4/10/2017

1

MATERNAL & NEWBORN HEALTH IN

LOW INCOME COUNTRIES: THE NEED

FOR BIOREPOSITORIES

NANSI BOGHOSSIAN PhD, MPH

UNIVERSITY OF SOUTH CAROLINA

April 12, 2017

Today’s Presentation

To outline the global causes of neonatal

mortality and available interventions

To describe some of the study cohorts and

biorepositories currently funded in LICs

To describe current studies for assessing

gestational age at birth

Beyond newborn survival : The world you are born into

determines survival & risk of disabilityWhere do 2.9 million newborns die?

Lawn J et al. Every newborn: progress, priorities, and potential beyond survival. Lancet 2014; 384:189-205.

4/10/2017

2

What causes child and newborn deaths?

Preterm birth is now #1

80% of neonatal

deaths are in

small babies, of

which two-thirds

are preterm (Born

too small and too

soon)

Liu L et al. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015;385:430-440

What causes child and newborn deaths?

Preterm birth is now #1 for neonatal deaths

Liu L et al. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015

priorities: an updated systematic analysis. Lancet 2015;385:430-440

965000

662000

421000

324000

27

60

00

PTB complications

Intrapartum complications

Neonatal infections

Injury

Congenital abnormalities

6.3 million deaths

2.7 million deaths

Cause-specific neonatal mortality rate (NMR) by level of NMR

Lawn J. et al. Every newborn: progress, priorities, and potential beyond survival. Lancet 2014; 384:189-205.

Cause-specific neonatal mortality by level of

neonatal mortality rate (NMR)

Lawn J. et al. Every newborn: progress, priorities, and potential beyond survival. Lancet 2014; 384:189-205.

4/10/2017

3

Global trends in cause-specific mortality rates in

neonates and children aged 1-59 months, 2000-2013

About 47% of the reduction in

mortality comes from pneumonia,

diarrhea, and measles

Liu L et al. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015;385:430-440

What can be done?

1.3 million neonatal deaths

Antenatal interventions

Bhutta Z et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347-370.

Near delivery interventions

Bhutta Z et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347-370.

4/10/2017

4

Newborn care at birth and beyondKangaroo Care

The 3 main causes of newborn deaths all have effective and

feasible interventions

Preterm birth

• Antenatal corticosteroids, preterm labor management

• Care: essential newborn care + kangaroo mother care

Birth complications

• Prevention by skilled attendance and obstetrics

• Care: essential newborn care + resuscitation

Neonatal infections

• Prevention, essential newborn care especially breastfeeding

• Case management of neonatal sepsis with antibiotics

1

2

3

Where are we now?

1990-2015, global <5 mortality rate declined by more than

half, dropping from 90 to 43 deaths/1000 live births.

1990-2015, number of deaths in children <5 yr worldwide

declined from 12.7 million in 1990 to almost 6 million in 2015.

Children in rural areas are about 1.7x more likely to die

before their 5th birthday as those in urban areas.

Children of mothers with secondary or higher education are

~3x as likely to survive as children of mothers with no

education.

Every day in 2015, 16,000 children <5 yr continue to die,

mostly from preventable causes.

http://www.un.org/millenniumgoals

4/10/2017

5

Vision for Every Newborn Action Plan

A world in which there are no

preventable deaths of newborns or

stillbirths, where every pregnancy is

wanted, every birth celebrated,

and women, babies and children

thrive and reach their full potential

http://www.everynewborn.org

http://www.everynewborn.org/Documents/Full-action-plan-EN.pdf

The 2030 Agenda for Sustainable

Development

Goal 3. Ensure healthy lives and promote well-

being for all at all ages

By 2030, reduce the global maternal mortality ratio to

less than 70 per 100,000 live births

By 2030, end preventable deaths of newborns and

children under 5 years of age, with all countries aiming

to reduce:

Neonatal mortality to at least 12 per 1,000 live births

Under-5 mortality to at least 25 per 1,000 live births

Faster progress is possible with:

Communication of priority interventions and overcoming bottlenecks for scale up

Improving data quality to monitor progress (e.g. intervention coverage)

Leadership and technical capacity in countries

Coordination of global partners in countries

Investment in newborn health, training health workers with skills and links to quality facility care

Accountability for results at all levels

What must we do differently?

