1
|
Nham E, Noh JY, Park O, Choi WS, Song JY, Cheong HJ, Kim WJ. COVID-19 Vaccination Strategies in the Endemic Period: Lessons from Influenza. Vaccines (Basel) 2024; 12:514. [PMID: 38793765 PMCID: PMC11125835 DOI: 10.3390/vaccines12050514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a highly contagious zoonotic respiratory disease with many similarities to influenza. Effective vaccines are available for both; however, rapid viral evolution and waning immunity make them virtually impossible to eradicate with vaccines. Thus, the practical goal of vaccination is to reduce the incidence of serious illnesses and death. Three years after the introduction of COVID-19 vaccines, the optimal vaccination strategy in the endemic period remains elusive, and health authorities worldwide have begun to adopt various approaches. Herein, we propose a COVID-19 vaccination strategy based on the data available until early 2024 and discuss aspects that require further clarification for better decision making. Drawing from comparisons between COVID-19 and influenza vaccination strategies, our proposed COVID-19 vaccination strategy prioritizes high-risk groups, emphasizes seasonal administration aligned with influenza vaccination campaigns, and advocates the co-administration with influenza vaccines to increase coverage.
Collapse
Affiliation(s)
- Eliel Nham
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (E.N.); (J.Y.N.); (O.P.); (W.S.C.); (J.Y.S.); (H.J.C.)
- Vaccine Innovation Center, Korea University, Seoul 02841, Republic of Korea
| | - Ji Yun Noh
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (E.N.); (J.Y.N.); (O.P.); (W.S.C.); (J.Y.S.); (H.J.C.)
- Vaccine Innovation Center, Korea University, Seoul 02841, Republic of Korea
| | - Ok Park
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (E.N.); (J.Y.N.); (O.P.); (W.S.C.); (J.Y.S.); (H.J.C.)
- Vaccine Innovation Center, Korea University, Seoul 02841, Republic of Korea
| | - Won Suk Choi
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (E.N.); (J.Y.N.); (O.P.); (W.S.C.); (J.Y.S.); (H.J.C.)
- Vaccine Innovation Center, Korea University, Seoul 02841, Republic of Korea
| | - Joon Young Song
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (E.N.); (J.Y.N.); (O.P.); (W.S.C.); (J.Y.S.); (H.J.C.)
- Vaccine Innovation Center, Korea University, Seoul 02841, Republic of Korea
| | - Hee Jin Cheong
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (E.N.); (J.Y.N.); (O.P.); (W.S.C.); (J.Y.S.); (H.J.C.)
- Vaccine Innovation Center, Korea University, Seoul 02841, Republic of Korea
| | - Woo Joo Kim
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (E.N.); (J.Y.N.); (O.P.); (W.S.C.); (J.Y.S.); (H.J.C.)
- Vaccine Innovation Center, Korea University, Seoul 02841, Republic of Korea
| |
Collapse
|
2
|
Lapinsky SE, Vasquez DN. Acute Respiratory Failure in Pregnancy. Crit Care Clin 2024; 40:353-366. [PMID: 38432700 DOI: 10.1016/j.ccc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Respiratory failure may affect up to 1 in 500 pregnancies, due to pregnancy-specific conditions, conditions aggravated by the pregnant state, or other causes. Management during pregnancy is influenced by altered maternal physiology, and the presence of a fetus influencing imaging, and drug therapy choices. Few studies have addressed the approach to invasive mechanical ventilatory management in pregnancy. Hypoxemia is likely harmful to the fetus, but precise targets are unknown. Hypocapnia reduces uteroplacental circulation, and some degree of hypercapnia may be tolerated in pregnancy. Delivery of the fetus may be considered to improve maternal respiratory status but improvement does not always occur.
Collapse
Affiliation(s)
- Stephen E Lapinsky
- Mount Sinai Hospital, Toronto, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue, Toronto M5G1X5, Canada.
| | - Daniela N Vasquez
- ICU Head of Department, Sanatorio Anchorena, Tomás M. de Anchorena 1872, City of Buenos Aires, Argentina
| |
Collapse
|
3
|
Yates EF, Mulkey SB. Viral infections in pregnancy and impact on offspring neurodevelopment: mechanisms and lessons learned. Pediatr Res 2024:10.1038/s41390-024-03145-z. [PMID: 38509227 DOI: 10.1038/s41390-024-03145-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 03/22/2024]
Abstract
Pregnant individuals with viral illness may experience significant morbidity and have higher rates of pregnancy and neonatal complications. With the growing number of viral infections and new viral pandemics, it is important to examine the effects of infection during pregnancy on both the gestational parent and the offspring. Febrile illness and inflammation during pregnancy are correlated with risk for autism, attention deficit/hyperactivity disorder, and developmental delay in the offspring in human and animal models. Historical viral epidemics had limited follow-up of the offspring of affected pregnancies. Infants exposed to seasonal influenza and the 2009 H1N1 influenza virus experienced increased risks of congenital malformations and neuropsychiatric conditions. Zika virus exposure in utero can lead to a spectrum of abnormalities, ranging from severe microcephaly to neurodevelopmental delays which may appear later in childhood and in the absence of Zika-related birth defects. Vertical infection with severe acute respiratory syndrome coronavirus-2 has occurred rarely, but there appears to be a risk for developmental delays in the infants with antenatal exposure. Determining how illness from infection during pregnancy and specific viral pathogens can affect pregnancy and neurodevelopmental outcomes of offspring can better prepare the community to care for these children as they grow. IMPACT: Viral infections have impacted pregnant people and their offspring throughout history. Antenatal exposure to maternal fever and inflammation may increase risk of developmental and neurobehavioral disorders in infants and children. The recent SARS-CoV-2 pandemic stresses the importance of longitudinal studies to follow pregnancies and offspring neurodevelopment.
Collapse
Affiliation(s)
- Emma F Yates
- Frank H. Netter School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Sarah B Mulkey
- Children's National Hospital, Washington, DC, USA.
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| |
Collapse
|
4
|
Kortsmit K, Oduyebo T, Simeone RM, Kahn KE, Razzaghi H, Galang RR, Ellington S, Ruffo N, Barfield WD, Warner L, Cox S. Influenza and Tetanus, Diphtheria, and Acellular Pertussis Vaccination Coverage During Pregnancy: Pregnancy Risk Assessment Monitoring System, 2020. Public Health Rep 2024; 139:218-229. [PMID: 37386826 PMCID: PMC10851903 DOI: 10.1177/00333549231179252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
OBJECTIVES Estimates of vaccination coverage during pregnancy and identification of disparities in vaccination coverage can inform vaccination campaigns and programs. We reported the prevalence of being offered or told to get the influenza vaccine by a health care provider (hereinafter, provider); influenza vaccination coverage during the 12 months before delivery; and tetanus, diphtheria, and acellular pertussis (Tdap) vaccination coverage during pregnancy among women with a recent live birth in the United States. METHODS We analyzed 2020 data from the Pregnancy Risk Assessment Monitoring System from 42 US jurisdictions (n = 41 673). We estimated the overall prevalence of being offered or told to get the influenza vaccine by a provider and influenza vaccination coverage during the 12 months before delivery. We estimated Tdap vaccination coverage during pregnancy from 21 jurisdictions with available data (n = 22 020) by jurisdiction and select characteristics. RESULTS In 2020, 84.9% of women reported being offered or told to get the influenza vaccine, and 60.9% received it, ranging from 35.0% in Puerto Rico to 79.7% in Massachusetts. Influenza vaccination coverage was lower among women who were not offered or told to get the influenza vaccine (21.4%) than among women who were offered or told to get the vaccine (68.1%). Overall, 72.7% of women received the Tdap vaccine, ranging from 52.8% in Mississippi to 86.7% in New Hampshire. Influenza and Tdap vaccination coverage varied by all characteristics examined. CONCLUSIONS These results can inform vaccination programs and strategies to address disparities in vaccination coverage during pregnancy and may inform vaccination efforts for other infectious diseases among pregnant women.
Collapse
Affiliation(s)
- Katherine Kortsmit
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Titilope Oduyebo
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Regina M. Simeone
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Katherine E. Kahn
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Leidos, Atlanta, GA, USA
| | - Hilda Razzaghi
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Romeo R. Galang
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sascha Ellington
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nan Ruffo
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Full Circle Computing, Inc, Exton, PA, USA
| | - Wanda D. Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lee Warner
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|
5
|
Sohn Y, Choi HK, Yun J, Kim EH, Kim YK. Clinical Characteristics and Risk of Hypoxemia Development in Women Infected with SARS-CoV-2 during Pregnancy. Yonsei Med J 2024; 65:27-33. [PMID: 38154477 PMCID: PMC10774648 DOI: 10.3349/ymj.2023.0270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 12/30/2023] Open
Abstract
PURPOSE There is limited information on the clinical characteristics and prognosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy. The clinical features and risk factors for hypoxemia development were investigated in pregnant women with coronavirus disease-2019 (COVID-19). MATERIALS AND METHODS From August 2020 to February 2022, we performed a retrospective cohort study of 410 pregnant women with COVID-19. The clinical characteristics and prognoses were compared between pregnant COVID-19 patients requiring oxygen and those who did not. RESULTS Of 410 patients, 100 (24.4%) required oxygen therapy. Among them, fever [163 (52.6%) vs. 81 (81.0%), p<0.001] and cough [172 (56.4%) vs. 73 (73.0%), p=0.003] were more frequently observed than in non-oxygen group. The proportion of unvaccinated women was higher in oxygen group than in non-oxygen group [264 (85.2%) vs. 98 (98.0%), p=0.003]. During the Omicron wave, patients were more likely to have no oxygen requirement [98 (31.6%) vs. 18 (18.0%), p=0.009]. The risk of hypoxemic respiratory difficulty increased if SARS-CoV-2 infection occurred during the third trimester [adjusted odds ratio (aOR) 5.083, 95% confidence interval (CI): 1.095-23.593, p=0.038] and C-reactive protein (CRP) was elevated (≥1.0 mg/dL) at admission (aOR 5.878, 95% CI: 3.099-11.146, p<0.001). The risk was higher in unvaccinated patients (aOR 5.376, 95% CI: 1.193-24.390, p=0.028). However, the risk was lower in patients during the Omicron wave (aOR 0.498, 95% CI: 0.258-0.961, p=0.038). CONCLUSION A quarter of SARS-CoV-2-infected women developed hypoxemic respiratory difficulty during pregnancy. SARS-CoV-2 infection during the third trimester, CRP elevation at admission, and no vaccination increased the risk of hypoxemia in pregnant women.
Collapse
Affiliation(s)
- Yujin Sohn
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hee Kyoung Choi
- Department of Infectious Diseases, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jisun Yun
- Department of Obstetrics and Gynecology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Eui Hyeok Kim
- Department of Obstetrics and Gynecology, CHA Ilsan Medical Center, CHA University School of Medicine, Goyang, Korea.
| | - Young Keun Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea.
| |
Collapse
|
6
|
Shah NM, Charani E, Ming D, Cheah FC, Johnson MR. Antimicrobial stewardship and targeted therapies in the changing landscape of maternal sepsis. JOURNAL OF INTENSIVE MEDICINE 2024; 4:46-61. [PMID: 38263965 PMCID: PMC10800776 DOI: 10.1016/j.jointm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 01/25/2024]
Abstract
Pregnant and postnatal women are a high-risk population particularly prone to rapid progression to sepsis with significant morbidity and mortality worldwide. Moreover, severe maternal infections can have a serious detrimental impact on neonates with almost 1 million neonatal deaths annually attributed to maternal infection or sepsis. In this review we discuss the susceptibility of pregnant women and their specific physiological and immunological adaptations that contribute to their vulnerability to sepsis, the implications for the neonate, as well as the issues with antimicrobial stewardship and the challenges this poses when attempting to reach a balance between clinical care and urgent treatment. Finally, we review advancements in the development of pregnancy-specific diagnostic and therapeutic approaches and how these can be used to optimize the care of pregnant women and neonates.
Collapse
Affiliation(s)
- Nishel M Shah
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Damien Ming
- Department of Infectious Diseases, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Fook-Choe Cheah
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mark R Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
| |
Collapse
|
7
|
Hora S, Pahwa P, Siddiqui H, Saxena A, Kashyap M, Sevak JK, Singh R, Javed M, Yadav P, Kale P, Ramakrishna G, Bajpai M, Rathore A, Maras JS, Tyagi S, Sarin SK, Trehanpati N. Metabolic alterations unravel the maternofetal immune responses with disease severity in pregnant women infected with SARS-CoV-2. J Med Virol 2023; 95:e29257. [PMID: 38054548 DOI: 10.1002/jmv.29257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 12/07/2023]
Abstract
Pregnancy being an immune compromised state, coronavirus disease of 2019 (COVID-19) disease poses high risk of premature delivery and threat to fetus. Plasma metabolome regulates immune cellular responses, therefore we aimed to analyze the change in plasma secretome, metabolome, and immune cells with disease severity in COVID-19 positive pregnant females and their cord blood. COVID-19 reverse transcriptase-polymerase chain reaction positive pregnant females (n = 112) with asymptomatic (Asy) (n = 82), mild (n = 21), or moderate (n = 9) disease, healthy pregnant (n = 18), COVID-19 positive nonpregnant females (n = 7) were included. Eighty-two cord blood from COVID-19 positive and seven healthy cord blood were also analyzed. Mother's peripheral blood and cord blood were analyzed for untargeted metabolome profiling and cytokines by using high-resolution mass spectrometry and cytokine bead array. Immune scan was performed only in mothers' blood by flow cytometry. In Asy severe acute respiratory syndrome coronavirus 2 infection, the amino acid metabolic pathways such as glycine, serine, l-lactate, and threonine metabolism were upregulated with downregulation of riboflavin and tyrosine metabolism. However, with mild-to-moderate disease, the pyruvate and nicotinamide adenine dinucleotide (NAD+ ) metabolism were mostly altered. Cord blood mimicked the mother's metabolomic profiles by showing altered valine, leucine, isoleucine, glycine, serine, threonine in Asy and NAD+ , riboflavin metabolism in mild and moderate. Additionally, with disease severity tumor necrosis factor-α, interferon (IFN)-α, IFN-γ, interleukin (IL)-6 cytokine storm, IL-9 was raised in both mothers and neonates. Pyruvate, NAD metabolism and increase in IL-9 and IFN-γ had an impact on nonclassical monocytes, exhausted T and B cells. Our results demonstrated that immune-metabolic interplay in mother and fetus is influenced with increase in IL-9 and IFN-γ regulated pyruvate, lactate tricarboxylic acid, and riboflavin metabolism with context to disease severity.
