2009 pandemic influenza A (H1N1) in pregnancy: a systematic review of the literature

The risk of clinical complications and death among pregnant women with COVID-19 in the Cerner COVID-19 cohort: a retrospective analysis

BACKGROUND

Pregnant women are potentially a high-risk population during infectious disease outbreaks such as COVID-19, because of physiologic immune suppression in pregnancy. However, data on the morbidity and mortality of COVID-19 among pregnant women, compared to nonpregnant women, are sparse and inconclusive. We sought to assess the impact of pregnancy on COVID-19 associated morbidity and mortality, with particular attention to the impact of pre-existing comorbidity.

METHODS

We used retrospective data from January through June 2020 on female patients aged 18-44 years old utilizing the Cerner COVID-19 de-identified cohort. We used mixed-effects logistic and exponential regression models to evaluate the risk of hospitalization, maximum hospital length of stay (LOS), moderate ventilation, invasive ventilation, and death for pregnant women while adjusting for age, race/ethnicity, insurance, Elixhauser AHRQ weighted Comorbidity Index, diabetes history, medication, and accounting for clustering of results in similar zip-code regions.

RESULTS

Out of 22,493 female patients with associated COVID-19, 7.2% (n = 1609) were pregnant. Crude results indicate that pregnant women, compared to non-pregnant women, had higher rates of hospitalization (60.5% vs. 17.0%, P < 0.001), higher mean maximum LOS (0.15 day vs. 0.08 day, P < 0.001) among those who stayed < 1 day, lower mean maximum LOS (2.55 days vs. 3.32 days, P < 0.001) among those who stayed ≥1 day, and higher moderate ventilation use (1.7% vs. 0.7%, P < 0.001) but showed no significant differences in rates of invasive ventilation or death. After adjusting for potentially confounding variables, pregnant women, compared to non-pregnant women, saw higher odds in hospitalization (aOR: 12.26; 95% CI (10.69, 14.06)), moderate ventilation (aOR: 2.35; 95% CI (1.48, 3.74)), higher maximum LOS among those who stayed < 1 day, and lower maximum LOS among those who stayed ≥1 day. No significant associations were found with invasive ventilation or death. For moderate ventilation, differences were seen among age and race/ethnicity groups.

CONCLUSIONS

Among women with COVID-19 disease, pregnancy confers substantial additional risk of morbidity, but no difference in mortality. Knowing these variabilities in the risk is essential to inform decision-makers and guide clinical recommendations for the management of COVID-19 in pregnant women.

Antenatal influenza vaccination in urban Pune, India: clinician and community stakeholders' awareness, priorities, and practices

The World Health Organization (WHO) recommends antenatal influenza vaccination (AIV) for pregnant women at any stage of pregnancy. This study assessed fundamental aspects of AIV acceptance and demand among key stakeholders in urban Pune, India. Semi-structured interviews for rapid ethnographic assessment of AIV-related awareness, priorities, and practices were used to study clinicians and their communities of practice. A qualitative survey was conducted among 16 private clinicians providing antenatal care (ANC) in slum and middle-class areas of Pune. Following the survey, clinicians were informed about authoritative AIV recommendations. A qualitative community survey was also conducted with 60 women aged 20-35 years and 30 spouses from the same slum and middle-class practice areas of the ANC providers. Subsequently, a second clinician survey was conducted to assess changes in clinicians' awareness, priority, and vaccination practice. After this interview, clinicians were informed of community survey findings. Most community respondents were unaware of AIV, in contrast with well-known and widely used antenatal tetanus vaccination. They expressed confidence in vaccines and trust in the clinicians. Clinicians' advice was reportedly the most important determinant of community vaccine acceptance. Clinicians were confident of the safety of AIV and they anticipated patients' acceptance if recommended. The second clinician interview showed increased awareness of AIV policy, but clinicians were more skeptical about the severity of maternal influenza in their practice. Our findings indicate community acceptance though not demand for AIV. We recommend five essential elements for vaccination program strategies to improve coverage with AIV and other ANC vaccines.

Insurance status predicts self-reported influenza vaccine coverage among pregnant women in the United States: A cross-sectional analysis of the National Health Interview Study Data from 2012 to 2018

While the influenza vaccine is recommended for all pregnant women, influenza vaccine coverage among this high-risk population remains inadequate. Factors associated with vaccine coverage among pregnant women, including insurance status, are poorly understood. In a cross-sectional study of the National Health Interview Survey (NHIS) data from 2012 to 2018, we evaluated predictors of self-reported influenza vaccine coverage in pregnant women. Among 1,942 pregnant women surveyed, 39% reported receiving the influenza vaccine in accordance with national recommendations. Influenza vaccine coverage increased by 8 percentage points from 2012 to 2018. Only 15% of uninsured pregnant women received the influenza vaccine, compared to 41% of those with insurance (design-corrected F-test, p-value < 0.001). In the multivariate Poisson regression analysis, significant predictors of influenza vaccine coverage were health insurance (prevalence ratio [PR] 1.90, 95% confidence interval [CI] 1.23-2.93), ratio of household income to federal poverty level (FPL) threshold greater than 400% (PR 1.54, 95% CI 1.20-1.96), graduate school education (PR 1.52, 95% CI 1.04-2.23), and the 2015-2018 survey year period (PR 1.27, 95% CI 1.08-1.49). While previous literature focuses heavily on demographics, our research underscores the need to further explore modifiable factors that impact vaccine uptake during pregnancy, particularly the interplay between health insurance and access to care.

Effect of COVID-19 on Mortality of Pregnant and Postpartum Women: A Systematic Review and Meta-Analysis

BACKGROUND

Based on what is known at this time, pregnant women are at an increased risk of severe illness from COVID-19 compared to nonpregnant women. Additionally, pregnant women with COVID-19 might have an increased risk of adverse pregnancy outcomes. To investigate the effects of coronavirus disease 2019 (COVID-19) on mortality of pregnant and postpartum women, we performed a systematic review of available published literature on pregnancies affected by COVID-19.

METHODS

Web of Science, SCOPUS, and MEDLINE- databases were searched for original studies concerning the effect of COVID-19 on mortality of pregnant and postpartum women published by July 10, 2020. Meta-analyses of proportions were used to combine data and report pooled proportions.

RESULTS

117 studies with a total of 11758 pregnant women were included. The age ranged between 15 and 48 years. Most subjects were infected with SARS-CoV-2 in the third trimester. Disease severity was not reported in 1125 subjects. Maternal mortality was 1.3%. In 100% of fatal cases with adequate data, fever alone or with cough was one of the presenting symptoms. Also, dyspnea (58.3%) and myalgia (50%) were the most common symptoms. Sore throat (8.3%) and gastrointestinal symptoms (anorexia, nausea) (8.3%) were rare. The rate of comorbidities was 20% among COVID-19 deaths. The majority of COVID-19-infected women who died had cesarean section (58.3%), 25% had a vaginal delivery, and 16.7% of patients were not full term.

CONCLUSION

COVID-19 infection in pregnant women was associated with higher rates (and pooled proportions) of cesarean section and mortality. Because new data are continuously being generated and published, the findings of this study can be complete and updated with new researches. The results of this study can guide and improve prenatal counseling of COVID-19-infected pregnant women.

Management of Viral Complications of Pregnancy: Pharmacotherapy to Reduce Vertical Transmission

Viral infections are common complications of pregnancy. Although some infections have maternal sequelae, many viral infections can be perinatally transmitted to cause congenital or chronic infection in fetuses or infants. Treatments of such infections are geared toward reducing maternal symptoms and complications and toward preventing maternal-to-child transmission of viruses. The authors review updates in the treatment of herpes simplex virus, cytomegalovirus, hepatitis B and C viruses, human immunodeficiency virus, and COVID-19 during pregnancy.

