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A HEALTHY NEWBORN
HEALTHY NEWBORN WHOSE RED
BLOOD CELLS WERE DAMAGED. SHE
HAS BRAIN DAMAGE.
Red Blood Cells Healthy and Abundant Hemolysis with Anemia
AN IRAQI NEWBORN WITH BRAIN
DAMAGE SOON AFTER BIRTH
• Rhesus blood type incompatibility
• ABO blood group incompatibility
• Glucose 6-phosphate dehydrogenase deficiency
• Prematurity
• Disorders of red blood cell structure and function.
Major Causes of Hemolytic Diseases of Newborns
• If you do not have this protein, you are Rh negative.
• If Rh negative person is exposed to Rh positive protein, this person becomes sensitized and produce antibodies
• This happens to a Rh negative woman who is pregnant.
• By 1950s, 20,000 babies born in USA either died or, were brain damaged, annually.
Rh factor is an inherited protein on surface of red blood cells
Red Blood Cell
Antigens: Rh, A, B
First
Pregnancy
Next
Pregnancy
A
B
Rh Philip Levine vs. Alexander Wiener:
1937
Landsteiner, 1900
Prenatal: stillbirth, serial fetal loss due to anemia (RBC damage)
During the first week after birth
• Increased bilirubin production leads to high neurotoxic levels.
• Hospitalization for “blue light” phototherapy to reduce bilirubin.
• Emergency care of bilirubin encephalopathy to save life.
Infancy:
• Damage: hearing loss, kernicterus.
• Subtle residual neurologic sequelae.
Maternal Child Health Impact
Dramatic impact of RhD antibody prevention on perinatal death
Tovey LA (1984) The contribution of antenatal anti-D prophylaxis to the reduction in Rh hemolytic disease of the newborn. Plasma Therapy Transf.
Technology 5:99-104
Global Burden
The following data represent estimates of Rh disease burden estimated for 2010 reported in Pediatrics Research: Bhutani, Zipursky et al. “Neonatal Hyperbilirubinemia and Rhesus Disease of the Newborn: Incidence & Impairment Estimates for 2010 at Regional and Global Levels.” (2013).
Prematurity
G6PD deficiency
ABO incompatibility
Rh disease
Annual Global Burden • Adverse hemolysis: 24 million births/year (18%)
• Rh disease or severe jaundice: 0.5 million births Risk of postnatal death: 24%
Stillbirth: 11%
Kernicterus: 13% (~75,000); with multiple
disabilities.
Kernicterus with Rh disease: 38, 28, 28, and 25/100,000 live births for Eastern
Europe/Central Asian, sub-Saharan African, South Asian, and Latin American
regions, respectively.
Women and Children
Prenatal
Maternal Rh typing
Screen for maternal
anti-D antibody
Postnatal
Screen for Neonatal
Hemolysis
Experts propose that CURhE will:
Galvanize medical communities to lead, launch, and replicate programs for societal partnerships.
Use affordable screening and prevention technologies embedded in existing maternal-child and adolescent health services.
Facilitate evidence-based “global standard of care.”
Global Program: Eliminate Rhesus Disease
We are of the opinion that, through a social-media
initiative (“Know Rh”) will lead to:
A globally endorsed universal curriculum
Identification of societal and provider champions
Implementation of an accountable and patient-
centered program using Institute of Medicine’s
principles of healthcare.
Know Rh
Every Person Knows Their Blood Type
Our Mandate
To promote that all parents and pregnant
women should know their blood type, and to
ensure free, unfettered access to Rh immune
prophylaxis for all women identified as being
Rh negative, through a community-led
(grassroots) “global campaign.”
Action Plan
To create and disseminate a social and
professional media infrastructure promoting a
global dialogue for awareness, training,
promotion for identification, prevention, and
sharing of personal experiences of individuals,
communities and providers.
Meta-Analysis Review
Country First dose # doses Dosages
Cochrane
Review
(2013)
28 - 34 wks of
pregnancy
All countries: <72h
at birth (10-28 days)
2 or 3 300μg,
130 - 100μg
Methodology:
• We identified national guidelines for Rh disease prevention in select countries in Europe, Asia, North America, South America, Africa, Oceania, and the Middle East that are reported by their public health agencies.
• We searched for keywords (Rhogam, Rh, rhogam suppliers, national rhesus guidelines, and Anti Immunoglobulin-D) and citations from literature pertaining to studies of Rh disease (English, French, Mandarin and other languages)
Are there National Guidelines?
