Association Between BNT162b2 Vaccination and Incidence of SARS-CoV-2 Infection in Pregnant Women

Effectiveness of Paxlovid, an Oral Antiviral Drug, Against the Omicron BA.5 Variant in Korea: Severe Progression and Death Between July and November 2022

BACKGROUND

Paxlovid is an oral antiviral drug that received emergency use authorization in South Korea for the treatment of patients with mild-to-moderate coronavirus disease 2019 (COVID-19) on January 14, 2022. Since the onset of the severe acute respiratory syndrome coronavirus 2 pandemic, the virus has continued to evolve. The emergence of new variants has raised concerns about possible reductions in the effectiveness of vaccines and drugs. The effectiveness of Paxlovid in patients infected with the omicron variant and subvariants has not yet been determined. This study assessed the effectiveness of Paxlovid at reducing the risk of severe/critical illness or death and death in patients with mild-to-moderate COVID-19 caused by omicron subvariant BA.5.

METHODS

In this nationwide retrospective cohort study, data on 8,902,726 patients were collected from four sources (the Drug Utilization Review database, COVID-19 Patient Information Management System, confirmed patient information, and basic epidemiological investigation data) between July 1 and November 30, 2022. Multivariable logistic regression analysis was conducted, with adjustment for age, sex, severe acute respiratory syndrome coronavirus 2 immunity (vaccination), and comorbidities.

RESULTS

A total of 1,936,925 patients with COVID-19 were included in the analysis, including 420,996 patients treated with Paxlovid, and 1,515,959 patients not treated with Paxlovid. Paxlovid treatment in patients aged ≥ 60 years of age was associated with significantly reduced risk of severe/critical illness or death (46.0%), and death rate (32.5%), and its effectiveness was high, regardless of vaccination status.

CONCLUSION

Paxlovid is effective at reducing the risk of death due to COVID-19 in patients with omicron BA.5 infection, especially in older patients, regardless of vaccination status. This suggests that older patients with COVID-19-related symptoms should be administered Paxlovid, regardless of their vaccination status, to reduce severity and risk of death.

Effectiveness, Immunogenicity and Safety of COVID-19 Vaccination in Pregnant Women: A Rapid Review Study

Background

Pregnant women infected with the coronavirus disease 2019 (COVID-19) are at risk for adverse pregnancy outcomes, and the only real preventive strategy against COVID-19 is mass vaccination. This study aimed to examine the effectiveness, immunogenicity, and safety of Covid-19 vaccination in pregnant women.

Methods

A combination of search terms was performed by 2 researchers independently in the Web of Science, PubMed, and Scopus databases, the World Health Organization website, and the US Centers for Disease Control (CDC) website up to February 2022. After the selection of eligible studies, the review process, description, and summarization of the selected studies were performed by the research team.

Results

Finally, 22 articles were included in this study. Evidence supports the safety of COVID-19 vaccination during pregnancy. There is no risk of transmitting COVID-19 to infants during lactation. In addition, antibodies made by vaccination can protect infants through breast milk.

Conclusion

The scientific community believes that being vaccinated as soon as possible is the best course of action because there is no evidence to suggest that the COVID-19 vaccine poses a risk to expectant or nursing women.

COVID-19 and Pregnancy: An Updated Review about Evidence-Based Therapeutic Strategies

The COVID-19 pandemic posed a significant challenge for clinicians in managing pregnant women, who were at high risk of virus transmission and severe illness. While the WHO declared in May 2023 that COVID-19 is no longer a public health emergency, it emphasized that it remains a global health threat. Despite the success of vaccines, the possibility of new pandemic waves due to viral mutations should be considered. Ongoing assessment of the safety and effectiveness of pharmacological therapies is crucial in clinical practice. This narrative review summarizes the evidence-based therapeutic strategies for pregnant women with COVID-19, considering over three years of pandemic experience. The review discusses the safety and effectiveness of various drug regimens (antivirals, anticoagulants, corticosteroids, immunoglobulins, monoclonal antibodies, and therapeutic gases) and procedures (prone positioning and extracorporeal membrane oxygenation). Drugs with contraindications, inefficacy during pregnancy, or unknown adverse effects were excluded from our evaluation. The aim is to provide healthcare professionals with a comprehensive guide for managing pregnant women with COVID-19 based on lessons learned from the pandemic outbreak.

Role of vaccination and anti-SARS-CoV-2 antibodies in the clinical outcome of hospitalized COVID-19 patients

Background

Although vaccination has considerably reduced the risk of hospitalization and death from COVID19, the impact of vaccination and anti-SARS-CoV-2 antibody status on the outcome of patients who required hospitalization has been poorly investigated.

Material and methods

A prospective observational study in 232 patients hospitalized for COVID19 was carried out from October 2021 to January 2022 to evaluate the role on patient outcome of their vaccination and anti-SARS-CoV-2 antibody status and titer, comorbidities, analytical determinations, clinical presentation at admission, treatments and requirements for respiratory support. Cox regression and survival analyzes were performed. The SPSS and "R" programs were used.

Results

Patients with complete vaccination schedule had higher S-protein antibody titers (log10 3.73 [2.83-4.6] UI/ml vs 1.6 [2.99-2.61] UI/ml; p < 0.001), lower probability of radiographic worsening (21.6% vs. 35.4%; p = 0.005), less likely required high doses of dexamethasone (28.4% vs. 45.4%; p = 0.012), high-flow oxygen (20.6% vs. 35.4%; p = 0.02), ventilation (13.7% vs, 33.8%; p = 0.001) and intensive care admissions (10.8% vs. 32.6%; p < 0.001). Remdesivir (HR = 0.38; p < 0.001) and complete vaccination schedule (HR = 0.34; p = 0.008) were protective factors. No differences in antibody status were detected between groups (HR = 0.58; p = 0.219).

Conclusions

SARS-CoV-2 vaccination was associated with higher S-protein antibody titers and lower probability of radiological progression, immunomodulators requirement and respiratory support or death. However, vaccination but not antibody titters protected from adverse events pointing a role of immune-protective mechanisms in addition to humoral response.

Safety of COVID-19 vaccines during pregnancy: A systematic review and meta-analysis

BACKGROUND

Assessment of COVID-19 vaccines safety during pregnancy is urgently needed.

METHODS

We conducted a systematic review and meta-analysis to evaluate the safety of COVID-19 vaccines, including their components and technological platforms used in other vaccines during pregnancy and animal studies to complement direct evidence. We searched literature databases from its inception to September 2021 without language restriction, COVID-19 vaccine websites, and reference lists of other systematic reviews and the included studies. Pairs of reviewers independently selected, data extracted, and assessed the risk of bias of the studies. Discrepancies were resolved by consensus. (PROSPERO CRD42021234185).

RESULTS

We retrieved 8,837 records from the literature search; 71 studies were included, involving 17,719,495 pregnant persons and 389 pregnant animals. Most studies (94%) were conducted in high-income countries, were cohort studies (51%), and 15% were classified as high risk of bias. We identified nine COVID-19 vaccine studies, seven involving 309,164 pregnant persons, mostly exposed to mRNA vaccines. Among non-COVID-19 vaccines, the most frequent exposures were AS03 and aluminum-based adjuvants. A meta-analysis of studies that adjusted for potential confounders showed no association with adverse outcomes, regardless of the vaccine or the trimester of vaccination. Neither the reported rates of adverse pregnancy outcomes nor reactogenicity exceeded expected background rates, which was the case for ASO3- or aluminum-adjuvanted non-COVID-19 vaccines in the proportion meta-analyses of uncontrolled studies/arms. The only exception was postpartum hemorrhage after COVID-19 vaccination (10.40%; 95% CI: 6.49-15.10%), reported by two studies; however, the comparison with non-exposed pregnant persons, available for one study, found non-statistically significant differences (adjusted OR 1.09; 95% CI 0.56-2.12). Animal studies showed consistent results with studies in pregnant persons.

CONCLUSION

We found no safety concerns for currently administered COVID-19 vaccines during pregnancy. Additional experimental and real-world evidence could enhance vaccination coverage. Robust safety data for non-mRNA-based COVID-19 vaccines are still needed.

Maternal and perinatal outcomes of COVID-19 vaccination during pregnancy

Objective

To investigate maternal adverse effects and perinatal and neonatal outcomes of women receiving coronavirus disease-2019 (COVID-19) vaccination during pregnancy.

Material and Methods

Seven hundred and sixty pregnant women who were followed up in obstetrics outpatients were included in this prospective cohort study. COVID-19 vaccination and infection histories of the patients were recorded. Demographic data, including age, parity, and presence of systemic disease and adverse events following COVID-19 vaccination were recorded. Vaccinated pregnant women were compared with unvaccinated women in terms of adverse perinatal and neonatal outcomes.

Results

Among the 760 pregnant women who met study criteria, the data of 425 pregnant women were analyzed. Among these, 55 (13%) were unvaccinated, 134 (31%) were vaccinated before pregnancy, and 236 (56%) pregnant women were vaccinated during pregnancy. Of those who were vaccinated, 307 patients (83%) received BioNTech, 52 patients (14%) received CoronaVac, and 11 patients (3%) received both CoronaVac and BioNTech. The local and systemic adverse effect profiles of patients who received COVID-19 vaccination either before or during pregnancy were similar (p=0.159), and the most common adverse effect was injection site pain. COVID-19 vaccination during pregnancy did not increase the ratio of abortion (<14 wk), stillbirth (>24 wk), preeclampsia, gestational diabetes mellitus, fetal growth restriction, second-trimester soft marker incidence, time of delivery, birth weight, preterm birth (<37 wk) or admission to the neonatal intensive care unit compared to the women who were not vaccinated during pregnacy.

