Mike Shildt Cardinals plan for coronavirus | St. Louis Cardinals

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JUPITER, Fla. — As every club adjusts its schedule and figures out the next steps after Major League Baseball decided to cancel Spring Training games and delay the start of the 2020 regular season, the Cardinals’ message on Friday was to remain flexible.

“We’re in a holding pattern,” manager Mike Shildt said. “We know the season is going to be, at a minimum of, [a] two-week delay. And we’re just trying to get a handle on what that looks like as far as just what’s next.”

The team held a meeting Friday morning with staff and players to discuss what comes next, even as plans change “hour by hour,” president of baseball operations John Mozeliak said. The Cardinals opened their training room and weight room to players who wanted to use either, but cancelled all baseball activities as they awaited instruction from Major League Baseball.

During a Friday conference call with media, Mozeliak said he requested that players remain close to Jupiter until clubs get clear guidance on the next steps.

“The most fair answer, the most current answer, is we just don’t know,” Mozeliak said about what those next steps are. “This is a very fluid situation. What we know now versus what we knew 24 hours ago has changed quite a bit. What we’re going to know later today or tonight or tomorrow is going to be different than what I know now.

“And so, the best response is that we have to remain nimble, flexible and then make sure that the health of our players, their families and our staff is on the foremost of what we’re thinking about.”

The Cardinals’ complex will remain open to players this weekend should they want to work out independently or if they need to receive treatment, and Shildt said that will remain the case until instructed by the Commissioner’s Office.

Shildt is meeting with his staff to lay out a plan for the multiple scenarios that could happen with the delayed season to make sure they will be ready for anything. While pitchers’ throwing schedules are unknown right now, Shildt said he’s encouraging pitchers to continue to play catch and stay in shape until they get more clarity on timeframes.

The biggest challenge in creating those plans is the unknown, with no sense yet of when Opening Day will be.

“It’s hard to plan with the unknown, but at least create a structure that we can work off of and then narrow the structures down as things start to become more clear as we go,” Shildt said. “One of the things we discussed is making sure we’re doing this together and we’re communicating. And we’re going to be — we have to be — fluid. That’s going to be crucial.”

Here are some other things that were discussed Friday morning:

• Shildt said the tone of the clubhouse meeting Friday was “professional,” as players process what the Opening Day delay means. Many questions were asked, even if the team didn’t have all the answers at this point.

• Minor League players, who just reported to camp this week, were told to remain at the hotel and await instruction Friday.

“Had we brought everybody in today, for example, we would have been over 300 people in this building,” Mozeliak said. “And we thought it was in the best interest of everybody just to keep all the Minor League players and staff back at the hotel, and then we’ll reassess today, tomorrow, day by day, hour by hour.”

Anne Rogers covers the Cardinals for MLB.com. Follow her on Twitter @anne__rogers and on Facebook.

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EBB 117 – The Evidence on Inducing for Due Dates – Evidence Based Birth®

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Hi, everyone. On today’s podcast, we’re going to talk about the evidence on inducing labor for going past your due date.

Welcome to the Evidence Based Birth podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi, everyone. On today’s podcast, we’re going to talk about the evidence on inducing versus waiting for labor when you’re going past your due date. I’m going to be joined by Anna Bertone, MPH, our Research Editor at Evidence Based Birth to talk about this topic.

Before we get started, I have a quick announcement, and that is next week we are hosting free webinars for the public all about the Evidence Based Birth Childbirth Class. On Monday, March 2, we’ll host a special webinar just for parents. We’ll give you a peek behind the scenes at what it’s like to take our Evidence Based Birth Childbirth Class. Then on Tuesday, March 3, we’ll have a special webinar just for birth professionals to give you a tour of the Evidence Based Birth Childbirth Class so that you can decide if it’s something you’d like to recommend to your clients or not. You can register for these free webinars at evidencebasedbirth.com/childbirthclasswebinar. That’s all one word /childbirthclasswebinar.

All right, now back to the topic at hand, inducing labor for going past your due dates. Now before we begin, I do want to give a brief trigger warning. In our discussion about the research evidence on this topic, we will be talking about stillbirth and newborn death. So there has been a ton of new research on the evidence on induction versus waiting for labor when you go past your due date. So much research, in fact, that we have decided to separate our Signature Article on due dates into two separate articles.

So we still have the original article, The Evidence on Due Dates, which you can find at ebbirth.com/duedates. And although we updated that article a little bit, it’s remained very similar to previous additions. It talks about the length of a normal pregnancy, factors that can make you more or less likely to have a long pregnancy, et cetera. But then we separated out the research on induction into a new article that you can find at ebbirth.com/inducingduedates. This is a peer-reviewed article that covers all of the research on induction versus something called “expectant management” for going past your due date. And in today’s podcast, we’re going to update you on the latest info that we found for that article.

Just a heads up, we will not be covering the research evidence on inducing at 39 weeks. We already covered the ARRIVE study, a randomized trial that looked at induction versus expectant management for 39 weeks of pregnancy in episode 10 of the Evidence Based Birth podcasts. And just a tip, if you’re having trouble finding any of our earlier episodes of this podcast, iTunes has stopped showing the earliest podcasts, but they’re still out there and you can find them on Spotify and any other podcasting app. You can also find info about the ARRIVE study at ebbirth.com/arrive.

So we’re not going to talk about induction at 39 weeks. Instead, we’re going to be focusing on the evidence on induction versus waiting for labor once you reach 41 weeks. And to do so, we’re going to talk with our Research Editor, Anna. So welcome, Anna, to the Evidence Based Birth podcasts.

Anna Bertone:   Thank you! I’m glad to be on the podcast again.

So I want to start by explaining to our audience a little bit kind of about the background of why this topic is important. Inductions for non-medical reasons have been on the rise in the United States and all around the world for the past 30 years. And increasingly, more people who are pregnant are being induced for reaching their estimated due date. So we really want to cover the benefits and risks of elective induction for going past your estimated due date. And we’ll also talk about whether or not your goals and preferences for your birth matter, which of course they do, but that kind of plays a role as well.

So how often are people induced for going past their due date? Well, we don’t know for sure because this hasn’t been measured recently. But according to the 2013 Listening to Mothers III survey, which was now published about seven years ago, more than 4 out of 10 mothers in the U.S. said that their care provider tried to induce labor. Inducing labor for going past your due date was one of the most common reasons for an induction. Out of everyone who had an induction in this study, 44% said they were induced because their baby was full term and it was close to the due date. Another 18% said that they were induced because the healthcare provider was concerned that the mother was overdue.

The Centers for Disease Control in the U.S. also reported in 2018 that about 27% of people had their labor induced, but we think that number is probably low and that the percentage of people who have labor induced is under-reported in the Vital Statistics Program in the United States. So Anna, can you talk a little bit about why there’s so much controversy over this concept of electively inducing labor once you go past your due date?

Anna Bertone:   So why is there so much controversy about elective induction? Elective inductions by definition are labor inductions that do not have a clear medical reason for taking place. They occur for social reasons, like the provider wanting the mother to give birth before the provider goes out of town or for other non-medical reasons like the pregnancy getting uncomfortable and for the mother’s convenience. But there’s also a gray zone about what constitutes an elective induction. Many providers only consider an induction to be “elective” when the mother is healthy, pregnant with a single baby, and less than 41 weeks pregnant. The gray zone is that sometimes when the pregnancy goes past 41 weeks, some providers consider that to be a medically indicated induction rather than an elective induction. But in general, inductions are considered medically indicated when there are accepted medical problems or complications with the pregnancy that make it less safe to continue the pregnancy.

For many years, and I remember when I first entered the birth world in 2012, a lot of people talked about the fact that if you have an induction it doubles your chance of cesarean. And then all of a sudden there were people saying that wasn’t true. So can you talk a little bit about that controversy?

Anna Bertone:   So for many years, the common belief was that elective induction doubles the cesarean rate, especially in first-time mothers. But researchers nowadays consider those earlier studies to be flawed. In the earlier studies, what they would do is they would compare people assigned to elective induction to people who went into spontaneous labor. Nowadays, they don’t compare those two groups anymore. They compare people assigned to elective induction to the people assigned to what’s called expectant management, or in other words waiting for labor. And in that group, the person could either go into spontaneous labor or they could require an induction for medical reasons (so that would be a medically indicated induction), or they could choose elective induction further along in the pregnancy.

So that’s a subtle difference but an important one because in the earlier studies they compared elective induction to spontaneous labor. But you don’t have the choice to go into spontaneous labor today. Your choice is to be induced today or to wait for labor to start. And sometimes during that waiting period you might develop complications that require an induction, or you might change your mind and decide to have an elective induction, or you might go into spontaneous labor.

Anna Bertone:   Right. So nowadays, we compare a group assigned to elective induction to a group assigned to expectant management. One example of this was the ARRIVE trial.

The ARRIVE trial was a study comparing elective induction at 39 weeks versus expectant management. We’re not going to go into that trial in detail because we already covered it in detail in episode 10 of the Evidence Based Birth podcasts. But they actually found a lower risk of cesarean in the elective induction group. Researchers think that had to do with the fact that of the people in the expectant management group, more of them developed problems with blood pressure that required medical inductions and increased risk for complications. So again, that just kind of goes to show you that it does make a difference when you compare elective induction to expectant management.

Although, one thing you have to keep in mind with the ARRIVE study is that they had a very low cesarean rate in both groups compared to some settings. The cesarean rate was 19% in the elective induction group versus 22% in the expectant management group. So those research results cannot probably be generalized to settings with extremely high cesarean rates or high cesarean rates with inductions. We have some, for example, some professional members at Evidence Based Birth who talked to us about where they’re practicing and how high the cesarean rates are with the elective inductions there. So I think you have to be careful how you generalize or apply that data from the ARRIVE study, and we talk more about that in episode 10 of the podcast.

