Correction: Inferring school district learning modalities during the COVID-19 pandemic with a hidden Markov model

[This corrects the article DOI: 10.1371/journal.pone.0292354.].

Characteristics of Sudden Unexpected Infant Deaths on Shared and Nonshared Sleep Surfaces

OBJECTIVES

Describe characteristics of sudden unexpected infant deaths (SUID) occurring on shared or nonshared sleep surfaces.

METHODS

We examined SUID among residents of 23 US jurisdictions who died during 2011 to 2020. We calculated frequencies and percentages of demographic, sleep environment, and other characteristics by sleep surface sharing status and reported differences of at least 5% between surface sharing and nonsharing infants.

RESULTS

Of 7595 SUID cases, 59.5% were sleep surface sharing when they died. Compared with nonsharing infants, sharing infants were more often aged 0 to 3 months, non-Hispanic Black, publicly insured, found supine, found in an adult bed or chair/couch, had a higher number of unsafe sleep factors present, were exposed to maternal cigarette smoking prenatally, were supervised by a parent at the time of death, or had a supervisor who was impaired by drugs or alcohol at the time of death. At least 76% of all SUID had multiple unsafe sleep factors present. Among surface-sharing SUID, most were sharing with adults only (68.2%), in an adult bed (75.9%), and with 1 other person (51.6%). Surface sharing was more common among multiples than singletons.

CONCLUSIONS

Among SUID, surface sharing and nonsharing infants varied by age at death, race and ethnicity, insurance type, presence of unsafe sleep factors, prenatal smoke exposure, and supervisor impairment. Most SUID, regardless of sleep location, had multiple unsafe sleep factors present, demonstrating the need for comprehensive safe sleep counseling for every family at every encounter.

Neighborhood Deprivation and Privilege: an Examination of Racialized-Economic Segregation and Preterm Birth, Florida 2019

The Black-White disparity in preterm birth persists and is not fully explained by individual-level social, behavioral, or clinical risk factors. Consequently, there is increasing emphasis on understanding the role of structural and area-level factors. Racialized-economic segregation measured as the index of concentration at the extremes (ICE) simultaneously captures extremes of deprivation and privilege. Our objective was to examine associations between preterm birth (PTB) and the index of concentration at the extremes (ICE). In this cross-sectional study, we analyzed 193,957 Florida birth records from 2019 linked to 2015-2019 census tract data from the American Community Survey. We assessed PTB (< 37 weeks gestation) by subtypes: (1) early (< 34 weeks) and late (34-36 weeks) and (2) spontaneous and indicated (i.e., provider-initiated) deliveries. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for three ICE measures: (1) ICE_INC: income, (2) INC_INC + WB: income + race/ethnicity (non-Hispanic White vs. Black), and (3) INC_INC + WH: income + race/ethnicity (non-Hispanic White vs. Hispanic). Results. For ICE_INC and INC_INC + WB, aORs for residing in the worst-off vs. best-off areas were 1.25 (95% CI: 1.12, 1.46) and 1.21 (95% CI: 1.07, 1.37) for early PTB, respectively, and 1.16 (95% CI: 1.05, 1.28) to 1.22 (95% CI: 1.12, 1.34) for indicated PTB. In conclusion, deprivation captured by ICE was associated with increased odds of early or indicated PTB. Eliminating PTB disparities may require a multifaceted approach that includes addressing the interplay between income and race/ethnicity in residential areas.

Pregnant Women's Experiences During and After Hurricanes Irma and Maria, Pregnancy Risk Assessment Monitoring System, Puerto Rico, 2018

OBJECTIVE

Exposure to natural disasters during and after pregnancy may increase adverse mental health outcomes. Hurricanes Irma and Maria struck Puerto Rico in September 2017. Our objectives were to understand hurricane-related experiences, maternal health concerns, and the impact of hurricane experiences on postpartum depressive symptoms (PDS).

METHODS

We used data from the 2018 Pregnancy Risk Assessment Monitoring System to describe differences in maternal hurricane experiences among women who were pregnant during and after the 2017 hurricanes. We assessed maternal concerns and PDS. We estimated adjusted prevalence ratios (aPRs) and 95% CIs for the associations between hurricane experiences and PDS.

RESULTS

The most frequently reported hurricane experiences were losing power for ≥1 week (97%) and feeling unsafe due to lack of order/security (70%). Almost 30% of women who were pregnant during the hurricanes reported missing prenatal care. PDS were reported by 13% of women. Most hurricane experiences were associated with an increased prevalence of PDS. Feeling unsafe (aPR = 2.4; 95% CI, 1.2-4.9) and having difficulty getting food (aPR = 2.1; 95% CI, 1.1-4.1) had the strongest associations.

CONCLUSIONS

Most women who were pregnant during or after hurricanes Irma and Maria struck Puerto Rico reported negative hurricane experiences, and most experiences were associated with an increased prevalence of PDS. Understanding the experiences of pregnant women during and after disasters and identifying risks for adverse mental health outcomes after pregnancy are important to inform emergency preparedness and prenatal and postpartum care.