Losing ground at the wrong time: trends in self-reported influenza vaccination uptake in Switzerland, Swiss Health Survey 2007-2017

OBJECTIVES

We studied time trends in seasonal influenza vaccination and associations with socioeconomic and health-related determinants in Switzerland, overall and in people aged ≥65 years.

DESIGN

Three cross-sectional surveys.

PARTICIPANTS

Individuals who participated in the Swiss Health Surveys 2007, 2012 and 2017. We calculated the proportion reporting influenza vaccination in the last 12 months, and performed multivariable logistic regression analyses.

RESULTS

We included 51 582 individuals in this analysis. The median age was 49 years (IQR 25-64), and 27 518 were women (53.3%). The proportion of reporting a history of influenza vaccination overall was 31.9% (95% CI 31.4 to 32.4); and dropped from 34.5% in 2007 to 28.8% in 2017. The uptake of vaccination within the past 12 months was 16% in 2007 and similar in 2012 and 2017 (around 14%). In people with chronic disease, uptake dropped from 43.8% in 2007 to 37.1% in 2012 and to 31.6% in 2017 (p<0.001). In people aged ≥65 years, uptake dropped from 47.8% in 2007 to 38.5% in 2012 to 36.2% in 2017 (p<0.001). In logistic regression, self-reported vaccination coverage decreased in the 65-75 years old (adjusted OR (aOR) 0.56, 95% CI 0.48 to 0.66 between 2007 and 2012; aOR 0.89, 95% CI 0.77 to 1.03 between 2012 and 2017). Uptake was positively associated with the ≥65 age group, living in French-speaking and urban areas, history of smoking, bad self-reported health status, private/semiprivate health insurance, having a medical profession and having any underlying chronic disease.

CONCLUSION

Influenza vaccination coverage was low in older and chronically ill persons. Significant efforts are required in preparing for the influenza season 2020/2021 to reduce the double burden of COVID-19 and seasonal influenza. These efforts should include campaigns but also novel approaches using social media.

Pregnancy as a risk factor for severe coronavirus disease 2019 using standardized clinical criteria

BACKGROUND

As of November 18, 2020, more than 11 million people have been infected with coronavirus disease 2019 and almost 250,000 people have died from the disease in the United States, less than 1 year since its discovery. Although literature is beginning to emerge on pregnancy as a risk factor for severe coronavirus disease 2019, these studies are heterogeneous and use primary outcomes such as intensive care unit admission or hospitalization as surrogate markers that may subject analyses to misclassification bias in pregnant patients.

OBJECTIVE

This study aimed to determine the risk of severe coronavirus disease 2019 among pregnant women with symptomatic coronavirus disease 2019 compared with nonpregnant women using nonadmission-based, standardized clinical criteria for severe disease.

STUDY DESIGN

This is a retrospective cohort study of women aged 13 to 45 years and diagnosed as having symptomatic coronavirus disease 2019 between May 28, 2020, and July 22, 2020. The primary outcome was severe coronavirus disease 2019 as defined by 2 sets of nonadmission-based, clinical criteria: the World Health Organization Ordinal Scale for Clinical Improvement and the Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Adjusted risk ratios were estimated using multivariable logistic regression analyses.

RESULTS

Of 262 women aged 13 to 45 years with symptomatic coronavirus disease 2019, 22 (8.4%) were pregnant and 240 (91.6%) were nonpregnant. After adjusting for covariates potentially associated with the primary outcome, symptomatic pregnant women were at a significantly increased risk of severe coronavirus disease 2019 compared with nonpregnant women using both the World Health Organization Ordinal Scale for Clinical Improvement (adjusted relative risk, 3.59; 95% confidence interval, 1.49–7.01) and Novel Coronavirus Pneumonia Emergency Response Epidemiology Team (adjusted relative risk, 5.65; 95% confidence interval, 1.36–17.31) criteria.

CONCLUSION

Pregnancy significantly increases the risk of severe coronavirus disease 2019 as defined by nonadmission-based, clinical criteria.

Pregnancy and COVID-19

There are many unknowns for pregnant women during the coronavirus disease 2019 (COVID-19) pandemic. Clinical experience of pregnancies complicated with infection by other coronaviruses e.g., Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome, has led to pregnant woman being considered potentially vulnerable to severe SARS-CoV-2 infection. Physiological changes during pregnancy have a significant impact on the immune system, respiratory system, cardiovascular function, and coagulation. These may have positive or negative effects on COVID-19 disease progression. The impact of SARS-CoV-2 in pregnancy remains to be determined, and a concerted, global effort is required to determine the effects on implantation, fetal growth and development, labor, and neonatal health. Asymptomatic infection presents a further challenge regarding service provision, prevention, and management. Besides the direct impacts of the disease, a plethora of indirect consequences of the pandemic adversely affect maternal health, including reduced access to reproductive health services, increased mental health strain, and increased socioeconomic deprivation. In this review, we explore the current knowledge of COVID-19 in pregnancy and highlight areas for further research to minimize its impact for women and their children.

Maternal clinical characteristics and perinatal outcomes among pregnant women with coronavirus disease 2019. A systematic review

OBJECTIVE

To describe the maternal clinical characteristics, maternal and perinatal outcomes in COVID-19-positive pregnant women.

METHODS

Articles in all languages on the SARS-CoV-2 infection in pregnant women were sought from MEDLINE, EMBASE, Cochrane Library and LILACS; China National Knowledge Infrastructure Database (CNKI), Chinese Science and Technology Periodical Database (VIP) and Wan Fang Data between December 1, 2019 and April 27, 2020. Bulletins and national reports were also searched.

RESULTS

From 12,168 retrieved articles, 143 were selected for full-text assessment; 33 for descriptive analyses, and 4 case-controls for meta-analysis. In 322 infected pregnant women, aged 20-45 years, the most frequent maternal comorbidity was obesity (24.2%). Forty-two (28.4%) were asymptomatic at admission. Cough (n = 148,59.7%) and fever (n = 147,59.3%) were the most prevalent symptoms. In the meta-analysis, fever (OR: 0.13,95% CI 0.05 to 0.36) and cough (0.26,95% CI 0.11 to 0.59) were lower in pregnant women with COVID-19 than non-pregnant women with COVID-19.195 (60.6%) delivered, and 125 (38.8%) remained pregnant during the study. Cesarean was reported in 99 (50.8%) women and vaginal delivery in 64 (32.8%). The main adverse obstetric outcome was premature birth (n = 37,18.9%). Thirty patients (10.3%) with COVID-19-related complications required intensive care, one (0.3%) died. SARS-CoV-2 was absent in breast milk, amniotic fluid, placenta or umbilical cord blood.

CONCLUSIONS

The maternal clinical characteristics of COVID-19-positive pregnant include frequently fever and cough; however significantly less frequently than non-pregnant women with COVID-19. Iatrogenic preterm birth is the main adverse obstetric outcome. Current data does not support vertical transmission in the third trimester.