Improve care at birth and for small and preterm newborns

Prevent stillbirth

Empower women and girls, improve family planning, preconception and pregnancy nutrition, early child development

Reach every woman and every newborn and achieve impact at scale (improve data and quality of care)

Ensure national-level political priority for newborn health

4/10/2017

6

Maternal and newborn study cohorts in LICs WHO AMANHI Study and Partnership

Alliance for Maternal Newborn Health

Improvement (AMANHI) study, led by Dr.

Rajiv Bahl

Consortium of investigators conducting

community-based studies on maternal

and newborn health in 11 sites of 8

countries of South Asia and Sub-Saharan

Africa

Regions experience most of the global

maternal, newborn and child deaths

Study design: Observational cohort

Coordinated by the WHO

AMANHI Objectives

1) Identify causes of maternal deaths, stillbirths, neonatal deaths

2) Determine burden of severe acute maternal morbidity and their association with adverse perinatal outcomes

3) Identify a feasible method for accurate gestational age assessment

4) Establish biorepository to identify biomarkers of predictors of adverse maternal and fetal outcomes

Why a biorespository in LICs?

Biobanking revolutionized medical care in last decade

Improvement in - omics technologies, potential benefit

from biobanks for maternal and child health

Major disease burden in maternal and child health in

LICs

Nearly all efforts in biobanks in developed countries

No biorepository work on MCH in developing countries

Urgent need for birth cohorts in LICs with large

population cohorts and epidemiological data, biological

samples, analyzed with advanced epidemiological and

statistical methods

4/10/2017

7

AMANHI-framework

AMANHI biorepository collaboration established in 3 sites with support from BMGF:

Bangladesh-PI. Abdullah Baqui JHU

Pakistan-PI. Fyezah Jehan AKU

Tanzania-Pemba-PI. Sunil Sazawal

WHO (Rajiv Bahl) coordinating center responsible for overall monitoring and coordination

All partners and Govt. agencies insisted that biobanks are in respective countries and ownership is with investigators, local institutions, and WHO

Sample collection, processing and storage in a harmonized way

Objective of AMANHI Biobank

Conduct powered case control studies nested within a well-characterized cohort of pregnant women and newborns:

To identify biomarkers for:

GA at birth and fetal growth using biological samples collected during pregnancy

Adverse perinatal and child health outcomes including preeclampsia, preterm births, IUGR, stillbirths, suboptimal child growth and development

Facilitate future discoveries on maternal, fetal, neonatal and child health employing “hypothesis free” approaches to biological and genetic markers and disease pathway discovery

Methods

Population based prospective cohorts

Women enrolled once confirmed by ultrasound (8-19 weeks) in early pregnancy

Collection of epidemiological/phenotypic data and biological data

AMANHI

Household visits (N=1000/site)

GAPPS (Global Alliance to Prevent Prematurity and Stillbirth)

Bangladesh-PI. Anisur Rahman: monthly household visits (N=4000)

Zambia-PI. Jeff Stringer: enrollment at ANC with community outreach (N=2000)