Inferring school district learning modalities during the COVID-19 pandemic with a hidden Markov model

During the COVID-19 pandemic, many public schools across the United States shifted from fully in-person learning to alternative learning modalities such as hybrid and fully remote learning. In this study, data from 14,688 unique school districts from August 2020 to June 2021 were collected to track changes in the proportion of schools offering fully in-person, hybrid and fully remote learning over time. These data were provided by Burbio, MCH Strategic Data, the American Enterprise Institute's Return to Learn Tracker and individual state dashboards. Because the modalities reported by these sources were incomplete and occasionally misaligned, a model was needed to combine and deconflict these data to provide a more comprehensive description of modalities nationwide. A hidden Markov model (HMM) was used to infer the most likely learning modality for each district on a weekly basis. This method yielded higher spatiotemporal coverage than any individual data source and higher agreement with three of the four data sources than any other single source. The model output revealed that the percentage of districts offering fully in-person learning rose from 40.3% in September 2020 to 54.7% in June of 2021 with increases across 45 states and in both urban and rural districts. This type of probabilistic model can serve as a tool for fusion of incomplete and contradictory data sources in order to obtain more reliable data in support of public health surveillance and research efforts.

Counseling women of reproductive age about emergency preparedness - Provider attitudes and practices

We report healthcare provider attitudes and practices on emergency preparedness counseling for women of reproductive age (WRA), including pregnant, postpartum, and lactating women (PPLW), for disasters and weather emergencies. DocStyles is a web-based panel survey of primary healthcare providers in the United States. During March 17-May 17, 2021, obstetricians-gynecologists, family practitioners, internists, nurse practitioners, and physician assistants were asked about the importance of emergency preparedness counseling, level of confidence, frequency, barriers to providing counseling, and preferred resources to support counseling among WRA and PPLW. We calculated frequencies of provider attitudes and practices, and prevalence ratios with 95% CIs for questions with binary responses. Among 1503 respondents (family practitioners (33%), internists (34%), obstetrician-gynecologists (17%), nurse practitioners (8%), and physician assistants (8%)), 77% thought emergency preparedness was important, and 88% thought counseling was necessary for patient health and safety. However, 45% of respondents did not feel confident providing emergency preparedness counseling, and most (70%) had never talked to PPLW about this topic. Respondents cited not having time during clinical visits (48%) and lack of knowledge (34%) as barriers to providing counseling. Most respondents (79%) stated they would use emergency preparedness educational materials for WRA, and 60% said they were willing to take an emergency preparedness training. Healthcare providers have opportunities to provide emergency preparedness counseling; however, many have not, noting lack of time and knowledge as barriers. Emergency preparedness resources combined with training may improve healthcare provider confidence and increase delivery of emergency preparedness counseling.

Sudden Unexpected Infant Deaths: 2015-2020

OBJECTIVE

Although the US infant mortality rate reached a record low in 2020, the sudden infant death syndrome (SIDS) rate increased from 2019. To understand if the increase was related to changing death certification practices or the coronavirus disease 2019 (COVID-19) pandemic, we examined sudden unexpected infant death (SUID) rates as a group, by cause, and by race and ethnicity.

METHODS

We estimated SUID rates during 2015 to 2020 using US period-linked birth and death data. SUID included SIDS, unknown cause, and accidental suffocation and strangulation in bed. We examined changes in rates from 2019 to 2020 and assessed linear trends during prepandemic (2015-2019) using weighted least squares regression. We also assessed race and ethnicity trends and quantified COVID-19-related SUID.

RESULTS

Although the SIDS rate increased significantly from 2019 to 2020 (P < .001), the overall SUID rate did not (P = .24). The increased SIDS rate followed a declining linear trend in SIDS during 2015 to 2019 (P < .001). Other SUID causes did not change significantly. Our race and ethnicity analysis showed SUID rates increased significantly for non-Hispanic Black infants from 2019 to 2020, widening the disparities between these two groups during 2017 to 2019. In 2020, <10 of the 3328 SUID had a COVID-19 code.

CONCLUSIONS

Diagnositic shifting likely explained the increased SIDS rate in 2020. Why the SUID rate increased for non-Hispanic Black infants is unknown, but warrants continued monitoring. Interventions are needed to address persistent racial and ethnic disparities in SUID.

Risk Factors for Suffocation and Unexplained Causes of Infant Deaths

BACKGROUND

Observational studies have improved our understanding of the risk factors for sudden infant death syndrome, but separate examination of risk for sleep-related suffocation and unexplained infant deaths has been limited. We examined the association between unsafe infant sleep practices and sudden infant deaths (sleep-related suffocation and unexplained causes including sudden infant death syndrome).

METHODS

We conducted a population-based case-control study using 2016 to 2017 Centers for Disease Control and Prevention data. Controls were liveborn infants from the Pregnancy Risk Assessment Monitoring System; cases were from the Sudden Unexpected Infant Death Case Registry. We calculated risk factor prevalence among cases and controls and crude and adjusted odds ratios.

RESULTS

We included 112 sleep-related suffocation cases with 448 age-matched controls and 300 unexplained infant death cases with 1200 age-matched controls. Adjusted odds for sleep-related suffocation ranged from 18.7 (95% confidence interval [CI]: 6.8-51.3) among infants not sharing a room with their mother or caregiver to 1.9 (95% CI: 0.9-4.1) among infants with nonsupine sleep positioning. Adjusted odds for unexplained death ranged from 7.6 (95% CI: 4.7-12.2) among infants not sharing a room with their mother or caregiver to 1.6 (95% CI: 1.1-2.4) among nonsupine positioned infants.