Collapse
Affiliation(s)
- Sandhya Hora
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prabhjyoti Pahwa
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Hamda Siddiqui
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Anoushka Saxena
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Minal Kashyap
- Department of Gynecology and Obstetrics, Lok Nayak Jai Prakash Hospital, New Delhi, India
| | - Jayesh K Sevak
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ravinder Singh
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Maryam Javed
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Pushpa Yadav
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Pratibha Kale
- Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Gayatri Ramakrishna
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Meenu Bajpai
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Asmita Rathore
- Department of Gynecology and Obstetrics, Lok Nayak Jai Prakash Hospital, New Delhi, India
| | - Jaswinder S Maras
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shakun Tyagi
- Department of Gynecology and Obstetrics, Lok Nayak Jai Prakash Hospital, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nirupama Trehanpati
- Department of Molecular and Cellular Medicine, Laboratory of Molecular Immunology, Institute of Liver and Biliary Sciences, New Delhi, India
| |
Collapse
|
8
|
Simbar M, Nazarpour S, Sheidaei A. Evaluation of pregnancy outcomes in mothers with COVID-19 infection: a systematic review and meta-analysis. J OBSTET GYNAECOL 2023; 43:2162867. [PMID: 36651606 DOI: 10.1080/01443615.2022.2162867] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Pregnant women are one of the endangered groups who need special attention in the COVID-19 epidemic. We conducted a systematic review and summarised the studies that reported adverse pregnancy outcomes in pregnant women with COVID-19 infection. A literature search was performed in PubMed and Scopus up to 1 September 2022, for retrieving original articles published in the English language assessing the association between COVID-19 infection and adverse pregnancy outcomes. Finally, in this review study, of 1790 articles obtained in the initial search, 141 eligible studies including 1,843,278 pregnant women were reviewed. We also performed a meta-analysis of a total of 74 cohort and case-control studies. In this meta-analysis, both fixed and random effect models were used. Publication bias was also assessed by Egger's test and the trim and fill method was conducted in case of a significant result, to adjust the bias. The result of the meta-analysis showed that the pooled prevalence of preterm delivery, maternal mortality, NICU admission and neonatal death in the group with COVID-19 infection was significantly more than those without COVID-19 infection (p<.01). A meta-regression was conducted using the income level of countries. COVID-19 infection during pregnancy may cause adverse pregnancy outcomes including of preterm delivery, maternal mortality, NICU admission and neonatal death. Pregnancy loss and SARS-CoV2 positive neonates in Lower middle income are higher than in High income. Vertical transmission from mother to foetus may occur, but its immediate and long-term effects on the newborn are unclear.
Collapse
Affiliation(s)
- Masoumeh Simbar
- Midwifery and Reproductive Health Research Center, Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sima Nazarpour
- Department of Midwifery, Varamin-Pishva Branch, Islamic Azad University, Tehran, Iran
| | - Ali Sheidaei
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
9
|
Taskou C, Sarantaki A, Georgakopoulou VΕ, Spyratos GA, Drossos PV, Daskalakis G, Beloukas A, Lykeridou A. Assessing the Presence of IgG Antibodies against Influenza Viruses in Neonates after Maternal Vaccination and Factors That May Affect the Transplacental Transfer. Diseases 2023; 11:166. [PMID: 37987278 PMCID: PMC10660699 DOI: 10.3390/diseases11040166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
Special populations, particularly pregnant women, are uniquely susceptible to infectious diseases due to alterations in their immunological, respiratory, and cardiovascular systems during gestation. Influenza infections during the perinatal period have been associated with more severe maternal and perinatal outcomes, underscoring the critical importance of vaccination data for pregnant women. According to the World Health Organization (WHO), all pregnant women and those of childbearing age should receive the inactivated influenza vaccine, irrespective of their pregnancy stage. This study aimed to elucidate factors influencing neonatal antibody presence following maternal influenza vaccination. Conducted through convenience sampling in Athens, Greece, this study involved 78 pregnant women who received flu vaccinations. The participants completed questionnaires covering demographics, obstetric history, attitudes toward influenza vaccination, and knowledge about the influenza virus and pregnancy vaccination. Blood samples were collected from 83 neonates to assess IgG antibody presence. Five of the surveyed women had twin pregnancies. The statistical analysis employed IBM SPSS-Statistics version 26.0. This study revealed the presence of positive influenza A and B antibodies in neonates following maternal immunization. Furthermore, it identified factors such as the gestational week and timing of vaccination during pregnancy that influenced the transfer of antibodies from mother to fetus. These findings offer valuable insights for healthcare professionals to provide informed recommendations on influenza vaccination during pregnancy and empower expectant mothers to make informed decisions about the benefits of immunization.
Collapse
Affiliation(s)
- Chrysoula Taskou
- Midwifery Department, University of West Attica, 11521 Athens, Greece; (A.S.); (A.L.)
| | - Antigoni Sarantaki
- Midwifery Department, University of West Attica, 11521 Athens, Greece; (A.S.); (A.L.)
| | | | - Gerasimos A. Spyratos
- Biomedical Sciences Department, University of West Attica, 11521 Athens, Greece; (G.A.S.); (P.V.D.)
- Labogen S.A. Laboratories, 11143 Athens, Greece
| | - Panagiotis V. Drossos
- Biomedical Sciences Department, University of West Attica, 11521 Athens, Greece; (G.A.S.); (P.V.D.)
| | - Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Apostolos Beloukas
- Biomedical Sciences Department, University of West Attica, 11521 Athens, Greece; (G.A.S.); (P.V.D.)
- National AIDS Reference Centre of Southern Greece, Department of Public Health Policy, University of West Attica, 11521 Athens, Greece
| | - Aikaterini Lykeridou
- Midwifery Department, University of West Attica, 11521 Athens, Greece; (A.S.); (A.L.)
| |
Collapse
|
10
|
Fajardo A, Rodríguez A, Chica C, Dueñas C, Carrillo R, Olaya X, Vera F. [Prone position in the third trimester of pregnancy during the COVID-19 era: a transdisciplinary approach.]. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023; 50:100906. [PMID: 38620219 PMCID: PMC10308227 DOI: 10.1016/j.gine.2023.100906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 06/22/2023] [Indexed: 04/17/2024]
Abstract
There is very limited evidence regarding the use of prone position as part of the treatment of severe ARDS in pregnant patients. Currently, recommendations for invasive ventilatory management in this population are very scarce and are based on the extrapolation of conclusions obtained in studies of non-pregnant patients. The available literature asserts that the anatomy and physiology of the pregnant woman undergoes complex adaptive changes that must be considered during invasive ventilatory support and prone position. With prone ventilation, the benefits obtained for the couple far outweigh the eventual risks. Adequate programming of the mechanical ventilator correlates with a clear and simple concept: individualization of support. In any case, the decision on the timing of termination of pregnancy should be based on adequate multidisciplinary clinical judgment and should be supported by strict monitoring of the product.
Collapse
Affiliation(s)
- Aurio Fajardo
- Servicio de Medicina Interna - Unidad de Paciente Crítico. Head of WeVent (International Mechanical Ventilation Group), Viña del Mar, Chile
| | - Asariel Rodríguez
- Unidad de Cuidados Intensivos Obstétricos. Hospital Materno Infantil RPG, TGZ. México
| | - Carmen Chica
- Asociación Colombiana de Medicina Crítica y Cuidado Intensivo (AMCI), Bogotá, Colombia
| | - Carmelo Dueñas
- Neumología y Medicina Crítica. Jefe UCI Gestión Salud, Cartagena, Colombia
| | - Raúl Carrillo
- Academia Nacional de Medicina. Subdirección de Áreas Críticas, Instituto Nacional de Rehabilitación, México
| | - Ximena Olaya
- Universidad de Manizales, COINT Grupo de Investigación, Colombia
| | - Fabricio Vera
- Medicina Crítica. Hospital General Manta del IESS, Manabí, Ecuador
| |
Collapse
|
11
|
Farias-Jofre M, Romero R, Xu Y, Levenson D, Tao L, Kanninen T, Galaz J, Arenas-Hernandez M, Liu Z, Miller D, Bhatti G, Seyerle M, Tarca AL, Gomez-Lopez N. Differential immunophenotype of circulating monocytes from pregnant women in response to viral ligands. BMC Pregnancy Childbirth 2023; 23:323. [PMID: 37149573 PMCID: PMC10163583 DOI: 10.1186/s12884-023-05562-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/30/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Viral infections during pregnancy can have deleterious effects on mothers and their offspring. Monocytes participate in the maternal host defense against invading viruses; however, whether pregnancy alters monocyte responses is still under investigation. Herein, we undertook a comprehensive in vitro study of peripheral monocytes to characterize the differences in phenotype and interferon release driven by viral ligands between pregnant and non-pregnant women. METHODS Peripheral blood was collected from third-trimester pregnant (n = 20) or non-pregnant (n = 20, controls) women. Peripheral blood mononuclear cells were isolated and exposed to R848 (TLR7/TLR8 agonist), Gardiquimod (TLR7 agonist), Poly(I:C) (HMW) VacciGrade™ (TLR3 agonist), Poly(I:C) (HMW) LyoVec™ (RIG-I/MDA-5 agonist), or ODN2216 (TLR9 agonist) for 24 h. Cells and supernatants were collected for monocyte phenotyping and immunoassays to detect specific interferons, respectively. RESULTS The proportions of classical (CD14hiCD16-), intermediate (CD14hiCD16+), non-classical (CD14loCD16+), and CD14loCD16- monocytes were differentially affected between pregnant and non-pregnant women in response to TLR3 stimulation. The proportions of pregnancy-derived monocytes expressing adhesion molecules (Basigin and PSGL-1) or the chemokine receptors CCR5 and CCR2 were diminished in response to TLR7/TLR8 stimulation, while the proportions of CCR5- monocytes were increased. Such differences were found to be primarily driven by TLR8 signaling, rather than TLR7. Moreover, the proportions of monocytes expressing the chemokine receptor CXCR1 were increased during pregnancy in response to poly(I:C) stimulation through TLR3, but not RIG-I/MDA-5. By contrast, pregnancy-specific changes in the monocyte response to TLR9 stimulation were not observed. Notably, the soluble interferon response to viral stimulation by mononuclear cells was not diminished in pregnancy. CONCLUSIONS Our data provide insight into the differential responsiveness of pregnancy-derived monocytes to ssRNA and dsRNA, mainly driven by TLR8 and membrane-bound TLR3, which may help to explain the increased susceptibility of pregnant women to adverse outcomes resulting from viral infection as observed during recent and historic pandemics.
Collapse
Affiliation(s)
- Marcelo Farias-Jofre
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
- Division of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, 8330024, Santiago, Chile
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, 48824, USA
| | - Yi Xu
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
| | - Dustyn Levenson
- Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Li Tao
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
| | - Tomi Kanninen
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
| | - Jose Galaz
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
- Division of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, 8330024, Santiago, Chile
| | - Marcia Arenas-Hernandez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
| | - Zhenjie Liu
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
| | - Derek Miller
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
| | - Gaurav Bhatti
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
| | - Megan Seyerle
- Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Adi L Tarca
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA
- Department of Computer Science, Wayne State University College of Engineering, Detroit, MI, 48202, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, 48201, USA
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, MI, 48201, USA.
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, 48201, USA.
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, 48201, USA.
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
| |
Collapse
|
12
|
Țieranu ML, Dragoescu NA, Zorilă GL, Istrate-Ofițeru AM, Rămescu C, Berbecaru EIA, Drăguşin RC, Nagy RD, Căpitănescu RG, Iliescu DG. Addressing Chronic Gynecological Diseases in the SARS-CoV-2 Pandemic. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040802. [PMID: 37109760 PMCID: PMC10145652 DOI: 10.3390/medicina59040802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Abstract
Introduction: the COVID-19 pandemic has had a considerable impact on healthcare systems worldwide. Since the actual influence of the pandemic on gynecological care is still unclear, we aim to evaluate the effect of the SARS-CoV-2 pandemic on gynecological procedures compared to the pre-pandemic period in Romania. Materials and Methods: this is a single-center retrospective observational study, involving patients hospitalized in the year before the SARS-CoV-2 pandemic (PP), in the first year of the pandemic (P1), and in the second year of the pandemic until February 2022 (P2). The percentages of interventions were analyzed globally but also according to the type of surgery applied on the female genital organs. Results: during pandemic, the number of gynecological surgeries dropped considerably, by more than 50% in some cases, or even decreased by up to 100%, having a major impact on women's health, especially in the first year of the pandemic (P1), before slightly increasing in the post-vaccination period (PV). Surgically treated cancer cases dropped by over 80% during the pandemic, and the consequences of this will be seen in the future. Conclusions: the COVID-19 pandemic played an important part in gynecological care management in the Romanian public health care system, and the effect will have to be investigated in the future.
Collapse
Affiliation(s)
- Maria-Loredana Țieranu
- Doctoral School, University of Medicine and Pharmacy of Craiova, 20039 Craiova, Romania
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
| | - Nicoleta Alice Dragoescu
- Department of Anesthesiology and Intensive Care, Emergency County Hospital of Craiova, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - George-Lucian Zorilă
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Anca-Maria Istrate-Ofițeru
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
- Department of Histology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Research Centre for Microscopic Morphology and Immunology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Cătălina Rămescu
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
| | - Elena-Iuliana-Anamaria Berbecaru
- Doctoral School, University of Medicine and Pharmacy of Craiova, 20039 Craiova, Romania
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
| | - Roxana Cristina Drăguşin
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Rodica Daniela Nagy
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
| | - Răzvan Grigoraș Căpitănescu
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dominic-Gabriel Iliescu
- Department of Obstetrics and Gynecology, Emergency County Hospital of Craiova, 200642 Craiova, Romania
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| |
Collapse
|
13
|
Lim MJ, Lakshminrusimha S, Hedriana H, Albertson T. Pregnancy and Severe ARDS with COVID-19: Epidemiology, Diagnosis, Outcomes and Treatment. Semin Fetal Neonatal Med 2023; 28:101426. [PMID: 36964118 PMCID: PMC9990893 DOI: 10.1016/j.siny.2023.101426] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Pregnancy-related acute respiratory distress syndrome (ARDS) is fast becoming a growing and clinically relevant subgroup of ARDS amidst global outbreaks of various viral respiratory pathogens that include H1N1-influenza, severe acute respiratory syndrome (SARS), middle east respiratory syndrome (MERS), and the most recent COVID-19 pandemic. Pregnancy is a risk factor for severe viral-induced ARDS and commonly associated with poor maternal and fetal outcomes including fetal growth-restriction, preterm birth, and spontaneous abortion. Physiologic changes of pregnancy further compounded by mechanical and immunologic alterations are theorized to impact the development of ARDS from viral pneumonia. The COVID-19 sub-phenotype of ARDS share overlapping molecular features of maternal pathogenicity of pregnancy with respect to immune-dysregulation and endothelial/microvascular injury (i.e., preeclampsia) that may in part explain a trend toward poor maternal and fetal outcomes seen with severe COVID-19 maternal infections. To date, current ARDS diagnostic criteria and treatment management fail to include and consider physiologic adaptations that are unique to maternal physiology of pregnancy and consideration of maternal-fetal interactions. Treatment focused on lung-protective ventilation strategies have been shown to improve clinical outcomes in adults with ARDS but may have adverse maternal-fetal interactions when applied in pregnancy-related ARDS. No specific pharmacotherapy has been identified to improve outcomes in pregnancy with ARDS. Adjunctive therapies aimed at immune-modulation and anti-viral treatment with COVID-19 infection during pregnancy have been reported but data in regard to its efficacy and safety is currently lacking.
