for such a woman to be abandoned and isolated to the point of neglect would simply be unethical. A pregnant woman in a medical facility in a developed country would have a high chance of survival with Ebola through use of standard supportive care. The survival of her infant with availability of modern medical care and support is yet to be tested. Even if an individual is deemed likely to die, compassionate palliative care would surely be the minimum that we would strive to offer. So how are these considerations balanced with the concerns and fears of health care providers about possible transmission of Ebola or indeed, in the past, fears of H1N1, SARS, and HIV transmission to attendants? Is it acceptable for maternity or neonatal care providers to refuse to provide care to persons they deem to be “too infectious”? Certainly there were many cases of HIVpositive individuals being refused care; this was more common decades ago, but examples still remain in Canada. I learned of health care providers refusing to provide care to infected or at-risk patients during the SARS outbreak. Is this an individual decision made at the time, or should this be a decision made on entering any of the health care professions? When infectious diseases were a more prominent part of medical care, and when infectious disease was the most common cause of mortality, students entering medical, midwifery, or nursing training clearly knew that there were personal risks in dealing with patients with tuberculosis, cholera, and other infectious diseases. Maternity care providers in Canada are exposed daily to blood and body fluids. Attempts to decrease the “medicalization” of birth have led to poor infection control practices, with blood, amniotic fluid, and feces contaminating the clothing and sometimes the skin of care providers. Such contaminants could contain pathogens such as Hepatitis C or HIV (or other yet to be identified agents), but there is a general lack of attention paid to having impermeable surgical scrubs, cover gowns, and eye 106 l FEBRUARY JOGC FÉVRIER 2015
protection. If we are to learn anything from the Ebola epidemic, it should be this: care providers anywhere should never be exposed to the blood or bodily fluids of the patients in their care. In our modern era, there is a perception that health care, including maternity care, can be a sterile, no risk vocation. This is untrue, and it is not likely to be true for many decades yet. New infectious agents with varying degrees of infectivity will come in outbreaks, epidemics, and pandemics, and they will not necessarily come with warnings or with full knowledge of how they are transmitted. Microbiologists must endeavour to inform public health agencies and the medical professions, and these organizations must be prepared to offer advice quickly on safe care. But practitioners also need to be reminded that they will always potentially be at some risk if they work on the “front lines” in general medical care or in maternity care. We have to learn from the excellent work that has been done in preparing for a disease that, as noted in the Committee Opinion13 in this issue, is unlikely to be seen in Canada during this pandemic. Let us learn from our colleagues who continue to fight this disease in West Africa. Let us support them as they try to rebuild their health care system after Ebola, and let us hope that women and their infants can receive the basic care they need. We must ensure that we can respond in an appropriate, safe, and compassionate way when the next infectious agent threatens to become a global pandemic. REFERENCES 1. World Health Organization (WHO). First PROMISE study results confirm WHO recommendations to treat pregnant women and reduce mother-to-child-transmission of HIV. Geneva (CH): WHO; 2014. Available at: http://www.who.int/hiv/mediacentre/news/promisestudy-result/en/#.VIjMwMd14wQ.email. Accessed December 11, 2014. 2. Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O’Sullivan MJ, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994;331:1173–80. 3. Hammer SM, Katzenstein DA, Hughes MD, Gundacker H, Schooley RT, Haubrich RH, et al. A trial comparing nucleoside monotherapy with combination therapy in HIV-infected adults with CD4 cell counts from 200 to 500 per cubic millimeter. AIDS Clinical Trials Group Study 175 Study Team. N Engl J Med 1996;335:1081–90. 4. Jamieson DJ, Uyeki TM, Callaghan WM, Meaney-Delman D, Rasmussen SA. What obstetrician-gynecologists should know about Ebola: a perspective from the Centers for Disease Control and Prevention. Obstet Gynecol 2014;124:1005–10. 5. Centers for Disease Control and Prevention. Interim guidance: considerations regarding 2009 H1N1 influenza in intrapartum and postpartum hospital settings. Atlanta (GA): CDC; 2014. Available at: http://www.cdc.gov/h1n1flu/guidance/obstetric.htm. Accessed December 11, 2014.