Which leads me to another point, and that is some cautions about the evidence. When I say generalize, that means taking research from a research study, and seeing if you can apply that to where people are giving birth in your community. So it’s important to understand that there are some major drawbacks to some of the research that we’re going to be talking about. Many of the studies are carried out in countries or time periods where there are low cesarean rates. So when that happens, when a study is carried out in a setting where culturally there’s low C-section rates, that might not apply to a hospital with high cesarean rates. If your hospital has high rates of “failed inductions” and strict time limits on the length of labor, then the evidence in these studies may not apply to you because induction might be more risky in your community hospital.

Also, another disclaimer about the evidence, in these trials, people are randomly assigned to induction or expectant management. And it’s important to remember that the people assigned to expectant management do not always go into labor spontaneously. There’s a mix of people in that group. Some of them do have a spontaneous labor. Others have an elective induction later on, and others have a medical induction for complications.

Also, you have to look at what they’re doing for fetal testing in the studies. In some studies there’s lots of fetal testing going on in the expectant management group. However, we’re going to talk about one of the studies where they were not doing any standard fetal monitoring during expected management. So those results might not apply to your community if your community does the fetal monitoring, and the study did not have fetal monitoring.

Finally, another disclaimer about the research evidence is that the induction protocols vary from study to study, and even within studies themselves. So knowing what the protocol was for induction in that study can be very helpful to decide if this is going to apply to your unique situation in your local community or not.

So with all of those disclaimers being said, there’s been quite a lot of new research in the past year about induction at 41 weeks. So Anna, can you talk about one of the most recent studies? Let’s talk about the INDEX trial from the Netherlands. There were two trials that came out in 2019, two large randomized control trials. Let’s talk about the INDEX one first.

Anna Bertone:   Sure. So the INDEX trial was from the Netherlands. INDEX stands for induction at 41 weeks, expectant management until 42 weeks. This was a large multicenter trial. It was conducted at 123 midwifery practices and 45 hospitals. Most of these pregnancies were managed by midwives.

…So this was the midwifery-led model of care-

Anna Bertone:   Exactly.

… which is very different than in the United States which is typically an obstetrician-led care model.

Anna Bertone:   The researchers randomly assigned a total of 1,801 pregnant people to either induction at 41 weeks and zero to one days or to wait for labor until 42 weeks and zero days, which is called expectant management. The reason they were able to conduct this study in the Netherlands and got ethical approval for it is because it was standard practice for them to not induce labor before 42 weeks with an uncomplicated pregnancy.

…Whereas in the U.S. it’s rare to see someone go to 42 weeks, in the Netherlands, they typically won’t induce you unless there’s medical reasons until you get to 42 weeks – 

Anna Bertone:   Exactly. So the mothers were enrolled in the study between 2012 and 2016. Everyone had to be healthy, and pregnant with single, head-down babies. The gestational ages were estimated with ultrasound before 16 weeks of pregnancy. They excluded people with a prior cesarean, with high blood pressure disorders, with expected problems with the baby’s growth, abnormal fetal heart rate, or known fetal malformations (congenital anomalies). In both groups, cervical ripening and induction methods depended on local protocol. It’s like what Rebecca was talking about earlier. There wasn’t a standard protocol to apply to both groups in this study when it came to cervical ripening and induction. It was based on local protocol. And this is an important weakness of the study because the providers might’ve managed labor inductions differently based on whether someone was being electively induced or was assigned to the expectant management group. It also limits the study’s generalizability, which means our ability to apply the results of this study to the population at large because providers don’t have an induction protocol that they can replicate.

…So we can learn from what happened in this study, but it’s difficult for us to apply it to across the board because there’s no specific induction protocol that could be followed – 

Anna Bertone:   Yeah. What happened was in the elective induction group, 29% of the participants went into labor before their induction and 71% were induced. Then in the expectant management group, 74% of the participants went into labor spontaneously before their planned induction and 26% were induced.

…And before we talk about how long the pregnancies were, I think it’s important for people to understand that when you have a randomized controlled trial like this the researchers do something called intent to treat analysis. So it doesn’t matter what type of birth they had, whether it was a spontaneous labor or a medical induction, the data were analyzed depending on which group you were originally assigned to. So if you were assigned to an elective induction but you happen to just quick go into labor on your own before the induction, you were still grouped with everyone in the elective induction group and vice versa. So that’s just an important distinction for people to understand. – 

Anna Bertone:   Yes. What happened with these results is that the median pregnancy was only two days shorter in the elective induction group compared to the expectant management group. This is interesting because they still found a difference between these two groups, but-

…And this is important because a lot of people ask us like, “Well, I only want to wait one more day, or two more days, or three or four more days,” but they’re saying by decreasing the length of the pregnancy by two days they found significant results. So what did they find in the INDEX trial? – 

Anna Bertone:   So for mothers, they found that there was no difference in the cesarean rates. This was taking place in a country with low cesarean rates. It was a midwifery model of care and the rates were very low in both groups (11%). 

They only had an 11% cesarean rate then?

Anna Bertone:   Yeah. They also had an outcome called a composite outcome, which is a combined outcome for mothers, and there was no difference in that measure either. They were looking for things like excessive bleeding after birth, manual removal of the placenta, severe tears, intensive care admission, and maternal death, and they didn’t find a difference in those things. There were no maternal deaths in either group. So as far as the bad outcomes for the mothers, there were about 11% to 14% in both groups, but not different.

…And what about for the babies then? – 

Anna Bertone:   And then for the babies, the babies in the elective induction group had a lower composite outcome rate. And in this composite outcome, what they were looking at was perinatal death, Apgar score less than seven at five minutes, low pH, meconium aspiration syndrome, nerve injury, brain bleeds, or admission to a NICU. And here they found a lower composite adverse outcome rate with the babies in the elective induction group (1.7% versus 3.1%). 

And why do they think that outcome was better with the elective induction group?

Anna Bertone:   They think that it was mostly due to the lower rate of Apgar scores less than seven at five minutes, and that probably contributed the most to having a lower adverse outcome rate with the babies in the elective induction group. The author’s note that there was no difference in rates of Apgar score less than four at five minutes, but they found that the combined outcome was still lower in the elective induction group if they used an Apgar score of less than four at five minutes and excluded fetal malformations. So basically, the babies in the elective induction group had better Apgar scores overall.

…And what about stillbirths? Because that’s like the main reason they’re doing these kinds of elective inductions, is to lower the risk of stillbirth. – 

Anna Bertone:   Yep. And they did not find a difference in stillbirth in this study. There was one stillbirth that occurred in the elective induction group. It was at 40 weeks and six days, before the mother was induced. Then, there were two stillbirths that occurred in the expectant management group while the mothers were waiting for labor.

Anna Bertone:   I looked for a few more details about those stillbirths because I was interested in that. Of the two stillbirths that occurred in the expectant management group, one was a small for gestational age baby at 41 weeks and three days to a first-time mother. The other one was to a mother with a prior birth, and that was at 41 weeks and four days. The mother’s placenta showed signs of infection (infection of the membranes). Then, the one stillbirth that occurred at in the elective induction group at 41 weeks was to an experienced mother (someone who had already had given birth before), and that was at 40 weeks and six days, and there was no explanation for that one. But with two versus one, they didn’t find a significant differences in stillbirths between those groups.

And what was the protocol for fetal monitoring in that study?

Anna Bertone:   There was no protocol for fetal monitoring. It depended on local guidelines, just like the induction and cervical ripening protocol. But the study authors say that fetal monitoring and assessment of amniotic fluid levels was typically done between 41 and 42 weeks. 

So how would you sum up the results of this INDEX study then?

Anna Bertone:   They found that elective induction at 41 weeks resulted in similar cesarean rates and less overall bad outcomes for babies compared to waiting for labor until 42 weeks. However, they say that the absolute risk of a bad outcome happening was low in both groups. It was 1.7% in the elective induction group versus 3.1% in the expectant management group (the group that waited until 42 weeks).

All right. Well, the next study we wanted to talk about was the SWEPIS trial from Sweden, also published in 2019, also coming out of Europe. It’s S-W-E-P-I-S, and it stands for the Swedish post-term induction study, or SWEPIS. It got a lot of media attention with headlines like … There was one that said, “Post-term pregnancy research canceled after six babies died.” And it is true that this study was ended early after deaths in the study. The researchers intended to enroll 10,000 mothers from multiple centers across Sweden, but they ended up stopping the study with about 1,380 people in each group after their data safety and monitoring board found a significant difference in perinatal death between the groups.

Data safety and monitoring boards are basically a board that keeps track of what’s going on in the study. They get interim reports. And if they see any concerning safety issues, they have the power to stop the studies. That’s a standard part of a lot of randomized controlled trials is to have one of these safety boards.

Similar to the INDEX trial in the Netherlands, in Sweden, labor is typically not induced before 42 weeks if you have an uncomplicated pregnancy. Also similar to the Netherlands, in Sweden, midwives manage most of the pregnancies and births. It’s a midwifery-led model of care.

The purpose of the SWEPIS study was to compare elective induction at 41 weeks and zero to two days versus expectant management and induction at 42 weeks and zero to one day if the mother hadn’t gone into labor by that point. The study was carried out in the years 2015 to 2018. The researchers enrolled healthy mothers with single babies in head-first position. They had accurate gestational ages. They excluded people with a prior cesarean, diabetes, and other complications such as high blood pressure, small for gestational age, or known fetal malformations.

There is a pretty low stillbirth rate in Sweden, so they thought they would need about 10,000 people to see a difference between groups, but they ended up not needing nearly that many people to find a difference in stillbirth rates. One of the big strengths of the SWEPIS trial is that in contrast to the INDEX trial, in the SWEPIS trial they defined an induction protocol and they used that same protocol with everyone in the elective induction group and everyone in the expected management group who had an induction. The protocol was basically if the mother’s cervix was already ripe, they simply broke her water and gave her oxytocin as needed by IV. If the mother’s cervix was not ripe or the baby’s head was not engaged, they used mechanical methods or Misoprostol, or prostaglandins, or oxytocin, but they did cervical ripening first.