Anxiety and depression symptoms in the same pregnant women before and during the COVID-19 pandemic

Objectives With clinical experience from previous coronavirus infections, public health measures and fear of infection may have negative psychological effects on pregnant women. This study aimed to compare the level of anxiety and depression in the same pregnant women before and during the COVID-19 pandemic. Methods The pregnant women continuing pregnancy who participated in the first study which was undertaken to clarify the factors associated with mental health of pregnant women before the COVID-19 pandemic, were included for the current study during the outbreak. Anxiety and depression symptoms of the same pregnant women were evaluated by using the Inventory of Depression and Anxiety Symptoms II and Beck Anxiety Inventory twice before and during the pandemic. Results A total of 63 pregnant women completed questionnaires. The mean age of the women and the mean gestational age was 30.35±5.27 years and 32.5±7 weeks, respectively. The mean total IDAS II score was found to increase from 184.78±49.67 (min: 109, max: 308) to 202.57±52.90 (min: 104, max: 329) before and during the SARS-CoV-2 pandemic. According to the BAI scores the number of patients without anxiety (from 10 to 6) and with mild anxiety (from 31 to 24) decreased and patients with moderate (from 20 to 25) and severe anxiety (from 2 to 8) increased after SARS-CoV-2 infection. Multivariate linear regression analysis revealed that obesity and relationship with her husband are the best predictors of IDAS II scores. Conclusions This study indicated that COVID-19 outbreak affects the mental health of pregnant women negatively which leads to adverse birth outcomes. The level of anxiety and depression symptoms of pregnant women during the COVID-19 infection significantly increased. Healthcare professionals should establish comprehensive treatment plans for pregnant women who are highly vulnerable population to prevent mental trauma during the infectious disease outbreaks.

Tocilizumab and Remdesivir in a Pregnant Patient With Coronavirus Disease 2019 (COVID-19)

BACKGROUND

There are limited data regarding treatment options for pregnant women with severe coronavirus disease 2019 (COVID-19).

CASE

A 35-year-old primigravid patient at 22 weeks of gestation presented with 7 days of fever, cough, anosmia, and dyspnea. Nasopharyngeal swab was positive for the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and a chest X-ray demonstrated bilateral patchy infiltrates. Laboratory evaluation was notable for marked elevation of interleukin-6 and C-reactive protein concentrations. On hospital day 3, owing to increased dyspnea and oxygen requirement, the patient was treated with tocilizumab followed by 5 days of remdesivir. She responded well, recovered to room air, and was discharged home after a 9-day hospitalization.

CONCLUSION

Tocilizumab and remdesivir may be effective for treatment of severe COVID-19 in pregnancy, but additional data are needed to guide risk-benefit considerations.

Psychological impact of infectious disease outbreaks on pregnant women: rapid evidence review

Objectives

Infectious disease outbreaks can be distressing for everyone, especially those deemed to be particularly vulnerable such as pregnant women, who have been named a high-risk group in the current COVID-19 pandemic. This paper aimed to summarise existing literature on the psychological impact of infectious disease outbreaks on women who were pregnant at the time of the outbreak.

Study design

The design of this study is a rapid review.

Methods

Five databases were searched for relevant literature, and main findings were extracted.

Results

Thirteen articles were included in the review. The following themes were identified: negative emotional states; living with uncertainty; concerns about infection; concerns about and uptake of prophylaxis or treatment; disrupted routines; non-pharmaceutical protective behaviours; social support; financial and occupational concerns; disrupted expectations of birth, prenatal care and postnatal care and sources of information.

Conclusions

Pregnant women have unique needs during infectious disease outbreaks and could benefit from up-to-date, consistent information and guidance; appropriate support and advice from healthcare professionals, particularly with regards to the risks and benefits of prophylaxis and treatment; virtual support groups and designating locations or staff specifically for pregnant women.

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Pregnant women may be particularly susceptible to distress during pandemics.

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Infection fears and prophylaxis concerns may exacerbate distress.

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Disrupted routines, financial concerns and uncertainty are also stressors.

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Disrupted expectations of birth and related healthcare may be distressing.

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Pregnant women may benefit from clear information/guidance and support groups.

Maternal Immunological Adaptation During Normal Pregnancy

The risk and severity of specific infections are increased during pregnancy due to a combination of physiological and immunological changes. Characterizing the maternal immune system during pregnancy is important to understand how the maternal immune system maintains tolerance towards the allogeneic fetus. This may also inform strategies to prevent maternal fatalities due to infections and optimize maternal vaccination to best protect the mother-fetus dyad and the infant after birth. In this review, we describe what is known about the immunological changes that occur during a normal pregnancy.

A Case Report of Vaginal Delivery at Home due to Fear of Covid-19

Introduction: Childbirth can be a normal and nonintervention process, but sometimes the process gets out of normal and requires immediate medical intervention. Thus, home delivery cannot be considered safe without coordination with the treatment staff. Sometimes fear of Covid-19 epidemic prevents mothers to go to the hospital for childbirth and they decide to do it in an unsafe condition, which puts the health of the mother and the neonate at risk. Presentation Case: Our case was a pregnant woman with a negative blood group (A-) who did not come to the hospital because of fear of contracting Covid-19 from the hospital and decided to give birth at home without medical and midwifery support. After giving birth at home, she called the midwife who was taking care of her pregnancy. But she was still afraid to go to the medical center for postpartum care. The midwife informed the mother and her husband that they would be transferred to the midwifery clinic for further care and follow-up, with the necessary counseling and assurance of protective care to control Covid 19 transmission. Conclusion: Counseling and training of protective methods during pregnancy can reduce the concerns of pregnant women. It is also recommended that pregnant women avoid unnecessary travel, public places, use of public transportation and contact with sick people, and most importantly, observe personal and public health issues. Some pregnant women may experience severe anxiety and depression during epidemics such as Covid 19, which require educational psychological counseling and continuous psychological support to prevent unintended consequences.

Innate Immune Responses to Acute Viral Infection During Pregnancy

Immunological adaptations in pregnancy allow maternal tolerance of the semi-allogeneic fetus but also increase maternal susceptibility to infection. At implantation, the endometrial stroma, glands, arteries and immune cells undergo anatomical and functional transformation to create the decidua, the specialized secretory endometrium of pregnancy. The maternal decidua and the invading fetal trophoblast constitute a dynamic junction that facilitates a complex immunological dialogue between the two. The decidual and peripheral immune systems together assume a pivotal role in regulating the critical balance between tolerance and defense against infection. Throughout pregnancy, this equilibrium is repeatedly subjected to microbial challenge. Acute viral infection in pregnancy is associated with a wide spectrum of adverse consequences for both mother and fetus. Vertical transmission from mother to fetus can cause developmental anomalies, growth restriction, preterm birth and stillbirth, while the mother is predisposed to heightened morbidity and maternal death. A rapid, effective response to invasive pathogens is therefore essential in order to avoid overwhelming maternal infection and consequent fetal compromise. This sentinel response is mediated by the innate immune system: a heritable, highly evolutionarily conserved system comprising physical barriers, antimicrobial peptides (AMP) and a variety of immune cells—principally neutrophils, macrophages, dendritic cells, and natural killer cells—which express pattern-receptors that detect invariant molecular signatures unique to pathogenic micro-organisms. Recognition of these signatures during acute infection triggers signaling cascades that enhance antimicrobial properties such as phagocytosis, secretion of pro-inflammatory cytokines and activation of the complement system. As well as coordinating the initial immune response, macrophages and dendritic cells present microbial antigens to lymphocytes, initiating and influencing the development of specific, long-lasting adaptive immunity. Despite extensive progress in unraveling the immunological adaptations of pregnancy, pregnant women remain particularly susceptible to certain acute viral infections and continue to experience mortality rates equivalent to those observed in pandemics several decades ago. Here, we focus specifically on the pregnancy-induced vulnerabilities in innate immunity that contribute to the disproportionately high maternal mortality observed in the following acute viral infections: Lassa fever, Ebola virus disease (EVD), dengue fever, hepatitis E, influenza, and novel coronavirus infections.