Study Flow

Enrollment

ANC 24-28

and/or 32-

36 wk

Delivery

D42-60

PPM visit

4/10/2017

8

AMANHI Biological Samples: Collection Timing

Sample type Visit

Maternal blood Enrollment, 24-28 wk or 32-36 wk,

delivery, postnatal D42-60

Maternal urine Enrolment, 24-28 wk or 32-36 wk,

postnatal D42-60

Cord blood At birth

AMANHI Biological Samples: Collection Timing

Sample type Visit

Cord & placenta tissues + placenta

membrane

At birth

Maternal & newborn feces Maternal at birth;

newborn D42-60

Paternal and (optionally) newborn saliva Paternal anytime;

newborn D42-60

AMANHI Biological Samples: Processing

Sample

type

Processing & planned use of the sample

Maternal

blood

DNA extraction, HbA1C analysis, and serum/plasma

extraction, aliquoting & storage

Maternal

urine

Non-centrifuged and centrifuged sample, biochemical &

pathological analysis

Cord blood DNA extraction, serum/plasma extraction, aliquoting &

storage

AMANHI Biological Samples: Processing

Sample type Processing & planned use of the sample

Cord & placenta tissues

+ placenta membrane

RNALater, flash frozen & formalin sample

Maternal & newborn

faeces

Fecal microbiome

Paternal & (optionally)

newborn saliva

DNA extraction

4/10/2017

9

GAPPS Biological Samples

Sample

type

Visit Processing & planned use of

the sample

Vaginal

swabs

Enrolment, 24-28 wk &

32-36 wk, delivery

Microbiome, metabolomics,

metagenomics & candida culture

Harmonization & QC

Uniform implementation protocols for ultrasound; sample collection, processing and storage & home visits

Procurement of uniform materials, equipment & supplies

Harmonized training on

Implementation and data collection including the use of common core variable tables built into a software

Sample collection, processing & storage

Quality control including expert reviews of processes and sample assays

AMANHI GAPPS

ORGANIZATIONAL MODEL

Prospective collection of data/samples ✔ ✔

In-country biobank ✔ ✔

Centralized database ✖ ✔

SPECIMEN TRACKING/AUDIT TRAIL

Specimen tracking system ✔ ✔

Meta data collected on specimen collection/processing ✔ ✔

LEGAL/ETHICS

Ethical approval from local IRB to collect & store samples ✔ ✔

INFORMED CONSENT

Allows biobanking samples for future studies ✔ ✔

Allows sending samples outside country ✔ ✔

GOVERNANCE

Use of data/samples overseen by governing committee ✔ ✔

In-country biobank governing committee ✔ ✖

AMANHI-Pemba

4/10/2017

10

Pemba Site Description

Pemba Island, east coast of Africa in Zanzibar

Archipelago, has four districts. Each district has one

hospital

Total population of ~450,000 in ~95,000 households,

distributed almost equally among the four districts

AMANHI biorepository work undertaken in 2 districts, 1

from each region

Mobile clinic for antenatal/postnatal samples

Project sample collection and processing lab for placenta

setup in each of 2 district hospitals

Team

75 community level workers, 40 supervisory

level staff, 20 health workers, 15 laboratory

technicians and assistants

GIS map of the whole island

In-house data management system development

with e-data capture

Study Implementation

• Identification of potential study subjects

• 2 monthly survey sweeps to identify pregnant women, urine pregnancy test wherever required, informal verbal consented women scheduled for clinic visit

• Enrollment, Antenatal and Postnatal samples

• In the clinic, the study team obtains formal consent, anthropometry measurements and other data

• For new subjects US assesses gestational age

The mobile clinic set up

Toyota Surf (SUV) is loaded with

• Sterling Shuttle unit (-80C)

• Sonoscape Ultrasound Unit with trolley and accessories

• Eppendorf Centrifuge

• Blood Collection and sampling Kits

• Anthropometry instruments

• CoolBox (withGelpacksto maintain 4 C)

• Needed laboratory supplies (Netbook, Forms, Scanner , stopwatch timer etc)