COCLUSIONS

We confirmed previously identified risk factors for unexplained infant death and independently estimated risk factors for sleep-related suffocation. Significance of associations for suffocation followed similar patterns but was of larger magnitude. This information can be used to improve messaging about safe infant sleep.

Participation in survey research among mothers with a recent live birth: A comparison of mothers with living versus deceased infants - Findings from the Pregnancy Risk Assessment Monitoring System, 2016-2019

BACKGROUND

Despite high infant mortality rates in the United States relative to other developed countries, little is known about survey participation among mothers of deceased infants.

OBJECTIVE

To assess differences in survey response, contact and cooperation rates for mothers of deceased versus. living infants at the time of survey mailing (approximately 2-6 months postpartum), overall and by select maternal and infant characteristics.

METHODS

We analysed 2016-2019 data for 50 sites from the Pregnancy Risk Assessment Monitoring System (PRAMS), a site-specific, population-based surveillance system of mothers with a recent live birth. We assessed differences in survey participation between mothers of deceased and living infants. Using American Association for Public Opinion Research (AAPOR) standard definitions and terminology, we calculated proportions of mothers who participated and were successfully contacted among sampled mothers (weighted response and contact rates, respectively), and who participated among contacted mothers (weighted cooperation rate). We then constructed multivariable survey-weighted logistic regression models to examine the adjusted association between infant vital status and weighted response, contact and cooperation rates, within strata of maternal and infant characteristics.

RESULTS

Among sampled mothers, 0.3% (weighted percentage, n = 2795) of infants had records indicating they were deceased at the time of survey mailing and 99.7% (weighted percentage, n = 344,379) did not. Mothers of deceased infants had lower unadjusted weighted response (48.3% vs. 56.2%), contact (67.9% vs. 74.3%) and cooperation rates (71.1% vs. 75.6%). However, after adjusting for covariates, differences in survey participation by infant vital status were reduced.

CONCLUSIONS

After covariate adjustment, differences in PRAMS participation rates were attenuated. However, participation rates among mothers of deceased infants remain two to four percentage points lower compared with mothers of living infants. Strategies to increase PRAMS participation could inform knowledge about experiences and behaviours before, during and shortly after pregnancy to help reduce infant mortality.

Condom use among women of reproductive age (18-49 years) in Puerto Rico during the 2016 Zika virus outbreak: secondary analysis of data from a cross-sectional, population-based, cell-phone survey

OBJECTIVES

Zika virus (ZIKV) can be sexually transmitted, and ZIKV infection during pregnancy can cause birth defects. Contraception is a medical countermeasure to reduce unintended pregnancy and ZIKV-associated birth defects. We estimated the prevalence of condom use and associated factors among women at risk for unintended pregnancy in Puerto Rico during the 2016 ZIKV outbreak.

DESIGN

Secondary analysis of a cross-sectional, population-based, cell-phone survey.

SETTING AND PARTICIPANTS

Women, 18-49 years, living in Puerto Rico during July-November 2016. We limited our analytical sample (n=1840) to women at risk for unintended pregnancy, defined as those who were sexually active with a man in the last 3 months and did not report menopause, hysterectomy, current pregnancy or desiring pregnancy.

OUTCOME MEASURES

We estimated the weighted prevalence of any condom use among women at risk for unintended pregnancy. We calculated crude and adjusted prevalence ratios (aPRs) to examine the association between condom use and ZIKV-related factors, stratified by use of more effective versus less effective or no contraception.

RESULTS

Overall, 32.7% (95% CI: 30.2% to 35.1%) of women reported any condom use in the last 3 months. Among women using more effective contraception, condom use was higher for women who received ZIKV counselling (aPR: 1.61, 95% CI: 1.15 to 2.25) and those worried about having a child with a ZIKV-associated birth defect (aPR: 1.47, 95% CI: 1.03 to 2.10). Among women using less effective or no contraception, condom use was associated with being worried (aPR: 1.20, 95% CI: 1.01 to 1.43) compared with those not worried about ZIKV infection or with a previous known infection.

CONCLUSIONS

During the 2016 ZIKV outbreak, one in three women at risk for unintended pregnancy reported any condom use. Counselling to promote consistent and correct condom use may address concerns regarding ZIKV among women of reproductive age, which may differ by use of effective contraception.

Preterm birth among pregnant persons with severe acute respiratory syndrome Coronavirus 2 infection

OBJECTIVE

We examined the relationship between trimester of SARS-CoV-2 infection, illness severity, and risk for preterm birth.

STUDY DESIGN

We analyzed data for 6336 pregnant persons with SARS-CoV-2 infection in 2020 in the United States. Risk ratios for preterm birth were calculated for illness severity, trimester of infection, and illness severity stratified by trimester of infection adjusted for age, selected underlying medical conditions, and pregnancy complications.

RESULT

Pregnant persons with critical COVID-19 or asymptomatic infection, compared to mild COVID-19, in the second or third trimester were at increased risk of preterm birth. Pregnant persons with moderate-to-severe COVID-19 did not show increased risk of preterm birth in any trimester.