Conclusion

COVID-19 vaccination during pregnancy did not increase maternal local and systemic adverse effects or poor perinatal and neonatal outcomes. Therefore, regarding the increased risk of morbidity and mortality related to COVID-19 in pregnant women, the authors propose that COVID-19 vaccination should be offered to all pregnant women.

Effects of Covid-19 Vaccination during Pregnancy on the Obstetric and Neonatal Outcomes in a Tertiary Health Care Center

BACKGROUND

Pregnancy is an immuno-compromised state, and pregnant women with COVID-19 are at an increased risk for adverse pregnancy outcomes. Thus, the Center for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization (ACIP) have advocated for COVID-19 vaccination in pregnant women. COVAXIN and COVISHIELD were the vaccines being used in India in the first phase of vaccination, but limited data exist on pregnancy outcomes regarding SARS-CoV-2 vaccines and pregnancy and lactation.

MATERIAL AND METHODS

A retrospective study was conducted which included only women who delivered after 24 weeks gestation. Women with an unknown vaccination status or with past or active COVID-19 infection were excluded. Demographic characteristics, maternal and obstetric outcomes, and fetal and neonatal outcomes were compared between the unvaccinated and vaccinated groups. Statistical analysis was done with Chi-square testing and the Fisher exact test using SPSS-26 software.

RESULTS

Deliveries before a gestation of 37 weeks were significantly higher in the unvaccinated group compared to the vaccinated group. Rates of vaginal deliveries and preterm deliveries were found to be higher in the unvaccinated population. Women who had taken COVAXIN had a higher rate of adverse events compared to those who had taken COVISHIELD.

CONCLUSION

There were no significant differences in adverse obstetric outcomes attributed to vaccine administration between the vaccinated and unvaccinated pregnant women. The beneficial effects of the vaccines in protecting against COVID-19 infection, particularly in pregnancy, outweigh the minor adverse events associated with vaccine administration.

Adverse events following COVID-19 vaccination among pregnant women attending primary health centers: An active-surveillance study

Introduction

Vaccine safety is a major barrier to the uptake of the COVID-19 vaccine by pregnant women. To bring confidence among pregnant women towards vaccine intake, there is a need to synthesize evidence on safety profile of vaccination.

Objective

To assess adverse events (AEs) following COVID-19 vaccination among pregnant women.

Materials and methods

A vaccine safety surveillance was conducted at 2 rural primary health centers (PHC) located in Anantapur District, India. A total of 420 pregnant women were monitored for AEs following COVID-19 vaccination for a period of 30 min and followed for 1 month for late reactions through telephonic interviews. All AEs were subjected to causality and severity assessment. Descriptive statistics were used to represent adverse events.

Results

The COVID-19 vaccine acceptance rate among pregnant women was 64.4%. A total of 420 pregnant women received 670 vaccine doses (Covishield = 372, Covaxin = 298) against COVID-19. Majority of vaccine intake was observed during the second trimester. The incidence rate of AEs following the COVID-19 vaccine among pregnant women was 93.8%, and the majority include injection site pain (28.4%, 29.6%), fever (25.5%, 19.0%), myalgia (8.21%, 12.3%), and malaise (13.6%, 8.4%). Most AEs notified are probable and mild in nature.

Conclusion

The COVID-19 vaccine acceptance rate among pregnant women was 64.4%. A 30 days incidence rate of AEs following COVID-19 vaccination among pregnant women was 93.8%, with the most common mild events like injection site pain, and fever. A further follow-up cohort study by taking an adequate sample size was recommended to capture fetal-maternal outcomes.

An Update on COVID-19 Vaccination and Pregnancy

Pregnant women are more prone to experience severe COVID-19 disease, including intensive care unit (ICU) admission, use of invasive ventilation, extracorporeal membrane oxygenation (ECMO), and mortality compared to non-pregnant individuals. Additionally, research suggests that SARS-CoV-2 infection during pregnancy is linked to adverse pregnancy outcomes, such as preterm birth, preeclampsia, and stillbirth, as well as adverse neonatal outcomes, including hospitalization and admission to the neonatal intensive care unit. This review assessed the available literature from November 2021 to 19 March 2023, concerning the safety and effectiveness of COVID-19 vaccination during pregnancy. COVID-19 vaccination administered during pregnancy is not linked to significant adverse events related to the vaccine or negative obstetric, fetal, or neonatal outcomes. Moreover, the vaccine has the same effectiveness in preventing severe COVID-19 disease in pregnant individuals as in the general population. Additionally, COVID-19 vaccination is the safest and most effective method for pregnant women to protect themselves and their newborns from severe COVID-19 disease, hospitalization, and ICU admission. Thus, vaccination should be recommended for pregnant patients. While the immunogenicity of vaccination in pregnancy appears to be similar to that in the general population, more research is needed to determine the optimal timing of vaccination during pregnancy for the benefit of the neonate.

Diverging maternal and infant cord antibody functions from SARS-CoV-2 infection and vaccination in pregnancy

Immunization in pregnancy is a critical tool that can be leveraged to protect the infant with an immature immune system but how vaccine-induced antibodies transfer to the placenta and protect the maternal-fetal dyad remains unclear. Here, we compare matched maternal-infant cord blood from individuals who in pregnancy received mRNA COVID-19 vaccine, were infected by SARS-CoV-2, or had the combination of these two immune exposures. We find that some but not all antibody neutralizing activities and Fc effector functions are enriched with vaccination compared to infection. Preferential transport to the fetus of Fc functions and not neutralization is observed. Immunization compared to infection enriches IgG1-mediated antibody functions with changes in antibody post-translational sialylation and fucosylation that impact fetal more than maternal antibody functional potency. Thus, vaccine enhanced antibody functional magnitude, potency and breadth in the fetus are driven more by antibody glycosylation and Fc effector functions compared to maternal responses, highlighting prenatal opportunities to safeguard newborns as SARS-CoV-2 becomes endemic.

Effects of COVID-19 vaccination during pregnancy on SARS-CoV-2 infection and maternal and neonatal outcomes: A systematic review and meta-analysis

SARS-CoV-2 infection during pregnancy is associated with adverse maternal and neonatal outcomes, but no systematic synthesis of evidence on COVID-19 vaccination during pregnancy against these outcomes has been undertaken. Thus, we aimed to assess the collective evidence on the effects of COVID-19 vaccination during pregnancy on maternal and neonatal outcomes. PubMed/MEDLINE, CENTRAL, and EMBASE were systematically searched for articles published up to 1 November 2022. A systematic review and meta-analysis were performed to calculate pooled effects size and 95% confidence interval (CI). We evaluated 30 studies involving 862,272 individuals (308,428 vaccinated and 553,844 unvaccinated). Overall pooled analyses in pregnant women during pregnancy showed reduced risks of SARS-CoV-2 infection by 60% (41%-73%), COVID-19 hospitalisation during pregnancy by 53% (31%-69%), and COVID-19 intensive care unit (ICU) admission by 82% (12%-99%). Neonates of vaccinated women were 1.78 folds more likely to acquire SARS-CoV-2 infection during the first 2, 4 and 6 months of life during the Omicron period. The risk of stillbirth was reduced by 45% (17%-63%) in association with vaccination (vs. no vaccination) in pregnancy. A decrease of 15% (3%-25%), 33% (14%-48%), and 33% (17%-46%) in the odds of preterm births before 37, 32 and 28 weeks' gestation were associated with vaccination (vs. no vaccination) in pregnancy, respectively. The risk of neonatal ICU admission was significantly lower by 20% following COVID-19 vaccination in pregnancy (16%-24%). There was no evidence of a higher risk of adverse outcomes including miscarriage, gestational diabetes, gestational hypertension, cardiac problems, oligohydramnios, polyhydramnios, unassisted vaginal delivery, cesarean delivery, postpartum haemorrhage, gestational age at delivery, placental abruption, Apgar score at 5 min below 7, low birthweight (<2500 g), very low birthweight (<1500 g), small for gestational age, and neonatal foetal abnormalities. COVID-19 vaccination during pregnancy is safe and highly effective in preventing maternal SARS-CoV-2 infection in pregnancy, without increasing the risk of adverse maternal and neonatal outcomes, and is associated with a reduction in stillbirth, preterm births, and neonatal ICU admission. Importantly, maternal vaccination did not reduce the risk of neonatal SARS-CoV-2 infection during the first 6 months of life during the Omicron period.

Vaccine intention and hesitancy among Australian women who are currently pregnant or have recently given birth: the Birth in the Time of COVID-19 (BITTOC) national online survey

OBJECTIVE

To examine the prevalence of COVID-19 vaccination, and factors associated with vaccination intention and hesitancy in pregnant and postnatal women in Australia.

DESIGN AND SETTING

A national online survey was conducted over 6 months between 31 August 2021 and 1 March 2022 and responses to vaccination status were categorised as: 'vaccinated', 'vaccine intended' and 'vaccine hesitant'. The data were weighted to reflect the proportion of women of reproductive age. Potential confounding variables were examined using multinomial logistic regression analyses, and all comparisons were made against vaccinated pregnant and postnatal women.