Pregnancy-specific transcriptional changes upon endotoxin exposure in mice

Objectives Pregnant women are more susceptible to certain infections; however, this increased susceptibility is not fully understood. Herein, systems biology approaches were utilized to elucidate how pregnancy modulates tissue-specific host responses to a bacterial product, endotoxin. Methods Pregnant and non-pregnant mice were injected with endotoxin or saline on 16.5 days post coitum (n=8-11 per group). The uterus, cervix, liver, adrenal gland, kidney, lung, and brain were collected 12 h after injection and transcriptomes were measured using microarrays. Heatmaps and principal component analysis were used for visualization. Differentially expressed genes between groups were assessed using linear models that included interaction terms to determine whether the effect of infection differed with pregnancy status. Pathway analysis was conducted to interpret gene expression changes. Results We report herein a multi-organ atlas of the transcript perturbations in pregnant and non-pregnant mice in response to endotoxin. Pregnancy strongly modified the host responses to endotoxin in the uterus, cervix, and liver. In contrast, pregnancy had a milder effect on the host response to endotoxin in the adrenal gland, lung, and kidney. However, pregnancy did not drastically affect the host response to endotoxin in the brain. Conclusions Pregnancy imprints organ-specific host immune responses upon endotoxin exposure. These findings provide insight into the host-response against microbes during pregnancy.

COVID-19-related disease severity in pregnancy

The pandemic caused by COVID-19 is affecting populations and healthcare systems worldwide. As we gain experience managing COVID-19, more data become available on disease severity, course, and treatment in patients infected with the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). However, data in pregnancy remain limited. This narrative review of COVID-19 during pregnancy underscores key knowledge gaps in our understanding of the impact of this viral infection on reproductive health. Current data suggest that pregnant people have similar disease course and outcomes compared to nonpregnant people, with the majority experiencing mild disease; however, pregnant people may have increased risk of hospitalization and intensive care unit (ICU) admission. Among patients who develop severe and critical disease, major maternal morbidity and mortality have been described including cardiomyopathy, mechanical ventilation, extracorporeal membrane oxygenation, and death. Many questions remain regarding maternal severity of disease in COVID-19. Further research is needed to better understand disease course in pregnancy. Additionally, the inclusion of pregnant patients in therapeutic trials will provide vital data on treatment options for patients. As we continue to treat more patients affected by SARS-CoV-2, multidisciplinary care and continued research are both needed to achieve optimal outcomes for mother and fetus.

Pregnancy Downregulates Plasmablast Metabolic Gene Expression Following Influenza Without Altering Long-Term Antibody Function

While the majority of influenza-infected individuals show no or mild symptomatology, pregnant women are at higher risk of complications and infection-associated mortality. Although enhanced lung pathology and dysregulated hormones are thought to underlie adverse pregnancy outcomes following influenza infection, how pregnancy confounds long-term maternal anti-influenza immunity remains to be elucidated. Previously, we linked seasonal influenza infection to clinical observations of adverse pregnancy outcomes, enhanced lung and placental histopathology, and reduced control of viral replication in lungs of infected pregnant mothers. Here, we expand on this work and demonstrate that lower infectious doses of the pandemic A/California/07/2009 influenza virus generated adverse gestational outcomes similar to higher doses of seasonal viruses. Mice infected during pregnancy demonstrated lower hemagglutination inhibition and neutralizing antibody titers than non-pregnant animals until 63 days post infection. These differences in humoral immunity suggest that pregnancy impacts antibody maturation mechanisms without alterations to B cell frequency or antibody secretion. This is further supported by transcriptional analysis of plasmablasts, which demonstrate downregulated B cell metabolism and post-translational modification systems only among pregnant animals. In sum, these findings corroborate a link between adverse pregnancy outcomes and severe pathology observed during pandemic influenza infection. Furthermore, our data propose that pregnancy directly confounds humoral responses following influenza infection which resolves post-partem. Additional studies are required to specify the involvement of plasmablast metabolism with early humoral immunity abnormalities to best guide vaccination strategies and improve our understanding of the immunological consequences of pregnancy.

Early Oseltamivir After Hospital Admission Is Associated With Shortened Hospitalization: A 5-Year Analysis of Oseltamivir Timing and Clinical Outcomes

BACKGROUND

Neuraminidase inhibitors (NAIs) are the only effective therapy for influenza, but few studies have assessed the impact of early NAI therapy on clinical outcomes or the patient-level factors that determine early NAI delivery in hospitalized patients.

METHODS

We conducted a retrospective cohort study of all adults hospitalized in a metropolitan tertiary care hospital with confirmed influenza from April 2009 to March 2014. We performed logistic regression to determine patient-level factors that were associated with early NAI therapy. We analyzed the association of early NAI therapy with hospital lengths of stay (LOS) and in-hospital mortality rates using linear and logistic regression, respectively.

RESULTS

In total, 699 patients were admitted with influenza during the 5 influenza seasons. Of those, 582 (83.4%) received NAI therapy; however, only 26.0% received the first dose within 6 hours of hospitalization (early NAI). Patients with diabetes mellitus or pregnancy were more likely to receive early NAI (P = .01, vs. P < .001 in those without these conditions), as were those reporting fever or myalgias at presentation (P = .002, vs. P = .005 without). Immunosuppressed patients were less likely to receive early NAI (P = .04). Early NAI was associated with shorter hospital LOS (P < .001). No patients died in the early NAI group, compared to 18 deaths in the 399 patients receiving NAI after 6 hours (4.5%) and 4 deaths in the 116 patients not receiving NAI (3.4%).

CONCLUSIONS

Over multiple influenza seasons, early NAI therapy was associated with shorter LOS in patients admitted with influenza. This suggests that efforts should focus on facilitating earlier therapy in patients with suspected influenza.

Severe Coronavirus Infections in Pregnancy: A Systematic Review

OBJECTIVE

To inform the current coronavirus disease 2019 (COVID-19) outbreak, we conducted a systematic literature review of case reports of Middle East respiratory syndrome coronavirus (MERS-CoV), severe acute respiratory syndrome coronavirus (SARS-CoV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, during pregnancy and summarized clinical presentation, course of illness, and pregnancy and neonatal outcomes.

DATA SOURCES

We searched MEDLINE and ClinicalTrials.gov from inception to April 23, 2020.

METHODS OF STUDY SELECTION

We included articles reporting case-level data on MERS-CoV, SARS-CoV, and SARS-CoV-2 infection in pregnant women. Course of illness, indicators of severe illness, maternal health outcomes, and pregnancy outcomes were abstracted from included articles.

TABULATION, INTEGRATION, AND RESULTS

We identified 1,328 unique articles, and 1,253 articles were excluded by title and abstract review. We completed full-text review on 75, and 29 articles were excluded by full-text review. Among 46 publications reporting case-level data, eight described 12 cases of MERS-CoV infection, seven described 17 cases of SARS-CoV infection, and 31 described 98 cases of SARS-CoV-2 infection. Clinical presentation and course of illness ranged from asymptomatic to severe fatal disease, similar to the general population of patients. Severe morbidity and mortality among women with MERS-CoV, SARS-CoV, or SARS-CoV-2 infection in pregnancy and adverse pregnancy outcomes, including pregnancy loss, preterm delivery, and laboratory evidence of vertical transmission, were reported.

CONCLUSION

Understanding whether pregnant women may be at risk for adverse maternal and neonatal outcomes from severe coronavirus infections is imperative. Data from case reports of SARS-CoV, MERS-CoV, and SAR-CoV-2 infections during pregnancy are limited, but they may guide early public health actions and clinical decision-making for COVID-19 until more rigorous and systematically collected data are available. The capture of critical data is needed to better define how this infection affects pregnant women and neonates. This review was not registered with PROSPERO.

