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Sunday 21 April 2019
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Situation critical for Hepatitis E infected pregnant women

A lack of resources to equip physicians among others has seen a higher percentage of Namibian women dying due to Hepatitis E infections, Associate Professor and Head of the Department of Internal Medicine and Physiology at the University of Namibia’s School of Medicine, Dr Christian John Hunter, has revealed.
As the country struggles to tame the crisis, the expert raised more red flags highlighting that case fatality rates of infected pregnant women have been drastically higher in Namibia, standing at 42.5%.
This is way above fatality rates of 25% which have been reported for women infected with Hepatitis E during their third trimester, he submitted.
Explaining this contrast, Dr.  Hunter said that in Namibia treatment predominantly consists of supportive care but said that staffing is not adequate to optimally provide this.
He adds that patients are currently being admitted to an acute care unit that does not have the resources to staff it with physicians at night.
The Hepatitis E epidemic is propagated by contaminated water and poor sanitation, and Dr Hunter has disclosed that despite  having been a whopping 4 000 cases in Namibia in 2018, there has only been one epidemiologist designated to address the source of it.
According to World Health Organisation’s Dr Petrus Mhata, as of 24 April 2019, a cumulative total of 4 913 people infected with the Hepatitis E Virus, were reported in health facilities in the country, since 2018.
Out of this, 292 were pregnant women or just after delivery.
A total of 42 people died since the outbreak started.
Of these, 18 were pregnant or died post-delivery, between January 2018 and 24 March 2019, said the doctor.
“These 18 maternal deaths constitute 6.2% of the total 292 maternal HEV cases who reported to clinics with Hepatitis E infections in Namibia, during this period,” said Mhata.
Pregnant women with hepatitis E, particularly those in the second or third trimester, are also at an increased risk of acute liver failure, foetal loss and death.
Dr Hunter cautioned that critical care cannot eradicate the disease.
“The best supportive care will not save everyone. ICU mortality is thus most significantly improved in the community, through public health measures. This epidemic is propagated by contaminated water and poor sanitation,” he said.
He narrated a recent case in which a 33-year old female patient suffered a Hepatitis E infection which led to her death under the watch of nurses in the aftermath of having given birth.
The patient had chronic Hepatitis B and was sent from a clinic to an antenatal ward for lower abdominal pain, dark urine and jaundice five days prior to her death.
“The nurses in the other room started yelling ‘Resusc’! This meant a patient was coding. The acute care team, in the middle of morning rounds, rushed to the bedside of the 33-year postpartum female in asystole (cardiac arrest rhythm with no discernible electrical activity on the EKG monitor) and without delay began chest compressions.
What followed was seamlessly executed ACLS (advanced cardiac life support) protocol. Rhythm check? Asystole. Continue compressions, administer epi. Blood sugar check? 18. Administer D50.

Reversible reasons? K was 5.8 earlier that morning. Calcium gluconate and insulin with dextrose given. Next pulse check? Ventricular fibrillation. Stand clear. Shock delivered. No pulse.

Continue compressions. Three rounds of epi later, time of death.”
He said six days after being admitted, she developed acute liver failure and was transferred to acute care due to brain conditions and bleeding from sites where she had intravenous injections.
According to the doctor, it was here that she went into premature labour and delivered a 1.545 kg baby boy, at 28 weeks gestational age.
She is said to have also suffered postbirth hemorrhage, which was eventually controlled but her condition deteriorated.
Said the doctor, “she developed worsening hypoglycemia and renal failure. MELD 37. She remained encephalopathic. She was given lactulose, but this was not titrated to bowel movements, and she had not produced one in the last 4 days.”
She was started on Mannitol. Her renal failure worsened. Her white count dramatically increased to 23, yet she remained on the Metronidazole, started on admission. On her next and final day,

early morning labs showed that her potassium was elevated, her blood sugar low, her white count remained up, her haemoglobin had dropped, and her renal failure was worse.
Six hours after those labs were drawn, she coded, before the team had a chance to round on her and address those abnormalities.”
Dr Hunter reiterated that in order to save more lives from these complications, there ought to be proper management of patients around the clock.
He said this required prompt recognition of abnormalities in the patient’s condition.
“These timeliness can only be achieved if multiple levels of medical professionals are trained and available to manage critical disease. However, house staff education is often overlooked by global health funders. Without appropriate training, healthcare capacity cannot improve,” he said.
According to a World Health Organisation report, an estimated 20 million infections and 3.3 million symptomatic cases of Hepatitis E occur annually worldwide with an estimated 56 600 deaths.




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