Ebola in Pregnancy: Have We Learned Any Lessons?
6. Boseley S, O’Carroll L. Number of Ebola deaths could be cut by use of basic measures, say experts. Guardian; 2014. Available at: http://www.theguardian.com/world/2014/dec/05/ebola-deathsbasic-medical-measures-lancet. Accessed December 11, 2014. 7. Lamontagne F, Clément C, Fletcher T, Jacob ST, Fischer WA 2nd, Fowler RA. Doing today’s work superbly well—treating Ebola with current tools. N Engl J Med 2014;1565–6. doi:10.1056/ NEJMp1411310.
10. Mupapa K, Mukundu W, Bwaka MA, Kipasa M, De Roo A, Kuvula K, et al. Ebola hemorrhagic fever and pregnancy. J Infect Dis 2000;179:22–3. 11. Lang J. Ebola in the maternity ward. New Yorker; 2014. Available at: http://www.newyorker.com/tech/elements/ebola-maternity-ward. Accessed December 11, 2014.
8. Chertow DS, Kleine C, Edwards JK, Scaini R, Giuliani R, Sprecher A. Ebola virus disease in West Africa—clinical manifestations and management. N Engl J Med 2014;371:2054–7.
12. Public Health England. Ebola in pregnancy: information for healthcare workers Ebola transmission Ebola risk and healthcare workers. London: Public Health England; 2014. Available at: https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/377176/ Ebola_in_pregnancy_information_for_healthcare_workers.pdf. Accessed December 11, 2014.
9. World Health Organization (WHO). Ebola response roadmap situation report. Geneva (CH): WHO; 2014. Available at: http://apps.who.int/iris/ bitstream/10665/144806/1/roadmapsitrep_3Dec2014_eng.pdf ?ua=1. Accessed December 3, 2014.
13. Money D; SOGC Infectious Disease Committee. SOGC committee opinion on the management of a pregnant woman exposed or infected with Ebola virus disease in Canada. SOGC Committee Opinion no. 319, February 2015. J Obstet Gynaecol Can 2015;37:183–90.
ERRATA
Singh SS, Scott S, Bougie O, Leyland N; SOGC Clinical Practice–Gynaecology Committee; GOC Executive Committee. Technical Update on Tissue Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy. SOGC Technical Update, No. 317, J Obstet Gynaecol Can 2015;37(1):68–78. This technical update was a joint effort by both the Society of Obstetrics and Gynaecology and the Society of Gynecologic Oncology of Canada. This should have been reflected in a main header titled SOGC Joint Technical Update, which should also replace the element SOGC Technical Update in citations. The GOC shares copyright in this update; none of its contents may be reproduced in any form without prior written permission of both the SOGC and the GOC. The Journal of Obstetrics and Gynaecology Canada regrets the errors and any inconvenience they may have caused.
Singh SS, Scott S, Bougie O, Leyland N; comité de pratique clinique-gynécologie de la SOGC; comité exécutif de la GOC. Mise à jour technique sur le morcellement tissulaire dans le cadre d’une chirurgie gynécologique : Son utilisation, ses complications et les risques liés à la présence insoupçonnée de tumeurs malignes. Mise à jour technique de la SOGC, n° 317. J Obstet Gynaecol Can 2015;37(1):79–81. Cette mise à jour technique a été le fruit d’efforts déployés conjointement par la Société de gynéco-oncologie du Canada et la Société des obstétriciens et gynécologues du Canada. Le titre aurait donc dû être rédigé comme suit dans la vedette principale et les citations : Mise à jour technique commune SOGC/GOC. La GOC partage les droits d’auteur liés à cette mise à jour; ainsi, aucune partie de ce document ne peut être reproduite sous quelque forme que ce soit sans l’obtention au préalable d’une permission écrite de la part tant de la SOGC que de la GOC. Le Journal d’obstétrique et gynécologie du Canada regrette cette erreur, ainsi que toute confusion que cela a pu causer.
FEBRUARY JOGC FÉVRIER 2015 l 107