In the elective induction group, most of the people were induced. 86% had their labor induced. 14% went into labor spontaneously before the induction. In the expectant management group, 67% of them went into labor spontaneously and 33% ended up with an induction. Similar to the INDEX trial, there was a really tiny difference in the length of pregnancy between groups. Pregnancy in the elective induction group was in general only three days shorter than pregnancy in the expectant management group, but yet they did go on to find significant differences.

So what the SWEPIS trial found was that for babies – this is why this study was stopped early – there were five stillbirths and one early newborn deaths in the expectant management group out of 1,379 participants for a death rate of 4.4 deaths per 1,000 women. There were zero deaths in the elective induction group out of 1,381 participants. All five stillbirths in the expectant management group happened between 41 weeks, two days and 41 weeks, six days. Three of the stillbirths had no known explanation. One was for a baby that was small for gestational age. The other was with a baby who had a heart defect. There was one newborn death that occurred four days after birth due to multiple organ failure in a baby that was large for gestational age.

The authors mentioned that when complications are present at the end of pregnancy, such as problems of the placenta, or the umbilical cord, or fetal growth, these problems may become increasingly important as each day of pregnancy progresses, which they believe is why they found a higher death rate with expectant management past 41 weeks.

Another key finding of the study was that all of these deaths occurred to first-time mothers, which suggests that 41-week induction may be especially beneficial for babies of first-time mothers. They found that it only took 230 inductions at 41 weeks to prevent one death for a baby, and this was a much lower number than previously thought. If you remember, though, as Anna was saying, the INDEX trial did not find a significant difference in death between the induction group and the expectant management group. We think the reason the SWEPIS study found a difference was because it was a larger study, it was better able to detect differences in rare outcomes like death. Also, with the SWEPIS study, there might not have been as good fetal monitoring. So it’s possible that the better fetal monitoring of participants between 41 weeks and 42 weeks in the INDEX trial might’ve been protective, leading to fewer perinatal deaths. We can’t be certain though because there were no fetal monitoring protocols in either trial.

Another thing to note is that participants in the SWEPIS expectant management group tended to give a birth a little later than the participants in the INDEX expectant management group. That might help explain the higher perinatal death rate in the expectant management group in SWEPIS. They did not find a difference in what they call the composite adverse perinatal outcome, which included death, low Apgar scores, low pH, brain bleeds, brain injury, seizures, and several other major complications, but there was that significant difference in perinatal death (either having a stillbirth or newborn death).

Also, the elective induction babies were less likely to have an admission to intensive care, 4% versus 5.9%. They had fewer cases of jaundice, 1.2% versus 2.3%, and fewer of them were big babies, 4.9% versus 8.3%.

For mothers, the outcomes were overall pretty good. There were no differences in cesarean rates similar to the other trial. The cesarean rate in this study in both groups was about 10% to 11%. More mothers in the elective induction group had an inflammation of the inner lining of the uterus called endometritis, 1.3% versus 0.4%. And on the other hand, more mothers in the expected management group developed high blood pressure, 3% versus 1.4%. They also interviewed the women in both groups and they found that the mothers in the expectant management group really struggled with negative thoughts. They described feeling in limbo while they waited to go into labor. So Anna, can you talk a little bit about the fetal monitoring in this study and how it may have differed from the other study?

Anna Bertone:   Sure. Fetal monitoring in this study was done per local guidelines. So there was no study protocol for fetal monitoring during the 41st week of pregnancy. However, the mothers recruited from one region of Sweden, called the Stockholm region, which made up about half the people in the study, had ultrasound measurements of their amniotic fluid volume and abdominal diameter at 41 weeks, whereas the people that came from the other areas of Sweden in the study did not receive these assessments regularly. None of the six deaths that occurred in this study occurred in the Stockholm region of Sweden where they received this type of fetal monitoring, which leaves us with the question of how important was this fetal monitoring. Could it have made the difference between the Stockholm region participants not experiencing fetal deaths whereas participants from other regions did?

Anna Bertone:   So that’s just an important thing to keep in mind with this study is that the fetal monitoring may have made a difference as far as the perinatal outcomes. It also means that the results of the SWEPIS study might not apply equally to mothers who receive fetal monitoring at the end of pregnancy, specifically during that 41st week of pregnancy which seems to be the really critical time period. Another thing, all of the perinatal deaths in this study occurred to first-time mothers, which tells us that the results might not apply equally to mothers who have already given birth before.

…So in the SWEPIS study, out of the mothers in the study who had already given birth before and were having a subsequent baby, none of them experienced this stillbirth or newborn death, correct?

Anna Bertone:   Correct. Yes.

Okay. So all of the perinatal deaths occurred to first-time mothers.

Anna Bertone:   And the first-time mothers, by the way, they only made up about half of the participants in the sample, so it was about a 50/50 split.

So all of the fetal and newborn deaths from this study came from first-time mothers who lived in the areas of Sweden that did not do any prescribed fetal monitoring during that 41st week of pregnancy.

Anna Bertone:   That’s my understanding. Correct.

Okay. So those are the two big randomized trials that came out in 2019. Before they were published, there was a 2018 Cochrane meta-analysis. Anna, I was wondering if you could talk a little bit about that. This study did not include the SWEPIS and the INDEX trials, but we still wanted to talk about it in our article. So can you explain to our listeners a little bit about this Cochrane review?

Anna Bertone:   Sure. There was a 2018 Cochrane review and meta-analysis by Middleton. Unlike these randomized control trials that we were just talking about, they didn’t focus specifically on the 41st week of pregnancy versus the 42nd week of pregnancy. It was much more broad than that. What they did was they looked at people who were electively induced at some point, and compared them to people who waited for labor to start on its own until some point. So there was a much more broad range of gestational ages there. But they included 30 randomized control trials with over 12,000 mothers, and they compared a policy of induction at or beyond term versus expectant management. All of the trials took place in Norway, China, Thailand, the U.S., Austria, Turkey, Canada, the UK, India, Tunisia, Finland, Spain, Sweden, and the Netherlands.

So it’s quite a global sample.

Anna Bertone:   Yes. But one study in this meta-analysis really dominated and accounted for about 75% of the data, and that was the Hannah post-term trial that I think Rebecca is going to be talking about soon. Because that one trial dominated this meta-analysis so much, most of the data was on giving birth at 41 weeks or later.

And they did not include the ARRIVE trial in this meta-analysis.

Anna Bertone:   Right. They didn’t include the ARRIVE, INDEX, or SWEPIS trials. So in its next update, it’s going to be updated with those three randomized control trials. But they did include 30 other randomized control trials. What they found was that a policy of induction at term or beyond term was linked to 67% fewer perinatal deaths compared to expectant management. So that was two deaths with induction at or beyond term versus 16 deaths in the people assigned to expected management.

Anna Bertone:   The Hannah post-term trial excluded deaths due to fetal malformations, but some of the smaller trials that were included in the Cochrane meta-analysis did not. So if we exclude the three deaths from severe fetal malformations, then the final count is one death in the induction group and 14 in the expectant management group. So it doesn’t change the results too much overall to exclude fetal malformations. Overall, they found that the number needed to treat was 426 people with induction at or beyond term to prevent one perinatal death. Specifically, there were fewer stillbirths with a policy of induction at or beyond term.

Which was a different number needed to treat than the SWEPIS trial, which found only took 230 inductions at 41 weeks to prevent one perinatal death.

Anna Bertone:   Yeah. I think part of the reason the SWEPIS trial was so groundbreaking and got so much media attention is because it did find a lower number needed to treat than had been found previously. So the absolute risk of perinatal death was 3.2 per 1,000 births with the policy of expected management versus 0.4 deaths per 1,000 births with the policy of induction at or beyond term. They found that a policy of induction was linked to slightly fewer cesareans compared to expectant management, 16.3% versus 18.4%.

Anna Bertone:   Fewer babies assigned to induction had Apgar scores less than seven at five minutes compared to those assigned to expectant management. They didn’t find any differences between the groups with the rate of forceps or vacuum assistance at birth, perinatal trauma, excessive bleeding after birth, total length of hospital stay for the mother, newborn intensive care admissions, or newborn trauma. The authors concluded that individualized counseling might help pregnant people choose between elective induction at or beyond term or continuing to wait for labor. They stress that providers should honor the values and preferences of the mothers.

We need more research to know who would or would not benefit from elective induction. And the optimal time for induction is still not clear from the research, which is what they said in 2018. I think Rebecca’s going to talk about the famous Hannah post-term study that accounted for 75% of the data in that meta-analysis.

Yeah, so we’re kind of working backwards through time. We started with the 2019 randomized trials, then the 2018 meta-analysis where they said the optimal time for induction is not clear, but they stated that before the two new randomized trials came out. Then even before then going back in time is the 1992 Hannah post-term study, which is one of the most important studies on inducing for going past your due date and it was the largest randomized trial ever done on this topic, larger even than INDEX or SWEPIS. And it controls most of the findings in that Cochrane meta-analysis that Anna just described.

So let’s look at what happened in this study because it plays so much of a role in the meta-analysis. It was carried out between the years 1985 and 1990 when a group of researchers enrolled 3,407 low-risk pregnant people from six different hospitals in Canada into the study. Women could be included if they were pregnant with a live single fetus, and they were excluded if they were already dilating, if they had a prior cesarean, pre-labor rupture membranes, or a medical reason for induction.

This study had a much different expectant management protocol than INDEX or SWEPIS because unlike those studies where the longest you would go was 42 weeks and zero to one or two days, in the Hannah post-term study, the people assigned expectant management were monitored for as long as 44 weeks pregnancy before they were induced, so up to a month past your due date, which is almost unheard of today. At around 41 weeks, people who agreed to be in the study were either randomly assigned to have an induction of labor or fetal monitoring with expectant management.