Pregnancy with COVID-19: Management considerations for care of severe and critically ill cases

Pregnant women are a potentially highly vulnerable population due to anatomical, physiological, and immunological changes under the COVID‐19 pandemic. Issues related to pregnancy with COVID‐19 attracted widespread attention from researchers. A large number of articles were published aiming to elaborate clinical characteristics and outcomes of pregnant women infected with COVID‐19, in order to provide evidence for management. The existing data suggest that the overall prognosis of pregnancy with COVID‐19 is promising when compared with that of other previous coronaviruses. There is still maternal morbidity and mortality related to COVID‐19 reported. However, the optimal management of severe and critically ill cases of COVID‐19–infected pregnancy is poorly clarified. The possibility of postpartum exacerbation in pregnancy with COVID‐19 is also worthy of attention for obstetricians. This review makes further elaboration of the above issues.

Does the human placenta express the canonical cell entry mediators for SARS-CoV-2?

The pandemic of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected more than 10 million people, including pregnant women. To date, no consistent evidence for the vertical transmission of SARS-CoV-2 exists. The novel coronavirus canonically utilizes the angiotensin-converting enzyme 2 (ACE2) receptor and the serine protease TMPRSS2 for cell entry. Herein, building upon our previous single-cell study (Pique-Regi et al., 2019), another study, and new single-cell/nuclei RNA-sequencing data, we investigated the expression of ACE2 and TMPRSS2 throughout pregnancy in the placenta as well as in third-trimester chorioamniotic membranes. We report that co-transcription of ACE2 and TMPRSS2 is negligible in the placenta, thus not a likely path of vertical transmission for SARS-CoV-2. By contrast, receptors for Zika virus and cytomegalovirus, which cause congenital infections, are highly expressed by placental cell types. These data show that the placenta minimally expresses the canonical cell-entry mediators for SARS-CoV-2.

Maternal death due to COVID-19

BACKGROUND

Despite 2.5 million infections and 169,000 deaths worldwide (as of April 20, 2020), no maternal deaths and only a few pregnant women afflicted with severe respiratory morbidity have been reported to be related to COVID-19 disease. Given the disproportionate burden of severe and fatal respiratory disease previously documented among pregnant women following other coronavirus-related outbreaks (SARS-CoV in 2003 and MERS-CoV in 2012) and influenza pandemics over the last century, the absence of reported maternal morbidity and mortality with COVID-19 disease is unexpected.

OBJECTIVE

To describe maternal and perinatal outcomes and death in a case series of pregnant women with COVID-19 disease.

STUDY DESIGN

We describe here a multiinstitution adjudicated case series from Iran that includes 9 pregnant women diagnosed with severe COVID-19 disease in their second or third trimester. All 9 pregnant women received a diagnosis of SARS-CoV-2 infection by reverse transcription polymerase chain reaction nucleic acid testing. Outcomes of these women were compared with their familial/household members with contact to the affected patient on or after their symptom onset. All data were reported at death or after a minimum of 14 days from date of admission with COVID-19 disease.

RESULTS

Among 9 pregnant women with severe COVID-19 disease, at the time of reporting, 7 of 9 died, 1 of 9 remains critically ill and ventilator dependent, and 1 of 9 recovered after prolonged hospitalization. We obtained self-verified familial/household cohort data in all 9 cases, and in each and every instance, maternal outcomes were more severe compared with outcomes of other high- and low-risk familial/household members (n=33 members for comparison).

CONCLUSION

We report herein maternal deaths owing to COVID-19 disease. Until rigorously collected surveillance data emerge, it is prudent to be aware of the potential for maternal death among pregnant women diagnosed as having COVID-19 disease in their second or third trimester.

COVID-19 and preeclampsia with severe features at 34-weeks gestation

The evolving coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a rapid expansion of knowledge on the disease's clinical manifestations, laboratory and radiographic abnormalities, and patient trajectories. One area of particular focus is the effect that this illness may have on pregnancy and maternal-fetal disease. As of April 24, 2020, we identified 55 English language reports in the scientific literature summarizing data for 339 women and 258 fetuses and neonates. The majority of these data have focused on maternal-fetal transmission and neonatal outcomes. One systematic review and meta-analysis including the spectrum of coronaviruses [Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and COVID-19] in pregnancy noted increased rates of adverse outcomes associated with this group of infections. Here, we report the case of a COVID-19 positive woman presenting to our emergency department (ED) at 34 weeks gestation with preeclampsia. This case highlights the unique diagnostic and therapeutic challenges associated with treating patients with these concomitant diseases.

Covid-19: The time to shield all pregnant frontline workers is now

Recent outbreaks of influenza, Ebola, and Zika viruses have taught us that pregnant women are uniquely vulnerable to emerging infectious threats. Let’s not fail pregnant frontline workers during the covid-19 pandemic.

Infección por SARS-CoV-2 en la paciente obstétrica: una perspectiva desde el cuidado crítico

La nueva infección por coronavirus (COVID-19) se constituye en el principal problema de salud pública en el mundo. Entre el 5 y el 30% de los pacientes afectados por esta enfermedad requieren manejo en una unidad de cuidado intensivo. Se han generado diferentes publicaciones con recomendaciones para la población general. Sin embargo, en la población obstétrica la evidencia científica es reducida, aún más cuando se trata de infección por COVID-19 en escenarios de cuidado intensivo obstétrico. Por esta razón, se realizó una revisión narrativa no sistemática de la literatura utilizando como fuente de información MEDLINE, sociedades científicas y los repositorios de la Organización Mundial de la Salud y el Ministerio de Salud y Protección Social de Colombia, con el objetivo de describir algunas sugerencias para el manejo de una paciente embarazada con COVID-19 en una unidad de cuidado intensivo. Se resalta que la atención debe ser realizada por un equipo interdisciplinario, bajo monitorización materna y fetal cuando corresponda, vigilando los niveles de saturación de oxígeno y la hemodinamia materna para minimizar la hipoxemia fetal. Se describen recomendaciones sobre algunos tópicos relevantes en el escenario crítico, como la intubación oportuna, la utilización adecuada de los equipos de protección personal (EPP), el manejo de la falla circulatoria, las estrategias restrictivas de fluidos y/o vasopresores, entre otros.

Nucleic Acid-Based Screening of Maternal Serum to Detect Viruses in Women with Labor or PROM

The purpose of this study was to determine whether timing of the initiating event of spontaneous labor (either uterine contractions with intact fetal membranes or rupture of membranes prior to labor (PROM)) is associated with maternal viral infection. It was a prospective case control study of women with either spontaneous labor or PROM occurring < 37 weeks' gestation ("cases") or at term ("controls"). An initial unbiased screen for viruses was performed with next-generation sequencing (NGS) in serum pooled from eight cases delivered by C/S and represents a range of gestational ages, membrane rupture status, and presence or absence of chorioamnionitis. Custom PCR was used to query individual patient samples from the original cohort. The NGS screen generated 15 million reads. Seven unique viral sequences were detected in two cases, all identified as torque teno virus (TTV), an ubiquitous DNA anellovirus of no known pathogenicity. Using nested and semi-nested PCR, sera from 72 patients (47 cases and 25 matched controls, stratified by ROM status) were screened for the 3 subtypes of anelloviruses (TTV, TTMDV, or TTMV). These were found in 43/47 cases (91%) and 16/25 controls (64%) (p = 0.012, OR = 5.9 (95% CI = 1.4-29.9)). In logistic regression, pregnant women with at least one type of anellovirus were more likely to experience preterm labor than those with no anellovirus (p = 0.03, aOR = 4.6, CI = 1.2-18.7). Among women experiencing a spontaneous initiating event of labor, TTV virus was more likely to be present in the serum of preterm than term patients. TTV may have a role in determining the timing of parturition.