PARTICIPANTS

2140 women responded to the survey (838 pregnant; 1302 recently post partum).

RESULTS

Amongst pregnant women, 586 (69.9%) were vaccinated, 166 (19.8%) indicated intention and 86 (10.3%) were hesitant. In postnatal women, this was 1060 (81.4%), 143 (11.0%) and 99 (7.6%), respectively. Only 52 (6.2%) of pregnant women stated never wanting a COVID-19 vaccine. Vaccine hesitancy increased over time, and for pregnant women was associated with: living in a state other than New South Wales (NSW) (Adjusted Relative Risk (ARR) 2.77, 95%CI: 1.68-4.56 for vaccine intention and ARR=3.31, 95%CI: 1.52-7.20 for vaccine hesitancy), younger age <30 years, not having a university education, income <80K AUD, gestation <28 weeks, having no pregnancy risk factors, and being less satisfied with life (ARR=2.20, 95%CI: 1.04-4.65 for vaccine intention and ARR=2.53, 95%CI: 1.02-6.25 for vaccine hesitancy) . For postnatal women: living in a state other than NSW or Victoria, income <80K AUD and having private obstetric care (ARR=2.06, 95%CI: 1.23-3.46) were significantly associated with vaccine hesitancy.

CONCLUSIONS

Around 1 in 10 pregnant women and just over 1 in 13 postnatal women reported vaccine hesitancy in this Australian survey, and hesitancy was higher in the latter 3-month period. Tailored messages to younger mothers and those from lower-middle socioeconomic groups, alongside advice from midwives and obstetricians, could help to reduce hesitancy among pregnant and postnatal women. Financial incentives may help to facilitate COVID-19 vaccine uptake. A real-time surveillance system and additional pregnancy fields added to the Australian immunisation register would support the safety monitoring of multiple vaccines in pregnancy and may build confidence.

Safety of COVID-19 vaccination in pregnant women: A study of the adverse perinatal outcomes

OBJECTIVE

To compare adverse perinatal outcome among coronavirus disease 2019 (COVID-19)-vaccinated and -unvaccinated pregnant women.

METHOD

Retrospective equivalence cohort study comparing 930 women who received at least one BNT162b2 (Pfizer/BioNTech) COVID-19 vaccine during the second or third trimester of pregnancy and 964 unvaccinated women. The primary outcome was a composite adverse perinatal outcome including at least one of the following: preterm delivery <35 weeks of gestation, intrauterine fetal death >23 weeks of gestation, intrauterine growth restriction defined as birth weight < 10th percentile, 5-min APGAR score ≤ 7, and neonatal care unit admission.

RESULTS

The authors found no effect of the COVID-19 vaccine on the rate of the individual adverse perinatal outcomes. At least one adverse perinatal outcome was found in 108 (11.25%) of unvaccinated women versus 82 (8.82%) of vaccinated pregnant women (P = 0.080). The observed proportion difference (unvaccinated minus vaccinated) was 0.024. In the equivalence analysis with a margin of 0.05, the 90% confidence interval (0.01-0.05) was entirely within the equivalence zone (-0.05 to 0.05) with a P value of 0.032.

CONCLUSION

The present study demonstrated an equivalent rate of adverse perinatal outcomes among vaccinated and unvaccinated women, thus supporting vaccine safety during the second and third trimesters of pregnancy. The authors believe this information is useful in counseling pregnant women regarding COVID-19 vaccination during pregnancy.

Maternal third dose of BNT162b2 mRNA vaccine and risk of infant COVID-19 hospitalization

Infants are at a higher risk of Coronavirus Disease 2019 (COVID-19)-related hospitalizations compared to older children. In this study, we investigated the effect of the recommended third maternal dose of BNT162b2 COVID-19 vaccine during pregnancy on rates of infant COVID-19-related hospitalizations. We conducted a nationwide cohort study of all live-born infants delivered in Israel between 24 August 2021 and 15 March 2022 to estimate the effectiveness of the third booster dose versus the second dose against infant COVID-19-related hospitalizations. Data were analyzed for the overall study period, and the Delta and Omicron periods were analyzed separately. Cox proportional hazard regression models estimated hazard ratios and 95% confidence intervals (CIs) for infant hospitalizations according to maternal vaccination status at delivery. Among 48,868 live-born infants included in the analysis, rates of COVID-19 hospitalization were 0.4%, 0.6% and 0.7% in the third-dose, second-dose and unvaccinated groups, respectively. Compared to the second dose, the third dose was associated with reduced infant hospitalization with estimated effectiveness of 53% (95% CI: 36-65%). Greater protection was associated with a shorter interval between vaccination and delivery. A third maternal dose during pregnancy reduced the risk of infant hospitalization for COVID-19 during the first 4 months of life, supporting clinical and public health guidance for maternal booster vaccination to prevent infant COVID-19 hospitalization.

Safety, immunogenicity, and effectiveness of COVID-19 vaccines for pregnant persons: A protocol for systematic review and meta analysis

INTRODUCTION

Numerous vaccines have been evaluated and approved for coronavirus disease 2019 (COVID-19). Since pregnant persons have been excluded from most clinical trials of COVID-19 vaccines, sufficient data regarding the safety of these vaccines for the pregnant person and their fetus have rarely been available at the time of product licensure. However, as COVID-19 vaccines have been deployed, data on the safety, reactogenicity, immunogenicity, and efficacy of COVID-19 vaccines for pregnant persons and neonates are becoming increasingly available. A living systematic review and meta-analysis of the safety and effectiveness of COVID-19 vaccines for pregnant persons and newborns could provide the information necessary to help guide vaccine policy decisions.

METHODS AND ANALYSIS

We aim to conduct a living systematic review and meta-analysis based on biweekly searches of medical databases (e.g., MEDLINE, EMBASE, CENTRAL) and clinical trial registries to systematically identify relevant studies of COVID-19 vaccines for pregnant persons. Pairs of reviewers will independently select, extract data, and conduct risk of bias assessments. We will include randomized clinical trials, quasi-experimental studies, cohort, case-control, cross-sectional studies, and case reports. Primary outcomes will be the safety, efficacy, and effectiveness of COVID-19 vaccines in pregnant persons, including neonatal outcomes. Secondary outcomes will be immunogenicity and reactogenicity. We will conduct paired meta-analyses, including prespecified subgroup and sensitivity analyses. We will use the grading of recommendations assessment, development, and evaluation approach to evaluate the certainty of evidence.

The dose- and time-dependent effectiveness and safety associated with COVID-19 vaccination during pregnancy: a systematic review and meta-analysis

OBJECTIVES

This study aimed to provide guidance for clinical treatment and increase public confidence in COVID-19 vaccines.

METHODS

The Cochrane Library, Embase, PubMed, Web of Science, ClinicalKey, and other COVID-19 datasets were searched from December 2019 to May 2022. Case-control studies and prospective cohort studies of COVID-19 vaccine effectiveness and safety in pregnant women were included.

RESULTS

From day 11 to day 13, after the first dose of the COVID-19 messenger RNA vaccine, the effectiveness was 54% (95% confidence interval: 0.33-0.69). On days 14 to 27, the effectiveness was 59%. There was a 14% increase in vaccine effectiveness 28 days after the first dose was given. The inactivated vaccines showed similar effectiveness. The proportions of placental abruptions, postpartum hemorrhages, miscarriages, stillbirths, premature births, and small for gestational age infants were not significantly different between vaccinated and nonvaccinated pregnant women. Fatigue and fever were also not associated with pregnancy.

CONCLUSION

Our findings affirm that the effectiveness varies for different types of vaccines and is significantly and positively correlated with time in the pregnant population. COVID-19 vaccines have also been deemed safe for pregnant women. Thus, we developed a comprehensive understanding of the role of vaccines in pregnant women.

Safety and Efficacy of Coronavirus Disease 2019 (COVID-19) mRNA Vaccines During Lactation

In this review, we summarize the data on the safety and side-effect profile of coronavirus disease 2019 (COVID-19) vaccines during lactation to date, review what is known about mRNA vaccine components in breast milk, and discuss the efficacy of COVID-19 vaccines in providing immune protection for the breastfeeding infant. The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists recommend that lactating individuals receive COVID-19 mRNA vaccines and stay up to date on booster doses, including the bivalent COVID-19 booster. The lack of serious side effects in mothers or infants across numerous large studies and registries of COVID-19 vaccination in pregnancy and lactation is reassuring. Although small quantities of mRNA may be transiently detectable in breast milk after maternal vaccination, there are no data demonstrating that vaccine mRNA can survive the infant gastrointestinal tract and no evidence that breast milk from lactating individuals who have received a COVID-19 mRNA vaccine can cause harm to breastfeeding infants. In contrast, numerous studies demonstrate that the breast milk of vaccinated individuals contains severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific functional antibodies and T cells, which benefit the breastfeeding infant's developing immune system. Transfer of SARS-CoV-2-specific antibodies from mother to infant is highest when vaccination occurs during pregnancy compared with lactation, because the breastfeeding infant receives both long-lasting antibodies through the placenta and breast-milk antibodies through breast milk. With clear data demonstrating efficacy and safety and no data demonstrating harm to mother or infant after COVID-19 vaccine administration during lactation, any recommendations to avoid vaccination while breastfeeding or to withhold breast milk from the infant for any period of time after vaccination are not supported by available evidence.