In the induction group, labor was induced within four days of entering the study, usually about 41 weeks and four days. If the cervix was not ripe and if the fetal heart rate was normal, they were given a prostaglandin E2 gel to ripen the cervix. They used a maximum of three doses of gel every six hours. If this did not induce labor or if they did not need the gel, people were given IV oxytocin, had their waters broken, or both. And they could not receive oxytocin until at least 12 hours after the last prostaglandin dose.

So one strength of this study is that it had a defined induction protocol that providers could replicate. But the big weakness of this study is that the expectant management group did not have that same induction protocol. In the monitored or expected management group, people were taught how to do kick counts every day and they had a non-stress tests three times per week. They also had their amniotic fluid levels checked by ultrasound two to three times per week. And labor was induced if there were concerning results in the non-stress test, or if there was low amniotic fluid, or if the mother developed complications, or if the person did not go into labor on their own by 44 weeks. And if doctors decided the baby needed to be born, mothers in expectant management group did not receive any cervical ripening. Instead, they either had their water broken and/or IV oxytocin, or they just went straight to a cesarean without labor. So Anna, do you want to talk a little bit about what the researchers found in the study?

Anna Bertone:   What the researchers found in the Hannah post-term study is that in the induction group, 66% of the people were induced and 34% went into labor on their own before induction. And in the expectant management group, 33% were induced and 67% went into labor on their own. There were two stillbirths in the group assigned to wait for labor and zero in the group assigned to induction. This difference was not considered to be statistically significant, which means we don’t know if it happened by chance or if it was a true difference between the groups. The more interesting outcome to look at with the Hannah post-term trial are the findings on cesarean rates because they differ depending on what numbers you look at. You can either look at the outcomes for the two original groups, which were the people randomly assigned to induction and then those assigned to expectant management, or you can look at the breakdown of what actually happened to the people in the two groups, in other words what happened to the people who were actually induced or who actually went into spontaneous labor.

Anna Bertone:   So what happened in the original randomly assigned groups? If you look at the two original groups, the overall cesarean rate was lower in the induction group. It was 21.2% versus 24.5%. That was even after taking into account factors like the mother’s age, whether or not it was her first baby, and cervical dilation at the time of study entry. Or you could look at what happened with the people who were actually induced or who actually went into labor on their own. And if you look at that, you see two very interesting things. You see that people who went into spontaneous labor, regardless of which group they were assigned to, they had a cesarean rate of only 25.7%. But if people in the monitoring group had an induction, their cesarean rate was much higher than all the other groups. It was 42%. The same was true for both first-time mothers and for mothers who had given birth before.

Anna Bertone:   So what does this mean? It means that only the people who were expectantly managed but then had an induction had a really high cesarean rate. The people who were expectantly managed and then went into labor spontaneously did not have a higher cesarean rate. One possible reason for this, for the highest cesarean rate seen in the people who were assigned to expectant management but then ended up getting an induction, is that the people in this group might’ve been higher risk to begin with since a medical complication could have led to their induction. The people that were assigned to expectant management and never developed a complication requiring an induction, those were the lower risk people, which means they were the ones less likely to end up giving birth by cesarean.

Anna Bertone:   Then, another important factor that I know Rebecca has discussed previously is that doctors might’ve been quicker to call for a cesarean when assisting the labors of people with medical inductions if their pregnancies were beyond 42 weeks. They may have been less patient waiting for labor.

…Or more easily worried about the course of the labor, big baby, etc. – 

Anna Bertone:   Yes. More worried.

So basically, it seems like from the Hannah post-term trial, one of the benefits of considering expectant management is that if you do have spontaneous labor, your chance of cesarean is pretty low. But the risk is that you’ll develop medical complications and need an induction, in which case an induction at 42 weeks is going to be riskier than an induction at 41 weeks. So what do you think? We have all this research from all over the world, from the Hannah post-term trial, to the 2018 meta-analysis, to two trials out in 2019. Do you still feel like routine induction at 41 weeks is still going to be controversial or not?

Anna Bertone:   I think it’s definitely still controversial, and I think everybody’s still processing the results from the INDEX trial and the SWEPIS trial. Rebecca and I reached out to Dr. Wennerholm who conducted the SWEPIS trial in Sweden, and she said she’s currently working on secondary analysis of the data. They’re talking about the economic implications of the findings in Sweden and what it means for Swedish national policy. So I think it’s still controversial. People are still talking about what to make of these findings.

Anna Bertone:   There was another systematic review from 2019 by Riedel. This one came out too early to include the SWEPIS and the INDEX trials, but it’s still interesting to look at. Because unlike the Middleton Cochrane review, these authors were specifically interested in induction during the 41st week of pregnancy versus during the 42nd week of pregnancy. So in their analysis, they restricted the studies only to people having a routine induction at 41 weeks and zero to six days versus routine induction at 42 weeks and zero to six days. If you remember, the Cochrane review was much broader than that. They also only looked at studies published within the last 20 years. They only looked at studies with low-risk participants, and they ended up with three observational studies, two randomized controlled trials, and two studies that they called “quasi experimental studies”, which they grouped with the randomized controlled trials even though these studies weren’t truly randomized.

Anna Bertone:   What they found was one perinatal death in the 41 week induction group and six deaths in the 42 week induction group. That was a rate of 0.4 versus 2.4 per 1,000. This finding was not statistically significant. In other words, we don’t have strong enough evidence that this couldn’t have happened by chance. These same studies, those two randomized controlled trials and the two quasi experimental studies, they showed no difference in cesarean rates between groups also. But the authors did report that one observational study found an increase in the cesarean rate with the 41 week induction group. So basically, they’re saying if you look much more narrowly at the evidence of induction during the 41st week versus the 42nd week, then there might not be a significant difference in the death rate.

But that Riedel study from 2019 is already outdated because that was before the two big randomized trials came out.

Anna Bertone:   Yes. We need to see a systematic review and meta-analysis that includes those two randomized controlled trials and see if that changes. These authors also expressed concerns about the cesarean rate possibly rising with 41-week induction because both the SWEPIS trial and the INDEX trial took place in countries with very low cesarean rates. So we just don’t really know at this point whether there would be a difference in cesarean rates if they took place in countries with higher rates of cesarean, such as the U.S.

Anna Bertone:   So I think it is still controversial. There’s also countries that are changing their policies about induction and going back and looking at whether that policy change led to any difference in outcomes. One such country is Denmark. They just published a study where they compared birth outcomes from 2000 to 2010 versus 2012 to 2016. And in that time period there was a change in policy from recommending induction at 42 weeks and zero days to 41 weeks and three to five days. They included over 150,000 births in the dataset. And when they looked back, they didn’t see any difference in stillbirths, or perinatal deaths, or low Apgar scores when they compared the period before versus after the policy change. The perinatal death rate was already declining before the policy change in 2011, and it just continued going down without any additional impact from the 2011 policy change. There was also no impact on the rate of Cesareans with the policy to switch from 42 weeks to 41 weeks.

Anna Bertone:   That’s just an example of how this is still controversial. Countries are implementing new policies, and Sweden and the Netherlands may implement new policies based on the INDEX and the SWEPIS studies. Then they’ll probably conduct a study the same way that Denmark did to see if that policy change had any real impact on the population.

I think it’s important to mention, though, that with the Denmark national policy, they switched from 42 weeks and zero days to 41 weeks and three to five days, and that might not have been early enough to make an impact on the stillbirth rate because the studies that we were looking at from 2019, SWEPIS and INDEX, were looking at inductions happening at 41 weeks and zero to one or two days and it was that couple of days difference that made the difference between low stillbirth rate and a higher stillbirth rate.

Anna Bertone:   Right. Exactly. I think that future researchers shouldn’t group 41 weeks and zero to six days together in one grouping because there seems to be differences between the earlier part of the 41st week and the later part of the 41st week because, like you said, SWEPIS and INDEX found that waiting even just two or three days make a difference in outcomes during that week.

So let’s just sum up the pros and cons of induction at 41 weeks versus continuing to wait for labor since that’s what we have the bulk of the evidence on now. I would say that the research shows that the pros of inducing labor at 41 weeks include a lower risk of stillbirth, especially among those with risk factors for stillbirths such as being pregnant with your first baby. In our article, we have a table of the pros and cons. The absolute risk of stillbirth is 4 out of 10,000 pregnancies at 39 weeks, 7 out of 10,000 pregnancies at 40 weeks, 17 out of 10,000 pregnancies at 41 weeks, and 32 stillbirths out of 10,000 pregnancies at 42 weeks. Research also shows a lower risk of the baby receiving intensive care with an elective induction at 41 weeks, lower risk of the baby having jaundice, lower risk of the baby being large for gestational age, and lower risk of needing a cesarean, although that finding may depend on your practice setting. There is a lower risk of mother developing a high blood pressure disorder. at the end of pregnancy. And for some people, they may find an elective induction at 41 weeks convenient and it could help them end an uncomfortable pregnancy.

Also, in our article, we reference one study that found some cognitive benefits for babies. It suggests that the cognitive benefits for the baby from the mom remaining pregnant appear to increase until about 40 to 41 weeks after which there’s no cognitive benefits to the baby’s brain development for continuing to remain pregnant. So Anna, can you share the cons of elective induction at 41 weeks?

Anna Bertone:   Yeah. One of the cons of being induced at 41 weeks instead of continuing to wait and see if you go into labor is the potential for medicalization of birth. One example of this is continuous fetal monitoring may occur if you have the induction, whereas you might not get continuous fetal monitoring if you go into labor on your own spontaneously during that 41st week. 

Anna Bertone:   Another con would be a potential for failed induction leading to a cesarean. That also depends a lot on your practice setting. Another con is the potential for uterine tachysystole, which is defined as more than five contractions in 10 minutes averaged over 30-minute window. There’s a potential increase in the risk of uterine rupture with medical induction. That is especially important among people with a previous cesarean having a VBAC.