The effectiveness of influenza vaccination in pregnancy in relation to child health outcomes: Systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of influenza vaccination during pregnancy on child health outcomes.

DESIGN

Systematic review/meta-analysis.

DATA SOURCES

Clinical Trials.gov, Cochrane Library, EMBASE, Medline, Medline in process, PubMed and Web of Science, from 1st January 1996 to 29th June 2018. An updated Medline search was performed 30th June 2018 to 31st October 2019.

METHODS

Randomised controlled trials (RCTs) and observational studies reporting health outcomes of infants and children born to women who received inactivated influenza vaccine during pregnancy. The primary outcome was infant laboratory confirmed influenza (LCI). Secondary outcomes included influenza-like illness (ILI), other respiratory illnesses, primary care, clinic visit or hospitalisations due to influenza illness and long-term respiratory childhood outcomes.

RESULTS

19 studies were included; 15 observational studies and 4 primary RCTs with an additional 3 papers reporting secondary outcomes of these RCTs. In a random effects meta-analysis of 2 RCTs including 5742 participants, maternal influenza vaccination was associated with an overall reduction of LCI in infants of 34% (95% confidence interval 15-50%). However, there was no effect of maternal influenza vaccination on ILI in infants ≤6 months old. Two RCTs were excluded from the meta-analysis for the outcome of LCI in infants (different controls used). Both of these studies showed a protective effect for infants from LCI, with a vaccine efficacy of up to 70%. Overall observational studies showed an inverse (protective) association between maternal influenza vaccination and infant LCI, hospitalisation and clinic visits due to LCI or ILI in infants and other respiratory illness in infants ≤6 months old.

CONCLUSIONS

This systematic review supports maternal influenza vaccination as a strategy to reduce LCI and influenza-related hospitalisations in young infants. Communicating these benefits to pregnant women may support their decision to accept influenza vaccination in pregnancy and increase vaccine coverage in pregnant women.

REGISTRATION

PROSPERO CRD42018102776.

Vaccinating pregnant women against influenza needs to be a priority for all countries: An expert commentary

BACKGROUND

In 2012, the World Health Organization recommended influenza vaccination for all pregnant women worldwide and the prioritisation of pregnant women in national influenza vaccination programmes. Nevertheless, vaccination rates in pregnant women often remain much lower than national targets.

OBJECTIVES

To assess the benefits and risks associated with influenza infection and vaccination during pregnancy, and to consider obstacles that work against influenza vaccine uptake during pregnancy.

RESULTS

There is strong evidence that maternal and foetal outcomes can be compromised if women develop influenza infections during pregnancy. Influenza vaccines have been administered to millions of pregnant women and have demonstrated benefits in terms of disease prevention in mothers and their infants. There is a consensus amongst several recommending authorities that influenza vaccines may be safely administered during all stages of pregnancy. Healthcare professionals are recognised as the most important influencers of vaccine uptake, being well placed to recommend vaccination and directly address safety concerns.

CONCLUSIONS

Despite data supporting the value of influenza vaccination during pregnancy, vaccine uptake remains low globally. Low uptake appears to be largely due to ineffective communication with pregnant women about the risks and benefits of influenza vaccination. A graphical abstract is available online.

Inactivated influenza vaccine and spontaneous abortion in the Vaccine Safety Datalink in 2012-13, 2013-14, and 2014-15

Introduction:

A recent study reported an association between inactivated influenza vaccine (IIV) and spontaneous abortion (SAB), but only among women who had also been vaccinated in the previous influenza season. We sought to estimate the association between IIV administered in three recent influenza seasons and SAB among women who were and were not vaccinated in the previous influenza season.

Methods:

We conducted a case-control study over three influenza seasons (2012–13, 2013–14, 2014–15) in the Vaccine Safety Datalink (VSD). Cases (women with SAB) and controls (women with live births) were matched on VSD site, date of last menstrual period, age group, and influenza vaccination status in the previous influenza season. Of 1908 presumptive cases identified from the electronic record, 1236 were included in the main analysis. Administration of IIV was documented in several risk windows, including 1–28, 29–56, and >56 days before the SAB date.

Results:

Among 627 matched pairs vaccinated in the previous season, no association was found between vaccination in the 1–28 day risk window and SAB (adjusted odds ratio (aOR) 0.9; 95% confidence interval (CI) 0.6–1.5). The season-specific aOR ranged from 0.5 to 1.7 with all CIs including the null value of 1.0. Similarly, no association was found among women who were not vaccinated in the previous season; the season-specific aOR in the 1–28 day risk window ranged from 0.6 to 0.7 and the 95% CI included 1.0 in each season. There was no association found between SAB and influenza vaccination in the other risk windows, or when vaccine receipt was analyzed relative to date of conception.

Conclusion:

During these seasons we found no association between IIV and SAB, including among women vaccinated in the previous season. These findings lend support to current recommendations for influenza vaccination at any time during pregnancy, including the first trimester.

Determinants of influenza and pertussis vaccine uptake in pregnant women in Ireland: A cross-sectional survey in 2017/18 influenza season

In Ireland seasonal influenza and pertussis vaccination during pregnancy is recommended and every year national campaigns are organised to raise awareness and improve uptake. We estimated influenza and pertussis vaccine uptake and identified factors associated with vaccination status in pregnant women in 2017/18. We conducted a face-to-face omnibus survey, with quota sampling, among women aged 18-55 years and collected socio-demographic characteristics, self-reported vaccination status, awareness of vaccine campaigns, and attitudes towards vaccination. Sample was weighted to ensure representativeness with the target population. We performed univariate and multivariable logistic regression analyses on survey data. Overall, 241 pregnant women were enrolled. Influenza and pertussis vaccine uptake was 61.7% and 49.9%, respectively. Awareness of vaccine campaign and socio-economic status (SES) were associated with both influenza and pertussis vaccine uptake. The association between SES and uptake of vaccines differed by awareness. Women aware of the influenza vaccine campaign and with mid and low SES were less likely to be vaccinated, compared to those with high SES (aOR = 0.46; 95%CI: 0.22-0.97; aOR = 0.27; 95%CI: 0.12-0.60, respectively); women not aware of the pertussis vaccine campaign and with mid and low SES were less likely to be vaccinated, compared to those aware and with high SES (aOR = 0.15; 95%CI: 0.04-0.48; aOR = 0.05; 95%CI: 0.01-0.24, respectively). General practitioner (GP) recommendation was the main reason for receiving influenza vaccine (39.2%), and 71.8% of women were recommended pertussis vaccination from their GPs. The survey reports moderate uptake of vaccines among pregnant women, inequalities in uptake by SES and identifies GPs as primary source for vaccine recommendation. We recommend multifaceted campaigns, by engaging GPs, to target all socio-economic groups.

Oseltamivir use in pregnancy: Risk of birth defects, preterm delivery, and small for gestational age infants

BACKGROUND

Influenza infection during pregnancy increases risks for adverse outcomes for both mother and fetus. For this reason, treatment for infection or postexposure prophylaxis with a neuraminidase inhibitor, such as oseltamivir, may be needed.

METHODS

Between 2009 and 2017, the Organization of Teratology Information Specialists (OTIS) MotherToBaby Pregnancy Studies enrolled pregnant women in the United States and Canada who were or were not treated with oseltamivir in a prospective cohort study. Data were collected on major birth defects, spontaneous abortion, preterm delivery, and small for gestational age birth size. Crude relative risks (RRs) or hazard ratios (HRs) were estimated together with 95% confidence intervals (CIs) for these outcomes.