CONCLUSION

Critical COVID-19 in the second or third trimester was associated with increased risk of preterm birth. This finding can be used to guide prevention strategies, including vaccination, and inform clinical practices for pregnant persons.

Emergency Preparedness and Response: Highlights from the Division of Reproductive Health, 2011-2021

This report provides historical context and rationale for coordinated, systematic, and evidence-based public health emergency preparedness and response (EPR) activities to address the needs of women of reproductive age. Needs of pregnant and postpartum women, and infants-before, during, and after public health emergencies-are highlighted. Four focus areas and related activities are described: (1) public health science; (2) clinical guidance; (3) partnerships, communication, and outreach; and (4) workforce development. Finally, the report summarizes major activities of the Division of Reproductive Health's EPR Team at the Centers for Disease Control and Prevention.

Workplace Leave and Breastfeeding Duration Among Postpartum Women, 2016-2018

Objectives. To examine associations of workplace leave length with breastfeeding initiation and continuation at 1, 2, and 3 months. Methods. We analyzed 2016 to 2018 data for 10 sites in the United States from the Pregnancy Risk Assessment Monitoring System, a site-specific, population-based surveillance system that samples women with a recent live birth 2 to 6 months after birth. Using multivariable logistic regression, we examined associations of leave length (< 3 vs ≥ 3 months) with breastfeeding outcomes. Results. Among 12 301 postpartum women who planned to or had returned to the job they had during pregnancy, 42.1% reported taking unpaid leave, 37.5% reported paid leave, 18.2% reported both unpaid and paid leave, and 2.2% reported no leave. Approximately two thirds (66.2%) of women reported taking less than 3 months of leave. Although 91.2% of women initiated breastfeeding, 81.2%, 72.1%, and 65.3% of women continued breastfeeding at 1, 2, and 3 months, respectively. Shorter leave length (< 3 months), whether paid or unpaid, was associated with lower prevalence of breastfeeding at 2 and 3 months compared with 3 or more months of leave. Conclusions. Women with less than 3 months of leave reported shorter breastfeeding duration than did women with 3 or more months of leave. (Am J Public Health. 2021;111(11):2036-2045. https://doi.org/10.2105/AJPH.2021.306484).

Half Century Since SIDS: A Reappraisal of Terminology

After a sudden infant death, parents and caregivers need accurate and open communication about why their infant died. Communicating tragic news about a child's death to families and caregivers is difficult. Shared and consistent terminology is essential for pediatricians, other physicians, and nonphysician clinicians to improve communication with families and among themselves. When families do not have complete information about why their child died, pediatricians will not be able to support them through the process and make appropriate referrals for pediatric specialty and mental health care. Families can only speculate about the cause and may blame themselves or others for the infant's death. The terminology used to describe infant deaths that occur suddenly and unexpectedly includes an assortment of terms that vary across and among pediatrician, other physician, or nonphysician clinician disciplines. Having consistent terminology is critical to improve the understanding of the etiology, pathophysiology, and epidemiology of these deaths and communicate with families. A lack of consistent terminology also makes it difficult to reliably monitor trends in mortality and hampers the ability to develop effective interventions. This report describes the history of sudden infant death terminology and summarizes the debate over the terminology and the resulting diagnostic shift of these deaths. This information is to assist pediatricians, other physicians, and nonphysician clinicians in caring for families during this difficult time. The importance of consistent terminology is outlined, followed by a summary of progress toward consensus. Recommendations for pediatricians, other physicians, and nonphysician clinicians are proposed.

Zika Prevention Behaviors Among Women of Reproductive Age in Puerto Rico, 2016

INTRODUCTION

Zika virus is primarily transmitted through mosquito bites. Because Zika virus infection during pregnancy can cause serious birth defects, reproductive-aged women need protection from Zika virus infection. This report describes Zika virus prevention behaviors among women aged 18-49 years and assesses whether pregnancy status and healthcare provider counseling increases Zika virus prevention behaviors.

METHODS

A population-based cell phone survey of women aged 18-49 years living in Puerto Rico was conducted in July-November 2016. Data were analyzed in 2018-2019. Prevalence estimates and 95% CIs were calculated for Zika virus prevention behaviors. Adjusted prevalence ratios were estimated to examine the association of pregnancy status with healthcare provider counseling on Zika virus prevention behaviors, controlling for age, education, and health insurance status.

RESULTS

Most women reported using screens on open doors/windows (87.7%) and eliminating standing water in/around their homes (92.3%). Other Zika virus prevention behaviors were less common (<33%). In adjusted analysis, pregnant women were more likely than women not at risk for unintended pregnancy to report using mosquito repellent every/most days (adjusted prevalence ratio=1.44, 95% CI=1.13, 1.85). Healthcare provider counseling was associated with receiving professional spraying/larvicide treatment (adjusted prevalence ratio=1.42, 95% CI=1.17, 1.74), sleeping under a bed net (adjusted prevalence ratio=2.37, 95% CI=1.33, 4.24), using mosquito repellent (adjusted prevalence ratio=1.57, 95% CI=1.40, 1.77), and wearing long sleeves/pants (adjusted prevalence ratio=1.32, 95% CI=1.12, 1.55).