Collapse
Affiliation(s)
- Michelle J Lim
- UC Davis School of Medicine, UC Davis Children's Hospital, Department of Pediatrics, Division of Critical Care and Neonatology, Sacramento, CA, USA.
| | - Satyan Lakshminrusimha
- UC Davis School of Medicine, UC Davis Children's Hospital, Department of Pediatrics, Division of Critical Care and Neonatology, Sacramento, CA, USA
| | - Herman Hedriana
- UC Davis School of Medicine, UC Davis Medical Center, Department of Obstetrics and Gynecology, Sacramento, CA, USA
| | - Timothy Albertson
- UC Davis School of Medicine, UC Davis Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Sacramento, CA, USA
| |
Collapse
|
14
|
An Overview of Antiviral Treatments in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:183-203. [PMID: 36822703 DOI: 10.1016/j.ogc.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Viral infections pose unique threats to pregnant persons and their infants. As the frequency of epidemics caused by novel pathogens increases, understanding pregnancy-specific considerations for antiviral treatments is critical for obstetric and nonobstetric providers alike. The use of pharmacologic therapeutics in pregnancy, which include antivirals, pathogen-specific antibodies, and vaccines, is limited due to the lack of purposeful, methodologic, pharmacometrics analyses in this special population. Our current understanding regarding dosing, safety, and efficacy stems from our knowledge of potential maternal or neonatal risks, observational data, and rarely clinical trials. In this review, we provide an overview on the use of antivirals during pregnancy.
Collapse
|
15
|
Zamparini J, Saggers R, Buga CE. A Review of Coronavirus Disease 2019 in Pregnancy. Semin Respir Crit Care Med 2023; 44:50-65. [PMID: 36646085 DOI: 10.1055/s-0042-1758853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jarrod Zamparini
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Robin Saggers
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Chandia Edward Buga
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Obstetrics and Gynaecology, Thelle Mogoerane Regional Hospital, Vosloorus, South Africa
| |
Collapse
|
16
|
Zayyan S, Frise C. COVID-19 in pregnancy: A UK perspective. Obstet Med 2022; 15:216-219. [PMID: 36514793 PMCID: PMC8943486 DOI: 10.1177/1753495x221083134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 12/15/2022] Open
Abstract
COVID-19 infection in pregnancy can cause respiratory and obstetric complications,1 however emerging evidence on its impact in pregnancy is limited. This article aims to review data collected and analysed so far over the course of the coronavirus pandemic, that examine demographic associations, patterns of disease, severity and outcomes of COVID-19 in pregnancy in the UK. Hospital admission, for which black and minority ethnic background and raised body mass index are risk factors, is associated with maternal mortality and admission to intensive care and is more likely in the late second or third trimester.2 Vaccination is safe in pregnancy3 and is protective against severe COVID-19 and admission to intensive care,4, 5 Maternal SARS CoV-2 is associated with a greater risk of stillbirth, preterm birth, small for gestational age (SGA) and preeclampsia.6 Efforts to reduce the incidence of COVID-19 in pregnancy, including vaccination, are therefore likely to reduce preventable complications from this disease.
Collapse
Affiliation(s)
- Sanaa Zayyan
- Oxford University Hospitals NHS Foundation
Trust, Oxford, UK,Sanaa Zayyan, John Radcliffe Hospital, Oxford, UK.
| | - Charlotte Frise
- Fetal Maternal Medicine Unit and Department of Acute and General Medicine,
Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
17
|
Hessami K, Aagaard KM, Castro EC, Arian SE, Nassr AA, Barrozo ER, Seferovic MD, Shamshirsaz AA. Placental Vascular and Inflammatory Findings from Pregnancies Diagnosed with Coronavirus Disease 2019: A Systematic Review and Meta-analysis. Am J Perinatol 2022; 39:1643-1653. [PMID: 35240710 DOI: 10.1055/a-1787-7933] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We aimed to perform a meta-analysis of the literature concerning histopathologic findings in the placentas of women with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection during pregnancy. Searches for articles in English included PubMed, Web of Science, Google Scholar, and reference lists (up to April 2021). Studies presenting data on placental histopathology according to the Amsterdam Consensus Group criteria in SARS-CoV-2 positive and negative pregnancies were identified. Lesions were categorized into: maternal and fetal vascular malperfusion (MVM and FVM, respectively), acute placental inflammation with maternal and fetal inflammatory response (MIR and FIR, respectively), chronic inflammatory lesions (CILs), and increased perivillous fibrin deposition (PVFD). A total of 15 studies reporting on 19,025 placentas, n = 699 of which were derived from women who were identified as being infected with SARS-CoV-2 and 18,326 as SARS-CoV-2-negative controls, were eligible for analysis. No significant difference in incidence of MVM (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 0.73-1.90), FVM (OR: 1.23, 95% CI: 0.63-2.42), MIR (OR: 0.66, 95% CI: 0.29-1.52) or FIR (OR: 0.85, 95% CI: 0.44-1.63), and CILs (OR: 0.97, 95% CI: 0.55-1.72) was found between placentae from gravida identified as being SARS-CoV-2 infected. However, placenta from gravida identified as being infected with SARS-CoV-2 were associated with significantly increased occurrence of PVFD (OR: 2.77, 95% CI: 1.06-7.27). After subgroup analyses based on clinical severity of COVID-19 infection, no significant difference was observed in terms of reported placental pathology between symptomatic or asymptomatic SARS-CoV-2 gravidae placenta. Current evidence based on the available literature suggests that the only pathologic finding in the placentae of women who are pregnant identified as having been infected with SARS-CoV-2 was an increased prevalence of PVFD. KEY POINTS: · No association between SARS-CoV-2 and maternal or fetal placental malperfusion.. · No association between SARS-CoV-2 and maternal or fetal inflammatory response.. · SARS-CoV-2 is associated with increased perivillous fibrin deposition in placenta..
Collapse
Affiliation(s)
- Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Kjersti M Aagaard
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Eumenia C Castro
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Sara E Arian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Enrico R Barrozo
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Maxim D Seferovic
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| |
Collapse
|
18
|
Fung SG, Fakhraei R, Condran G, Regan AK, Dimanlig-Cruz S, Ricci C, Foo D, Sarna M, Török E, Fell DB. Neuropsychiatric outcomes in offspring after fetal exposure to maternal influenza infection during pregnancy: A systematic review. Reprod Toxicol 2022; 113:155-169. [PMID: 36100136 DOI: 10.1016/j.reprotox.2022.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 01/15/2023]
Abstract
Increasing evidence suggests that influenza infection in pregnancy may disrupt fetal neurodevelopment. The impact of maternal influenza infection on offspring neuropsychiatric health has not been comprehensively reviewed. We systematically reviewed comparative studies evaluating associations between maternal influenza infection and neuropsychiatric health outcomes in offspring. We searched MEDLINE, EMBASE, CINAHL, and Web of Science for articles published until January 7, 2022. Included were English studies evaluating neuropsychiatric outcomes in offspring aged > 6 months born to women with and without influenza during pregnancy, defined as clinical or laboratory-confirmed influenza illness, or being pregnant during pandemics/epidemics. Of 12,010 records screened, 42 studies were included. Heterogeneity in study design, exposures, and outcome definitions precluded meta-analyses. Four of 14 studies assessing schizophrenia reported adjusted ratio estimates from 0.5 to 8.2; most 95% CIs contained the null value; study quality was high in three of four. Two studies reported an increased risk of schizophrenia with influenza exposure any time during pregnancy (adjusted incidence rate ratio 8.2, 95% CI: 1.4-48.8; adjusted odds ratio 1.3, 95% CI: 1.2-1.5); another reported a reduced risk with first-trimester exposure (adjusted risk ratio 0.5, 95% CI: 0.3-0.9). Seven studies of autism spectrum disorder reported adjusted ratio estimates from 0.9 to 4.0; all 95% CIs included the null value; study quality was high in four. No conclusions could be drawn about the association between exposure to maternal influenza and neuropsychiatric outcomes due to the limited quantity and quality of available research. Large observational studies with long-term follow-up are required to investigate these associations.
Collapse
Affiliation(s)
- Stephen G Fung
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, ON, Canada
| | - Romina Fakhraei
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | | | - Annette K Regan
- School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, United States; Curtin School of Population Health, Curtin University, Perth, WA, Australia; Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | | | | | - Damien Foo
- Curtin School of Population Health, Curtin University, Perth, WA, Australia; Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Mohinder Sarna
- Curtin School of Population Health, Curtin University, Perth, WA, Australia; Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | | | - Deshayne B Fell
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| |
Collapse
|
19
|
Abstract
Pregnancy is an independent risk factor for severe covid-19. Vaccination is the best way to reduce the risk for SARS-CoV-2 infection and limit its morbidity and mortality. The current recommendations from the World Health Organization, Centers for Disease Control and Prevention, and professional organizations are for pregnant, postpartum, and lactating women to receive covid-19 vaccination. Pregnancy specific considerations involve potential effects of vaccination on fetal development, placental transfer of antibodies, and safety of maternal vaccination. Although pregnancy was an exclusion criterion in initial clinical trials of covid-19 vaccines, observational data have been rapidly accumulating and thus far confirm that the benefits of vaccination outweigh the potential risks. This review examines the evidence supporting the effectiveness, immunogenicity, placental transfer, side effects, and perinatal outcomes of maternal covid-19 vaccination. Additionally, it describes factors associated with vaccine hesitancy in pregnancy. Overall, studies monitoring people who have received covid-19 vaccines during pregnancy have not identified any pregnancy specific safety concerns. Additional information on non-mRNA vaccines, vaccination early in pregnancy, and longer term outcomes in infants are needed. To collect this information, vaccination during pregnancy must be prioritized in vaccine research.
Collapse
Affiliation(s)
- Martina L Badell
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA. USA
| | - Carolynn M Dude
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA. USA
| | - Sonja A Rasmussen
- Departments of Pediatrics and Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Denise J Jamieson
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA. USA
| |
Collapse
|
20
|
de Carvalho FC, da Silva ET, de Almeida WAF, Maroneze MA, Schwartz JDA, Jardim JPV, Peixoto HM. Clinical and epidemiological aspects of severe acute respiratory infection: before and during the first year of the COVID-19 pandemic in Brazil. Trans R Soc Trop Med Hyg 2022; 117:161-173. [PMID: 35929810 PMCID: PMC9384673 DOI: 10.1093/trstmh/trac074] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/09/2022] [Accepted: 07/19/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Widespread respiratory infections with high morbidity rates caused by respiratory viruses represent a significant global public health problem. Our objective was to describe cases and deaths from severe acute respiratory infection (SARI) in Brazil over the past 8 y as well as changes in the distribution and risk of illness and death from SARI before and in the first year of the coronavirus disease 2019 (COVID-19) pandemic (FYP). METHODS We performed a descriptive epidemiological study of hospitalized SARI cases and deaths between 2013 and 2020 in Brazil, separated into pre-pandemic (2013 to 2019) and FYP (2020). We estimate the increase in SARI cases and deaths in the FYP as well as the mortality and infection risks attributable to the FYP (MRAP and IRAP, respectively). RESULTS In 2020, an excess of 425 054 cases and 109 682 deaths was observed, with a significant increase in the risk of falling ill and dying from SARI, with an IRAP of 200.06 and an MRAP of 51.68 cases per 100 000 inhabitants. The increase in SARI cases and deaths was particularly prominent among patients with COVID-19, the elderly, males, those self-identifying as mixed race and patients with heart disease and diabetes. We conclude that an important increase in morbidity and mortality due to SARI was observed in the FYP. More vulnerable groups and those living in the Southeast, North and Center-West regions of the country suffered the most.
Collapse
Affiliation(s)
| | - Erica Tatiane da Silva
- Evidence Program for Health Policies and Technologies, Oswaldo Cruz Foundation, Brasilia, Federal District, Brazil
| | | | | | | | | | - Henry Maia Peixoto
- Center of Tropical Medicine, Faculty of Medicine, University of Brasilia, Brasilia, Brazil,National Institute of Science and Technology for Health Technology Assessment, Porto Alegre, Brazil
| |
Collapse
|
21
|
Cervantes O, Talavera IC, Every E, Coler B, Li M, Li A, Li H, Adams Waldorf K. Role of hormones in the pregnancy and sex-specific outcomes to infections with respiratory viruses. Immunol Rev 2022; 308:123-148. [PMID: 35373371 PMCID: PMC9189035 DOI: 10.1111/imr.13078] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 01/13/2023]
Abstract
Pregnant women infected with pathogenic respiratory viruses, such as influenza A viruses (IAV) and coronaviruses, are at higher risk for mortality, hospitalization, preterm birth, and stillbirth. Several factors are likely to contribute to the susceptibility of pregnant individuals to severe lung disease including changes in pulmonary physiology, immune defenses, and effector functions of some immune cells. Pregnancy is also a physiologic state characterized by higher levels of multiple hormones that may impact the effector functions of immune cells, such as progesterone, estrogen, human chorionic gonadotropin, prolactin, and relaxin. Each of these hormones acts to support a tolerogenic immune state of pregnancy, which helps prevent fetal rejection, but may also contribute to an impaired antiviral response. In this review, we address the unique role of adaptive and innate immune cells in the control of pathogenic respiratory viruses and how pregnancy and specific hormones can impact their effector actions. We highlight viruses with sex-specific differences in infection outcomes and why pregnancy hormones may contribute to fetal protection but aid the virus at the expense of the mother's health.
Collapse
Affiliation(s)
- Orlando Cervantes
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Irene Cruz Talavera
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Emma Every
- University of Washington School of Medicine, Spokane, Washington, United States of America
| | - Brahm Coler
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, United States of America
| | - Miranda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Department of Biological Sciences, Columbia University, New York City, New York, United States of America
| | - Amanda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Case Western Reserve, Cleveland, Ohio, United States of America
| | - Hanning Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Kristina Adams Waldorf
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| |
Collapse
|
22
|
Zuo Q, Gao Z, Cai L, Bai L, Pei Y, Liu M, Xue H, Xu J, Wang S. A predicting model of child-bearing-aged women' spontaneous abortion by co-infections of TORCH and reproductive tract. Congenit Anom (Kyoto) 2022; 62:142-152. [PMID: 35322463 DOI: 10.1111/cga.12466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/13/2022] [Accepted: 01/25/2022] [Indexed: 11/29/2022]
Abstract
To develop a predicting model of child-bearing-aged women' spontaneous abortion (SA) by co-infections of TORCH and reproductive tract, in order to provide a reference tool for accurately predicting the risk of SA and guide the early prevention, diagnosis and treatment of SA. A prospective cohort study was designed based on 218 958 child-bearing-aged women following up in Hebei province in China from 2010 to 2017. Multivariable logistic regression analysis was used to select candidate predictive variables. Fisher's discriminant analysis was performed to build a predictive model, and the validity of the model was evaluated. The incidence rate of SA was 2.4%. Multivariable logistic regression analysis showed that age (OR = 3.507), adverse pregnancy history (OR = 1.509), co-infections status of Candida and HBsAg (ORCandida positive×HBsAg negative = 4.091, ORCandida negative×HBsAg positive = 3.327, and ORCandida positive×HBsAg positive = 13.762), and co-infections status of HBsAg, Rubella (IgG) and CMV (IgG) (ORHBs-Ag negative×Rubella (IgG) negative×CMV (IgG) positive = 1.789, ORHBs-Ag positive×Rubella (IgG) positive×CMV (IgG) negative = 3.809, and ORHBsAg positive×Rubella (IgG) positive×CMV (IgG) positive = 11.919) were the independent predictors of SA. The total discriminant rate reached 91%, with 82% of the sensitivity and 91% of the specificity. The predicting model of child-bearing-aged women' SA by co-infections status has a good performance. The co-infection status of TORCH and reproductive tract are suggested to be considered in pre-pregnancy physical examination.