4/10/2017

11

Centralized Biobank & Power Backup

Centralized Biobank located in main Public Health

Laboratory

Access control (automatic door lock) mechanism in

place ensuring restricted and authorized entry

Temperature controlled room to ensure proper

functioning of the biobank freezers

Temperature logger & alarm system with

automatic SMS alert to key personnel

Multi tier power supply/backup system

Solar backup & generators

Sample utilization

Opportunities to Utilize Samples

Current projects

Early prediction of PTB

Prediction of gestational age

Other

Opportunities to Utilize Samples

Current planned projects

Early prediction of PTB

Prediction of gestational age

Other

4/10/2017

12

Early Prediction of PTB

Sera Prognostics: diagnostic test for analyzing

maternal serum for early prediction of PTB risk

US based nested case-control study of 217

sPTB

Cases: deliveries <37 wk

Spontaneous onset of labor

Preterm premature rupture of membranes

Controls: deliveries ≥37 wk

Saade GR et al. Development and validation of a spontaneous preterm delivery predictor in

asymptomatic women. AJOG 2016; 214(5):633

Early Prediction of PTB

Phases

Discovery: Optimal GA window & best

proteins

Verification: Blinded confirmation of

biomarkers

Validation: Blinded independent

validation

Saade GR et al. Development and validation of a spontaneous preterm delivery

predictor in asymptomatic women. AJOG2016; 214(5):633

Early Prediction of PTB

IBP4 & SHBG best predictive protein pair (147

evaluated) in 19-21 wk window

AUC: 0.75 for <37 vs. ≥37 wk

Early Prediction of PTB in AMANHI

Case-control study100 spontaneous

preterm cases and 200 controls

Evaluate US PTB risk classifier

Discovery phase

4/10/2017

13

Opportunities to Utilize Samples

Current planned projects

Early prediction of PTB

Gestational age assessment

Other

Clinical and Programmatic

Pregnancy to more

effectively identify, refer, and

deliver interventions for

preterm labor (ex. antenatal

corticosteroids)

Newborn to improve

identification and case

management of small babies

(Preterm vs small for

gestational age)

Research and Epidemiology

To more accurately and consistently

classify preterm birth and small for

gestational age in a standardized way

across studies, countries, regions

To enable across study comparisons of

risk factors and intervention trials

To improve global burden of disease

estimates of prevalence and long term

outcomes of preterm birth/SGA

The Need for Improved Gestational Age Assessment

in Low-income settings

Born too Soon Report 2012MOD, PMNCH, Save the Children,WHO

Courtesy of CC Lee

Neonatal Assessment of gestational age

Method Description Accuracy* Limitations

Neonatal

Clinical Exam (Physical signs (Farr),

Neurologic signs (Amiel

Tison))

Standard Clinical Assessments

1) Dubowitz (21 signs) (1970)

2) Ballard (12 signs) (1979)

Simpler Assessments

3) Capurro (6 signs)

4) Parkin (4 signs)

5) Eregie (4 signs+HC, MUAC)

1) ±2 weeks

2) ±2 wks

3) ±2.5 weeks

• Overestimation in premature,

post-term

•Inaccurate in very sick infants

•Long duration/complicated

•“Maturity” vs. Gestational Age

•Most validation studies compare

to LMP gold standard

Anterior vascular

lens capsule (Hittner)

Ophthalmoscope exam of dilated

pupil; Disappearance of pupillary

membrane (anterior vascular lens

capsule)

±2 wks •Must be done within 48 hours of

birth

•Requires skill, ophthalmoscope

Birth weight Weight of baby at birth as a

surrogate for GA

More sensitive/specific

at lower GA

(<1500g)

•50% of babies not weighed at

birth

•Requires scale and skill

•59% of LBW babies are term in

LIC

Foot Length Measurement of foot length at

birth

<8cm

93% sensitivity, 58%

specificity* for preterm

(clinical exam gold

standard)

•Affected by fetal growth

•Better at identifying LBW babies

Adapted from Blencowe et al, Repro Health 2013 10:S2; Blencowe et al, BMC Pub health 2010 10:624