CONCLUSIONS

Receipt of healthcare provider counseling was more consistently associated with Zika virus prevention behaviors than pregnancy status. Healthcare provider counseling is an important strategy for increasing the uptake of Zika virus prevention behaviors among women aged 18-49 years.

Adverse Pregnancy Outcomes, Maternal Complications, and Severe Illness Among US Delivery Hospitalizations With and Without a Coronavirus Disease 2019 (COVID-19) Diagnosis

Background

Evidence on risk for adverse outcomes from COVID-19 among pregnant women is still emerging. We examined the association between COVID-19 at delivery and adverse pregnancy outcomes, maternal complications, and severe illness, whether these associations differ by race/ethnicity; and described discharge status by COVID-19 diagnosis and maternal complications.

Methods

Data from 703 hospitals in the Premier Healthcare Database during March–September 2020 were included. Adjusted risk ratios overall and stratified by race/ethnicity were estimated using Poisson regression with robust standard errors. Proportion not discharged home was calculated by maternal complications, stratified by COVID-19 diagnosis.

Results

Among 489,471 delivery hospitalizations, 6,550 (1.3%) had a COVID-19 diagnosis. In adjusted models, COVID-19 was associated with increased risk for: acute respiratory distress syndrome (adjusted risk ratio [aRR] = 34.4), death (aRR = 17.0), sepsis (aRR = 13.6), mechanical ventilation (aRR = 12.7), shock (aRR = 5.1), intensive care unit admission (aRR = 3.6), acute renal failure (aRR = 3.5), thromboembolic disease (aRR = 2.7), adverse cardiac event/outcome (aRR = 2.2) and preterm labor with preterm delivery (aRR = 1.2). Risk for any maternal complications or for any severe illness did not significantly differ by race/ethnicity. Discharge status did not differ by COVID-19; however, among women with concurrent maternal complications, a greater proportion of those with (versus without) COVID-19 were not discharged home.

Conclusions

These findings emphasize the importance of implementing recommended mitigation strategies to reduce risk for SARS-CoV-2 infection and further inform counseling and clinical care for pregnant women during the COVID-19 pandemic.

Evaluating Differences in Whole Blood, Serum, and Urine Screening Tests for Zika Virus, Puerto Rico, USA, 2016

We evaluated nucleic acid amplification testing (NAAT) for Zika virus on whole-blood specimens compared with NAAT on serum and urine specimens among asymptomatic pregnant women during the 2015–2016 Puerto Rico Zika outbreak. Using NAAT, more infections were detected in serum and urine than in whole blood specimens.

Preventing Vector-Borne Transmission of Zika Virus Infection During Pregnancy, Puerto Rico, USA, 2016-20171

We examined pregnant women’s use of personal protective measures to prevent mosquito bites during the 2016–2017 Zika outbreak in Puerto Rico. Healthcare provider counseling on recommended measures was associated with increased use of insect repellent among pregnant women but not with wearing protective clothing.

Association of Preterm Birth Rate With COVID-19 Statewide Stay-at-Home Orders in Tennessee

This cohort study analyzes preterm birth rates during statewide stay-at-home orders in Tennessee during the coronavirus disease 2019 (COVID-19) pandemic.

Explaining Sudden Unexpected Infant Deaths, 2011-2017

BACKGROUND

Sudden unexpected infant death (SUID) represents a broad group of explained and unexplained infant deaths (<1 year old). Explaining why SUID occurs is critical to understanding etiology and prevention. Death certificate data cannot differentiate explained from unexplained SUID cases nor describe the surrounding circumstances. We report SUID rates by explained and unexplained categories and describe demographics and history of recent injury or illness using the Centers for Disease Control and Prevention SUID Case Registry.

METHODS

The registry is a population-based surveillance system built on Child Death Review programs. Data are derived from multiple sources, including death certificates, scene investigations, and autopsy reports. Cases included SUIDs reported by states or jurisdictions participating in the registry during 2011-2017. Cases were classified into explained and unexplained categories by using the registry's classification system. Frequencies, percentages, and mortality rates per 100 000 live births were calculated.

RESULTS

Of the 4929 SUID cases, 82% were categorized as unexplained. Among all cases, 73% had complete case information. Most SUIDs (72%) occurred in an unsafe sleep environment. The SUID mortality rate was 97.3 per 100 000 live births. Among explained and possible suffocation deaths, ∼75% resulted from airway obstruction attributed to soft bedding.

CONCLUSIONS

Unsafe sleep factors were common in explained and unexplained SUID cases, but deaths could only be classified as explained suffocation for ∼20% of cases. Further analysis of unexplained deaths, including continued improvements to death scene investigation and documentation, may generate hypotheses for physiologic and genetic research, advance our understanding of gaps in SUID investigation, and enhance our understanding of infants at highest risk.

Severe Coronavirus Infections in Pregnancy: A Systematic Review

OBJECTIVE

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

DATA SOURCES

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

METHODS OF STUDY SELECTION

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

TABULATION, INTEGRATION, AND RESULTS

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

CONCLUSION

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

Assessment of contraceptive use in Puerto Rico during the 2016 Zika virus outbreak

OBJECTIVES

The objectives of this analysis were to 1) estimate prevalence of contraceptive use among women at risk for unintended pregnancy and 2) identify correlates of contraceptive use among women with ongoing or potential need for contraceptive services in Puerto Rico during the 2016 Zika virus (ZIKV) outbreak.