Collapse
Affiliation(s)
- Qun Zuo
- School of Public Health, Hebei University/Key Laboratory of Public Health Safety of Hebei Province, Baoding, China
| | - Zhangquan Gao
- Hebei Institute of Reproductive Health Science and Technology (formerly known as Hebei Province Family Planning Science and Technology Institute)/NHC Key Laboratory of Family Planning and Healthy/Hebei Key Laboratory of Reproductive Medicine Key Laboratory of Public Health Safety of Hebei Province, Shijiazhuang, China
| | - Li Cai
- School of Public Health, Hebei University/Key Laboratory of Public Health Safety of Hebei Province, Baoding, China
| | - Linlin Bai
- School of Public Health, Hebei University/Key Laboratory of Public Health Safety of Hebei Province, Baoding, China
| | - Yu Pei
- Hebei Institute of Reproductive Health Science and Technology (formerly known as Hebei Province Family Planning Science and Technology Institute)/NHC Key Laboratory of Family Planning and Healthy/Hebei Key Laboratory of Reproductive Medicine Key Laboratory of Public Health Safety of Hebei Province, Shijiazhuang, China
| | - Mengchao Liu
- School of Public Health, Hebei University/Key Laboratory of Public Health Safety of Hebei Province, Baoding, China
| | - Hongmei Xue
- School of Public Health, Hebei University/Key Laboratory of Public Health Safety of Hebei Province, Baoding, China
| | - Juan Xu
- School of Public Health, Hebei University/Key Laboratory of Public Health Safety of Hebei Province, Baoding, China
| | - Shusong Wang
- Hebei Institute of Reproductive Health Science and Technology (formerly known as Hebei Province Family Planning Science and Technology Institute)/NHC Key Laboratory of Family Planning and Healthy/Hebei Key Laboratory of Reproductive Medicine Key Laboratory of Public Health Safety of Hebei Province, Shijiazhuang, China
| |
Collapse
|
23
|
Dolk H, Damase‐Michel C, Morris JK, Loane M. COVID-19 in pregnancy-what study designs can we use to assess the risk of congenital anomalies in relation to COVID-19 disease, treatment and vaccination? Paediatr Perinat Epidemiol 2022; 36:493-507. [PMID: 35234297 PMCID: PMC9115419 DOI: 10.1111/ppe.12840] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/07/2021] [Accepted: 11/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The COVID-19 pandemic has accelerated pregnancy outcome research, but little attention has been given specifically to the risk of congenital anomalies (CA) and first trimester exposures. OBJECTIVES We reviewed the main data sources and study designs used internationally, particularly in Europe, for CA research, and their strengths and limitations for investigating COVID-19 disease, medications and vaccines. POPULATION We classify research designs based on four data sources: a) spontaneous adverse event reporting, where study subjects are positive for both exposure and outcome, b) pregnancy exposure registries, where study subjects are positive for exposure, c) congenital anomaly registries, where study subjects are positive for outcome and d) population healthcare data where the entire population of births is included, irrespective of exposure and outcome. STUDY DESIGN Each data source allows different study designs, including case series, exposed pregnancy cohorts (with external comparator), ecological studies, case-control studies and population cohort studies (with internal comparator). METHODS The quality of data sources for CA studies is reviewed in relation to criteria including diagnostic accuracy of CA data, size of study population, inclusion of terminations of pregnancy for foetal anomaly, inclusion of first trimester COVID-19-related exposures and use of an internal comparator group. Multinational collaboration models are reviewed. RESULTS Pregnancy exposure registries have been the main design for COVID-19 pregnancy studies, but lack detail regarding first trimester exposures relevant to CA, or a suitable comparator group. CA registries present opportunities for improving diagnostic accuracy in COVID-19 research, especially when linked to other data sources. Availability of inpatient hospital medication use in population healthcare data is limited. More use of ongoing mother-baby linkage systems would improve research efficiency. Multinational collaboration delivers statistical power. CONCLUSIONS Challenges and opportunities exist to improve research on CA in relation to the COVID-19 pandemic and future pandemics.
Collapse
|
24
|
McClymont E, Albert AY, Alton GD, Boucoiran I, Castillo E, Fell DB, Kuret V, Poliquin V, Reeve T, Scott H, Sprague AE, Carson G, Cassell K, Crane J, Elwood C, Joynt C, Murphy P, Murphy-Kaulbeck L, Saunders S, Shah P, Snelgrove JW, van Schalkwyk J, Yudin MH, Money D. Association of SARS-CoV-2 Infection During Pregnancy With Maternal and Perinatal Outcomes. JAMA 2022; 327:1983-1991. [PMID: 35499852 PMCID: PMC9062768 DOI: 10.1001/jama.2022.5906] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE There are limited high-quality, population-level data about the effect of SARS-CoV-2 infection on pregnancy using contemporaneous comparator cohorts. OBJECTIVES To describe maternal and perinatal outcomes associated with SARS-CoV-2 infection in pregnancy and to assess variables associated with severe disease in the pregnant population. DESIGN, SETTING, AND PARTICIPANTS CANCOVID-Preg is an observational surveillance program for SARS-CoV-2-affected pregnancies in Canada. This analysis presents exploratory, population-level data from 6 Canadian provinces for the period of March 1, 2020, to October 31, 2021. A total of 6012 pregnant persons with a positive SARS-CoV-2 polymerase chain reaction test result at any time in pregnancy (primarily due to symptomatic presentation) were included and compared with 2 contemporaneous groups including age-matched female individuals with SARS-CoV-2 and unaffected pregnant persons from the pandemic time period. EXPOSURE SARS-CoV-2 infection during pregnancy. Incident infections in pregnancy were reported to CANCOVID-Preg by participating provinces/territories. MAIN OUTCOMES AND MEASURES Maternal and perinatal outcomes associated with SARS-CoV-2 infection as well as risk factors for severe disease (ie, disease requiring hospitalization, admission to an intensive care unit/critical care unit, and/or oxygen therapy). RESULTS Among 6012 pregnant individuals with SARS-CoV-2 in Canada (median age, 31 [IQR, 28-35] years), the greatest proportion of cases were diagnosed at 28 to 37 weeks' gestation (35.7%). Non-White individuals were disproportionately represented. Being pregnant was associated with a significantly increased risk of SARS-CoV-2-related hospitalization compared with SARS-CoV-2 cases among all women aged 20 to 49 years in the general population of Canada (7.75% vs 2.93%; relative risk, 2.65 [95% CI, 2.41-2.88]) as well as an increased risk of intensive care unit/critical care unit admission (2.01% vs 0.37%; relative risk, 5.46 [95% CI, 4.50-6.53]). Increasing age, preexisting hypertension, and greater gestational age at diagnosis were significantly associated with worse maternal outcomes. The risk of preterm birth was significantly elevated among SARS-CoV-2-affected pregnancies (11.05% vs 6.76%; relative risk, 1.63 [95% CI, 1.52-1.76]), even in cases of milder disease not requiring hospitalization, compared with unaffected pregnancies during the same time period. CONCLUSIONS AND RELEVANCE In this exploratory surveillance study conducted in Canada from March 2020 to October 2021, SARS-CoV-2 infection during pregnancy was significantly associated with increased risk of adverse maternal outcomes and preterm birth.
Collapse
Affiliation(s)
- Elisabeth McClymont
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada
| | - Arianne Y. Albert
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
| | - Gillian D. Alton
- Better Outcomes Registry and Network (BORN) Ontario, Ottawa, Canada
- Children’s Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Canada
| | - Isabelle Boucoiran
- Département d’Obstétrique-Gynécologie, Université de Montréal, Montréal, Quebec, Canada
- School of Public Health, Université de Montréal, Montréal, Quebec, Canada
| | - Eliana Castillo
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Deshayne B. Fell
- Children’s Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Verena Kuret
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Vanessa Poliquin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Manitoba, Winnipeg, Canada
| | - Tiffany Reeve
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
| | - Heather Scott
- Department of Obstetrics and Gynecology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ann E. Sprague
- Better Outcomes Registry and Network (BORN) Ontario, Ottawa, Canada
- Children’s Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Canada
| | - George Carson
- Department of Obstetrics and Gynecology, University of Saskatchewan, Saskatoon, Canada
| | - Krista Cassell
- Department of Obstetrics and Gynecology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Joan Crane
- Department of Obstetrics and Gynecology, Memorial University of Newfoundland, St John’s, Canada
- Children’s and Women’s Health Program, Eastern Health, St John’s, Newfoundland and Labrador, Canada
| | - Chelsea Elwood
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
| | - Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Phil Murphy
- Department of Obstetrics and Gynecology, Memorial University of Newfoundland, St John’s, Canada
- Children’s and Women’s Health Program, Eastern Health, St John’s, Newfoundland and Labrador, Canada
| | | | | | - Prakesh Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - John W. Snelgrove
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Julie van Schalkwyk
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Mark H. Yudin
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Deborah Money
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
| |
Collapse
|
25
|
Saberi H, Ghorashi Z, Loripoor M. Comparison of pregnancy outcome during pandemic of COVID-19 and non-pandemic situations, Yazd, Iran, in 2019-2020. J OBSTET GYNAECOL 2022; 42:1937-1943. [PMID: 35603710 DOI: 10.1080/01443615.2022.2054685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This study aimed to compare the pregnancy outcomes during pandemic and non-pandemic COVID-19 in women referred to health service centres in Yazd. This descriptive study was performed based on the information obtained from all pregnant women referred to comprehensive health service centres in Yazd city using census method, between March 21 2019 and December 21 2019 and between March 20 2020 and December 20 2020. The pregnant mothers' information, including their pregnancy outcome, and maternal and neonatal complications, was extracted from the electronic health information system of Yazd city. The obtained data were analysed by Chi-Square test. No significant difference was found between non-pandemic and pandemic COVID-19 situations in most variables. As well, maternal and neonatal death were equally observed in both non-pandemic and pandemic COVID-19 situations. Wanted pregnancy, post term birth, multiple pregnancy and caesarean section rates were found to be higher in pandemic than non-pandemic COVID-19 (p<.001). Reported abortion, screening for foetal anueploidy in the first and second trimesters as well as the number of episodes of prenatal care during COVID-19 pandemic were significantly lower than those of non-pandemic period (p<.001). The outcome of pregnancy during the pandemic was not significantly different from that of non-pandemic situation.Impact StatementWhat is already known on this subject? Studies already showed COVID-19 in pregnancy alter the maternal and neonatal outcomes in different degrees compared with pregnant individuals without COVID-19. However, it is not clear that pregnancy outcome dose alter during pandemic of COVID-19 compared to non-pandemic situations in general population?What do the results of this study add? The results of this study revealed that the outcome of pregnancy during pandemic was not significantly different from that of non-pandemic situation.What are the implications of these findings for clinical practice and/or further research? According to results of this study, we can ensure pregnant women in the situation of pandemic COVID-19 that they are not in greater risk. We suggest future research should be done for comparison of pregnancy outcome in the situation of delta variant pandemic with non-pandemic COVID-19.
Collapse
Affiliation(s)
- Hengameh Saberi
- Department of Midwifery, School of Nursing and Midwifery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Zohreh Ghorashi
- Department of Midwifery, School of Nursing and Midwifery, Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Marzeyeh Loripoor
- Department of Midwifery, School of Nursing and Midwifery, Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| |
Collapse
|
26
|
Santa S, Doku DA, Olwal CO, Brown CA, Tagoe EA, Quaye O. Paradox of COVID-19 in pregnancy: are pregnant women more protected against or at elevated risk of severe COVID-19? Future Microbiol 2022; 17:803-812. [PMID: 35510478 PMCID: PMC9070559 DOI: 10.2217/fmb-2021-0233] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Many underlying medical conditions have been linked to worse COVID-19 prognosis. Based on reports on SARS-CoV-1 and Middle East respiratory syndrome infections, pregnancy has been considered a predisposing factor to severe COVID-19, with pregnant women being a high-risk group for several physiological reasons. Specifically, pregnant women undergo physiological adaptations that predispose them to severe respiratory viral diseases, including SARS-CoV-2. However, a significant amount of evidence suggests that the clinical outcome of COVID-19 among pregnant women is not different from the general population. In view of this, this report discusses the physiological conditions in pregnant women that adversely affect their immunity, cardiovascular homeostasis, and their endothelial and coagulopathic functions, thereby making them more prone to severe viral infections. We also discuss how these physiological adaptations appear to paradoxically offer protection against severe COVID-19 among pregnant women.