We compared each of identified guideline for: 1) timing of drug
administration, 2) dosages, 3) number of doses, and 4) the
attributes to guidelines from other national guidelines
Europe
Country First Dose # doses Dosages
Britain
(2013) 29 - 34 wks 2 or 3
50μg:12 - 20 wks
100μg: >20 wks
Ireland
(2012) 28 wks 2
130μg < 20 wks
200μg > 20 wks
Greece
(2012) 28, 34 wks 3 N/A
Country First dose # doses Dosages
France (2001) Sensitizing event
(or, birth): <72h 1 100μg
Switzerland
(2013) 28 wks 2 300μg
Czech
Republic
(2010)
28 - 34 wks 2 or 3
250μg, 125μg
50μg <20 wks
100μg > 20 wks
Europe
Country First dose # doses Dosages
USA
(2013) 26 - 34 wks 2 or 3
300μg
50μg <20 wks
100μg >20 wks
Canada
(2003) 28 - 40 wks
2, 3, or
4
300μg or 150μg
120μg < 12 wks
300μg > 12 wks
Mexico
(2009) 24 - 34 wks 2 or 3
300μg, 200μg, 100μg
100μg <12 wks
300μg>12 wks
Quebec
(2013) 28 - 40 wks 2, 3, or4
120μg <12 wks
300μg >12 wks
North America
Country First dose # doses Dosages
Afghanista
n (2003) 32 wks 2 -
Israel
(2014) 28 wks 2
300μg
120μg for
sensitizing
event
Middle East
Country First dose # doses Dosages
Ghana
(2013) 28 or 34 wks 3
120μg <20 wk
300μg >20 wk
Kwazulu
(2005) 28 - 34 wks 2 or 3
100μg
50μg <20 wk
100μg >20 wk
South
Africa
(2005) 28 - 34 wks 2 or 3
100μg
50μg <20 wk
100μg >20 wk
Sub-Saharan Africa
Country First dose # doses Dosages
India
(2011)
72hr of
sensitizing event 1
50μg <20 wks
100μg >20 wks
Japan 26 - 28 wks 2, 3 or 4 250μg
China
(2011) 28 - 34 wks 2 300μg
Asia
Country Timing # doses Dosages
Singapore
(2014) 28 - 34 wks 2 or 3
300μg
or 100μg
Sri Lanka
(2007) 24 - 34 wks 3
300μg
50μg<20 wks
100μg >20 wks
Asia
Country First dose # doses Dosage
Australia
(2012) 28, 34 wks 2 or 3
50μg 1st trimester;
125μg 2nd and 3rd
trimester
New Zealand
(2013) 28, 34 wks 3
50μg for 1st
pregnancy;
120μg for
subsequent.
Oceania
Country First dose # doses Dosages
Brazil
(2014) 28 wks 2 300μg
Chile
(2014) 26 - 28 wks 2 250μg - 300μg
South America
24 national guidelines were available online and in
the public domain.
Limited uniformity for timing of drug administration,
the number of doses, and dosages.
3 main sources: UK, Canada, and USA were the
most frequently cited resources, and these were
adapted to national guidelines.
Uniformity
Time: first prenatal dose (24, 28, 32, 34 wks).
Time: dose at birth (<1 , 3, 10 or 28 days).
Dosage. 100, 120, 125, 200, or 300μg.
Variations defined health bureaucrats (access,
cost and convenience) and not on evidence for
systems-approach.
“Lost in translation”
• Are these local guidelines are scalable to national, regional or global levels? Work that we have to do.
• Inter- and intra- country challenges: fractured health care systems, local fiscal priorities, bottlenecks for timely patient access, and impediments to navigate health infrastructure. Work that we have to do.
• Costs for both screening and prevention need to updated to contemporary standards of care.
Scalability
Rhesus disease burden: East Europe
Every year at least 25,000
children are estimated to
develop life-long brain
damage (kernicterus) due
to Rh disease in these
Eastern European nations.
FIGO
• CURhE believes that a global campaign will inform prospective parents of Rhesus Factor worldwide such that a preventable life threatening disease is eliminated. Know your blood type.
Take Home Messages
CURhE
@Stanford
Katharine Kuong Judith Y. Hall
Shan. Srinivas Martin C-Cuadrado
Rajiv Sancheti
Nathan Meng