COVID-19 Therapeutics and Considerations for Pregnancy

The COVID-19 pandemic has generated an unprecedented amount of novel and repurposed vaccines and therapeutics that have been rapidly developed and implemented into clinical use. Unfortunately, pregnant persons have been excluded from most phase III clinical studies; therefore, our understanding regarding their safety for use in this population stems from understanding of theoretic risks and observational data. In this review, the authors discuss pregnancy-specific considerations for COVID-19 therapeutics.

Adopting international recommendations to design a model for maternal health service to cope with pandemic disruption for Indonesian primary care

BACKGROUND

Limited evidence is available as the reference for the model of care on providing maternity care in low-and-middle-income countries (LMICs) to cope with pandemic disruption. This study aimed to adopt international recommendations to develop the model of care with the context of Indonesian settings.

METHODS

Four codesign workshops and substitute interviews with stakeholders, covering the (i) exploration of service provision during the pandemic, (ii) adoption of international recommendations, (iii) designing and (iv) finalising model of care for maternal health services in primary care under the COVID-19 pandemic. The study took place in Yogyakarta Province Indonesia from July-November 2021. The participants were general practitioners, midwives, nurses, patients, and obstetricians. The data were analysed thematically.

RESULTS

Twenty-three participants were recruited. As many as 23, 16, 14 and 16 participants participated in the first to fourth codesign workshops or substitute interviews. Key recommendations agreed upon in the workshop were health screening, maintaining antenatal-postnatal breastfeeding care, limiting visitors, using telemedicine, and creating a multidisciplinary team to provide the care. A model of care for improving maternal service was also agreed and received suggestions from the participants. Identified barriers to the recommendation implementation, such as the available clinical resources and negotiating providers' authority in practice.

CONCLUSION

Recommendations and the model of care for improving maternity care in Indonesia are beneficial to be implemented in Indonesian primary care during the COVID-19 pandemic. Further research includes pilot studies to explore the acceptability of the model and recommendation implementation in practice.

Effectiveness of BNT162b2 Vaccination During Pregnancy in Preventing Hospitalization for Severe Acute Respiratory Syndrome Coronavirus 2 in Infants

OBJECTIVE

To assess the clinical effectiveness of the BNT162b2 vaccine during pregnancy in preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) hospitalizations of infants.

STUDY DESIGN

A retrospective, multicenter, 1:3 case-control (test-negative) study. Symptomatic hospitalized infants less than 6 months of age, with a positive SARS-CoV-2 polymerase chain reaction test between January 3, 2021, and March 11, 2021, were matched by age and time to negative controls, hospitalized with symptoms compatible with SARS-CoV-2 infection. Mothers were defined as fully vaccinated who received 2 doses of BNT162b2 with the second given 2 weeks to 6 months before delivery; or partially vaccinated, if they received only 1 dose or 2 doses with the second given more than 6 months or less than 2 weeks before delivery. Severe SARS-CoV-2 was defined as a need for assisted ventilation.

RESULTS

We matched 116 SARS-CoV-2 positive infants with 348 negative controls with symptoms compatible with SARS-CoV-2 infection. The effectiveness of fully vaccinated mothers was 61.6% (95% CI, 31.9-78.4) and the effectiveness of partially vaccinated mothers was not significant. Effectiveness was higher in infants 0-2 vs 3-6 months of age. The effectiveness (57.1%; 95% CI, 22.8-76.4) was similar when excluding mothers who were infected with SARS-CoV-2 during pregnancy. The OR of severe infection in infants born to unvaccinated vs fully vaccinated mothers was 5.8.

CONCLUSIONS

At least 2 doses of BNT162b2 vaccine administered during the second or third trimester of pregnancy had an effectiveness of 61.6% in decreasing hospitalization for SARS-CoV-2 infection in infants less than 6 months of age.

Recommendations for improving maternal health services in Indonesian primary care under the COVID-19 pandemic: Results of a systematic review and appraisal of international guidelines

BACKGROUND

A large volume of evidence and reviews about COVID-19 recommendations have been published; however, only a few provide recommendations on maternal health services ready for their adoption in Indonesia. This review aims to identify a set of potential recommendations for improving maternal care in the Indonesian primary care setting under the COVID-19 pandemic.

METHODS

A literature search to identify articles that cover a set of recommendations, or maternal guideline under the SARS-COV-1 outbreak or COVID-19 pandemic that were published from 2020 to 1 November 2022 was applied in six academic databases. The search used various keywords and phrases of 'maternal', 'model' and 'coronavirus', and excluded reviews and those evaluating interventions or medicine prescription. The eligible guidelines were appraised using AGREE II instrument, coded, and thematically analysed for their potential adoption to Indonesian settings.

FINDINGS

Fourteen guidelines were fully reviewed, and most of them had high AGREE II scores. Two main themes emerged from the analysis: clinical and supporting arrangements for maternal health services. Potential challenges for the implementation of these recommendations in Indonesia were also discussed.

CONCLUSION AND IMPLICATION FOR PRACTICE

Potential recommendations for improving maternal health for women in Indonesia under the COVID-19 pandemic both on the clinical and supporting services arrangements have been identified. Available clinical resources, different context of providers' practice authority and patients' literacy may challenge their implementation in practice. Further research is needed to seek consensus on the recommendation adoption in practice and to desirably redesign maternal health service in Indonesia.

Comparison of in-hospital mortality of COVID-19 between pregnant and non-pregnant women infected with SARS-CoV-2: a historical cohort study

OBJECTIVES

This study aimed to compare pregnant and non-pregnant women infected with SARS-CoV-2 disease (COVID-19) in terms of in-hospital mortality.

METHODS

This historical cohort study was conducted on hospitalized women of reproductive ages (15-49 years) infected with SARS-CoV-2 in Fars province, Iran during 15 March 2019-10 May 2021.

RESULTS

Out of the 5,322 patients, 330 were pregnant. The fatality rate of SARS-CoV-2 was 1.2% amongst pregnant women and 3.5% amongst non-pregnant ones. Pregnant and non-pregnant women reported the same history of smoking, opium use, previous COVID-19 infection, vaccination against SARS-CoV-2, and COVID-19 symptoms (p>0.05 for all). However, the pregnant women were younger and had fewer underlying diseases (p<0.001 for both). The results revealed no significant difference between the two groups regarding in-hospital clinical manifestations including the number of days after the onset of COVID-19 symptoms, mechanical ventilation, and long involvement (cRR; 95% CI=0.99 (0.96-1.02), 1.18 (0.72-2.02), and 0.95 (0.88-1.02), respectively). Nonetheless, Intensive Care Unit (ICU) admission was significantly higher in pregnant women (cRR; 95% CI=2.37(1.85-3.02)). After adjusting for age, history of underlying diseases, and ICU admission, pregnant women showed lower in-hospital mortality due to COVID-19 compared to non-pregnant women (aRR; 95% CI=0.32 (0.12-0.87)).

CONCLUSIONS

Based on the current study findings, pregnant women showed lower in-hospital mortality due to COVID-19 compared to non-pregnant ones. Nevertheless, they should follow the same recommendations as non-pregnant women, avoiding exposure to the virus and receiving medical treatment and vaccination. Further studies are recommended to address the follow-up of recovered pregnant women, their babies, and puerperium.

Impact of the COVID-19 Pandemic on Influenza Vaccination and Associated Factors among Pregnant Women: A Cross-Sectional Study in Korea

Pregnant women are vulnerable to developing influenza complications. Influenza vaccination during pregnancy is crucial to avoid infection. The COVID-19 pandemic might exacerbate fear and anxiety in pregnant women. The purpose of this study was to evaluate the effect of the COVID-19 pandemic on influenza vaccination and determine the factors associated with influenza vaccine acceptance among pregnant women in Korea. We conducted a cross-sectional study using an online survey in Korea. A survey questionnaire was distributed among pregnant or postpartum women within 1 year after delivery. Multivariate logistic regression analysis was performed to identify the factors associated with influenza vaccination among pregnant women. A total of 351 women were included in this study. Of them, 51.0% and 20.2% were vaccinated against influenza and COVID-19 during pregnancy, respectively. The majority of participants who had a history of influenza vaccination reported that the COVID-19 pandemic did not affect (52.3%, n = 171) or increased the importance (38.5%, n = 126) of their acceptance of the influenza vaccine. Factors associated with influenza vaccine acceptance were knowledge of influenza vaccine (OR 1.21; 95% CI 1.09, 1.35), trust in healthcare providers (OR 2.57; 95% CI 1.43, 4.65), and COVID-19 vaccination during pregnancy (OR 6.11, 95% CI 2.86, 13.01). Participants were more likely to accept the influenza vaccine when they received a COVID-19 vaccine during pregnancy, but the rate of influenza vaccination was not affected by the COVID-19 pandemic. This study showed that the COVID-19 pandemic did not influence influenza vaccine uptake in the majority of pregnant women in Korea. The results emphasize the necessity of appropriate education for pregnant women to enhance awareness of vaccination.