Collapse
Affiliation(s)
- Sheila Santa
- West African Centre for Cell Biology of Infectious Pathogens (WACCBIP), University of Ghana, Accra, Ghana.,Department of Biochemistry, Cell & Molecular Biology, College of Basic & Applied Sciences, University of Ghana, Accra, Ghana.,Department of Medical Laboratory Sciences, University of Ghana, Accra, Ghana
| | - Derek A Doku
- Department of Biochemistry, Cell & Molecular Biology, College of Basic & Applied Sciences, University of Ghana, Accra, Ghana.,Department of Medical Laboratory Sciences, University of Ghana, Accra, Ghana.,West African Genetic Medicine Center, University of Ghana, Accra, Ghana
| | - Charles O Olwal
- West African Centre for Cell Biology of Infectious Pathogens (WACCBIP), University of Ghana, Accra, Ghana.,Department of Biochemistry, Cell & Molecular Biology, College of Basic & Applied Sciences, University of Ghana, Accra, Ghana
| | - Charles A Brown
- Department of Medical Laboratory Sciences, University of Ghana, Accra, Ghana
| | - Emmanuel A Tagoe
- Department of Medical Laboratory Sciences, University of Ghana, Accra, Ghana
| | - Osbourne Quaye
- West African Centre for Cell Biology of Infectious Pathogens (WACCBIP), University of Ghana, Accra, Ghana.,Department of Biochemistry, Cell & Molecular Biology, College of Basic & Applied Sciences, University of Ghana, Accra, Ghana
| |
Collapse
|
27
|
Manti S, Leonardi S, Rezaee F, Harford TJ, Perez MK, Piedimonte G. Effects of Vertical Transmission of Respiratory Viruses to the Offspring. Front Immunol 2022; 13:853009. [PMID: 35359954 PMCID: PMC8963917 DOI: 10.3389/fimmu.2022.853009] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/21/2022] [Indexed: 12/15/2022] Open
Abstract
Overt and subclinical maternal infections in pregnancy can have multiple and significant pathological consequences for the developing fetus, leading to acute perinatal complications and/or chronic disease throughout postnatal life. In this context, the current concept of pregnancy as a state of systemic immunosuppression seems oversimplified and outdated. Undoubtedly, in pregnancy the maternal immune system undergoes complex changes to establish and maintain tolerance to the fetus while still protecting from pathogens. In addition to downregulated maternal immunity, hormonal changes, and mechanical adaptation (e.g., restricted lung expansion) make the pregnant woman more susceptible to respiratory pathogens, such as influenza virus, respiratory syncytial virus (RSV), and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Depending on the infectious agent and timing of the infection during gestation, fetal pathology can range from mild to severe, and even fatal. Influenza is associated with a higher risk of morbidity and mortality in pregnant women than in the general population, and, especially during the third trimester of pregnancy, mothers are at increased risk of hospitalization for acute cardiopulmonary illness, while their babies show higher risk of complications such as prematurity, respiratory and neurological illness, congenital anomalies, and admission to neonatal intensive care. RSV exposure in utero is associated with selective immune deficit, remodeling of cholinergic innervation in the developing respiratory tract, and abnormal airway smooth muscle contractility, which may predispose to postnatal airway inflammation and hyperreactivity, as well as development of chronic airway dysfunction in childhood. Although there is still limited evidence supporting the occurrence of vertical transmission of SARS-CoV-2, the high prevalence of prematurity among pregnant women infected by SARS-CoV-2 suggests this virus may alter immune responses at the maternal-fetal interface, affecting both the mother and her fetus. This review aims at summarizing the current evidence about the short- and long-term consequences of intrauterine exposure to influenza, RSV, and SARS-CoV-2 in terms of neonatal and pediatric outcomes.
Collapse
Affiliation(s)
- Sara Manti
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Salvatore Leonardi
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Fariba Rezaee
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
- Center for Pediatric Pulmonology, Cleveland Clinic Children’s, Cleveland, OH, United States
| | - Terri J. Harford
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Miriam K. Perez
- Department of General Pediatrics, Cleveland Clinic Children’s, Cleveland, OH, United States
| | - Giovanni Piedimonte
- Department of Pediatrics, Biochemistry and Molecular Biology, Tulane University, New Orleans, LA, United States
- *Correspondence: Giovanni Piedimonte,
| |
Collapse
|
28
|
Fu W, Sivajohan B, McClymont E, Albert A, Elwood C, Ogilvie G, Money D. Systematic review of the safety, immunogenicity, and effectiveness of COVID-19 vaccines in pregnant and lactating individuals and their infants. Int J Gynaecol Obstet 2022; 156:406-417. [PMID: 34735722 PMCID: PMC9087489 DOI: 10.1002/ijgo.14008] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/09/2021] [Accepted: 11/02/2021] [Indexed: 12/05/2022]
Abstract
BACKGROUND There is significant risk of complications and vulnerability to severe COVID-19 disease in pregnancy, yet hesitancy exists around COVID-19 vaccination during pregnancy and lactation. OBJECTIVE To summarize the safety, immunogenicity, and effectiveness of COVID-19 vaccines in pregnancy and lactation. SEARCH STRATEGY A systematic search of MEDLINE, Embase, PubMed, medRxiv, and bioRxiv. SELECTION CRITERIA Identified original studies published on pregnant and/or lactating individuals who received one or more doses of a COVID-19 vaccine. DATA COLLECTION AND ANALYSIS A descriptive summary organized by safety, immunogenicity, and effectiveness outcomes of COVID-19 vaccination in pregnancy and lactation. MAIN RESULTS In total, 23 studies were identified. Humoral response and functional immunity were interrogated and found. Increasing placental transfer ratios in cord blood were associated with increasing time from the first vaccine dose to delivery. Safety data indicated that pregnant and lactating populations experienced vaccine-related reactions at similar rates to the general population. No increased risk of adverse obstetrical or neonatal outcomes were reported. One study demonstrated that pregnant individuals were less likely to experience COVID-19 when vaccinated. CONCLUSION COVID-19 vaccination in pregnant and lactating individuals is immunogenic, does not cause significant vaccine-related adverse events or obstetrical and neonatal outcomes, and is effective in preventing COVID-19 disease.
Collapse
Affiliation(s)
- Winnie Fu
- Faculty of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Brintha Sivajohan
- Schulich School of Medicine and DentistryUniversity of Western OntarioLondonOntarioCanada
| | - Elisabeth McClymont
- Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Canadian HIV Trials NetworkVancouverBritish ColumbiaCanada
| | - Arianne Albert
- Women’s Health Research InstituteVancouverBritish ColumbiaCanada
| | - Chelsea Elwood
- Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Gina Ogilvie
- Women’s Health Research InstituteVancouverBritish ColumbiaCanada
- School of Population and Public HealthUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- British Columbia Centre for Disease ControlVancouverBritish ColumbiaCanada
| | - Deborah Money
- Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Women’s Health Research InstituteVancouverBritish ColumbiaCanada
| |
Collapse
|
29
|
Raut S, Apte A, Srinivasan M, Dudeja N, Dayma G, Sinha B, Bavdekar A. Determinants of maternal influenza vaccination in the context of low- and middle-income countries: A systematic review. PLoS One 2022; 17:e0262871. [PMID: 35081138 PMCID: PMC8791521 DOI: 10.1371/journal.pone.0262871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 01/06/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pregnancy and early infancy are considered to be the vulnerable phases for severe influenza infection causing morbidity and mortality. Despite WHO recommendations, influenza is not included in the immunization programs of many low- and middle-income countries. This systematic review is aimed at identifying barriers and facilitators for maternal influenza vaccination amongst the perinatal women and their health care providers in low- and middle-income countries. METHODS We selected 11 studies from the 1669 records identified from PubMed, CABI, EMBASE and Global Health databases. Studies related to both pandemic and routine influenza vaccination and studies conducted amongst women in the antenatal as well as postnatal period were included. Both qualitative, quantitative, cross-sectional and interventional studies were included. RESULTS Knowledge about influenza disease, perception of the disease severity during pregnancy and risk to the foetus/newborn and perceived benefits of influenza vaccination during pregnancy were associated with increased uptake of influenza vaccination during pregnancy. Recommendation by health care provider, vaccination in previous pregnancy and availability of vaccine in public health system facilitated vaccine uptake. High parity, higher education, vaccination in the later months of pregnancy, less than 4 antenatal visits, concerns about vaccine safety and negative publicity in media were identified as barriers for influenza vaccination. Lack of government recommendation, concerns about safety and effectiveness and distrust in manufacturer were the barriers for the healthcare providers to recommend vaccination. CONCLUSION While availability of influenza vaccine in public health system can be a key to the success of vaccine implementation program, increasing the awareness about need and benefits of maternal influenza vaccination amongst pregnant women as well as their health care providers is crucial to improve the acceptance of maternal influenza vaccination in low and middle-income countries.
Collapse
Affiliation(s)
- Shrish Raut
- PRERNA Young Investigator, KEM Hospital Research Centre, Pune, India
| | - Aditi Apte
- PRERNA Young Scientist, KEM Hospital Research Centre, Pune, India
| | | | - Nonita Dudeja
- PRERNA Young Investigator, Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Girish Dayma
- PRERNA Young Investigator, KEM Hospital Research Centre, Pune, India
| | - Bireshwar Sinha
- PRERNA Young Scientist, Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Ashish Bavdekar
- Associate Professor, Department of Pediatrics; Consultant, Pediatric Research & Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| |
Collapse
|
30
|
Balachandren N, Davies MC, Hall JA, Stephenson JM, David AL, Barrett G, O’Neill HC, Ploubidis GB, Yasmin E, Mavrelos D. OUP accepted manuscript. Hum Reprod 2022; 37:1126-1133. [PMID: 35389480 PMCID: PMC9047154 DOI: 10.1093/humrep/deac062] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/14/2022] [Indexed: 11/24/2022] Open
Abstract
STUDY QUESTION Does maternal infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the first trimester affect the risk of miscarriage before 13 week’s gestation? SUMMARY ANSWER Pregnant women with self-reported diagnosis of SARS-CoV-2 in the first trimester had a higher risk of early miscarriage. WHAT IS KNOWN ALREADY Viral infections during pregnancy have a broad spectrum of placental and neonatal pathology. Data on the effects of the SARS-CoV-2 infection in pregnancy are still emerging. Two systematic reviews and meta-analyses reported an increased risk of preterm birth, caesarean delivery, maternal morbidity and stillbirth. Data on the impact of first trimester infection on early pregnancy outcomes are scarce. This is the first study, to our knowledge, to investigate the rates of early pregnancy loss during the SARS-CoV-2 outbreak among women with self-reported infection. STUDY DESIGN, SIZE, DURATION This was a nationwide prospective cohort study of pregnant women in the community recruited using social media between 21 May and 31 December 2020. We recruited 3545 women who conceived during the SARS-CoV-2 pandemic who were <13 week’s gestation at the time of recruitment. PARTICIPANTS/MATERIALS, SETTING, METHODS The COVID-19 Contraception and Pregnancy Study (CAP-COVID) was an on-line survey study collecting longitudinal data from pregnant women in the UK aged 18 years or older. Women who were pregnant during the pandemic were asked to complete on-line surveys at the end of each trimester. We collected data on current and past pregnancy complications, their medical history and whether they or anyone in their household had symptoms or been diagnosed with SARS-CoV-2 infection during each trimester of their pregnancy. RT-PCR-based SARS-CoV-2 RNA detection from respiratory samples (e.g. nasopharynx) is the standard practice for diagnosis of SARS-CoV-2 in the UK. We compared rate of self-reported miscarriage in three groups: ‘presumed infected’, i.e. those who reported a diagnosis with SARS-CoV-2 infection in the first trimester; ‘uncertain’, i.e. those who did not report a diagnosis but had symptoms/household contacts with symptoms/diagnosis; and ‘presumed uninfected’, i.e. those who did not report any symptoms/diagnosis and had no household contacts with symptoms/diagnosis of SARS-CoV-2. MAIN RESULTS AND THE ROLE OF CHANCE A total of 3545 women registered for the CAP-COVID study at <13 weeks gestation and were eligible for this analysis. Data for the primary outcome were available from 3041 women (86%). In the overall sample, the rate of self-reported miscarriage was 7.8% (238/3041 [95% CI, 7–9]). The median gestational age (GA) at miscarriage was 9 weeks (interquartile range 8–11). Seventy-seven women were in the ‘presumed infected’ group (77/3041, 2.5% [95% CI 2–3]), 295/3041 were in the uncertain group (9.7% [95% CI 9–11]) and the rest in the ‘presumed uninfected’ (87.8%, 2669/3041 [95% CI 87–89]). The rate of early miscarriage was 14% in the ‘presumed infected’ group, 5% in the ‘uncertain’ and 8% in the ‘presumed uninfected’ (11/77 [95% CI 6–22] versus 15/295 [95% CI 3–8] versus 212/2669 [95% CI 7–9], P = 0.02). After adjusting for age, BMI, ethnicity, smoking status, GA at registration and the number of previous miscarriages, the risk of early miscarriage appears to be higher in the ‘presumed infected’ group (relative rate 1.7, 95% CI 1.0–3.0, P = 0.06). LIMITATIONS, REASONS FOR CAUTION We relied on self-reported data on early pregnancy loss and SARS-CoV-2 infection without any means of checking validity. Some women in the ‘presumed uninfected’ and ‘uncertain’ groups may have had asymptomatic infections. The number of ‘presumed infected’ in our study was low and therefore the study was relatively underpowered. WIDER IMPLICATIONS OF THE FINDINGS This was a national study from the UK, where infection rates were one of the highest in the world. Based on the evidence presented here, women who are infected with SARS-CoV-2 in their first trimester may be at an increased risk of a miscarriage. However, the overall rate of miscarriage in our study population was 8%. This is reassuring and suggests that if there is an effect of SARS-CoV-2 on the risk of miscarriage, this may be limited to those with symptoms substantial enough to lead to a diagnostic test. Further studies are warranted to evaluate a causal association between SARS-CoV-2 infection in early pregnancy and miscarriage risk. Although we did not see an overall increase in the risk of miscarriage, the observed comparative increase in the presumed infected group reinforces the message that pregnant women should continue to exercise social distancing measures and good hygiene throughout their pregnancy to limit their risk of infection STUDY FUNDING/COMPETING INTEREST(S) This study was supported by a grant from the Elizabeth Garrett Anderson Hospital Charity (G13-559194). The funders of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. J.A.H. is supported by an NIHR Advanced Fellowship. A.L.D. is supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support to J.A.H. and A.L.D. as above; no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. TRIAL REGISTRATION NUMBER N/A.
Collapse
Affiliation(s)
| | - Melanie C Davies
- Reproductive Medicine Unit, University College London Hospital, London, UK
| | - Jennifer A Hall
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Judith M Stephenson
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Geraldine Barrett
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Helen C O’Neill
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - George B Ploubidis
- Centre for Longitudinal Studies, Social Research Institute, University College London, London, UK
| | - Ephia Yasmin
- Correspondence address. Reproductive Medicine Unit, University College London Hospital, London NW1 2BU, UK. E-mail:
| | | |
Collapse
|
31
|
Dauby N, Flamand V. From maternal breath to infant's cells: Impact of maternal respiratory infections on infants 'immune responses. Front Pediatr 2022; 10:1046100. [PMID: 36419921 PMCID: PMC9676445 DOI: 10.3389/fped.2022.1046100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
In utero exposure to maternally-derived antigens following chronic infection is associated with modulation of infants 'immune response, differential susceptibility to post-natal infections and immune response toward vaccines. The maternal environment, both internal (microbiota) and external (exposure to environmental microbes) also modulates infant's immune response but also the clinical phenotype after birth. Vertical transmission of ubiquitous respiratory pathogens such as influenza and COVID-19 is uncommon. Evidence suggest that in utero exposure to maternal influenza and SARS-CoV-2 infections may have a significant impact on the developing immune system with activation of both innate and adaptive responses, possibly related to placental inflammation. Here in, we review how maternal respiratory infections, associated with airway, systemic and placental inflammation but also changes in maternal microbiota might impact infant's immune responses after birth. The clinical impact of immune modifications observed following maternal respiratory infections remains unexplored. Given the high frequencies of respiratory infections during pregnancy (COVID-19, influenza but also RSV and HMPV), the impact on global child health could be important.