Anna Bertone:   Another con is missing the hormonal benefits of spontaneous labor. Another con is increased risk of mother getting inflammation of the inner lining of the uterus, endometritis. One study found that as a possible risk of induction 41 weeks. Then, lastly, medically-induced contractions might increase pain and make epidural use more likely.

We also have a section in the article where we talk about whether there are any benefits to going past your due date. That table we just took you through was comparing the benefits and risks of elective induction. In terms of benefits of going past your due date, one of the major benefits of awaiting for spontaneous labor are the hormonal benefits, which Anna briefly mentioned. In our article, we link to the book Hormonal Physiology of Childbearing by Dr. Sarah Buckley, which talks about the physiologic understandings and the physiology of spontaneous labor. So that is something to keep in mind, and that’s one reason why some people prefer to wait for spontaneous labor. So Anna, if someone wants to wait for labor to begin on its own and they’re talking with their care provider about expectant management, what’s kind of the bottom line about that?

Anna Bertone:   I think the bottom line about that is it all needs to be very individualized. When someone goes past their estimated due date, they could talk to their care provider about the benefits and the risks of elective induction versus continuing to wait for labor and how those benefits and risks apply to them personally. Most research articles and guidelines say that because there are benefits and risks to both options, the pregnant person’s values, goals, and preferences should play a part in the decision-making process.

Anna Bertone:   It’s important for expectant families to be aware of the growing research evidence showing that there could be worse health outcomes for those who wait for labor after 41 weeks of pregnancy instead of being induced at 41 weeks, especially among first-time mothers and those with additional risk factors for stillbirth. But ultimately, after receiving accurate evidence-based information and having conversations with their care providers, pregnant people have the right to decide whether they prefer to induce labor or wait for spontaneous labor with appropriate fetal monitoring.

I want to also let people know about a couple more resources that are in this article at evidencebasedbirth.com/inducingduedates. We have a section all about how people and their care providers can talk about the risk of stillbirth with some sample scripts that healthcare providers can use when they’re talking about risks of stillbirth. We also have links to different guidelines from different organizations about induction at 41 weeks. Then we also have our section called The Bottom Line. So what would you say are some of the bottom lines, Anna, about elective induction at 41 weeks and zero to two days?

Anna Bertone:   I think the bottom line is that elective induction at 41 weeks and zero to two days could help to reduce stillbirths and poor health outcomes for babies without increasing harm, like the risk of Cesarean for mothers. We’re getting that from those two large randomized controlled trials published in 2019 that both found benefits to elective induction at 41 weeks instead of continuing to wait for labor until 42 weeks. One of those studies, as we mentioned, found less perinatal death with 41 week induction and the other found fewer poor health outcomes for babies like intensive care unit admission and low Apgar scores with 41 week induction. Neither of those trials found an increase in the risk of Cesarean during birth with 41 induction compared to continuing to wait for labor until 42 weeks. However, both of those trials took place in countries that follow the midwifery model of care and the overall Cesarean rates were very low. So I think it remains to be seen how that will translate into countries like the U.S. that have higher Cesarean rates. 

So I hope you all found this podcast helpful in looking at the recent research on induction at 41 weeks versus expectant management. Make sure you check out the blog article that goes along with this podcast episode for all of the resources, links, research references. We also have a free one-page handout you can download that summarizes the results of this research. Just go to evidencebasedbirth.com/inducingduedates to download that new article. Thank you so much, Anna, for joining us to help our listeners understand the evidence.

Anna Bertone:   Happy to do it, Rebecca. Thank you.

Today’s podcast was brought to you by the PDF library inside the Evidence Based Birth Professional Membership. The free articles that we provide to the public at evidencebasedbirth.com and this free podcast as well as other resources are supported by our Professional Membership program. Everyone who joins our professional membership gets access to a library with all our printer-friendly PDFs. Each signature article that we publish online has been turned into a professionally-designed, easy-to-print PDF so that our members can print and share evidence-based info with their clients, other parents, or other professionals. To learn how you can become a member today, visit ebbirth.com/membership.

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Andrea Hayden Twins’ strength and conditioning coach | Minnesota Twins

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FORT MYERS, Fla. — Andrea Hayden isn’t too accustomed to having Twins players upset with her. But she was thrilled about it.

Several players had seen Hayden featured in a television segment that highlighted her as the first female strength and conditioning coach in Major League Baseball, and they approached her in the weight room, aghast that they hadn’t already been aware of Hayden’s place in league history.

“How did we not know?” they asked her.

“I wear that as a badge because you’re not supposed to know,” Hayden said. “‘Good. I’m doing my job, because you shouldn’t be aware. You need to focus on what we’re doing and where we’re headed as an organization.'”

Hayden officially became a member of the Twins’ coaching staff last November, when strength and conditioning director Ian Kadish promoted her to assistant coach following a year-long fellowship during the 2019 season. Nobody was really aware of it at the time, but that made her not only the first female strength and conditioning coach in MLB history, but also the first full-time female member of a Major League staff.

It was only later on that Kadish and Hayden got curious and looked through the MLB staff directory to see if there was anyone else. There wasn’t. (Gabe Kapler and the San Francisco Giants have since hired Alyssa Nakken to their Major League staff.)

“OK, cool,” Hayden told Kadish. “Let’s move on. We have work to do.”

That workmanlike attitude defines how both Hayden and the Twins’ organization have approached this move. Kadish offered her the job because he saw her personality as a great fit on his staff and he felt a strong connection to her working philosophy. Kadish considers Hayden to be more of an expert than himself in Olympic lifts and has given her a lead role in the Twins’ performance-testing initiatives.

Hayden is here to contribute her knowledge to the championship push of a 101-win team, and that’s a responsibility she takes very seriously.

“She’s got a great personality, she’s got great knowledge in her field, and she’s adapted to the Major League clubhouse, it feels like effortlessly,” Twins manager Rocco Baldelli said. “It didn’t take very long for a lot of our players to come forward and say that they really enjoyed working with her, and it was a pretty straightforward, pretty easy decision for us to want to have her here and have her here full-time and do her thing, which is great.”

Hayden laughs as she reflects on what her life was like just one year ago, when she was very happy in her role as an athletic performance coach at Lindenwood University, near her hometown of St. Louis. Even without considering her budding Major League career, she’s the first to admit that her professional career has been anything but traditional.

Her interest in the field stemmed in part from her own experiences of looking for any competitive advantage when she played basketball, softball and soccer when she was young. (“I’m five-two-and-a-half with shoes on,” she says with a laugh.) Academics didn’t come easily to her, so she started her career as an 18-year-old as a physical trainer and managed some gyms around the St. Louis area until she “got burnt out of training soccer moms.”

That gave her important, hands-on experience with developing people skills and sharing her knowledge with a wide variety of people. When she found that she needed the scientific background to bring out her full potential in the field, she went to college at age 24 and emerged with degrees in exercise science and human performance. Her career has since seen stops at EXOS, the University of Louisville, USA Hockey and Team China Women’s Hockey.

“I think it’s just a love of what the weight room means and the power that it can have in the culture that is kind of driven out of that, where we work hard and we see the benefits of it on the field,” Hayden said. “And not to say that that’s everything, but it is something really powerful.”

One day last February, a former colleague, Aaron Rhodes, told her on the phone that a friend had an opportunity in baseball. He asked her to call and just to listen to what the friend had to offer. That friend was Kadish, and he and Hayden immediately had a strong connection as the pair discussed an opportunity with the Major League team.

Except, well, Hayden thought she was missing something.

“I remember being like, a third of the way into our conversation, he hadn’t brought up one time that I was a girl,” Hayden remembers. “And I’m like, ‘Does he not know?'”

“So, do you have any more questions?” Kadish asked at the end of the call.

“Yeah, like, I’m female,” Hayden recalls. “Where do you see that as being an issue or a problem?”

She remembers Kadish laughing.

“Look. Your job is the same as my job,” Kadish told her. “The only way it’s going to be difficult is if you do it differently than I do it. I’m not viewing it at all any differently than what I have to do.”

“He never once flinched at it,” Hayden said. “It never was an option. Like, it never was a disadvantage because of being a female. He only saw it as an advantage.”

Five days later, Hayden was in her car, driving down to Spring Training in Fort Myers. She left a full-time job with benefits and her hometown behind when she left Lindenwood for the fellowship with Kadish and the Twins.

“A personal motto is ‘courage over comfort,’ and choosing the things that maybe are unknown and scary and taking that leap,” Hayden said. “It’s always paid off. And I’m really fortunate that it has.”

It’s a reflection of Hayden’s personality and the seriousness with which she takes her role on a winning team that she’s never really looked to carry herself as any sort of figurehead — and there’s nothing about her day-to-day life that really makes her feel the need to do so. She calls the players her “brothers” and gives and takes friendly jabs with the best of them as she works the weight room.

She jokes that the only difference is that all of her team shirts are in men’s sizes.

“She wants to be low-key,” Kadish said. “She wants to lay low and do her job to the best of her ability and let her work speak for itself. I commend her for that in every aspect. I have no problem blowing her tires up and bumping her up, because she deserves it.”

“I think my success in my career, it’s secondary to [the players] and our success as a team, and I feel that I’m part of them,” Hayden said. “So I’d never want to make myself feel as if I have an individual platform. I have a platform with the Twins. And I really take that seriously. So every win, every loss, I wear that.”

Whether fairly or not, she knows the expectations for her — at least, looking from the outside in — might be higher than they would be for others in her position. She is aware that her success and how she carries herself in this position could open or close the door for other women to follow.

With that in mind, Hayden also said she feels that Kadish, Baldelli, the Twins’ organization and her network also deserve the acknowledgment for putting her in this position and giving her the well-deserved opportunity.