STUDY DESIGN

We conducted a cell-phone survey July-November, 2016. Women aged 18-49 years living in Puerto Rico were eligible. We completed 3059 interviews; the overall response rate was 69.2%. After weighting, the data provide population-based estimates. For this analysis, we included women at risk for unintended pregnancy, and assessed ongoing or potential need for contraceptive services in this group, excluding women using permanent contraceptive methods.

RESULTS

Most women reported using contraception (82.8%), and use increased with age. Female sterilization and male condoms were most frequently reported (40.8% and 17.1%, respectively). Among women with ongoing or potential need for contraceptive services, 24.7% talked to a healthcare provider about ZIKV, and 31.2% reported a change in childbearing intentions due to ZIKV. Most women were at least a little worried about getting infected with ZIKV (74.3%) or having a baby with a birth defect (80.9%). Being very worried about getting infected with ZIKV and already having Zika were significantly associated with use of any contraception (adjusted prevalence ratio: 1.19, 95% CI: 1.03-1.38 and 1.32, 95% CI: 1.01-1.72, respectively).

CONCLUSIONS

These findings underscore the need for regular contraceptive prevalence studies to inform programs about contraceptive needs, especially during public health emergencies.

IMPLICATIONS

When the 2016 Zika virus outbreak began in Puerto Rico there were no recent population-based data available on contraceptive prevalence. To fill this information gap, we conducted a population-based survey. Our findings provided baseline contraceptive prevalence estimates to support response planning and allocation of health resources.

Women's Awareness and Healthcare Provider Discussions about Zika Virus during Pregnancy, United States, 2016-2017

We surveyed women with a recent live birth who resided in 16 US states and 1 city during the 2016 Zika outbreak. We found high awareness about the risk of Zika virus infection during pregnancy and about advisories to avoid travel to affected areas but moderate levels of discussions with healthcare providers.

Epidemiology of Sudden Death in a Population-Based Study of Infants and Children

Objective

To describe epidemiologic data from the Sudden Death in the Young (SDY) Case Registry. Understanding the scope of SDY may optimize prevention efforts.

Study design

We analyzed sudden, unexpected deaths of infants (<365 days) and children (1–17 years) from a population-based registry of 8 states/jurisdictions in 2015 and 9 in 2016. Natural deaths and injury deaths from drowning, motor vehicle accident drivers, and infant suffocation were included; other injury deaths, homicide, suicide, intentional overdose, and terminal illness were excluded. Cases were categorized using a standardized algorithm. Descriptive statistics were used to characterize deaths, and mortality rates were calculated.

Results

Of 1319 cases identified, 92% had an autopsy. We removed incomplete cases, leaving 1132 analyzable deaths (889 infants, 243 children). The SDY rate for infants was 120/100 000 live births and for children was 1.9/100 000 children. Explained Cardiac rates were greater for infants (2.7/100 000 live births) than children (0.3/100 000 children). The pediatric Sudden Unexpected Death in Epilepsy (SUDEP) mortality rate was 0.2/100 000 live births and children. Blacks comprised 42% of infant and 43% of child deaths but only 23% of the population. In all ages, myocarditis/endocarditis was the most common Explained Cardiac cause; respiratory illness was the most common Explained Other cause. SDY occurred during activity in 13% of childhood cases.

Conclusions

Prevention strategies include optimizing identification and treatment of respiratory and cardiac diseases.

U-Shaped Pillows and Sleep-Related Infant Deaths, United States, 2004-2015

OBJECTIVES

To describe infant deaths where a u-shaped pillow was under or around an infant and to describe cases classified as Explained Suffocation.

METHODS

We examined demographics and circumstances of 141 infant deaths during 2004-2015 in the US National Fatality Review Case Reporting System with u-shaped pillows in the sleep environment.

RESULTS

Most infants were < 6 months old (92%), male (58%), non-Hispanic White (53%), and of the nine explained suffocation deaths, four occurred when the u-shaped pillow obstructed the infant's airway; five occurred when the infant rolled off the pillow and their airway was obstructed by another object.

CONCLUSIONS FOR PRACTICE

Although infrequent, infant deaths with u-shaped pillows have occurred. Health care providers may include discussion of the importance of caregivers following infant product packaging precautions and warning labels for commonly used consumer products, such as u-shaped pillows in their advice to caregivers.

Protocols, practices, and needs for investigating sudden unexpected infant deaths

Understanding case identification practices, protocols, and training needs of medical examiners and coroners (MEC) may inform efforts to improve cause-of-death certification. We surveyed a U.S.-representative sample of MECs and described investigation practices and protocols used in certifying sudden unexpected infant deaths (SUID). We also identified MEC training and resource needs. Of the 377 respondents, use of the SUID Investigation Reporting Form or an equivalent was 89% for large, 87% for medium, and 52% for small jurisdictions. Routine completion of infant medical history, witness interviews, autopsy, photos or videos, and family social history for infant death investigations was ≥80%, but routine scene re-creation with a doll was 30% in small, 64% in medium, and 59% in large offices. Seventy percent of MECs reported infant death investigation training needs. Increased training and use of standardized practices may improve SUID cause-of-death certification, allowing us to better understand SUID.