Collapse
Affiliation(s)
- Nicolas Dauby
- Institute for Medical Immunology, ULB Center for Research in Immunology, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Department of Infectious Diseases, CHU Saint-Pierre, Brussels, Belgium.,School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Véronique Flamand
- Institute for Medical Immunology, ULB Center for Research in Immunology, Université Libre de Bruxelles (ULB), Brussels, Belgium
| |
Collapse
|
32
|
Roberts NF, Sprague AE, Taljaard M, Fell DB, Ray JG. Maternal-Newborn Health System Changes and Outcomes in Ontario Canada during Wave 1 of the COVID-19 Pandemic - A Retrospective Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:664-674. [PMID: 34973435 PMCID: PMC8716144 DOI: 10.1016/j.jogc.2021.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the population-level impact of COVID-19 pandemic-related obstetric practice changes on maternal and newborn outcomes. METHODS Segmented regression analysis examined changes that occurred 240 weeks pre-pandemic through the first 32 weeks of the pandemic using data from Ontario's Better Outcomes Registry & Network. Outcomes included birth location, length of stay, labour analgesia, mode of delivery, preterm birth, and stillbirth. Immediate and gradual effects were modelled with terms representing changes in intercepts and slopes, corresponding to the start of the pandemic. RESULTS There were 799 893 eligible pregnant individuals included in the analysis; 705 767 delivered in the pre-pandemic period and 94,126 during the pandemic wave 1 period. Significant immediate decreases were observed for hospital births (relative risk [RR] 0.99; 95% CI 0.98-0.99), length of stay (median change -3.29 h; 95% CI -3.81 to -2.77), use of nitrous oxide (RR 0.11; 95% CI 0.09-0.13) and general anesthesia (RR 0.69; 95% CI 0.58- 0.81), and trial of labour after cesarean (RR 0.89; 95% CI 0.83-0.96). Conversely, there were significant immediate increases in home births (RR 1.35; 95% CI 1.21-1.51), and use of epidural (RR 1.02; 95% CI 1.01-1.04) and regional anesthesia (RR 1.01; 95% CI 1.01-1.02). There were no significant immediate changes for any other outcomes, including preterm birth (RR 0.99; 95% CI 0.93-1.05) and stillbirth (RR 1.11; 95% CI 0.87-1.42). CONCLUSION Provincial health system changes implemented at the start of the pandemic resulted in immediate clinical practice changes but no significant increases in adverse outcomes.
Collapse
Affiliation(s)
- Nicole F Roberts
- Better Outcomes Registry & Network (BORN) Ontario, Centre for Practice Changing Research, 401 Smyth Rd, Ottawa, ON K1H 8L1.
| | - Ann E Sprague
- Better Outcomes Registry & Network Ontario; Children's Hospital of Eastern Ontario (CHEO) Research Institute 401 Smyth Rd, Ottawa, ON K1H 8L1
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Clinical Epidemiology Program; School of Epidemiology and Public Health, University of Ottawa 451 Smyth Rd, Ottawa, ON K1H 8L1
| | - Deshayne B Fell
- Children's Hospital of Eastern Ontario (CHEO) Research Institute; School of Epidemiology and Public Health, University of Ottawa 401 Smyth Rd, Ottawa, ON K1H 8L1
| | - Joel G Ray
- Department of Obstetrics and Gynecology, St. Michael's Hospital 36 Queen St E, Toronto, ON M5B 1W8
| |
Collapse
|
33
|
Irving SA, Ball SW, Booth SM, Regan AK, Naleway AL, Buchan SA, Katz MA, Effler PV, Svenson LW, Kwong JC, Feldman BS, Klein NP, Chung H, Simmonds K. A multi-country investigation of influenza vaccine coverage in pregnant individuals, 2010-2016. Vaccine 2021; 39:7598-7605. [PMID: 34802789 DOI: 10.1016/j.vaccine.2021.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Many countries recommend influenza vaccination during pregnancy. Despite this recommendation, influenza vaccine among pregnant individuals remains under-utilized and uptake varies by country. Factors associated with influenza vaccine uptake during pregnancy may also vary across countries. METHODS As members of the Pregnancy Influenza Vaccine Effectiveness Network (PREVENT), five sites from four countries (Australia, Canada, Israel, and the United States) retrospectively identified cohorts of individuals aged 18-50 years who were pregnant during pre-defined influenza seasons. Influenza vaccine coverage estimates were calculated for the 2010-11 through 2015-16 northern hemisphere and the 2012 through 2015 southern hemisphere influenza seasons, by site. Sites used electronic health records, administrative data, and immunization registries to collect information on pregnancy, health history, demographics, and vaccination status. Each season, vaccination coverage was calculated as the percentage of individuals who received influenza vaccine among the individuals in the cohort that season. Characteristics were compared between those vaccinated and unvaccinated, by site. RESULTS More than two million pregnancies were identified over the study period. Influenza vaccination coverage ranged from 5% to 58% across sites and seasons. Coverage increased consistently over the study period at three of the five sites (Western Australia, Alberta, and Israel), and was highest in all seasons at the United States study site (39-58%). Associations with vaccination varied by country and across seasons; where available, parity >0, presence of a high-risk medical condition, and urban residence were consistently associated with increased likelihood of vaccination. CONCLUSIONS Though increasing, uptake of influenza vaccine among pregnant individuals remains lower than recommended. Coverage varied substantially by country, suggesting an ongoing need for targeted strategies to improve influenza vaccine uptake in this population.
Collapse
Affiliation(s)
| | - Sarah W Ball
- Abt Associates, Cambridge MA, USA; Westat, Rockville, MD, USA
| | | | - Annette K Regan
- School of Public Health, Curtin University, Perth, Australia; Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia; School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA
| | | | - Sarah A Buchan
- ICES, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Public Health Ontario, Toronto, Canada
| | - Mark A Katz
- Clalit Research Institute, Tel Aviv, Israel; Medical School for International Health and School of Public Health, Ben Gurion University of the Negev, Beersheva, Israel; University of Michigan School of Public Health, Ann Arbor MI, USA
| | - Paul V Effler
- Communicable Disease Control Directorate, Department of Health Western Australia, Perth, WA, Australia
| | - Lawrence W Svenson
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Ministry of Health, Edmonton, Canada; Division of Preventive Medicine, University of Alberta, Edmonton, Canada; School of Public Health, University of Alberta, Edmonton, Canada
| | - Jeffrey C Kwong
- ICES, Toronto, Canada; Medical School for International Health and School of Public Health, Ben Gurion University of the Negev, Beersheva, Israel; Public Health Ontario, Toronto, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada
| | | | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, CA, USA
| | | | - Kimberley Simmonds
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Ministry of Health, Edmonton, Canada
| | | |
Collapse
|
34
|
Boelig RC, Aagaard KM, Debbink MP, Shamshirsaz AA. Society for Maternal-Fetal Medicine Special Statement: COVID-19 research in pregnancy: progress and potential. Am J Obstet Gynecol 2021; 225:B19-B31. [PMID: 34481778 PMCID: PMC8413099 DOI: 10.1016/j.ajog.2021.08.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The COVID-19 global pandemic has broad implications for obstetrical care and perinatal outcomes. As we approach the 2-year mark into an unprecedented international pandemic, this review presents the progress and opportunities for research related to COVID-19 and pregnancy. Research is the basis for evidence-based clinical guidelines, and we aim to provide the structure and guidance for framing COVID-19-related obstetrical research. This structure will pertain not only to this pandemic but future ones as well.
Collapse
|
35
|
Arslan B, Bicer IG, Sahin T, Vay M, Dilek O, Destegul E. Clinical characteristics and hematological parameters associated with disease severity in COVID-19 positive pregnant women undergoing cesarean section: A single-center experience. J Obstet Gynaecol Res 2021; 48:402-410. [PMID: 34837446 PMCID: PMC9011896 DOI: 10.1111/jog.15108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/11/2021] [Accepted: 11/17/2021] [Indexed: 12/11/2022]
Abstract
AIM The study aimed to describe clinical characteristics and outcomes of pregnant women with COVID-19 undergoing cesarean section, and evaluated the association of blood values at admission with severe COVID-19 disease in this group of patients. METHOD We retrospectively analyzed the clinical data of 110 patients infected with COVID-19 who underwent cesarean section at Adana City Education and Research Hospital in Turkey. The COVID-19 severity of the patients was classified as either severe or nonsevere disease according to World Health Organization of COVID-19 clinical management guidance. We compared blood values, clinical characteristics, and outcomes between severe and nonsevere patients. Receiver operating characteristics (ROC) curves analyses and area under the ROC curve (AUC) value was calculated to evaluate the predictive value of blood parameters on the COVID-19 severity. RESULTS Of the 110 women, 12 were severe cases. Severe patients had higher ferritin, neutrophil-to-lymphocyte ratio (NLR), lactate dehydrogenase (LDH), alanine transaminase (ALT), aspartate transaminase (AST), and procalcitonin levels on admission (p < 0.05). The ROC analysis demonstrated AUC of NLR, LDH, AST, ALT, ferritin, and procalcitonin was 0.757, 0.856, 0.840, 0.771, 0.821, and 0.698, respectively. The LDH had a maximum specificity (90.8%), with the cutoff value of 365. The O-blood group was more likely to have severe illness than the non-O-blood group (relative risk: 3.6; 95% confidence interval; 1.2-10.4). CONCLUSION This study shows that LDH values at admission are an early and powerful predictor of severe infection for pregnant women with COVID-19 who will undergo a cesarean section.
Collapse
Affiliation(s)
- Baris Arslan
- Department of Anesthesia and Intensive Care, Adana City Education and Research Hospital, Adana, Turkey
| | - Ilhan G Bicer
- Department of Anesthesia and Intensive Care, Adana City Education and Research Hospital, Adana, Turkey
| | - Tuna Sahin
- Department of Anesthesia and Intensive Care, Adana City Education and Research Hospital, Adana, Turkey
| | - Merve Vay
- Department of Obstetrics and Gynecology, Adana City Education and Research Hospital, Adana, Turkey
| | - Okan Dilek
- Department of Radiology, Adana City Education and Research Hospital, Adana, Turkey
| | - Emre Destegul
- Department of Obstetrics and Gynecology, Adana City Education and Research Hospital, Adana, Turkey
| |
Collapse
|
36
|
Critto ME, Enriquez Y, Bravo M, Quevedo LDJ, Weinberg R, Etchegaray A, Koch ES. Impact of emerging virus pandemics on cause-specific maternal mortality time series: a population-based natural experiment using national vital statistics, Argentina 1980-2017. LANCET REGIONAL HEALTH. AMERICAS 2021; 6:100116. [PMID: 36777885 PMCID: PMC9904057 DOI: 10.1016/j.lana.2021.100116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Emerging pandemic viruses may have multiple deleterious effects on maternal health. This study examines the effects of a pandemic influenza virus on cause-specific maternal mortality time series, using Argentinian vital statistics. Methods We conducted a population-based natural experiment from national vital records of maternal deaths between 1980 and 2017. Joinpoint regression models were used to model time series of the maternal mortality ratio (MMR). The sensitivity of the registry to detect the effects of the pandemic H1N1 2009 influenza virus on cause-specific MMR was analysed using a panel of parallel interrupted time series (ITS). Findings Over this 38-year study, the MMR decreased by 58·6% (69·5 to 28·8 deaths/100,000 live births), transitioning from direct obstetric causes (67·0 to 21·1/100,000 live births; 68·4% decrease) to indirect causes (2·6 to 7·7/100,000 live births; 196·2% increase). The regression analysis showed an average reduction of -2·2%/year (95% CI: -2·9 to -1·4) with 2 join points in the total trend (1998 and 2009). Parallel ITS analyses revealed the pandemic H1N1 virus had an increasing effect on mortality from the respiratory system- and sepsis-related complications (level change 4·7 and 1·6/100,000 live births respectively), reversing after the outbreak. No effect was found on MMR from hypertensive disorders, haemorrhage, abortive outcomes, other direct obstetric causes, and indirect non-respiratory comorbidities. Interpretation The Argentinian maternal death registry appears sensitive to detect different effects of emerging infectious epidemics on maternal health. In a population-based natural experiment, pandemic H1N1 virus impacted maternal mortality almost exclusively from the respiratory system- and sepsis-related complications. Funding Supported by FISAR www.fisarchile.org.
Collapse
Affiliation(s)
- María Elena Critto
- Division of Epidemiology, MELISA Institute, Concepción, Chile,Programa de Doctorado en Sociología, Facultad de Ciencias Sociales, Pontificia Universidad Católica de Argentina, Ciudad de Buenos Aires, Argentina
| | - Yordanis Enriquez
- Facultad de Ciencias de la Salud, Universidad Católica Sedes Sapientiae, Lima, Perú
| | - Miguel Bravo
- Division of Epidemiology, MELISA Institute, Concepción, Chile,School of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Lenin de Janon Quevedo
- Facultad de Ciencias Médicas, Pontificia Universidad Católica de Argentina, Ciudad de Buenos Aires, Argentina
| | - Ruth Weinberg
- Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Adolfo Etchegaray
- Hospital Universitario Austral, Facultad de Medicina, Universidad Austral, Buenos Aires, Argentina
| | - Elard S. Koch
- Division of Epidemiology, MELISA Institute, Concepción, Chile,Corresponding author. Dr. Elard S. Koch, Division of Epidemiology, MELISA Institute. Dalcahue 1120, Suite 101-103, San Pedro de la Paz, 4133515, Concepción, Chile Telephone: +56 41 246 7242
| |
Collapse
|
37
|
Morton S, Lamont H, Silvey N, Browning T, Hayes M, Keays R, Christie L, Davies R, Singh S, Lockie C, Sisson A, Vizcaychipi M. Adult intensive care unit admissions with severe COVID-19 infection following emergency Caesarean section deliveries: A case series. J Intensive Care Soc 2021; 22:288-299. [PMID: 35154366 PMCID: PMC8829764 DOI: 10.1177/1751143720947547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND UK data suggest 6% of COVID-19 hospital admissions are either currently pregnant or immediately post-partum. However, the current literature suggests that if COVID-19 occurs in pregnancy, or post-partum, symptoms are mostly mild. METHODS All COVID-19 admissions to one acute London National Health Service Foundation trust were reviewed since the beginning of the COVID-19 pandemic to 1 May 2020 to establish whether there were any pregnant or immediately post-partum admissions. Data were extracted from hospital electronic records and anonymised. Any patients admitted to adult intensive care unit had their case notes reviewed in detail and comparison made to a local risk-assessment guideline identifying patients at-risk of thromboembolic events or cytokine storms. Local hospital guidelines were followed. Patients admitted to adult intensive care unit gave written consent. RESULTS A total of 24 pregnant or immediately post-partum patients with COVID-19 were admitted. Three patients required long adult intensive care unit admissions for severe single-organ respiratory failure after emergency C-sections. Two of these patients required proning (three times and eight times, respectively). All were considered medium risk for thromboembolic events but had rising D-dimers following adult intensive care unit admission, resulting in increased dosing of pharmacological thromboprophylaxis throughout their admission. All were considered low risk for a cytokine storm, and none had any significant cardiovascular or renal involvement. One patient developed a super-imposed fungal lung infection. All three patients developed delirium following cessation of sedation. CONCLUSION Pregnant or immediately post-partum women can develop severe COVID-19 symptoms requiring prolonged adult intensive care unit admission. It is likely to be single-organ failure, but patients are at a high risk of a thromboembolic event and delirium.
