Alert: Severe cases and deaths associated with Chikungunya in Brazil

Abstract Since the detection of the Chikungunya virus in America in 2013, two million cases of the disease have been notified worldwide. Severe cases and deaths related to Chikungunya have been reported in India and Reunion Island, estimated at 1 death per 1,000 inhabitants. Joint involvement in the acute and chronic phase is the main clinical manifestation associated with Chikungunya. The severity of the infection may be directly attributable to viral action or indirectly, owing to decompensation of preexisting comorbidities. In Brazil, the virus was identified in 2014, and recently, there has been a significant increase in the number of deaths caused by the Chikungunya virus infection, especially in Pernambuco. However, the numbers of fatalities are probably underreported, since for many cases, the diagnosis of Chikungunya infection may not be considered, for deaths by indirect causes. An increase in the mortality rate within months of epidemic occurrence, compared to previous years has also been reported and may be associated with Chikungunya virus infection. An in-depth investigation of reported mortality in Brazil is necessary, to measure the actual impact of the deaths, thereby, allowing the identification of possible causes. This will alert professionals about the risks, and hence, enable creation of protocols that target reducing mortality.

Similarities and differences between WHO criteria and two other approaches for maternal near miss diagnosis.

OBJECTIVES: To evaluate the similarities, differences and diagnostic aspects between World Health Organization (WHO) criteria and two other maternal near miss (MNM) diagnostic tools. METHODS: A cross-sectional study was conducted from June 2011 to May 2012 in two reference maternity hospitals in Aracaju, Brazil. Prospective case identification and data collection were performed and patients were classified as an MNM case according to WHO, Waterstone and literature-based criteria. The diagnostic properties and concordance of literature-based and Waterstone criteria were calculated using WHO criteria as standard. RESULTS: Of a total of 20 435 patients, 19 239 women did not have potentially life-threatening conditions, there were 17 maternal deaths, and 77 MNM cases based on the WHO criteria. Waterstone and literature-based criteria identified 404 and 959 MNM cases, respectively, most of them related to hypertensive disorders and haemorrhage. The sensitivity, specificity and accuracy in diagnosing MNM cases using Waterstone and literature-based criteria were above 90%, but Waterstone sensitivity was 48.1%. The similarities between the Waterstone and literature-based criteria were very weak compared to WHO criteria, with a positive percentage concordance below 9%. CONCLUSIONS: Although using WHO guidelines to detect MNM cases can be difficult when implemented in low-resource settings, the results from this study reinforce the importance of this tool in detecting the truly severe cases. Waterstone and literature-based criteria are not suitable for identifying indubitable MNM. However, they remain useful as a preliminary step to select potentially severe cases, mainly those related to hypertension and haemorrhage.