RESULTS

There were 716 subjects available for analysis; 112 were exposed to oseltamivir sometime in pregnancy and 604 were unexposed. 2/30 (6.7%) first-trimester-exposed pregnancies resulted in a fetus or infant with one or more major birth defects compared to 48/604 (7.9%) in the unexposed cohort (RR 0.84, 95% CI 0.19, 2.80). There were no spontaneous abortions reported. Risk of preterm delivery was not elevated in exposed versus comparison women (HR 0.65, 95% CI 0.26, 1.63). RRs for small for gestational age infants on weight, length, and head circumference following oseltamivir exposure anytime in pregnancy ranged from 0.70 to 1.30 with all 95% CIs including 1.

CONCLUSION

We found no evidence of increased risks with oseltamivir for any of the outcomes evaluated. While numbers are small, these data are reassuring for pregnant women who need to be treated for infection or for postexposure prophylaxis.

Why Should We Advocate Maternal Immunization?

Maternal vaccination provides a method for protecting the pregnant woman, fetus and neonate during a period when there is increased susceptibility to infectious diseases. A dynamic state of immune tolerance during pregnancy and the need to develop adaptive memory to a new foreign antigen-rich environment lead to windows of vulnerability to infection for the mother and neonate, respectively. Passive transfer of humoral immunity through the placenta and breast milk from the mother can bridge the gap in immunity for the neonate. Studies on boosting this natural process of antibody transfer have led to the recommendation for administering inactivated influenza, diphtheria, tetanus toxoid and acellular pertussis vaccines during pregnancy. Several new maternal vaccine candidates are on the horizon.

Influenza and pertussis vaccination of women during pregnancy in Victoria, 2015-2017

OBJECTIVES

To assess variations by time of year and hospital in the uptake of influenza and pertussis vaccinations by pregnant women in Victoria; to identify factors associated with vaccination uptake.

DESIGN, SETTING

Retrospective analysis of data in the Victorian Perinatal Data Collection (VPDC), a population surveillance system for obstetric conditions, procedures, and pregnancy and birth outcomes.

PARTICIPANTS

Women whose pregnancies ended in a live or stillbirth during July 2015 - June 2017.

MAIN OUTCOME MEASURES

Influenza and pertussis vaccinations during pregnancy.

RESULTS

153 980 pregnancies in 67 hospitals ended during July 2015 - June 2017; 59 968 pregnant women (39.0%) were vaccinated against influenza and 98 583 (64.0%) against pertussis. Coverage varied by pregnancy end date, rising for influenza during winter and spring, but for pertussis rising continuously across the two years from 37.5% to 82.2%. Differences between hospitals in coverage were marked. Factors associated with vaccination included greater maternal age, primigravidity, early antenatal care, and GP-led care. The odds of vaccination were statistically significantly lower for women born overseas and those who smoked during pregnancy; the odds of vaccination were also lower for Aboriginal and Torres Strait Islander women.

CONCLUSIONS

Pertussis vaccination of pregnant women in Victoria has increased, but influenza vaccination rates remain moderate and variable. Structural changes at the system level may improve maternal vaccination rates. Embedding the delivery of maternal vaccination programs in antenatal care pathways should be a priority.

Progress and Remaining Gaps in Estimating the Global Disease Burden of Influenza

Influenza has long been a global public health priority because of the threat of another global pandemic. Although data are available for the annual burden of seasonal influenza in many developed countries, fewer disease burden data are available for low-income and tropical countries. In recent years, however, the surveillance systems created as part of national pandemic preparedness efforts have produced substantial data on the epidemiology and impact of influenza in countries where data were sparse. These data are leading to greater interest in seasonal influenza, including implementation of vaccination programs. However, a lack of quality data on severe influenza, nonrespiratory outcomes, and high-risk groups, as well as a need for better mathematical models and economic evaluations, are some of the major gaps that remain. These gaps are the focus of multilateral research and surveillance efforts that will strengthen global efforts in influenza control in the future.

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

Influenza vaccination of pregnant women: Engaging clinicians to reduce missed opportunities for vaccination

BACKGROUND

Antenatal influenza vaccination (AIV) is an effective intervention for protecting pregnant women and their newborns against influenza. Although the World Health Organization recommends AIV at any stage of pregnancy, in low- and middle-income countries, including India, it is rarely provided. Research suggests that antenatal care (ANC) provider practices explain much of this limited coverage. Our study in urban Pune, India, assessed the feasibility of a two-stage clinician-engagement strategy to reduce missed opportunities for AIV in urban private-practice ANC clinics.

METHODS

Clinicians were randomized to intervention and control groups in slum and middle-class study sites. Intervention-group clinicians (active clinicians) were assessed on vaccination-related views and practices, and were presented with authoritative AIV recommendations from global, academic and professional medical organizations. In a second meeting after a community survey, findings concerning vaccination-related views and experiences were explained to active clinicians. Assessments of community vaccination views were not provided to control-group clinicians. Both groups maintained logs of ANC clinic visit vaccination status throughout the 11-month study period to enable identification of missed and taken opportunities for vaccination. Analyses were restricted to visits of women in their third trimester without previous AIV in the current pregnancy.

RESULTS

Overall, 30 clinicians participated. After first and second interactions, active clinicians in middle-class communities vaccinated at 12.2% and 37.8%, respectively. Middle-class control clinicians vaccinated at <0.2% throughout the study. This difference in AIV taken opportunities between middle-class active and control clinics was statistically significant (p < 0.05) after first and second interactions. In slum-community sites, active clinicians' AIV activity was minimal throughout.

CONCLUSIONS

Our approach for engaging clinicians effectively reduced missed opportunities for AIV in urban middle-class settings of Pune. It may also improve maternal vaccination for other conditions. The absence of any similar effect in slum-based clinics likely reflects critical limitations of vaccine access.

Adherence and Concordance of Influenza and Pertussis Vaccination Coverage in Pregnant Women in Spain

Background: Pregnant women should receive two vaccines during pregnancy due to maternal-foetal complications and risks as well as the influenza and pertussis vaccinations. The goal was to evaluate vaccination coverage against influenza and pertussis in pregnant women, following midwife professional advice during the pregnancy follow-up; Methods: Prospective cohort study of 1017 pregnancies during the vaccination campaign in 2015⁻2016. To estimate the degree of consistency between the coverage declared by mothers and that registered in the Nominal Vaccination Registry (NVR), we used the Cohen's kappa index (k); Results: 95.4% were registered in the NVR. Vaccination coverage recorded against influenza was 64.2% (95% CI: 61.2⁻67.2), and 89.8% (95% CI: 87.9⁻91.7) against pertussis. The coverage of the pregnant women interviewed was 61.7% (95% CI: 58.1⁻67.3)) for influenza and 92.3% (95% CI: 91.4⁻95.3) for pertussis. Subsequent interviews of 67.2% of the women produced a kappa agreement index between the data obtained from interviews and those recorded in the NVR of 0.974 (IC95%: 98.0⁻99.6) for influenza, and 0.921 (IC95%: 98.1⁻99.7) for pertussis. The women identified midwives as the main source of vaccination information and advice 88.4% (IC95%: 85.8⁻90.9); Conclusions: The NVR is an effective platform for estimating immunisation coverage in pregnant women. The degree of agreement between declared vaccinations and registered vaccinations was high for both vaccines.