Collapse
Affiliation(s)
- Sarah Morton
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Holly Lamont
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Natalie Silvey
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Thomas Browning
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Michelle Hayes
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Richard Keays
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Linsey Christie
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Roger Davies
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Suveer Singh
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Chris Lockie
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Alice Sisson
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| | - Marcela Vizcaychipi
- Adult Intensive Care Unit, Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
- Academic Department of Anaesthesia, Chelsea Campus, Imperial College London, Chelsea, London, UK
| | | |
Collapse
|
38
|
Abstract
The outbreak and spread of the coronavirus disease 2019 pandemic has led to an unprecedented wealth of literature on the impact of human coronaviruses on pregnancy. The number of case studies and publications alone are several orders of magnitude larger than those published in all previous human coronavirus outbreaks combined, enabling robust conclusions to be drawn from observations for the first time. However, the importance of learning from previous human coronavirus outbreaks cannot be understated. In this narrative review, we describe what we consider to the major learning points arising from the SARS-CoV-2 pandemic in relation to pregnancy, and where these confound what might have been expected from previous coronavirus outbreaks.
Collapse
|
39
|
Foo SS, Cambou MC, Mok T, Fajardo VM, Jung KL, Fuller T, Chen W, Kerin T, Mei J, Bhattacharya D, Choi Y, Wu X, Xia T, Shin WJ, Cranston J, Aldrovandi G, Tobin N, Contreras D, Ibarrondo FJ, Yang O, Yang S, Garner O, Cortado R, Bryson Y, Janzen C, Ghosh S, Devaskar S, Asilnejad B, Moreira ME, Vasconcelos Z, Soni PR, Gibson LC, Brasil P, Comhair SA, Arumugaswami V, Erzurum SC, Rao R, Jung JU, Nielsen-Saines K. The systemic inflammatory landscape of COVID-19 in pregnancy: Extensive serum proteomic profiling of mother-infant dyads with in utero SARS-CoV-2. Cell Rep Med 2021; 2:100453. [PMID: 34723226 PMCID: PMC8549189 DOI: 10.1016/j.xcrm.2021.100453] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 08/30/2021] [Accepted: 10/21/2021] [Indexed: 12/22/2022]
Abstract
While pregnancy increases the risk for severe COVID-19, the clinical and immunological implications of COVID-19 on maternal-fetal health remain unknown. Here, we present the clinical and immunological landscapes of 93 COVID-19 mothers and 45 of their SARS-CoV-2-exposed infants through comprehensive serum proteomics profiling for >1,400 cytokines of their peripheral and cord blood specimens. Prenatal SARS-CoV-2 infection triggers NF-κB-dependent proinflammatory immune activation. Pregnant women with severe COVID-19 show increased inflammation and unique IFN-λ antiviral signaling, with elevated levels of IFNL1 and IFNLR1. Furthermore, SARS-CoV-2 infection re-shapes maternal immunity at delivery, altering the expression of pregnancy complication-associated cytokines, inducing MMP7, MDK, and ESM1 and reducing BGN and CD209. Finally, COVID-19-exposed infants exhibit induction of T cell-associated cytokines (IL33, NFATC3, and CCL21), while some undergo IL-1β/IL-18/CASP1 axis-driven neonatal respiratory distress despite birth at term. Our findings demonstrate COVID-19-induced immune rewiring in both mothers and neonates, warranting long-term clinical follow-up to mitigate potential health risks.
Collapse
Affiliation(s)
- Suan-Sin Foo
- Department of Cancer Biology, Infection Biology Program, and Global Center for Pathogen Research and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Mary Catherine Cambou
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Thalia Mok
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Viviana M. Fajardo
- Department of Pediatrics, Division of Neonatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Kyle L. Jung
- Department of Cancer Biology, Infection Biology Program, and Global Center for Pathogen Research and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Trevon Fuller
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Manguinhos, Rio de Janeiro 21040-360, Brazil
| | - Weiqiang Chen
- Department of Cancer Biology, Infection Biology Program, and Global Center for Pathogen Research and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Tara Kerin
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Jenny Mei
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Debika Bhattacharya
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Younho Choi
- Department of Cancer Biology, Infection Biology Program, and Global Center for Pathogen Research and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Xin Wu
- Department of Cancer Biology, Infection Biology Program, and Global Center for Pathogen Research and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Tian Xia
- Department of Cancer Biology, Infection Biology Program, and Global Center for Pathogen Research and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Woo-Jin Shin
- Department of Cancer Biology, Infection Biology Program, and Global Center for Pathogen Research and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Jessica Cranston
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Grace Aldrovandi
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Nicole Tobin
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Deisy Contreras
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Francisco J. Ibarrondo
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Otto Yang
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Shangxin Yang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Omai Garner
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Ruth Cortado
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Yvonne Bryson
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Carla Janzen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Shubhamoy Ghosh
- Department of Pediatrics, Division of Neonatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Sherin Devaskar
- Department of Pediatrics, Division of Neonatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Brenda Asilnejad
- Georgetown University School of Medicine, Washington, DC 20007, USA
| | | | - Zilton Vasconcelos
- Instituto Fernades Figueira, Fiocruz, Flamengo, Rio de Janeiro 20140-360, Brazil
| | - Priya R. Soni
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA 90049, USA
| | - L. Caroline Gibson
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA 90049, USA
| | - Patricia Brasil
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Manguinhos, Rio de Janeiro 21040-360, Brazil
| | - Suzy A.A. Comhair
- Respiratory Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Vaithilingaraja Arumugaswami
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Serpil C. Erzurum
- Respiratory Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Rashmi Rao
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Jae U. Jung
- Department of Cancer Biology, Infection Biology Program, and Global Center for Pathogen Research and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA,Corresponding author
| | - Karin Nielsen-Saines
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA,Corresponding author
| |
Collapse
|
40
|
Easterlin MC, Crimmins EM, Finch CE. Will prenatal exposure to SARS-CoV-2 define a birth cohort with accelerated aging in the century ahead? J Dev Orig Health Dis 2021; 12:683-687. [PMID: 33168125 PMCID: PMC7674789 DOI: 10.1017/s204017442000104x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/04/2020] [Accepted: 10/16/2020] [Indexed: 12/21/2022]
Abstract
The 1918 Influenza pandemic had long-term impacts on the cohort exposed in utero which experienced earlier adult mortality, and more diabetes, ischemic heart disease, and depression after age 50. It is possible that the Coronavirus Disease 2019 (COVID-19) pandemic will also have long-term impacts on the cohort that was in utero during the pandemic, from exposure to maternal infection and/or the stress of the pandemic environment. We discuss how COVID-19 disease during pregnancy may affect fetal and postnatal development with adverse impacts on health and aging. Severe maternal infections are associated with an exaggerated inflammatory response, thromboembolic events, and placental vascular malperfusion. We also discuss how in utero exposure to the stress of the pandemic, without maternal infection, may impact health and aging. Several recently initiated birth cohort studies are tracking neonatal health following in utero severe acute respiratory syndrome virus 2 (SARS-CoV-2) exposure. We suggest these cohort studies develop plans for longer-term observations of physical, behavioral, and cognitive functions that are markers for accelerated aging, as well as methods to disentangle the effects of maternal infection from stresses of the pandemic environment. In utero exposure to COVID-19 disease could cause developmental difficulties and accelerated aging in the century ahead. This brief review summarizes elements of the developmental origins of health, disease, and ageing and discusses how the COVID-19 pandemic might exacerbate such effects. We conclude with a call for research on the long-term consequences of in utero exposure to maternal infection with COVID-19 and stresses of the pandemic environment.
Collapse
MESH Headings
- Adult
- Aged
- Aging/physiology
- COVID-19/physiopathology
- COVID-19/transmission
- COVID-19/virology
- Child
- Child Development/physiology
- Child, Preschool
- Female
- History, 20th Century
- Humans
- Infant
- Infant, Newborn
- Infectious Disease Transmission, Vertical/history
- Influenza A Virus, H1N1 Subtype/pathogenicity
- Influenza Pandemic, 1918-1919/history
- Influenza Pandemic, 1918-1919/statistics & numerical data
- Influenza, Human/history
- Influenza, Human/physiopathology
- Influenza, Human/virology
- Middle Aged
- Pandemics/history
- Pandemics/statistics & numerical data
- Pregnancy
- Pregnancy Complications, Infectious/physiopathology
- Pregnancy Complications, Infectious/virology
- Prenatal Exposure Delayed Effects/physiopathology
- Prenatal Exposure Delayed Effects/virology
- SARS-CoV-2/pathogenicity
Collapse
Affiliation(s)
| | | | - Caleb E. Finch
- Leonard Davis School of Gerontology, University of Southern California
- Dornsife College, University of Southern California
| |
Collapse
|
41
|
Couillard S, Connolly C, Borg C, Pavord I. Asthma in pregnancy: An update. Obstet Med 2021; 14:135-144. [PMID: 34646341 PMCID: PMC8504309 DOI: 10.1177/1753495x20965072] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/16/2020] [Indexed: 01/13/2023] Open
Abstract
AIM To update obstetric care providers about asthma management. SUMMARY Asthma is the most frequent comorbid chronic illness in pregnancy. Convincing evidence shows that uncontrolled asthma magnifies the risk of maternal, fetal and neonate complications. Unfortunately, one in four women take no inhaler during pregnancy, and it is likely that decreased adherence, rather than changes in pathology, explains uncontrolled maternal asthma. Patient surveys reveal a need for information and reassurance. Although some molecules are preferred in pregnancy, there is currently no basis to withhold any asthma medication - old or new. Biomarkers such as blood eosinophils and fractional exhaled nitric oxide are an effective way to assess the risk of asthma attacks and the likelihood of responding to inhaled steroids. Furthermore, practice-changing trials in mild asthma show that switching reliever-only regimens to as-needed 'controller-and-reliever' therapy is effective. We suggest that applying these changes can alleviate women's concerns and improve outcomes.
Collapse
Affiliation(s)
- Simon Couillard
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Clare Connolly
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Catherine Borg
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ian Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
42
|
Lim RK, Kalagara S, Chen KK, Mylonakis E, Kroumpouzos G. DERMATOLOGY IN A MULTIDISCIPLINARY APPROACH WITH INFECTIOUS DISEASE AND OBSTETRIC MEDICINE AGAINST COVID-19. Int J Womens Dermatol 2021; 7:640-646. [PMID: 34462725 PMCID: PMC8388141 DOI: 10.1016/j.ijwd.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/21/2021] [Accepted: 08/22/2021] [Indexed: 12/27/2022] Open
Abstract
The care for patients infected with COVID-19 requires a team approach, and dermatologists may collaborate with other specialties, especially infectious disease (ID) medicine and obstetrics and gynecology (ObGyn), at every stage of the infection process. A broad spectrum of cutaneous manifestations may occur early in COVID-19 infection, making appropriate dermatologic identification critical for an early diagnosis. There is prognostic value in appropriately identifying different types of COVID-19–associated skin manifestations, which have been linked to disease severity. Such observations emanated from dermatology research, especially large series and international registries of cutaneous manifestations relating to COVID-19, and impact COVID-19 care provided by most health care providers. Also, research based on international registries of skin reactions from the COVID-19 vaccines has an impact across disciplines. An increased risk for severe illness from COVID-19 is encountered during pregnancy, and dermatologists’ role is to urge ObGyn and other clinicians to monitor and educate pregnant patients about the potential for eruptions as a manifestation of COVID-19. ID and ObGyn experts indicate that teledermatology enhanced the interaction among health care providers and improved COVID-19 care. More than 40% of all dermatology consultations at a tertiary care hospital were done via teledermatology. Future collaborative research involving dermatology and specialties, such as ID and ObGyn, could help delineate guidelines for dermatology consultations in patients infected with COVID-19 and determine cases appropriate for teledermatology.
Collapse
Affiliation(s)
- Rachel K. Lim
- Alpert Medical School at Brown University, Providence, Rhode Island
| | - Saisanjana Kalagara
- Division of Infectious Diseases, Alpert Medical School at Brown University, Providence, Rhode Island
| | - Kenneth K. Chen
- Division of Obstetric and Consultative Medicine, Alpert Medical School at Brown University, Providence, Rhode Island
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Alpert Medical School at Brown University, Providence, Rhode Island
| | - George Kroumpouzos
- Department of Dermatology, Alpert Medical School at Brown University, Providence, Rhode Island
- Department of Dermatology, Medical School of Jundiaí, São Paulo, Brazil
- GK Dermatology, PC, S Weymouth, Massachusetts
- Corresponding Author.
| |
Collapse
|
43
|
Rasmussen SA, Jamieson DJ. Coronavirus disease 2019 and pregnancy is déjà vu all over again. BJOG 2021; 129:188-191. [PMID: 34379870 PMCID: PMC8441905 DOI: 10.1111/1471-0528.16859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/29/2022]
Affiliation(s)
- S A Rasmussen
- Departments of Pediatrics and Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Epidemiology, University of Florida College of Public Health and Health Professions and College of Medicine, Gainesville, FL, USA
| | - D J Jamieson
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
44
|
Arditi B, Wen T, Riley LE, D'Alton M, Sobhani NC, Friedman AM, Venkatesh KK. Associations of influenza, chronic comorbid conditions, and severe maternal morbidity among U.S. pregnant women with influenza at delivery hospitalization, 2000-2015. Am J Obstet Gynecol MFM 2021; 3:100445. [PMID: 34303850 DOI: 10.1016/j.ajogmf.2021.100445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/15/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic comorbid conditions increase the risk of influenza-related morbidity. Whether this holds for pregnant women who are at high risk of complications from influenza remains to be determined. OBJECTIVES To determine whether chronic comorbid conditions are associated with an increased risk of severe maternal morbidity (SMM) among pregnant women with an influenza diagnosis at delivery hospitalization. STUDY DESIGN We performed a cross-sectional analysis of delivery hospitalizations complicated by an influenza diagnosis using the National Inpatient Sample from 2000-2015. We assessed four prevalent chronic comorbid conditions associated with increased influenza-complications outside of pregnancy, obstructive lung disease (asthma and chronic obstructive pulmonary disease [COPD]), chronic hypertension, obesity, and pregestational diabetes, overall and individually. The primary outcome was SMM excluding transfusion as defined by the Centers for Disease Control and Prevention, and secondarily, specific SMM measures recognized as influenza-related complications, acute respiratory distress syndrome (ARDS), mechanical intubation and ventilation, and sepsis and shock. Multivariable survey-weighted log linear models were used, adjusting for patient, hospital, and clinical characteristics. RESULTS Of 62.7 million delivery hospitalizations, 0.2% (n=144,572) were complicated by an influenza diagnosis at delivery hospitalization (23 cases of influenza per 10,000 delivery hospitalizations), and 24.9% (n=36,054) with 1 or more chronic comorbid conditions, of which 77.4% included obstructive lung disease. Pregnant women with an influenza diagnosis at delivery hospitalization with a chronic comorbid condition had a slightly higher risk of SMM compared to those without (2.6% vs. 1.7%; adjusted risk ratio (aRR): 1.11; 95% CI: 1.03, 1.21), as well as ARDS (0.9% vs. 0.5%; aRR: 1.42; 95% CI: 1.23, 1.64) and mechanical intubation and ventilation (0.2% vs. 0.1%; aRR: 1.92; 95% CI: 1.37, 2.69), but a lower risk of sepsis and shock (0.2% vs. 0.3%; aRR: 0.57; 95% CI: 0.45, 0.73). Regarding specific conditions, obstructive lung disease was associated with an increased risk of SMM (adjusted risk ratio (aRR): 1.21; 95% CI: 1.11, 1.32), as well as ARDS (aRR: 1.54; 95% CI: 1.32, 1.79) and mechanical intubation and ventilation (aRR: 2.80; 95% CI: 2.00, 3.91). Chronic hypertension was associated with an increased risk of ARDS (aRR: 1.70; 95% CI: 1.16, 2.49), but a lower risk of sepsis and shock (aRR: 0.34; 95% CI: 0.13, 0.85). Obesity was associated with a lower risk of SMM (aRR: 0.84; 95% CI: 0.74, 0.97). Pregestational diabetes was not associated with SMM. CONCLUSIONS Among women with a diagnosis of influenza at delivery hospitalization, chronic comorbid conditions may increase the risk of SMM, and in particular, those outcomes related to influenza. These results can inform efforts to increase influenza vaccination for pregnant women with chronic comorbidities.
