An early output of the Initiative
An early output of the Initiative is the new WHO definition of maternal sepsis, which reads as follows: “Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, child-birth, post-abortion, or post-partum period”. The new maternal sepsis definition was developed on the basis of a review of existing definitions (including the 2016 Third International Consensus Definitions for Sepsis and Septic Shock) and through an international technical consultation. This process indicated that there are several definitions currently in use, which affects the identification of maternal sepsis cases. Standardising the definition and bringing it in line with the current understanding of sepsis in the adult mpges-1 inhibitors was considered a mandatory step to improve the assessment of the burden of maternal sepsis.
The Comment by Louise Ivers (November, 2016) references a supposed debate in cholera control between investing in universal access to water and sanitation and a multidisciplinary approach focused on cholera vaccination with specific evidence-based water, sanitation, and hygiene (WASH) interventions. As advocates for the importance of WASH, WaterAid is concerned to see this view being propagated. We strongly support WHO\'s recommendations that controlling cholera and, importantly, preventing outbreaks requires a coordinated approach including improvements in WASH, immunisation with the oral cholera vaccine, improved disease surveillance, and strengthened health systems.
In their correspondence, Yael Velleman and Megan Wilson-Jones agree that controlling and preventing cholera requires a multidisciplinary approach including vaccination and safe water, sanitation, and hygiene (WASH) interventions. The affirmation that colleagues at a prominent organisation known for working to improve access to WASH—WaterAid—strongly agree with a combined, integrated approach to prevention and control of this disease is welcome. We also agree on how to leverage cholera vaccination campaigns into positive public-health opportunities. Our group found, for example, that in one cholera vaccination campaign in Haiti, knowledge about WASH improved after vaccination against cholera, probably because the campaign was designed as part of a combined, integrated response. Velleman and Wilson-Jones state concern that my view is being propagated. However, their exact concern is not entirely clear, since we appear to agree on the merits of both combined approaches to disease-specific control of cholera and universal access to WASH as a basic principle of public health and as a human right. One interpretation of their concern as written might be that they do not believe a debate on the issue exists as I have described. If so, this disbelief might be because, although Velleman and Wilson-Jones have expansive global experience, they have not been involved in cholera control in Haiti in recent years, from whence my perspective arises. A debate between WASH and a combined approach to cholera control and prevention has been a prominent feature of cholera-related discussions in Haiti. However, studies such as the one by Azman and colleagues, and others from Bangladesh, Haiti, South Sudan, and Guinea, as well as an increasing global experience in the use of oral cholera vaccines, have contributed in recent years both to the scientific understanding of the place of the oral cholera vaccine in cholera control and prevention and to informing WHO recommendations. Although the public stockpile of oral cholera vaccines is indeed limited in supply, one manufacturer recently announced their ability to produce up to 10 million doses of vaccine per year at low cost (US$1·75 per dose). Public-health debates in resource-limited settings are all too often focused on pitting one approach against another. For example, the history of epidemic infectious diseases is littered with examples of prevention pitted against treatment, from HIV infection to Ebola virus disease. These debates can be attributed to governments and implementing organisations being socialised for scarcity, compelled by long experience to ration the meagre resources at their disposal by arguing for one approach at the expense of the other, when the real problem is the need for more resources to ensure equitable access to basic human needs for the world\'s poor. The fact that 650 million people in the world do not have access to safe water means that we have much work to do to change the status quo. A cholera vaccine will never provide the broad social and health benefits of universal access to clean water. However, in the short term, we must use all of the available tools, including vaccines, to protect lives from cholera, while accelerating progress towards the long-term goal of universal WASH.