Key considerations for successful implementation of maternal immunization programs in low and middle income countries

The Maternal Neonatal Tetanus Elimination program is proof of concept for the feasibility and potential for maternal immunization to reduce neonatal mortality particularly in low and middle-income countries. Introduction of any additional vaccine into the antenatal space, such as Influenza and Pertussis, and potentially Respiratory Syncytial Virus and Group B Streptococcus vaccines in the future, requires strengthening of antenatal care and immunization services. Successful implementation also requires robust disease surveillance in pregnant women and neonates and active surveillance for adverse events following immunization to monitor the impact and ensure the safe use of the vaccine. This review outlines five key elements essential for successful implementation of a maternal immunization program focusing particularly on low and middle-income countries. These include; relevant considerations in supporting a decision to undertake a maternal immunization program including knowledge of local disease epidemiology, involvement of the consumer, healthcare provider recommendation, equitable access to maternal vaccination, and systems for disease surveillance, program evaluation and safety monitoring.

Outcomes of infants born to women with influenza A(H1N1)pdm09

BACKGROUND

Pregnant women with influenza are more likely to have complications, but information on infant outcomes is limited.

METHODS

Five state/local health departments collected data on outcomes of infants born to pregnant women with 2009 H1N1 influenza reported to the Centers for Disease Control and Prevention from April to December 2009. Collaborating sites linked information on pregnant women with confirmed 2009 H1N1 influenza, many who were severely ill, to their infants' birth certificates. Collaborators also collected birth certificate data from two comparison groups that were matched with H1N1-affected pregnancies on month of conception, sex, and county of residence.

RESULTS

490 pregnant women with influenza, 1,451 women without reported influenza with pregnancies in the same year, and 1,446 pregnant women without reported influenza with prior year pregnancies were included. Women with 2009 H1N1 influenza admitted to an intensive care unit (ICU; n = 64) were more likely to deliver preterm infants (<37 weeks), low birth weight infants, and infants with Apgar scores <=6 at 5 min than women in comparison groups (adjusted relative risk, aRR = 3.9 [2.7, 5.6], aRR = 4.6 [2.9, 7.5], and aRR = 8.7 [3.6, 21.2], for same year comparisons, respectively). Women with influenza who were not hospitalized and hospitalized women not admitted to the ICU did not have significantly elevated risks for adverse infant outcomes.

CONCLUSIONS

Severely ill women with 2009 H1N1 influenza during pregnancy were more likely to have adverse birth outcomes than women without influenza, providing more support for influenza vaccination during pregnancy.

Antibody levels in a cohort of pregnant women after the 2009 influenza A(H1N1) pandemic: Waning and association with self-reported severity and duration of illness

BACKGROUND

A population-based pregnancy cohort was established in Norway to study potential effects of exposure to the 2009 influenza pandemic or pandemic vaccination during pregnancy.

OBJECTIVES

We studied maternal A(H1N1)pdm09-specific hemagglutination inhibition (HI)-titer levels and waning in women with influenza-like illness (ILI) in pregnancy compared to vaccinated women. Moreover, we studied the association between HI-titers and self-reported severity and duration of ILI.

METHODS

HI-titers against the pandemic virus were measured in maternal blood samples obtained at birth, 3-9 months after exposure, and linked with information about pregnancy, influenza and vaccination from national registries and a cohort questionnaire.

RESULTS

Among 1821 pregnant women included, 43.7% were unvaccinated and 19.3% of these had ILI. HI-titers were low (geometric mean titer (GMT) 11.3) in the unvaccinated women with ILI. Higher HI-titers (GMT 37.8) were measured in the vaccinated women. Estimated HI-titer waning was similar for vaccinated women and women with ILI. Most ILI episodes were moderate and lasted 3-5 days. Women with ILI reporting specific influenza symptoms such as fever or cough had higher HI-titers than women without these symptoms. Women who reported being "very ill" or illness duration of >5 days had higher HI-titers than women reporting less severe illness or illness of shorter duration, respectively.

CONCLUSIONS

Antibody waning was similar in vaccinated women and women with ILI. More severe ILI or longer duration of illness was associated with higher HI-titers. Most unvaccinated pregnant women with ILI had low HI-titers, probably due to moderate illness and HI-titer waning between exposure and sampling.

Short-Term Birth Sequelae of the 1918-1920 Influenza Pandemic in the United States: State-Level Analysis

This paper examines short-term birth sequelae of the influenza pandemic of 1918-1920 in the United States using monthly data on births and all-cause deaths for 19 US states in conjunction with data on maternal deaths, stillbirths, and premature births. The data on births and all-cause deaths are adjusted for seasonal and trend effects, and the residual components of the 2 time series coinciding with the timing of peak influenza mortality are examined for these sequelae. Notable findings include: 1) a drop in births in the 3 months following peak mortality; 2) a reversion in births to normal levels occurring 5-7 months after peak mortality; and 3) a steep drop in births occurring 9-10 months after peak mortality. Interpreted in the context of parallel data showing elevated premature births, stillbirths, and maternal mortality during times of peak influenza mortality, these findings suggest that the main impacts of the 1918-1920 influenza on reproduction occurred through: 1) impaired conceptions, possibly due to effects on fertility and behavioral changes; 2) an increase in the preterm delivery rate during the peak of the pandemic; and 3) elevated maternal and fetal mortality, resulting in late-term losses in pregnancy.

Rift Valley fever virus induces fetal demise in Sprague-Dawley rats through direct placental infection

Rift Valley fever virus (RVFV) infections in pregnant livestock cause high rates of fetal demise; miscarriage in pregnant women has also been associated with RVFV infection. To address how RVFV infection during pregnancy causes detrimental effects on the fetus, we developed a pregnant rodent model of RVFV infection. We found that pregnant rats were more susceptible to RVFV-induced death than their nonpregnant counterparts and that RVFV infection resulted in intrauterine fetal death and severe congenital abnormalities, even in pups from infected asymptomatic pregnant rats. Virus distribution in infected dams was widespread, with a previously unrecognized preference for infection, replication, and tissue damage in the placenta. In human mid-gestation placental tissue, RVFV directly infected placental chorionic villi, with replication detected in the outermost syncytial layer. Our work identifies direct placental infection by RVFV as a mechanism for vertical transmission. This is the first study to show vertical transmission of RVFV with a lethal outcome in a species other than livestock. This study highlights the potential impact of a future epidemic of this emerging mosquito-borne virus.

Oseltamivir in pregnancy and birth outcomes

Background

Prenatal exposure to influenza or fever is associated with risk of congenital malformations. Oseltamivir is used to treat influenza and to provide post-exposure prophylaxis. We examined the association between oseltamivir use during pregnancy and birth outcomes.

Methods

This was a nationwide registry-based prevalence study with individual level data linkage, in a setting of universal health care access. We included all recorded pregnancies in Denmark in 2002–2013, and used data from population registries to examine associations between dispensings for oseltamivir during pregnancy (first trimester, second/third trimester, none) and congenital malformations, foetal death, preterm birth, foetal growth, and low 5-min Apgar score. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed using propensity score matching.

Results

The study included 946,176 pregnancies. Of these, 449 had first-trimester exposure and 1449 had second/third-trimester exposure to oseltamivir. Adjusted ORs following first-trimester exposure were 0.94 (95% CI 0.49 to 1.83) for any major congenital malformation and 1.75 (95% CI 0.51 to 5.98) for congenital heart defects, based on 7 exposed cases. The association with congenital heart defects was present for etiologically implausible exposure periods and for known safe exposures. There was no evidence of an association between prenatal exposure to oseltamivir and any of the other birth outcomes assessed.

Conclusions

The study does not provide evidence of risk associated with oseltamivir treatment additional to that associated with influenza infection.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3423-z) contains supplementary material, which is available to authorized users.