Pregnancy Outcomes in SARS-CoV-2-Positive Patients: A 20-Month Retrospective Analysis of Delivery Cases

Background and Objectives: The SARS-CoV-2 infection brings supplemental risks for pregnant women. Due to controversial hesitancy, their vaccination rate was lower in 2021 compared to the general population. In addition, access to maternal care was reduced during the pandemic. We conducted a retrospective cross-sectional analysis of the health records data over 20 months (1 April 2020 to 20 November 2021) aiming to explore the outcomes in SARS-CoV-2-positive cases referred for delivery to a tertiary public hospital in Western Romania. Materials and Methods: Women with SARS-CoV-2 infection diagnosed for the first time at the moment of birth who delivered singletons after 24 weeks of gestation, and had a clear immunization status were included in the analysis. Results: Out of the 97 patients included in the study, 35 (36%) had undergone ARN-based vaccination. Five cases of maternal death were recorded (all unvaccinated). Our retrospective exploratory analysis showed that the presence of COVID-19 symptoms in the SARS-CoV-2-positive patients made a significant impact on the delivery hospitalization, with a median hospital stay increase from 5 to 9 days (Mann-Whitney test, p = 0.014): longer hospitalization was recorded in the symptomatic cases irrespective of their vaccination status. No other adverse outcomes, such as gestational age at delivery, C-section rate, 5 min Apgar index, or birth weight were associated with the presence of symptoms. Conclusions: Our clinic maintained safe maternal care for the COVID-19 patients during the analyzed period. Vaccination of the expectant women was beneficial in SARS-CoV-2-positive patients by lowering the risk of COVID-19 symptoms, with subsequent implications on the newborns' health and maternal attachment.

Maternal mRNA covid-19 vaccination during pregnancy and delta or omicron infection or hospital admission in infants: test negative design study

OBJECTIVE

To estimate the effectiveness of maternal mRNA covid-19 vaccination during pregnancy against delta and omicron severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and hospital admission in infants.

DESIGN

Test negative design study.

SETTING

Community and hospital testing in Ontario, Canada.

PARTICIPANTS

Infants younger than six months of age, born between 7 May 2021 and 31 March 2022, who were tested for SARS-CoV-2 between 7 May 2021 and 5 September 2022.

INTERVENTION

Maternal mRNA covid-19 vaccination during pregnancy.

MAIN OUTCOME MEASURES

Laboratory confirmed delta or omicron infection or hospital admission of the infant. Multivariable logistic regression estimated vaccine effectiveness, with adjustments for clinical and sociodemographic characteristics associated with vaccination and infection.

RESULTS

8809 infants met eligibility criteria, including 99 delta cases (4365 controls) and 1501 omicron cases (4847 controls). Infant vaccine effectiveness from two maternal doses was 95% (95% confidence interval 88% to 98%) against delta infection and 97% (73% to 100%) against infant hospital admission due to delta and 45% (37% to 53%) against omicron infection and 53% (39% to 64%) against hospital admission due to omicron. Vaccine effectiveness for three doses was 73% (61% to 80%) against omicron infection and 80% (64% to 89%) against hospital admission due to omicron. Vaccine effectiveness for two doses against infant omicron infection was highest with the second dose in the third trimester (53% (42% to 62%)) compared with the first (47% (31% to 59%)) or second (37% (24% to 47%)) trimesters. Vaccine effectiveness for two doses against infant omicron infection decreased from 57% (44% to 66%) between birth and eight weeks to 40% (21% to 54%) after 16 weeks of age.

CONCLUSIONS

Maternal covid-19 vaccination with a second dose during pregnancy was highly effective against delta and moderately effective against omicron infection and hospital admission in infants during the first six months of life. A third vaccine dose bolstered protection against omicron. Effectiveness for two doses was highest with maternal vaccination in the third trimester, and effectiveness decreased in infants beyond eight weeks of age.

The association of neonatal SARS-CoV-2 anti-spike protein receptor-binding domain antibodies at delivery with infant SARS-CoV-2 infection under the age of 6 months: a prospective cohort study

OBJECTIVES

The aim of this study was to assess the association between neonatal SARS-CoV-2 antibody level at delivery and infant SARS-CoV-2 infection under the age of 6 months and to identify predictive factors for neonatal antibody level at delivery.

METHODS

In a prospective observational study, conducted between September 2021 and mid-February 2022, cord blood sera were tested for SARS-CoV-2 anti-spike receptor-binding domain antibodies after maternal BNT162b2 vaccination or infection. Infants were followed up for 6 months for SARS-CoV-2 infection.

RESULTS

Sixty-seven mother-infant dyads were enrolled; nine of those did not meet the eligibility criteria. Of the 58 mother-infant dyads included, 6-month follow-up data were available for 57 mother-infant dyads. The mean ± standard deviation log SARS-CoV-2 anti-spike antibody level at delivery was lower among infants who were COVID-19 positive versus negative during follow-up (3.41 ± 0.74 AU/mL, n = 12; vs. 3.87 ± 0.84 AU/mL, n = 46; p 0.036); a log titre of ≥4.07 AU/mL (11 750) at delivery was associated with a significantly lower likelihood of infant infection (1/26 vs. 11/32 in infants with antibody level of <4.07 log AU/mL, OR = 0.076 [95% CI, 0.076, 0.64], p 0.018). A spline curve model showed a linear decrease in antibody levels when the last dose was administered at ≤30 weeks of gestation (50 days before delivery), after which the antibody levels increased (R² = 0.50). In multivariate analysis, more vaccine doses, prior maternal infection, and last administered dose at ≥31 weeks of gestation were associated with higher antibody levels at delivery.

DISCUSSION

Higher anti-spike antibodies at delivery were associated with decreased risk of COVID-19 at the age of <6 months; the antibody level decreased linearly when the last dose was administered at ≤30 weeks of gestation. Future research should assess the effectiveness of a second booster during pregnancy against infant infection.

Primary Antibody Immunodeficiency and the Pregnant Patient

An overview of primary antibody immunodeficiency in pregnancy is presented. Indications for immunoglobulin replacement therapy (IGRT), dosing, and safety considerations are highlighted. Uses of immunizations and antimicrobial therapy are also discussed. In general, IGRT, both intravenous and subcutaneous, is considered safe in pregnancy.

A Review of Coronavirus Disease 2019 in Pregnancy

Pregnancy is an independent risk factor for morbidity and mortality in coronavirus disease 2019 (COVID-19) with increased rates of operative delivery, intensive care unit admission, and mechanical ventilation as well as a possible increased risk of death, independent of other risk factors, compared with nonpregnant women with COVID-19. Furthermore, pregnancy outcomes are worse in those with COVID-19 with increased risk for preeclampsia, venous thromboembolism, preterm birth, miscarriage, and stillbirth compared with pregnant women without COVID-19. Importantly, pregnant women of nonwhite ethnicity appear to be at greater risk of severe COVID-19, necessitating improved access to care and closer monitoring in these women. The management of COVID-19 in pregnancy is largely similar to that in nonpregnant people; however, there is an important emphasis on multidisciplinary team involvement to ensure favorable outcomes in both mother and baby. Similarly, vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is safe in pregnancy and improves maternal and neonatal outcomes.

Associations of COVID-19 vaccination during pregnancy with adverse neonatal and maternal outcomes: A systematic review and meta-analysis

Objectives

The low COVID-19 vaccine uptake rate among pregnant women is mainly due to safety concerns about COVID-19 vaccines due to limited safety evidence. Our goal was to evaluate the safety of COVID-19 vaccination during pregnancy with up-to-date evidence.

Methods

A comprehensive search of MEDLINE, EMBASE, the Cochrane Library, and clinicaltrials.gov was performed on April 5th, 2022, and updated on May 25th, 2022. Studies evaluating the association of COVID-19 vaccination during pregnancy with adverse maternal and neonatal outcomes were included. Two reviewers independently performed the risk of bias assessment and data extraction. Inverse variance random effect meta-analyses were performed to pool outcome data.

Results

Forty-three observational studies were included. COVID-19 vaccination [96,384 (73.9%) BNT162b2, 30,889 (23.7%) mRNA-1273, and 3,172 (2.4%) other types] during pregnancy [23,721 (18.3%) in the first trimester, 52,778 (40.5%) in the second trimester, and 53,886 (41.2%) in the third trimester].was associated with reduced risks of stillbirth or neonatal death (OR, 0.74; 95% CI, 0.60-0.92). Sensitivity analysis restricted to studies in participants without COVID-19 showed that the pooled effect was not robust. COVID-19 vaccination during pregnancy was not associated with congenital anomalies (OR, 0.83; 95% CI, 0.63-1.08), preterm birth (OR, 0.98; 95% CI, 0.90-1.06), NICU admission or hospitalization (OR, 0.94; 95% CI, 0.84-1.04), an Apgar score at 5 min <7 (OR, 0.93; 95% CI, 0.86-1.01), low birth weight (OR, 1.00; 95% CI, 0.88-1.14), miscarriage (OR, 0.99; 95% CI, 0.88-1.11), cesarean delivery (OR, 1.07; 95% CI, 0.96-1.19), or postpartum hemorrhage (OR, 0.91; 95% CI, 0.81-1.01).

Conclusions

COVID-19 vaccination during pregnancy was not associated with any of the adverse neonatal or maternal outcomes studied. Interpretation of study findings is limited by the types and timing of vaccination. The vaccinations in our study received during pregnancy were primarily mRNA vaccines administered in the second and third trimester. Future RCTs and meta-analysis are warranted to evaluate the efficacy and long-term effects of the COVID-19 vaccines.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022322525, identifier: PROSPERO, CRD42022322525.