“I attribute a lot of it to a really powerful network of people,” Hayden said. “I’m so humbled that they put their name on me. I say I wear a jersey with a lot of people’s names on my back that have taken a risk on me, whether that was when I was 18 or currently in the big leagues. People have taken a risk to allow me to do what I love, and so I take that really seriously.”

Still, she’s careful to acknowledge the fact that other women around the industry may not have the strong base of support and understanding to facilitate such an easy transition into the industry. Hayden understands that there could be uphill battles and double standards for others in her position.

But that’s not the path she’s forged in the Twins’ organization. And for that, she remains encouraged — and grateful.

“It’s a direction that is obviously needed in the game, and one that nobody sits and stops, and really, it’s what times have evolved into, for the better,” said veteran starter Rich Hill.

“My story has just been awesome,” Hayden said. “And it’s so good and so supportive and being with all these dudes is awesome, and I wouldn’t trade it for anything. So that’s honestly the best part.”

Do-Hyoung Park covers the Twins for MLB.com. Follow him on Twitter at @dohyoungpark and on Instagram at dohyoung.park.

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From Near Death Experience To Top Of Her Class

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The induction of Shrdha Mala as the new head girl of Rakiraki Public Secondary School has got people talking.

Shrdha, 18, who has had a history of heart problems, is not only a student body leader but is also a top academic student, as well.

In 2014 she survived a near-death experience.

She suffered severe chest pain and acute breathing difficulties. Shrdha thought she was going to die.

She was flown to New Zealand and successfully underwent an emergency laser treatment.

Kalidass Mani, a farmworker, said Shrdha “is an inspiration to everyone and a very strong girl.”

Mr Mani said he knew her family and how they struggled after she was diagnosed with a heart defect in 2008. Shrdha was in year two then.

“She is a fighter. Others may have given up after what she went through. But not Shrdha,” he said.

Her mathematics teacher, Ashneel Raju, said Shrdha kept up her maths study despite her condition.

Ravi Chand, her school principal, said Shrdha was among the students who never gave up.

“She has inspired the students and the teachers with her excellent performance and is tackling her challenges very well,” he said.

He said Shrdha was an example to many students who did not do well in their studies as she was good in managing her time with school work and with leadership.

She has made the school and her parents proud by excelling in her education despite her challenges.

Shrdha said her battle was not over yet, but she was not allowing it to slow her down.

She has some breathing issues and she still fights to tackle the challenge and to become an inspiration to others.

Shrdha’s experience has motivated her to become a cardiologist to treat people like her and to show them that nothing is impossible.

She said if anyone had health or medical problems, they could still fight their battles and chase their dreams.

Shrdha topped the Fiji Year 12 Certificate Examination last year and she is looking forward to top this year and become the dux at her school.

Edited by Naisa Koroi

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Pluto’s famous heart powers icy winds on the dwarf planet | Live Science

Pluto’s icy heart is beating.

The dwarf planet’s famous heart-shaped feature, which NASA’s discovered during its epic July 2015 flyby, drives atmospheric circulation patterns on Pluto, a new study suggests.

Most of the action comes courtesy of the heart’s left lobe, a 600-mile-wide (1,000 kilometers) nitrogen-ice plain called Sputnik Planitia. This exotic ice vaporizes during the day and condenses into ice again at night, causing nitrogen winds to blow, the researchers determined. ( is dominated by nitrogen, like Earth’s, though the dwarf planet’s air is about 100,000 times thinner than the stuff we breathe.)  

These winds carry heat, particles of haze and grains of ice westward, staining the ices there with dark streaks.

“This highlights the fact that Pluto’s atmosphere and winds — even if the density of the atmosphere is very low — can impact the surface,” study lead author Tanguy Bertrand, an astrophysicist and planetary scientist at NASA’s Ames Research Center in California, . 

And that westward direction is interesting in itself, considering that Pluto spins eastward on its axis. The dwarf planet’s atmosphere therefore exhibits an odd “retrorotation,” study team members said.

Bertrand and his colleagues studied data gathered by New Horizons during the probe’s 2015 close encounter. The researchers also performed computer simulations to model Pluto’s nitrogen cycle and weather, especially the dwarf planet’s winds.

This work revealed the likely presence of westerly winds — a high-altitude variety that races along at least 2.5 miles (4 kilometers) above the surface and a fast-moving type closer to the ground that follows Sputnik Planitia’s western edge.

That edge is bounded by high cliffs, which appear to trap the near-surface winds inside the Sputnik Planitia basin for a spell before they can escape to the west, the new study suggested.

“It’s very much the kind of thing that’s due to the topography or specifics of the setting,” planetary scientist Candice Hansen-Koharcheck, of the Planetary Science Institute in Tucson, Arizona, said in the same statement. 

“I’m impressed that Pluto’s models have advanced to the point that you can talk about regional weather,” added Hansen-Koharcheck, who was not involved in the new study.

New Horizons’ Pluto flyby revealed that the dwarf planet is far more complex and diverse than anyone had thought, featuring towering water-ice mountains and weird “bladed” terrain in addition to the photogenic heart (whose official name, Tombaugh Regio, honors the discoverer of Pluto, ).

The , which was published online Tuesday (Feb. 4) in the Journal of Geophysical Research: Planets, reinforces and extends that basic message.

“Sputnik Planitia may be as important for Pluto’s climate as the ocean is for Earth’s climate,” Bertrand said. “If you remove Sputnik Planitia — if you remove the heart of Pluto — you won’t have the same circulation.”

Mike Wall’s book about the search for alien life, “” (Grand Central Publishing, 2018; illustrated by), is out now. Follow him on Twitter . Follow us on Twitter or

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Nats double down on commitment to coal, Joyce rants against wind and solar | RenewEconomy

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If there were any questions over the National Party’s commitment to the coal sector after the loss of Matt Canavan from the resources portfolio, they were quickly answered by new deputy leader David Littleproud who reasserted his party’s commitment to a new coal generator in Queensland on his first day in the job.

In an interview with ABC’s RN Breakfast program on Wednesday, Littleproud trotted out the three consistent assertions of the coal lobby; that you can reduce emissions using more coal, that more coal generation is necessary to lower electricity prices and that baseload power is a necessary feature of the future energy system.

Each of these three assertions have been repeatedly debunked, but it confirms that it’s business as usual in a Morrison cabinet that will continue to face internal divisions over a need to act on climate change and the fossil fuel advocates within its ranks.

It is understood that Queensland Nationals MP Keith Pitt is the front runner to take over Canavan’s former positions as the minister for resources and Northern Australia when new ministerial appointments are announced by Prime Minister Scott Morrison on Thursday.

Pitt himself has been an outspoken advocate for a new coal-fired power station in Queensland, so while Canavan – who liked to describe himself as “Mr Coal” – has exited the federal cabinet, the pressure to push forward with the Collinsville project is likely to continue.

Pitt has also been a strong supporter of a nuclear industry in Australia, and will have the backing of failed Nationals leadership candidate Barnaby Joyce, who again argued for nuclear power to be considered as part of Australia’s efforts to reduce emissions as part of a bizarre Facebook rant against renewable energy.

“We have to recognise that the public acceptance of wind towers on the hill in front of their veranda is gone, and the public dissonance on that issue is as strong as any other environmental subject,” Joyce said.

“If zero emissions are the goal then surely nuclear energy should be supported, but it is not. If wind towers are a moral good and environmentally inoffensive, why can’t we have them just off the beach at Bondi so we can feel good about ourselves while going for a surf? It would cause a riot.”

“Do you want a 3,000ha solar farm next door to you? Lots of glass and aluminium neatly in rows pointing at the sun. I am not sure others will want to buy that view off you when you go to sell your house.”

The coal industry might have lost its most enthusiastic advocate from the federal cabinet, but the Nationals were quick to show that it won’t lead to any changes on the party’s energy and climate change policies.

In his interview, Littleproud, who is also tipped to take on the now vacant agriculture portfolio, told the ABC that investments in new coal generators would help lower emissions and lower electricity prices.

“You need to make sure that you create an environment in the marketplace with a mix of renewables and coal-fired power stations, and if you can improve the emissions of coal fired power stations, you should make that investment if it means that we hit our targets and we reduce energy prices,” Littleproud claimed.

It has been well established for some time that the cheapest source of new electricity generation capacity are renewable sources like wind and solar.

A recent update to the CSIRO’s GenCost assessment of the costs of different generation technologies re-confirmed that new wind and solar are, by far, the cheapest sources of electricity generation. Even when additional storage is accounted for, prices of firmed renewables are competitive with fossil fuel generators when the costs of carbon emissions are considered.

Renewables are already helping to drive down electricity prices.

This week, the ACT, which has recently achieved its 100 per cent renewable electricity target, is also set to see an almost 7 per cent fall in its electricity prices this year, as the territory’s investments in wind and solar projects have helped deliver lower electricity prices for Canberra households, ensuring they continue to pay some of Australia’s lowest electricity prices.

But this also didn’t stop Littleproud asserting that it is possible to achieve reductions in greenhouse gas emissions while still embracing coal.

“You can invest in clean coal technology in and reduce emissions,” Littleproud said.

“I’m not disputing the science, what I’m saying is I’m not gifted academically to have that science background myself.” – @D_LittleproudMP when asked about his recent statement that he didn’t know if climate change was man made. #abc730 @leighsales #auspol pic.twitter.com/sFh44eNP2a

— abc730 (@abc730) February 4, 2020

Again, there are fundamental limits to how much emissions from coal-fired power stations can be improved. Even with a complete transition to the Coalition’s favoured high-efficiency low-emissions (HELE) coal power station technologies, the most generous estimates put the amount of emissions reductions at 20 per cent.

In his review of the National Electricity Market, chief scientist Dr Alan Finkel compared the emissions intensity of different generation technologies, showing that the HELE coal-fired power stations promoted by the Nationals will still produce 0.7 tonnes of carbon dioxide equivalent for each megawatt-hour of electricity produced, and is only slightly below the NEM’s current average emissions intensity.