Prevalence and Factors Associated With Safe Infant Sleep Practices

OBJECTIVES

To examine prevalence of safe infant sleep practices and variation by sociodemographic, behavioral, and health care characteristics, including provider advice.

METHODS

Using 2016 Pregnancy Risk Assessment Monitoring System data from 29 states, we examined maternal report of 4 safe sleep practices indicating how their infant usually slept: (1) back sleep position, (2) separate approved sleep surface, (3) room-sharing without bed-sharing, and (4) no soft objects or loose bedding as well as receipt of health care provider advice corresponding to each sleep practice.

RESULTS

Most mothers reported usually placing their infants to sleep on their backs (78.0%), followed by room-sharing without bed-sharing (57.1%). Fewer reported avoiding soft bedding (42.4%) and using a separate approved sleep surface (31.8%). Reported receipt of provider advice ranged from 48.8% (room-sharing without bed-sharing) to 92.6% (back sleep position). Differences by sociodemographic, behavioral, and health care characteristics were larger for safe sleep practices (∼10-20 percentage points) than receipt of advice (∼5-10 percentage points). Receipt of provider advice was associated with increased use of safe sleep practices, ranging from 12% for room-sharing without bed-sharing (adjusted prevalence ratio: 1.12; 95% confidence interval: 1.09-1.16) to 28% for back sleep position (adjusted prevalence ratio: 1.28; 95% confidence interval: 1.21-1.35). State-level differences in safe sleep practices spanned 20 to 25 percentage points and did not change substantially after adjustment for available characteristics.

CONCLUSIONS

Safe infant sleep practices, especially those other than back sleep position, are suboptimal, with demographic and state-level differences indicating improvement opportunities. Receipt of provider advice is an important modifiable factor to improve infant sleep practices.

Vital Signs: Pregnancy-Related Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017

Background

Approximately 700 women die from pregnancy-related complications in the United States every year.

Methods

Data from CDC’s national Pregnancy Mortality Surveillance System (PMSS) for 2011–2015 were analyzed. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics. The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated. Detailed data on pregnancy-related deaths during 2013–2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors.

Results

For 2011–2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1–6 days postpartum, 21.4% 7–42 days postpartum, and 11.7% 43–365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. MMRC data indicated that multiple factors contributed to pregnancy-related deaths. Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care.

Conclusions

Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. Approximately three in five pregnancy-related deaths were preventable.

Implications for Public Health Practice

Strategies to address contributing factors to pregnancy-related deaths can be enacted at the community, health facility, patient, provider, and system levels.

Sleep-Related Infant Suffocation Deaths Attributable to Soft Bedding, Overlay, and Wedging

BACKGROUND

Unintentional suffocation is the leading cause of injury death among infants <1 year old in the United States, with 82% being attributable to accidental suffocation and strangulation in bed. Understanding the circumstances surrounding these deaths may inform prevention strategies.

METHODS

We analyzed data from the population-based Sudden Unexpected Infant Death Case Registry from 2011 to 2014. Cases categorized as explained suffocation with unsafe sleep factors (suffocation), per the Centers for Disease Control and Prevention's Sudden Unexpected Infant Death Case Registry classification system, were included and assigned a mechanism of obstruction, including soft bedding, overlay, or wedging. We calculated frequencies and percentages of suffocation deaths by mechanism and selected demographic and sleep-environment characteristics.

RESULTS

Fourteen percent of sudden unexpected infant death cases were classified as suffocation; these cases were most frequently attributed to soft bedding (69%), followed by overlay (19%) and wedging (12%). Median age at death in months varied by mechanism: 3 for soft bedding, 2 for overlay, and 6 for wedging. Soft-bedding deaths occurred most often in an adult bed (49%), in a prone position (82%), and with a blanket (or blankets) obstructing the airway (34%). Overlay deaths occurred most often in an adult bed (71%), and infants were overlaid by the mother (47%). Wedging deaths occurred most often when the infant became entrapped between a mattress and a wall (48%).

CONCLUSIONS

Safe sleep environments can reduce infant suffocation deaths. Increased knowledge about the characteristics of suffocation deaths can help inform prevention strategies by targeting highest-risk groups.

Contraceptive Use Among Women at Risk for Unintended Pregnancy in the Context of Public Health Emergencies - United States, 2016

Ensuring access to and promoting use of effective contraception have been identified as important strategies for preventing unintended pregnancy (1). The importance of ensuring resources to prevent unintended pregnancy in the context of public health emergencies was highlighted during the 2016 Zika virus outbreak when Zika virus infection during pregnancy was identified as a cause of serious birth defects (2). Accordingly, CDC outlined strategies for state, local, and territorial jurisdictions to consider implementing to ensure access to contraception (3). To update previously published contraceptive use estimates* among women at risk for unintended pregnancy^† and to estimate the number of women with ongoing or potential need for contraceptive services,^§,¶ data on contraceptive use were collected during September–December 2016 through the Behavioral Risk Factor Surveillance System (BRFSS). Results from 21 jurisdictions indicated that most women aged 18–49 years were at risk for unintended pregnancy (range across jurisdictions = 57.4%–76.8%). Estimates of the number of women with ongoing or potential need for contraceptive services ranged from 368 to 617 per 1,000 women aged 18–49 years. The percentage of women at risk for unintended pregnancy using a most or moderately effective contraceptive method** ranged from 26.1% to 65.7%. Jurisdictions can use this information to estimate the number of women who might seek contraceptive services and to plan and evaluate efforts to increase contraceptive use. This information is particularly important in the context of public health emergencies, such as the recent Zika virus outbreak, which have been associated with increased risk for adverse maternal-infant outcomes (2,4–6) and have highlighted the importance of providing women and their partners with resources to prevent unintended pregnancy.