Role of vaccination and anti-SARS-CoV-2 antibodies in the clinical outcome of hospitalized COVID-19 patients

BACKGROUND

Although vaccination has considerably reduced the risk of hospitalization and death from COVID19, the impact of vaccination and anti-SARS-CoV-2 antibody status on the outcome of patients who required hospitalization has been poorly investigated.

MATERIAL AND METHODS

A prospective observational study in 232 patients hospitalized for COVID19 was carried out from October 2021 to January 2022 to evaluate the role on patient outcome of their vaccination and anti-SARS-CoV-2 antibody status and titer, comorbidities, analytical determinations, clinical presentation at admission, treatments and requirements for respiratory support. Cox regression and survival analyzes were performed. The SPSS and "R" programs were used.

RESULTS

Patients with complete vaccination schedule had higher S-protein antibody titers (log10 3.73 [2.83-4.6]UI/ml vs 1.6 [2.99-2.61]UI/ml; p<0.001), lower probability of radiographic worsening (21.6% vs. 35.4%; p=0.005), less likely required high doses of dexamethasone (28.4% vs. 45.4%; p=0.012), high-flow oxygen (20.6% vs. 35.4%; p=0.02), ventilation (13.7% vs, 33.8%; p=0.001) and intensive care admissions (10.8% vs. 32.6%; p<0.001). Remdesivir (HR=0.38; p<0.001) and complete vaccination schedule (HR=0.34; p=0.008) were protective factors. No differences in antibody status were detected between groups (HR=0.58; p=0.219).

CONCLUSIONS

SARS-CoV-2 vaccination was associated with higher S-protein antibody titers and lower probability of radiological progression, immunomodulators requirement and respiratory support or death. However, vaccination but not antibody titters protected from adverse events pointing a role of immune-protective mechanisms in addition to humoral response.

The State of Play on COVID-19 Vaccination in Pregnant and Breastfeeding Women: Recommendations, Legal Protection, Ethical Issues and Controversies in Italy

To date, extensive research has been conducted on vaccination against COVID-19 during pregnancy to verify the safety and efficacy of the vaccines, despite the fact that pregnant women were excluded from the initial clinical trials. The ever-increasing number of scientific publications has confirmed the absence of biological mechanisms associating mRNA vaccines with adverse effects in pregnancy and breastfeeding, although few studies have been carried out on their effect on fertility. While the Italian legal system provides for maternity protection measures and indemnity for vaccination damages pursuant to law no. 210/1992, it is not exempt from controversy. This contribution describes the state of play on COVID-19 vaccination in pregnant and lactating women, including: current recommendations for pregnant and lactating women; ethical issues related to vaccination hesitancy among pregnant women; the legislative paradox whereby sanctions may be imposed on women in certain professional categories who refuse vaccination because they are pregnant; and the possible legal consequences in the event of harm to the unborn child due to vaccination. All of this is considered in accordance with the principles of medical ethics, taking into account the national legislation.

COVID-19 vaccination during pregnancy: a systematic review and meta-analysis

BACKGROUND

SARS-CoV-2 exposure during pregnancy is related to adverse effects for both the mother and the infant. SARS-CoV-2 vaccination has lowered the risk of symptomatic disease substantially. Recently published studies have evaluated the outcomes of women who received the COVID-19 vaccine during pregnancy; systematic evidence regarding vaccination safety is crucial to ensure that COVID-19 vaccination is not associated with adverse pregnancy and neonatal outcomes.

METHODS

Pubmed/MEDLINE, EMBASE, Scopus, Web of Science, and Clinicaltrials.gov were searched from each database's inception through April 7, 2022. All interventional and observational studies comparing neonatal or pregnancy outcomes between pregnant women who received COVID-19 vaccines during their pregnancy and unvaccinated pregnant women were included. The random-effects model was used in the meta-analyses.

RESULTS

A total of 11 studies comprising 756,098 pregnant mothers were included. The rate of neonates with 5-min Apgar score ≤ 7 (log RR -0.08 (95% CI: -0.15 to -0.00), (P = 0.03)) and pregnant mothers with preterm birth (log RR -0.11 (95% CI: -0.21 to -0.01), (P = 0.02)) was significantly lower among vaccinated group. No significant difference was observed in adverse neonatal outcomes (log RR -0.07 (95% CI: -0.17 to 0.03)), small for gestational age (log RR -0.06 (95% CI: -0.14 to 0.02)), caesarean delivery (log RR 0.05 (95% CI: -0.05 to 0.15)), postpartum hemorrhage (log RR -0.05 (95% CI: -0.13 to 0.02)), stillbirth (log RR -0.05 (95% CI: -0.54 to 0.45)).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, no evident differences were observed when comparing vaccinated pregnant mothers with those who had not received COVID-19 vaccines. Based on low certainty of evidence, vaccination during pregnancy was accompanied by a favorable Apgar score in neonates and fewer preterm births.

Midwives' Knowledge, Attitudes, and Practice Regarding COVID-19 Vaccination for Pregnant Women: A Nationwide Web-Based Survey in Italy

This cross-sectional survey investigated the knowledge, attitudes, and practices concerning the COVID-19 vaccination for pregnant women among midwives in Italy and the associated factors. Midwives with at least five years of midwifery education and who had received information about the COVID-19 vaccination from official government organizations or scientific journals were more likely to know in which trimester this vaccine can be administered. A higher perceived utility of this vaccination was observed among midwives working in the public sector, in those concerned by being infected by SARS-CoV-2, who have received at least one dose of this vaccination, in those who considered COVID-19 a severe disease for pregnant women and their fetus, and who believed that the vaccination is safe. One-third of the midwives routinely provided information and half recommended this vaccination. Midwives with more years of activity, who received information about the vaccination from official government organizations or scientific journals, those who had never assisted patients with SARS-CoV-2, and those who believed in midwives' role in COVID-19 prevention were more likely to routinely provide information. Participants who perceived a higher utility of this vaccination, those who believed in midwives' role in COVID-19 prevention, those who received information from official government organizations or scientific journals were more likely to routinely provide a recommendation for the vaccine. Midwives' knowledge must be improved for ensuring that they communicate and recommend the vaccination to their patients.

Impact of prenatal COVID-19 vaccination on delivery and neonatal outcomes: Results from a New York City cohort

Research suggest prenatal vaccination against coronavirus disease-19 (COVID-19) is safe. However, previous studies utilized retrospectively collected data or examined late pregnancy vaccinations. We investigated the associations of COVID-19 vaccination throughout pregnancy with delivery and neonatal outcomes. We included 1,794 mother-neonate dyads enrolled in the Generation C Study with known prenatal COVID-19 vaccination status and complete covariate and outcome data. We used multivariable quantile regressions to estimate the effect of prenatal COVID-19 vaccination on birthweight, delivery gestational age, and blood loss at delivery; and Poisson generalized linear models for Caesarean delivery (CD) and Neonatal Intensive Care Unit (NICU) admission. Using the above methods, we estimated effects of trimester of vaccine initiation on these outcomes. In our sample, 13.7% (n = 250) received at least one prenatal dose of any COVID-19 vaccine. Vaccination was not associated with birthweight (β = 12.42 g [-90.5, 114.8]), gestational age (β = 0.2 days [-1.1, 1.5]), blood loss (β = -50.6 ml [-107.0, 5.8]), the risks of CD (RR = 0.8; [0.6, 1.1]) or NICU admission (RR = 0.9 [0.5, 1.7]). Trimester of vaccine initiation was also not associated with these outcomes. Our findings suggest that there is no associated risk between prenatal COVID-19 vaccination and adverse delivery and neonatal outcomes in a cohort sample from NYC.

Maternal Antibody Response and Transplacental Transfer Following Severe Acute Respiratory Syndrome Coronavirus 2 Infection or Vaccination in Pregnancy

BACKGROUND

Pregnant persons are at increased risk of severe coronavirus disease 2019 (COVID-19) and adverse obstetric outcomes. Understanding maternal antibody response, duration, and transplacental transfer after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and COVID-19 vaccination is important to inform public health recommendations.

METHODS

This prospective observational cohort study included 351 pregnant people who had SARS-CoV-2 infection or COVID-19 vaccination during pregnancy. Immunoglobulin (Ig) G and IgM to SARS-CoV-2 S1 receptor binding domain were measured in maternal and cord blood. Antibody levels and transplacental transfer ratios were compared across (1) disease severity for those with SARS-CoV-2 infection and (2) infection versus vaccination.

RESULTS

There were 252 individuals with SARS-CoV-2 infection and 99 who received COVID-19 vaccination during pregnancy. Birthing people with more severe SARS-CoV-2 infection had higher maternal and cord blood IgG levels (P = .0001, P = .0001). Median IgG transfer ratio was 0.87-1.2. Maternal and cord blood IgG were higher after vaccination than infection (P = .001, P = .001). Transfer ratio was higher after 90 days in the vaccinated group (P < .001). Modeling showed higher amplitude and half-life of maternal IgG following vaccination (P < .0001). There were no significant differences by fetal sex.

CONCLUSIONS

COVID-19 vaccination in pregnancy leads to higher and longer lasting maternal IgG levels, higher cord blood IgG, and higher transfer ratio after 90 days compared with SARS-CoV-2 infection. Greater infection severity leads to higher maternal and cord blood antibodies. Maternal IgG decreases over time following both vaccination and infection, reinforcing the importance of vaccination, even after infection, and vaccine boosters for pregnant patients.