When the science, and the international commitments made under the Paris Agreement, are calling for governments to achieve zero net emissions by 2050, a 20 per cent cut in coal power station emissions is going to be grossly insufficient.

It’s a position that leaves the Nationals at odds with science, but also the business community which is undergoing an accelerating exit from the coal industry. This includes BlackRock, which manages USD$7 trillion (A$10.15 trillion) in investments, which announced in January that it was divesting its portfolios from thermal coal companies.

Littleproud argued for the need for “baseload” power, suggesting that coal-fired power stations are necessary, as Australia currently lacks sufficient levels of battery storage.

“We’ve still got to have baseload, the thing is that we don’t have battery storage to the capacity that we need to be able to keep the lights on,” Littleproud said.

With the emergence of new energy management technologies, a growing market for energy storage that is outpacing growth in coal generation in Australia, demand response platforms and the falling prices of renewables, the concept of baseload is quickly becoming outdated.

With system planners recognising the crucial role that a ‘flexible’ energy system will have into the future, pushing new inflexible baseload power stations, like a new coal generator, into the energy system will only be counterproductive.

Chair of the Energy Security Board, which has been tasked with redesigning Australia’s energy market in response to the widescale transformation underway in the energy sector, labelled Australia’s existing “baseload” generators as “dinosaurs”, singling out coal-fired generators Bayswater and Liddell saying that their inflexibility made them poorly suited to a future energy system.

There has been a surge of installations of large-scale battery storage systems, and new investments continue to be made in deploying storage projects, while coal-fired generators are readying to exit the market.

The renewed push from the Nationals for a new coal generator appears to have been bolstered by the findings of a $10 million feasibility study into a potential new coal-fired power station in Collinsville. The feasibility study was funded as part of the government’s Underwriting New Generation Investments initiative and has yet to be released publicly.

“Collinsville, there’s a there’s now a report that’s come back to say that that business case should advance and then obviously, that will be backed by the economics of it,” Littleproud told ABC’s RN Breakfast.

The saga of the Collinsville power station has been a source of tension within the Coalition party room. Outgoing resources minister Matt Canavan had been desperate to get the project off the ground, and confronted prime minister Scott Morrison when he thought progress on the proposal was progressing too slowly.

Those tensions continue to play out in the party room, with a fiery confrontation occurring during the first coalition party room meeting of the year, and after a summer dominated by bushfires and calls for stronger climate action.

Several Nationals members shouted down calls from moderate Liberal MPs, who called for the Morrison government to demonstrate that it was taking climate change seriously.

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In the ground and off the page: why we’re banning ads from fossil fuels extractors | Membership | The Guardian

dog

In a bid to reduce our carbon footprint, confront greenwashing and increase our focus on the climate crisis, the Guardian this week announced it will no longer run ads from fossil fuel extractors alongside any of its content in print or online. The move will come into immediate effect, and follows the announcement in October last year that we intend to reduce our net emissions to zero by 2030.

Once upon a time, a newspaper was a rather straightforward business. You generated enough material of interest to attract a significant number of readers. You then ‘sold’ those readers to advertisers happy to pay to get their ideas, products or brands in front of consumers with cash to spend.

Of course, digital disruption over the past 20 years has upended that model, but advertising remains an important part of the media business ecosystem. At the Guardian, it is still responsible for about two-fifths of our income.

But what happens when the readers don’t like the adverts? What do you do when the message that advertisers want to spread jars awkwardly with the work your journalists are doing?

What if your journalists are some of the best in the world at revealing and investigating the deepening climate catastrophe and the disaster that is fossil fuel growth, while some of your advertisers are the very people digging the stuff out of the ground?

This contradiction has bothered us – and some of you – for some time. We came up with a rather bold answer this week: turn away the money and double down on the journalism.

“It’s something we thought about for a long time,” says Anna Bateson, the interim chief executive officer of Guardian Media Group, the Guardian’s parent company. “We always felt it was in line with our editorial values but were cautious for commercial reasons.”

She said it was the logical next step after the Guardian committed last year to becoming carbon neutral by 2030 and was certified as a B Corp – a company that puts purpose before profit. But she added that the move had to be weighed carefully, given the fact that the Guardian only recently returned to breakeven after years in the red.

“You have to be careful you are not making cavalier decisions,” she said. “ We are still having to fight for our financial future. But because of the support we get from our readers, it is less of a risk.”

On the advertising side of our business, Adam Foley said there were no complaints at all that potential customers were suddenly off-limits, adding that staff felt that “being part of a company that shares their values” was the biggest motivation for his teams.

“A statement like this reaffirms to all of us that we’re contributing to a business that really lives those values – to the extent where it is prepared to sacrifice profit for purpose.”

The response from the wider world has been a pleasant surprise. Hundreds of you have written in, pledging your support, and in some cases, one-off contributions to start making up the shortfall. (EDS: See below – I’m going to append the best responses below. In print you can use as the panel)

The environmental movement was instantly appreciative, with activists quickly urging our peers to follow suit. “The Guardian will no longer accept advertising from oil and gas companies,” Greta Thunberg tweeted. “A good start, who will take this further?” Greenpeace called it “a huge moment in the battle against oil and gas for all of us.”

Some readers have been calling for the Guardian to go the whole hog and forsake advertising from any company with a substantial carbon footprint. Bateson said that was not realistic, adding that such a move would result in less money for journalism. She said the fossil fuel extractors were specifically targeted because of their efforts to skew the climate change debate through their lobbying effort.

“We are committed to advertising,” she said. “It will continue to be part of our future. We want advertisers who want to be appear alongside our high quality journalism.”

And how will we know if this has worked?
“We will listen to our readers, we will listen to our advertisers. The response so far has been gratifying. If we continue to hear positive noises from our readers and supporters, then it will have been a success.”




Pinterest

Responses from our supporters

That is such a brilliant decision and it will be tough, but it is the correct one and I am very proud of The Guardian. Barbara Syer

Following the Guardian’s decision to ban ads from fossil fuel companies I’m making a monthly contribution to support its fearless journalism: reader support is essential for independent scrutiny of the powerful in business, finance and politics. Titus Alexander, Hertfordshire, England

I live at present in Canada, home to the Alberta Tar Sands: another name for ecological devastation resulting from fossil fuel extraction. I fully support The Guardian’s action in ceasing to be a vehicle for advertising by fossil fuel extractive companies, and I’m proud to be a supporter. My monthly donation is small, but when I can I will make it much greater. Rosemary Delnavine, Canada

Congratulations. At this time it may be a bold step, indeed, within this industry, but true leaders have to take bold steps for the betterment of the quality of life, and more importantly for the life of future generations. I applaud this decision, and will spread the word. Raphael Sulkovitz, Boston MA

What a bravery! This is what the life on earth needs, thank you. Karri Kuikka, Finland (EDS: please leave her wonderful Finglish intact!)

Keep it up. Here in Canada, we’re still trying to have it both ways — sell the product internationally but discourage buying domestically. As I recall, it was the same with tobacco. Eventually, it took a change in public opinion to solve the problem. As a news source, your efforts are part of this solution. Robert Shotton, Ottawa

I applaud your decision to”walk the talk.” I will therefore continue to contribute to The Guardian. Bob Wagenseil

Bravo yr decision to eschew $ from the FFI. Please do continue to hold to the fire(s) the feet of the deniers and the willfully ignorant. Sydney Alonso, Vermont, US

I am very happy to hear that good news. It’s quite courageous on your part, and I’m happy to support you! Have a great year ahead, you’ll have my continuous support! Julien Psomas

I completely support your plan to refuse ads from fossils, despite the
financial hit to the Guardian. I have made a donation to help out. David Thompson

A very commendable decision, very much in keeping with the Guardian’s position as leader of green issues to leave a better planet for following generations. Richard Vernon, Oxford

Yay! I’m so proud of the Guardian! We can no longer support or fund in any manner the fossil fuel industry if we have any chance of survival as a civilization on this planet. You’ve taken a courageous and moral step that will hopefully embolden others to join you. Good on you! Best, Carol Ross, Missouri, US

Good decision. I’ll support you as much as I can, which unfortunately is not much as I live on age pension only. Keep up the good work, we need it desperately! Ursula Brandt, South Australia

I am absolutely delighted by this decision. So many people pledge to do something about Climate Change, but few actually are willing to get uncomfortable and DO it. I am very proud of you as my favourite source of Information and this only makes a case for me to donate next time to you again. Christiane Gross

It was great reading what The Guardian is doing re the climate. As a Guardian on-line reader from The Netherlands I’m going to contribute monthly now instead of ‘now and again’. The amount will be relatively small as I do not have a great income. I really hope more of your supporters will do so, because it is really great what you are doing.
With kind regards, Aleida Oostendorp, Netherlands

I congratulate you and your team on taking this step regarding fossil fuel companies. The Guardian’s stance on the environment and its excellent coverage of related stories and events is the major reason for my support. Well done, and good luck in the future. Deirdre Moore

Love your new policy about accepting money from fossil fuels. Will contribute more to help make up for the shortfall. Todd Misk

I live on a fixed income with a strict budget so my continuing support of your excellent news organisation represents my commitment to the fight to address climate change. Every step counts. Barbara Hirsch, Texas, US

Only when we speak truth to power can change take place. thank yo for your courageous and expensive decision. Nancy Shepherd, Vermont, US

Love your journalism, especially your investigative work and the climate change topic. And with the bold statement about not receiving any more sponsorship from the fossil extracting companies? Well, the already great newspapers became even more impressive now. Keep up the good work. Miroslav Řezníček, Czech Republic

Thank you for taking the bold step of refusing advertising from fossil fuel extractive companies. I think it is the right thing to do & hope many more companies do the same. We must all work together if we want to save our planet. It is one of the most important issues of our times. Ginger Comstock, New York, US

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UK officially leaves EU after 47 years of European membership – World – TASS

LONDON, February 1. /TASS/. After 47 years of European membership, the United Kingdom officially withdrew from the European Union at 23:00 GMT (2:00 Moscow time on Saturday).