Collapse
Affiliation(s)
- Brittany Arditi
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center
| | - Timothy Wen
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Laura E Riley
- Department of Obstetrics and Gynecology, Weill Cornell Medicine
| | - Mary D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center
| | - Nasim C Sobhani
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center
| | - Kartik K Venkatesh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University.
| |
Collapse
|
45
|
Lokken EM, Huebner EM, Taylor GG, Hendrickson S, Vanderhoeven J, Kachikis A, Coler B, Walker CL, Sheng JS, al-Haddad BJ, McCartney SA, Kretzer NM, Resnick R, Barnhart N, Schulte V, Bergam B, Ma KK, Albright C, Larios V, Kelley L, Larios V, Emhoff S, Rah J, Retzlaff K, Thomas C, Paek BW, Hsu RJ, Erickson A, Chang A, Mitchell T, Hwang JK, Erickson S, Delaney S, Archabald K, Kline CR, LaCourse SM, Adams Waldorf KM. Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State. Am J Obstet Gynecol 2021; 225:77.e1-77.e14. [PMID: 33515516 PMCID: PMC7838012 DOI: 10.1016/j.ajog.2020.12.1221] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/20/2020] [Accepted: 12/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Evidence is accumulating that coronavirus disease 2019 increases the risk of hospitalization and mechanical ventilation in pregnant patients and for preterm delivery. However, the impact on maternal mortality and whether morbidity is differentially affected by disease severity at delivery and trimester of infection are unknown. OBJECTIVE This study aimed to describe disease severity and outcomes of severe acute respiratory syndrome coronavirus 2 infections in pregnancy across the Washington State, including pregnancy complications and outcomes, hospitalization, and case fatality. STUDY DESIGN Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 1, 2020, and June 30, 2020, were identified in a multicenter retrospective cohort study from 35 sites in Washington State. Sites captured 61% of annual state deliveries. Case-fatality rates in pregnancy were compared with coronavirus disease 2019 fatality rates in similarly aged adults in Washington State using rate ratios and rate differences. Maternal and neonatal outcomes were compared by trimester of infection and disease severity at the time of delivery. RESULTS The principal study findings were as follows: (1) among 240 pregnant patients in Washington State with severe acute respiratory syndrome coronavirus 2 infections, 1 in 11 developed severe or critical disease, 1 in 10 were hospitalized for coronavirus disease 2019, and 1 in 80 died; (2) the coronavirus disease 2019-associated hospitalization rate was 3.5-fold higher than in similarly aged adults in Washington State (10.0% vs 2.8%; rate ratio, 3.5; 95% confidence interval, 2.3-5.3); (3) pregnant patients hospitalized for a respiratory concern were more likely to have a comorbidity or underlying conditions including asthma, hypertension, type 2 diabetes mellitus, autoimmune disease, and class III obesity; (4) 3 maternal deaths (1.3%) were attributed to coronavirus disease 2019 for a maternal mortality rate of 1250 of 100,000 pregnancies (95% confidence interval, 257-3653); (5) the coronavirus disease 2019 case fatality in pregnancy was a significant 13.6-fold (95% confidence interval, 2.7-43.6) higher in pregnant patients than in similarly aged individuals in Washington State with an absolute difference in mortality rate of 1.2% (95% confidence interval, -0.3 to 2.6); and (6) preterm birth was significantly higher among women with severe or critical coronavirus disease 2019 at delivery than for women who had recovered from coronavirus disease 2019 (45.4% severe or critical coronavirus disease 2019 vs 5.2% mild coronavirus disease 2019; P<.001). CONCLUSION Coronavirus disease 2019 hospitalization and case-fatality rates in pregnant patients were significantly higher than in similarly aged adults in Washington State. These data indicate that pregnant patients are at risk of severe or critical disease and mortality compared to nonpregnant adults, and also at risk for preterm birth.
Collapse
Affiliation(s)
- Erica M. Lokken
- Department of Global Health, University of Washington, Seattle, WA,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - G. Gray Taylor
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Jeroen Vanderhoeven
- Swedish Maternal and Fetal Specialty Center—First Hill, Seattle, WA,Obstetrix Medical Group of Washington, Seattle, WA
| | - Alisa Kachikis
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Brahm Coler
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | | | | | | | | | - Nicole M. Kretzer
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - Nena Barnhart
- Department of Obstetrics and Gynecology, PeaceHealth St. Joseph Medical Center, Bellingham, WA
| | - Vera Schulte
- University of Washington School of Medicine, Seattle, WA
| | | | - Kimberly K. Ma
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Catherine Albright
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - Lori Kelley
- Yakima Valley Farm Workers Clinic, Yakima, WA
| | | | | | - Jasmine Rah
- University of Washington School of Medicine, Seattle, WA
| | - Kristin Retzlaff
- Quality Department, EvergreenHealth Medical Center Kirkland, Kirkland, WA
| | - Chad Thomas
- Department of Obstetrics and Gynecology, PeaceHealth St. Joseph Medical Center, Bellingham, WA
| | - Bettina W. Paek
- Eastside Maternal-Fetal Medicine, EvergreenHealth Medical Center Kirkland, Kirkland, WA,Obstetrix Medical Group of Washington, Bellevue, WA
| | - Rita J. Hsu
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA,Women’s and Children’s Health, Confluence Health, Wenatchee, WA
| | - Anne Erickson
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - Timothy Mitchell
- Department of Obstetrics and Gynecology, Vancouver Clinic, Vancouver, WA
| | - Joseph K. Hwang
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Stephen Erickson
- University of Washington School of Medicine, Seattle, WA,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA,Jefferson Healthcare, Port Townsend, WA
| | - Shani Delaney
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Karen Archabald
- Legacy Medical Group—Maternal-Fetal Medicine, Legacy Health, Vancouver, WA
| | - Carolyn R. Kline
- Eastside Maternal-Fetal Medicine, EvergreenHealth Medical Center Kirkland, Kirkland, WA,Obstetrix Medical Group of Washington, Bellevue, WA
| | - Sylvia M. LaCourse
- Department of Global Health, University of Washington, Seattle, WA,Department of Medicine, University of Washington, Seattle, WA
| | - Kristina M. Adams Waldorf
- Department of Global Health, University of Washington, Seattle, WA,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA,Corresponding author: Kristina M. Adams Waldorf, MD
| | | |
Collapse
|
46
|
Lee JS, Jeong O, Yang H. Screening and Vaccination Against Measles and Varicella Among Health Care Workers: A Cost-effectiveness Analysis. Asia Pac J Public Health 2021; 33:508-515. [PMID: 34165349 DOI: 10.1177/10105395211026468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to examine the most cost-effective strategy of screening and vaccinating measles- and varicella-susceptible health care workers (HCWs). A retrospective cost-effectiveness analysis was conducted at a tertiary hospital in Korea with 300 HCWs who were at high risk of infection. Self-reported histories of vaccinations, infectious diseases, and contact with such cases were collected. Serological tests for immunoglobulin G titers of measles and varicella were performed. Data were analyzed using analysis of variance, Kruskal-Wallis test, χ2 test, and Fisher exact test. Seropositivity rates were 96.3% for measles and 95.7% for varicella. Four different strategies (cases) for vaccination were investigated. Considering the progressive decline in antibody concentrations and the false-positive responses in self-reported histories, case 3, which involved administering 2-dose vaccinations to susceptible HCWs demonstrated by antibody screening tests for both measles and varicella, was the most cost-effective strategy. Health care facilities should establish mandatory immunization policies that reduce the risk of transmission of vaccine-preventable diseases.
Collapse
Affiliation(s)
- Ji-Suk Lee
- Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Oh Jeong
- Department of Surgery, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyunju Yang
- College of Nursing, Chonnam National University, Gwangju, Republic of Korea
| |
Collapse
|
47
|
Bowman CJ, Bouressam M, Campion SN, Cappon GD, Catlin NR, Cutler MW, Diekmann J, Rohde CM, Sellers RS, Lindemann C. Lack of effects on female fertility and prenatal and postnatal offspring development in rats with BNT162b2, a mRNA-based COVID-19 vaccine. Reprod Toxicol 2021; 103:28-35. [PMID: 34058573 PMCID: PMC8163337 DOI: 10.1016/j.reprotox.2021.05.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/17/2022]
Abstract
BNT162b2 is a vaccine developed to prevent coronavirus disease 2019 (COVID-19). BNT162b2 is a lipid nanoparticle formulated nucleoside-modified messenger RNA (mRNA) encoding the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein locked in its prefusion conformation. A developmental and reproductive toxicity study was conducted in rats according to international regulatory guidelines. The full human BNT162b2 dose of 30 μg mRNA/dose (>300 times the human dose on a mg/kg basis) was administered intramuscularly to 44 female rats 21 and 14 days prior to mating and on gestation days 9 and 20. Half of the rats were subject to cesarean section and full fetal examination at the end of gestation, and the other half were allowed to deliver and were monitored to the end of lactation. A robust neutralizing antibody response was confirmed prior to mating and at the end of gestation and lactation. The presence of neutralizing antibodies was also confirmed in fetuses and offspring. Nonadverse effects, related to the local injection site reaction, were noted in dams as expected from other animal studies and consistent with observations in humans. There were no effects of BNT162b2 on female mating performance, fertility, or any ovarian or uterine parameters nor on embryo-fetal or postnatal survival, growth, physical development or neurofunctional development in the offspring through the end of lactation. Together with the safety profile in nonpregnant people, this ICH-compliant nonclinical safety data supports study of BNT162b2 in women of childbearing potential and pregnant and lactating women.
Collapse
Affiliation(s)
- Christopher J Bowman
- Drug Safety Research and Development, Pfizer Worldwide Research, Development & Medical, Groton, CT, USA.
| | - Marie Bouressam
- Charles River Laboratories France Safety Assessmsent SAS, Lyon, France
| | - Sarah N Campion
- Drug Safety Research and Development, Pfizer Worldwide Research, Development & Medical, Groton, CT, USA
| | - Gregg D Cappon
- Drug Safety Research and Development, Pfizer Worldwide Research, Development & Medical, Groton, CT, USA
| | - Natasha R Catlin
- Drug Safety Research and Development, Pfizer Worldwide Research, Development & Medical, Groton, CT, USA
| | - Mark W Cutler
- Vaccine Research and Development, Pfizer Worldwide Research, Development & Medical, Pearl River, NY, USA
| | - Jan Diekmann
- Non-Clinical Safety, BioNTech SE, Mainz, Germany
| | - Cynthia M Rohde
- Drug Safety Research and Development, Pfizer Worldwide Research, Development & Medical, Pearl River, NY, USA
| | - Rani S Sellers
- Drug Safety Research and Development, Pfizer Worldwide Research, Development & Medical, Pearl River, NY, USA
| | | |
Collapse
|
48
|
Qeadan F, Mensah NA, Tingey B, Stanford JB. The risk of clinical complications and death among pregnant women with COVID-19 in the Cerner COVID-19 cohort: a retrospective analysis. BMC Pregnancy Childbirth 2021; 21:305. [PMID: 33863292 PMCID: PMC8051832 DOI: 10.1186/s12884-021-03772-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/05/2021] [Indexed: 02/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way, Ste A, Salt Lake City, UT, 84108, USA.
| | - Nana A Mensah
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way, Ste A, Salt Lake City, UT, 84108, USA
| | - Benjamin Tingey
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way, Ste A, Salt Lake City, UT, 84108, USA
| | - Joseph B Stanford
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way, Ste A, Salt Lake City, UT, 84108, USA
| |
Collapse
|
49
|
Qeadan F, Mensah NA, Tingey B, Stanford JB. The risk of clinical complications and death among pregnant women with COVID-19 in the Cerner COVID-19 cohort: a retrospective analysis. BMC Pregnancy Childbirth 2021; 21:305. [PMID: 33863292 PMCID: PMC8051832 DOI: 10.1186/s12884-021-03772-y#citeas] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/05/2021] [Indexed: 06/18/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way, Ste A, Salt Lake City, UT, 84108, USA.
| | - Nana A Mensah
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way, Ste A, Salt Lake City, UT, 84108, USA
| | - Benjamin Tingey
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way, Ste A, Salt Lake City, UT, 84108, USA
| | - Joseph B Stanford
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way, Ste A, Salt Lake City, UT, 84108, USA
| |
Collapse
|
50
|
Giduthuri JG, Purohit V, Kudale A, Utzinger J, Schindler C, Weiss MG. Antenatal influenza vaccination in urban Pune, India: clinician and community stakeholders' awareness, priorities, and practices. Hum Vaccin Immunother 2021; 17:1211-1222. [PMID: 32966146 PMCID: PMC8018408 DOI: 10.1080/21645515.2020.1806670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/01/2020] [Indexed: 12/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Joseph G. Giduthuri
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Vidula Purohit
- The Maharashtra Association of Anthropological Sciences, Centre for Health Research and Development, Pune, India
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India
| | - Abhay Kudale
- The Maharashtra Association of Anthropological Sciences, Centre for Health Research and Development, Pune, India
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India
| | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Christian Schindler
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Mitchell G. Weiss
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| |
Collapse
|