Boosting maternal and neonatal anti-SARS-CoV-2 humoral immunity using a third mRNA vaccine dose

BACKGROUND

To minimize COVID-19 pandemic burden and spread, 3-dose vaccination campaigns commenced worldwide. Since patients who are pregnant are at increased risk for severe disease, they were recently included in that policy, despite the lack of available evidence regarding the impact of a third boosting dose during pregnancy, underscoring the urgent need for relevant data. We aimed to characterize the effect of the third boosting dose of mRNA Pfizer BNT162b2 vaccine in pregnancy.

METHODS

We performed a prospective cohort study of anti-SARS-CoV-2 antibody titers (n = 213) upon delivery in maternal and cord blood of naive fully vaccinated parturients who received a third dose (n = 86) as compared with 2-dose recipients (n = 127).

RESULTS

We found a robust surge in maternal and cord blood levels of anti-SARS-CoV-2 titers at the time of delivery, when comparing pregnancies in which the mother received a third boosting dose with 2-dose recipients. The effect of the third boosting dose remained significant when controlling for the trimester of last exposure, suggesting additive immunity extends beyond that obtained after the second dose. Milder side effects were reported following the third dose, as compared with the second vaccine dose, among the fully vaccinated group.

CONCLUSION

The third boosting dose of mRNA Pfizer BNT162b2 vaccine augmented maternal and neonatal immunity with mild side effects. These data provide evidence to bolster clinical and public health guidance, reassure patients, and increase vaccine uptake among patients who are pregnant.

FUNDING

Israel Science Foundation KillCorona grant 3777/19; Research grant from the "Ofek" Program of the Hadassah Medical Center.

Systematic review and meta-analysis of neonatal outcomes of COVID-19 vaccination in pregnancy

BACKGROUND

The safety of coronavirus disease 2019 (COVID-19) vaccines during pregnancy is a particular concern. Here, we addressed the neonatal outcomes after maternal vaccination of COVID-19 during pregnancy.

METHODS

We systematically searched PubMed, EMBASE, and the WHO COVID-19 Database for studies on neonatal outcomes after maternal COVID-19 vaccination from inception to 3 July 2022. Main neonatal outcomes were related to preterm, small for gestation (SGA), NICU admission, low Apgar score at 5 min (<7), and additional neonatal outcomes such as gestation <34 weeks, low birth weight and some neonatal morbidity were all also analyzed.

RESULTS

A total of 15 studies were included. We found that maternal vaccination during pregnancy was related to the reduction rates of Preterm, SGA, Low Apgar score at 5 min (<7). In addition, there was no evidence of a higher risk of adverse neonatal outcomes after maternal vaccination of COVID-19 during pregnancy, including NICU admission, preterm birth with gestation <34 weeks, low birth weight, very low birth weight, congenital anomalies, and so on.

CONCLUSIONS

COVID-19 vaccination in pregnant women does not raise significant adverse effects on neonatal outcomes and is related to a protective effect on some neonatal outcomes.

IMPACT

Present study has addressed the neonatal outcomes after maternal vaccination of COVID-19 during pregnancy. COVID-19 vaccination in pregnant women does not raise significant adverse effects on neonatal outcomes and is related to a protective effect on some neonatal outcomes. The present study could encourage pregnant women to be vaccinated against COVID-19.

Efficacy of an accelerated vaccination schedule against hepatitis E virus infection in pregnant rabbits

An important goal of the Hepatitis E virus (HEV) vaccine is to prevent adverse pregnancy outcomes caused by different HEV genotypes during pregnancy, but studies directly evaluating maternal vaccination for HEV are lacking. Here we report maternal vaccination using HEV 239 vaccine in a pregnant rabbit model. Two dose of accelerated vaccination schedule (0, 7 days) induced high titers of anti-HEV protective antibodies in a short period of time in pregnant rabbits, which could protect the pregnant rabbits from HEV infection and adverse pregnancy outcomes. In addition, the immunized rabbits transfer maternal antibodies to pups through the placenta and breast milk, which protect neonates against HEV infection. Our results suggest that, besides vaccinating nonpregnant individuals, HEV 239 vaccine may also be discreetly considered for maternal vaccination.

COVID-19 Vaccine Acceptance During Pregnancy, Women's Views, and Influencing Factors

BACKGROUND

COVID-19 vaccination is advised for pregnant women all over the world; however, vaccine acceptance is variable across the globe.

METHODS

This study was conducted by enrolling 292 antenatal women attending the outpatient department (OPD) in a tertiary care hospital in Delhi, India, between August 1, 2022 and October 31, 2022, with the aim to determine the acceptability of vaccination against COVID-19 disease in pregnancy, women's views regarding the vaccine and to ascertain reasons for acceptance or denial during pregnancy.

RESULT

Of the 292 pregnant women who completed the questionnaire, 39.73% had received both doses of vaccination against COVID-19 disease before pregnancy, and 39.04% had received a single dose. Twenty-one percent of women did not receive any vaccine. Eighty-four percent of the unvaccinated and 35% of the women with a single dose of the vaccine refused further doses during pregnancy. The most common concern was the fear that the vaccine might cause harm to the fetus (35.3%), followed by the fear of vaccine-related reactions (25.4%). Also, 14.6% of women feared that the vaccine might cause them to abort the ongoing pregnancy. Thirteen percent of women stated their intent to receive the vaccine after they were informed regarding its safety and requirement. No difference was found in the acceptability of the vaccine based on the educational status of women or on the monthly income of the families.

CONCLUSION

Adequate communication regarding safety information on COVID-19 vaccines is a must for pregnant women and their families to provide reassurance about the need and safety of the vaccines. It would facilitate making informed decisions and is likely to be helpful in increasing vaccine acceptance.

COVID-19 and pregnancy: clinical outcomes; mechanisms, and vaccine efficacy

As the COVID-19 pandemic continues into its third year, emerging data indicates increased risks associated with SARS-CoV-2 infection during pregnancy, including pre-eclampsia, intrauterine growth restriction, preterm birth, stillbirth, and risk of developmental defects in neonates. Here, we review clinical reports to date that address different COVID-19 pregnancy complications. We also document placental pathologies induced by SARS-CoV-2 infection, entry mechanisms in placental cells, and immune responses at the maternal-fetal interface. Since new variants of SARS-CoV-2 are emerging with characteristics of higher transmissibility and more effective immune escape strategies, we also briefly highlight the genomic and proteomic features of SARS-CoV-2 investigated to date. Vector and mRNA-based COVID-19 vaccines continue to be rolled out globally. However, because pregnant individuals were not included in the vaccine clinical trials, some pregnant individuals have safety concerns and are hesitant to take these vaccines. We describe the recent studies that have addressed the effectiveness and safety of the current vaccines during pregnancy. This review also sheds light on important areas that need to be carefully or more fully considered with respect to understanding SARS-CoV-2 disease mechanisms of concern during pregnancy.

Adverse events of COVID-19 vaccines in pregnant and postpartum women in Brazil: A cross-sectional study

BACKGROUND

By the fact that pregnant and postpartum women are currently using COVID-19 vaccines, ensure their safety is critical. So, more safety evidence is crucial to include this new technology to their vaccine's calendar and to develop public policies regarding the support and training of Health Care Personnel. This study aims to describe the adverse events (AE) of COVID-19 vaccines in pregnant and postpartum women in the early stage of vaccination campaign in Brazil.

METHODS

An observational cross-sectional study using data from the Brazilian surveillance information system to characterize the AE of COVID-19 vaccines (Sinovac/Butantan, Pfizer/BioNTech, AstraZeneca and Janssen) in Brazilian pregnant and postpartum women from April to August 2021. Frequency and incidence rate of AE for COVID-19 vaccines were assessed.

RESULTS

3,333 AE following immunization were reported for the study population. AE incidence was 309.4/100,000 doses (95% CI 297.23, 321.51). Within the vaccines available, Sinovac/Butantan had the lowest incidence (74.08/100,000 doses; 95% CI 63.47, 84.69). Systemic events were the most frequent notified (82.07%), followed by local (11.93%) and maternal (4.74%), being most of them classified as non-severe (90.65%).

CONCLUSION

Our results corroborate the recommendation of vaccination for these groups. Even though, further studies appraising a longer observation time are still needed to provide a broader safety aspect for the vaccines currently under use for this population.

Trends and Correlates of Early-Life Exposure to Acid-Suppressant Therapy in Israel (2005-2020)

OBJECTIVES

To describe trends and correlates of acid-suppressant therapy usage during the first year of life.

STUDY DESIGN

A population-based cohort in a large state-mandated health fund in Israel, including members born between 2005 and 2020, was conducted. Acid-suppressant therapy initiation was defined by any purchase within the first year of life. The association between acid-suppressant therapy initiation with medical and sociodemographic characteristics was assessed via logistic regression.

RESULTS

Among 595 860 children, acid-suppressant therapy was initiated in 22 412 (37.6 per 1000). The incidence rate increased by 2.8-fold from 18.2 per 1000 in 2005 to 51.0 per 1000 in 2020, furthermore the median age at initiation decreased. Primary care providers accounted for 74.8% of prescribing physicians in 2005 vs 96.1% in 2020, whereas the prevalence of prescribing gastroenterologists decreased from 18.8% to 2.8%. Preterm birth and small weight per gestational age were associated with acid-suppressant therapy usage, with an aOR of 4.23 (95% CI 3.59-4.99), 3.05 (95% CI 2.72-3.42), and 1.65 (95% CI 1.58-1.74) for extreme, very, and moderate preterm vs term birth and aOR 1.22 (95% CI 1.16-1.28) for small weight per gestational age. Birth order was inversely associated with acid-suppressant therapy initiation, with aOR 0.62 (95% CI 0.60-0.65) for third born vs firstborns. High socioeconomic status was linearly associated with initiation, with aOR 1.12 (95% CI 1.11-1.12) per 1-point increase on a 10-point score.