AMANHI Gestational Age Validation Study Design

Pregnancy Detection Pregnancy Surveillance and

LMP Calendars

Gold Standard Ultrasonography

<20 weeks

Antenatal visit 2nd and 3rd trimester

Newborn Assessment<72 hours of life

Birth

Crown rump length

Val

idat

ion

Symphsis Fundal Height TranscerebellarDiameter

Courtesy of CC Lee

4/10/2017

14

NEUROMUSCULAR

MATURITY SIGN0 1 2 3 4 5

1.1 POSTURE

1.2 ARM RECOIL

1.3 POPLITEAL ANGLE

1.4 SCARF SIGN

1.5 HEEL TO EAR

1.6 ANKLE DORSIFLEXION

WHO AMANHI Newborn Assessment

Neuromuscular maturity signs

53

Courtesy of CC Lee

Skin (Texture, Opacity, Color)

Ear (Shape, Recoil)

Breast (Bud, formation)

Lanugo/Body Hair

Genitals

Male (Testes, Scrotum)

Female (Labia, Clitoris)

Foot Creases

WHO AMANHI Newborn Assessment

Physical maturity signs

Courtesy of CC Lee

WHO AMANHI Newborn Assessment

Anthropometrics

Birth weight

Infant Length

Circumferences

Head

Chest

Mid-upper arm

Foot length

Courtesy of CC Lee

Assessment of GA by Newborn

Screening Analyte Data

4/10/2017

15

Assessment of GA by Newborn Screening

Analyte Data in AMANHI & GAPPS

Validate GA prediction algorithm against

ultrasound using metabolites generated

from

Cord blood dried spots

Heel prick dried blood spots

Based on findings, develop population-

specific GA prediction algorithm

Other GA assessment tools

Ophthalmoscope (PI. Jennifer Griffin)

NeoGest (BabyFace Crowd Sourcing)

4/10/2017

16

Smartphone Ophthalmoscope Lens

Vascularity Estimated Gestational Age

Courtesy of Jennifer Griffin

Computer Vision Lab ‘BabyFace App’

• Crowd-sourcing app allows parents to upload photographs and measures of their

babies

• Data collected used to test the software developed as part of the GA Estimation

Tool project

• Data to help Drs. estimate if a baby was born preterm in places without US scans

What is needed in a low resource

setting?

Simple, accurate and reliable

Robust for a harsh environment

Safe and environmentally friendly

Affordable

Not dependent on consumables or batteries

Appropriate training material

Ethical Issues

Lack of newborn screening programs

Spots to be shipped every wk to US & Canada

Recommendations for conditions to be reported

Validity of results

Screens conducted <24 hr; exclude reporting of

conditions where collection timing may have a

significant impact on diagnostic accuracy

Potential for confirmatory testing

Potential for interventions

4/10/2017

17

Ethical Issues

High priority conditions to be reported

setting PPV ≥99%

Congenital hypothyroidism

Hemoglobinopathies

Medium-chain acyl-CoA dehydrogenase

deficiency

Beyond the neonatal period

AMANHI: All Children Thriving

Extension and expansion of the AMANHI

biorepository study from 3000 to 6000

Extension of follow-up per child up to 3 yr

Assess physical growth: biomarkers of poor

linear growth as stunting

Assess neurodevelopment: mechanisms

underlying adverse neurodevelopmental

outcomes

Challenges

Navigating country and study IRBs

Data/sample ownership, storage & sharing issues

Protection of human subjects

Legal & regulatory challenges

Protection of samples, especially limited ones

4/10/2017

18

Challenges

Building trust and partnerships with full & open

sharing of generated data across all partners

might require considerable time to establish

Involvement of multiple countries, with

variations in both cultural norms & levels of

access to resources

Long-term sustainability & utilization of

specimens to promote innovative research

Acknowledgements

BMGF: Jeff Murray

AMANHI

WHO: Rajiv Bahl

Bangladesh: Abdullah Baqui

Tanzania: Sunil Sazawal

Pakistan: Fyezah Jehan, Imran Nisar

CC Lee

GAPPS

Eve Lackritz

Bangladesh: Anisur Rahman

Zambia: Jeff Stringer

Ottawa: Kumanan Wilson

Donna Russell

Thank you