The withdrawal, known as Brexit, was initiated after Britons voted to quit the European Union during the 2016 referendum. The margin was 1.3 million votes (52% versus 48%).

Thousands of Brexit supporters celebrated the withdrawal by gathering in downtown London. Brexiteers have gathered in Parliament Square to celebrate the historic moment, chanting and waving flags. Governmental buildings were illuminated with national flag colors – blue, red and white.

An hour before this turning point in the UK’s political history, British Prime Minister Boris Johnson, an ardent Brexit supporter, delivered his address to the nation.

Flag removed

Earlier in the day, the flag of the United Kingdom has been removed from the building of the EU Council. The video of the flag being removed was released via the Council’s official Twitter shortly before midnight.

“The UK flag is removed from the EU Council building in Brussels as the country leaves the EU at midnight,” the EU Council said in a Twitter post.

Premier’s speech

After quitting the European Union, the United Kingdom will finally “rediscover muscles that we have not used for decades,” UK Prime Minister Boris Johnson said in a televised address to the nation shortly before Brexit.

“For all its strengths and for all its admirable qualities, the EU has evolved over 50 years in a direction that no longer suits this country. And that is a judgment that you, the people, have now confirmed at the polls,” Johnson said.

“I believe that with every month that goes by we will grow in confidence not just at home but abroad,” he continued. “And in our diplomacy, in our fight against climate change, in our campaigns for human rights or female education or free trade we will rediscover muscles that we have not used for decades.”

According to the premier, in order to achieve those ambitious tasks, the country needs to overcome the differences, generated by the Brexit issue.

“Tonight we are leaving the European Union. For many people this is an astonishing moment of hope, a moment they thought would never come. And there are many of course who feel a sense of anxiety and loss. And then of course there is a third group – perhaps the biggest – who had started to worry that the whole political wrangle would never come to an end,” he said.

The premier went on to say that finding a common ground for all political and social groups was his cabinet’s task.

“I understand all those feelings, and our job as the government – my job – is to bring this country together now and take us forward,” he said. “And the most important thing to say tonight is that this is not an end but a beginning. This is the moment when the dawn breaks and the curtain goes up on a new act in our great national drama.”

Johnson expressed hope that constructive dialogue with the European Union would continue.

“We want this to be the beginning of a new era of friendly cooperation between the EU and an energetic Britain,” he said.

After January 31, the UK and the EU enter a transition period meant to maintain the existing state of affairs, particularly on trade and tariffs, while the two sides are negotiating a deal on future trading relations. The transition period is scheduled to end on December 31, 2020. London is also obliged to continue paying membership fees to the EU budget until the end of 2020.

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Brit man, 24, plummets to his death off a cliff during night out in French ski resort

A BRITISH man has died in the French Alps after a night out with friends.

The 24-year-old’s body was discovered yesterday afternoon at the foot of a cliff after he was reported missing at 5am.

The British man died after a fall near the resort of Brides les Bains, Savoie, French Alps,
The British man died after a fall near the resort of Brides les Bains, Savoie, French Alps,
Alamy

Police believe he fell off a cliff after getting lost on his way back to his accommodation after a night in the pub.

The man, who has not been named, was staying in Brides-les-Bains, near the ski resorts of Courchevel and Méribel.

His body was discovered near Les Allues where he had been socialising for the night.

A search involving police, firefighters and mountain rescue equipped with dogs was launched and continued throughout yesterday.

His body was spotted by a helicopter crew at 4.50pm, almost 12 hours after he was reported missing.

‘FELL WHILE WALKING HOME AFTER NIGHT OUT’

A spokesman for Albertville police said: “Unfortunately the body of a man was discovered yesterday after a big search. 

“He was most probably the victim of a fall.

“We believe he was walking back from Les Allues to his accommodation in Brides-les-Bains. He departed with some other people but they became separated. 

“He was reported missing in the early hours. He was discovered not far from Les Allues. It appears he had not walked that far.

“We have no further information. An investigation into the death of the man has been opened and this will determine how he died and how far he fell. We can give no further details.

“Currently we have little information about him and are trying to establish if he was a season worker or a tourist.”

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The three-mile walk between Les Allues and Brides-Les-Bains takes about an hour-and-a-half. In the early hours of Thursday the temperature was minus three degrees celsius. 

Brides-les-Bains is directly linked by a cable-car to the famous resort of Méribel, popular with British skiers. The town was an Olympic Village for the 1992 Winter Olympics based in Albertville. 

The tragedy comes just weeks after British doctor William Reid, 25, fell to his death in the French ski resort of Avoriaz.

William, from Edinburgh, was on the fifth day of a New Year holiday with his girlfriend and his family. 

They had just enjoyed lunch and were making their way back to their accommodation. His family said he took a wrong turn and fell. Medics battled in vain to try and save him.

For the latest news on this story keep checking back at Sun Online.

Thesun.co.uk is your go to destination for the best celebrity news, football news, real-life stories, jaw-dropping pictures and must-see video.

Download our fantastic, new and improved free App for the best ever Sun Online experience. For iPhone click here, for Android click here. 

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Coronavirus spreads to more than 800 in China: First death outside epicentre | Stuff.co.nz

person

China’s National Health Commission said Friday afternoon (NZ time) the confirmed cases of the new coronavirus had risen to 830 with 25 deaths.

The first death was also confirmed outside the central province of Hubei, where the capital, Wuhan, has been the epicentre of the outbreak.

The health commission in Hebei, a northern province bordering Beijing, said an 80-year-old man died after returning from a two-month stay in Wuhan to see relatives.

The vast majority of cases have been in and around Wuhan or people with connections the city. Other cases have been confirmed in the United States, Japan, Taiwan, South Korea and Thailand. Singapore and Vietnam reported their first cases Thursday, and cases have also been confirmed in the Chinese territories of Hong Kong and Macau.

Many countries are screening travellers from China for symptoms of the virus, which can cause fever, coughing, breathing difficulties and pneumonia.

The World Health Organisation has decided against declaring the outbreak a global emergency, a step that can bring more money and resources to fight a threat but that can also cause trade and travel restrictions and other economic damage, making the decision a politically fraught one.

The decision “should not be taken as a sign that WHO does not think the situation is serious or that we’re not taking it seriously. Nothing could be further from the truth,” WHO Director General Tedros Adhanom Ghebreyesus said. “WHO is following this outbreak every minute of every day.”

The coronaviruses are a family of viruses that originate in animals before making the jump to humans.

Chinese authorities moved to lock down at least three cities with a combined population of more than 18 million in an unprecedented effort to contain the deadly new virus that has sickened hundreds of people and spread to other parts of the world during the busy Lunar New Year travel period.

Chinese officials have not said how long the shutdowns of the cities will last. While sweeping measures are typical of China’s Communist Party-led government, large-scale quarantines are rare around the world, even in deadly epidemics, because of concerns about infringing on people’s liberties. And the effectiveness of such measures is unclear.

“To my knowledge, trying to contain a city of 11 million people is new to science,” said Gauden Galea, the WHO”s representative in China. “It has not been tried before as a public health measure. We cannot at this stage say it will or it will not work.”

GETTY IMAGES
People wear face masks as they wait at Hankou Railway Station in Wuhan

Jonathan Ball, a professor of virology at molecular virology at the University of Nottingham in Britain, said the lockdowns appear to be justified scientifically.

“Until there’s a better understanding of what the situation is, I think it’s not an unreasonable thing to do,” he said. “Anything that limits people’s travels during an outbreak would obviously work.”

But Ball cautioned that any such quarantine should be strictly time-limited. He added: “You have to make sure you communicate effectively about why this is being done. Otherwise you will lose the goodwill of the people.”

GETTY IMAGES
A resident wears a mask to buy vegetables in the market in Wuhan.

During the devastating West Africa Ebola outbreak in 2014, Sierra Leone imposed a national three-day quarantine as health workers went door to door, searching for hidden cases. Burial teams collecting corpses and people taking the sick to Ebola centres were the only ones allowed to move freely. Frustrated residents complained of food shortages.

In China, the illnesses from the newly identified coronavirus first appeared last month in Wuhan, an industrial and transportation hub. Local authorities demanded all residents wear masks in public places and urged civil servants wear them at work.

After the city was closed off Thursday, images showed long lines and empty shelves at supermarkets, as people stocked up. Trucks carrying supplies into the city are not being restricted, although many Chinese recall shortages in the years before the country’s recent economic boom.

Analysts predicted cases will continue to multiply, although the jump in numbers is also attributable in part to increased monitoring.

KEVIN FRAYER/GETTY IMAGES
A Chinese passenger that just arrived on the last bullet train from Wuhan to Beijing is checked for a fever by a health worker at a Beijing railway station.

“Even if (cases) are in the thousands, this would not surprise us,” the WHO’s Galea said, adding, however, that the number of infected is not an indicator of the outbreak’s severity so long as the death rate remains low.

The coronavirus family includes the common cold as well as viruses that cause more serious illnesses, such as the SARS outbreak that spread from China to more than a dozen countries in 2002-03 and killed about 800 people, and Middle Eastern respiratory syndrome, or MERS, which is thought to have originated from camels.

China is keen to avoid repeating mistakes with its handling of SARS. For months, even after the illness had spread around the world, China parked patients in hotels and drove them around in ambulances to conceal the true number of cases and avoid WHO experts. This time, China has been credited with sharing information rapidly, and President Xi Jinping has emphasised that as a priority.

Health authorities are taking extraordinary measures to prevent the spread of the virus, placing those believed infected in plastic tubes and wheeled boxes, with air passed through filters.

The first cases in the Wuhan outbreak were connected to people who worked at or visited a seafood market, now closed for an investigation. Experts suspect that the virus was first transmitted from wild animals but that it may also be mutating. Mutations can make it deadlier or more contagious.

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