CONCLUSIONS

Our analysis demonstrates a substantial increase in early life exposure to acid-suppressant therapy during recent years in Israel. Correlates for initiation in early life were identified to define a population for intervention to reduce potential unnecessary use.

Risk factors for severe disease and impact of severity on pregnant women with COVID-19: a case-control study based on data from a nationwide survey of maternity services in Japan

OBJECTIVE

To identify independent risk factors for severe COVID-19 in pregnant women and to evaluate the impact of disease severity on preterm birth.

DESIGN

A case-control study based on data from a nationwide questionnaire-based survey of maternity services in Japan.

SETTING

A questionnaire was mailed to all 2135 delivery institutions in Japan between July and August 2021. A total of 1288 institutions responded (60% of all delivery institutions in Japan). 566 facilities reported having cared for pregnant women with COVID-19, and 722 facilities reported having had no such patients.

PARTICIPANTS

One thousand and forty-three hospitalised and non-hospitalised pregnant women diagnosed with COVID-19 between July 2020 and 30 June 2021.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was progression to severe COVID-19. The secondary outcome was preterm birth due to COVID-19 infection.

RESULTS

56 cases (5.4%) were severe, and 987 (94.6%) were non-severe. Multivariable logistic regression analysis showed that gestational age≥24 weeks (adjusted OR (aOR) 6.68, 95% CI 2.8 to 16.0) and maternal age≥32 years (aOR 2.40, 95% CI 1.3 to 4.3) were independently associated with severe cases. Using the Kaplan-Meier method, the probability of continued pregnancy at 14 days after diagnosis for severe cases was 0.57 between 24 and 31 weeks' gestation and 0.27 between 32 and 36 weeks' gestation. The probability for non-severe cases was 1.0 between 24 and 31 weeks' gestation and 0.8 between 32 and 36 weeks' gestation. Among the patients with COVID-19 in the preterm period, preterm birth due to infection was significantly more common in severe than non-severe cases (48% vs 6%, p< 0.0001).

CONCLUSIONS

Severe COVID-19 in pregnant women was associated with gestational age≥24 weeks and maternal age≥32. The rate of preterm delivery due to the infection was significantly higher in severe COVID-19 cases.

Effectiveness and safety of COVID-19 vaccine in pregnant women: A systematic review with meta-analysis

BACKGROUND

There are limited data regarding COVID-19 vaccination during pregnancy.

OBJECTIVES

To evaluate the effects of COVID-19 vaccination received during pregnancy on SARS-CoV-2 infection, COVID-19-related hospitalisation, COVID-19-related intensive care unit (ICU) admission and maternal-fetal complications.

SEARCH STRATEGY

MEDLINE, CINHAL, Embase, Scopus and CENTRAL databases, as well as ClinicalTrials.gov, reference lists, related articles and grey literature sources.

SELECTION CRITERIA

Randomised controlled trials, non-randomised studies of interventions, pregnant women, COVID-19 vaccination during pregnancy.

DATA COLLECTION AND ANALYSIS

Study selection, risk-of-bias assessment, data extraction and assessment of the certainty of evidence using the GRADE method were performed independently by two authors. Meta-analyses were performed using Cochrane RevMan 5.4. PROSPERO registration number: CRD42022308849.

MAIN RESULTS

We included 14 observational studies (362 353 women). The administration of a COVID-19 vaccine during pregnancy resulted in a statistically significant reduction in SARS-CoV-2 infection (OR 0.46, 95% CI 0.28-0.76) and COVID-19-related hospitalisation (OR 0.41, 95% CI 0.33-0.51). The effect appeared to be greater in fully vaccinated women, for both infection (OR 0.31, 95% CI 0.16-0.59) and hospitalisation (OR 0.15, 95% CI 0.10-0.21). However, the certainty of evidence was very low. The difference in COVID-19-related ICU admission between vaccinated and unvaccinated individuals did not reach statistical significance (OR 0.58, 95% CI 0.13-2.58). Finally, there were no statistically significant differences in any of the maternal-fetal complications considered in the included studies.

CONCLUSIONS

COVID-19 vaccination administered during pregnancy seems to reduce SARS-CoV-2 infection and COVID-19-related hospitalisation, with no significant effects on maternal-fetal complications.

The impact of maternal SARS-CoV-2 infection and COVID-19 vaccination on maternal-fetal outcomes

The rapidly evolving COVID-19 pandemic has resulted in an upsurge of scientific productivity to help address the global health crisis. One area of active research is the impact of COVID-19 on pregnancy. Here, we provide an epidemiological overview about what is known about the effects of maternal SARS-CoV-2 infection and COVID-19 vaccination on maternal-fetal outcomes, and identify gaps in knowledge. Pregnant people are at increased risk for severe COVID-19, and maternal SARS-CoV-2 infection increases the risk of negative maternal-fetal outcomes. Despite this elevated risk, there have been high rates of vaccine hesitancy, heightened by the initial lack of safety and efficacy data for COVID-19 vaccination in pregnancy. In response, retrospective cohort studies were performed to examine the impact of COVID-19 vaccination during pregnancy. Here, we report the vaccine's efficacy during pregnancy and its impact on maternal-fetal outcomes, as well as an overview of initial studies on booster shots in pregnancy. We found that pregnant people are at risk for more severe COVID-19 outcomes, maternal SARS-CoV-2 infection is associated with worse birth outcomes, COVID-19 vaccine hesitancy remains prevalent in the pregnant population, and COVID-19 vaccination and boosters promote better maternal-fetal outcomes. The results should help reduce vaccine hesitancy by alleviating concerns about the safety and efficacy of administering the COVID-19 vaccine during pregnancy. Overall, this review provides an introduction to COVID-19 during pregnancy. It is expected to help consolidate current knowledge, accelerate research of COVID-19 during pregnancy and inform clinical, policy, and research decisions regarding COVID-19 vaccination in pregnant people.

Evaluation of Safety Concerns for COVID-19 Immunization of Pregnant Women: a Systematic Review of Emerging Evidence

Objectives: There is an urgent need to review the status of COVID-19 vaccine immunization in pregnant women globally, so that adverse outcomes may be prevented. In this study, we performed a systematic review to evaluate the probable outcomes of COVID-19 vaccination in pregnant women. Materials and methods:An electronic search over three months (June 15-August 15, 2021) was conducted. Original studies evaluating safety concerns in pregnant women for COVID-19 vaccination were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines were used for data collection and reporting of findings. Results:COVID-19 vaccination in pregnant women was not associated with increased adverse effects or complications to the mother as well as the developing fetus or new-born compared to non-vaccinated pregnant women. Vaccinated pregnant women showed a robust immune response against COVID-19 infection. Conclusion:COVID-19 vaccination during pregnancy causes no significant health risks for the mother or the developing fetus or new-born.

Viral pulmonary infection in pregnancy - Including COVID-19, SARS, influenza A, and varicella

The COVID-19 pandemic has been at the forefront of medicine over the last few years. Pregnant women are often exposed to infectious agents that can be harmful not only to the mother but also to the foetus. Moreover, changes during pregnancy means that pregnant women have increased vulnerability to viral infections, especially pulmonary infections. Epidemiological studies have shown a link between maternal viral infections and miscarriage, preterm birth as well as congenital defects. With potential poor outcomes for both women and their newborns, having a good understanding of the presentation and management of these viral pulmonary infections is essential. The increased risk of adverse outcomes has been highlighted during the COVID-19, SARS and H1N1 influenza pandemics.

Adverse Maternal Outcomes in Pregnant Women Affected by Severe-Critical COVID-19 Illness: Correlation with Vaccination Status in the Time of Different Viral Strains' Dominancy

This is a monocentric and cross-sectional study conducted at the COVID-19 Division of the Obstetrical and Gynecological Unit and Intensive Care Units (ICUs) of Policlinico di Bari, in Bari, Italy, between September 2020 and April 2022. This study aimed to identify the prevalence of severe-critical COVID-19 illness requiring access to the Intensive Care Unit (ICU) among 287 pregnant patients, and possible correlations between the SARS-CoV-2 variants, the specific pandemic wave (dominated by wild, Alpha, Delta, and Omicron strains), and severe-critical adverse maternal outcomes. The prevalence of severe-critical COVID-19 illness was 2.8% (8/287), reaching 4.9% (8/163) excluding the 4th wave (Omicron dominant). The Delta variant determined the highest risk ratio and odds for access to the ICU due to severe-critical COVID-19-related symptoms compared to the other variants (wild, Alpha, Omicron). During the third wave (Delta), the ICU cases underwent a higher rate of hyperimmune plasma infusion (75%), antibiotic therapy (75%), and remdesivir (33%); all of the patients were intubated. During the Omicron wave, the patients were asymptomatic or with few symptoms: most of them (70%) were vaccinated with a median of two doses. The maternal outcome worsened in the case of Alpha and, especially, Delta variants for severe-critical COVID-19-related symptoms and ICU access.