Vital Signs: Zika-Associated Birth Defects and Neurodevelopmental Abnormalities Possibly Associated with Congenital Zika Virus Infection - U.S. Territories and Freely Associated States, 2018

INTRODUCTION

Zika virus infection during pregnancy causes serious birth defects and might be associated with neurodevelopmental abnormalities in children. Early identification of and intervention for neurodevelopmental problems can improve cognitive, social, and behavioral functioning.

METHODS

Pregnancies with laboratory evidence of confirmed or possible Zika virus infection and infants resulting from these pregnancies are included in the U.S. Zika Pregnancy and Infant Registry (USZPIR) and followed through active surveillance methods. This report includes data on children aged ≥1 year born in U.S. territories and freely associated states. Receipt of reported follow-up care was assessed, and data were reviewed to identify Zika-associated birth defects and neurodevelopmental abnormalities possibly associated with congenital Zika virus infection.

RESULTS

Among 1,450 children of mothers with laboratory evidence of confirmed or possible Zika virus infection during pregnancy and with reported follow-up care, 76% had developmental screening or evaluation, 60% had postnatal neuroimaging, 48% had automated auditory brainstem response-based hearing screen or evaluation, and 36% had an ophthalmologic evaluation. Among evaluated children, 6% had at least one Zika-associated birth defect identified, 9% had at least one neurodevelopmental abnormality possibly associated with congenital Zika virus infection identified, and 1% had both.

CONCLUSION

One in seven evaluated children had a Zika-associated birth defect, a neurodevelopmental abnormality possibly associated with congenital Zika virus infection, or both reported to the USZPIR. Given that most children did not have evidence of all recommended evaluations, additional anomalies might not have been identified. Careful monitoring and evaluation of children born to mothers with evidence of Zika virus infection during pregnancy is essential for ensuring early detection of possible disabilities and early referral to intervention services.

Breast milk transmission of flaviviruses in the context of Zika virus: A systematic review

BACKGROUND

Since the Zika virus epidemic in the Americas began in 2015, Zika virus transmission has occurred throughout the Americas. However, limited information exists regarding possible risks of transmission of Zika virus and other flaviviruses through breast feeding and human milk. We conducted a systematic review of the evidence regarding flaviviruses detection in and transmission through milk, specifically regarding Zika virus, Japanese encephalitis virus, tick-borne encephalitis virus, Powassan virus, West Nile virus, dengue virus, and yellow fever virus.

METHODS

Medline, Embase, Global Health, CINAHL, Cochrane Library, Scopus, Popline, Virtual Health Library, and WorldCat were searched through June 2017. Two authors independently screened potential studies for inclusion and extracted data. Human and nonhuman (animal) studies describing: 1) confirmed or suspected cases of mother-to-child transmission through milk; or 2) the presence of flavivirus genomic material in milk.

RESULTS

Seventeen studies were included, four animal models and thirteen observational studies. Dengue virus, West Nile virus, and Zika virus viral ribonucleic acid was detected in human milk, including infectious Zika virus and dengue virus viral particles. Human breast-feeding transmission was confirmed for only yellow fever virus. There was evidence of milk-related transmission of dengue virus, Powassan virus, and West Nile virus in animal studies.

CONCLUSIONS

Because the health advantages of breast feeding are considered greater than the potential risk of transmission, the World Health Organization recommends that mothers with possible or confirmed Zika virus infection or exposure continue to breast feed. This review did not identify any data that might alter this recommendation.

Population-based pregnancy and birth defects surveillance in the era of Zika virus

BACKGROUND

Zika virus is a newly recognized human teratogen; monitoring its impact on the birth prevalence of microcephaly and other adverse pregnancy outcomes will continue to be an urgent need in the United States and worldwide.

METHODS

When the Centers for Disease Control and Prevention (CDC) activated the Emergency Operations Center for the Zika virus outbreak response in January of 2016, public health leadership recognized that a joint, coordinated effort was required between activities focused on the effects of the infection among pregnant women and those focused on birth defects in fetuses and infants. Before the introduction of Zika virus in the Americas, population-based birth defects surveillance occurred independently of pregnancy surveillance activities.

RESULTS

The coordination of pregnancy surveillance and birth defects surveillance implemented through the CDC Zika virus response represents a paradigm shift.

CONCLUSION

Coordination of these surveillance systems provides an opportunity to capture information from both a prospective and retrospective approach. This relatively modest investment in the public health infrastructure can continue to protect pregnant women and their infants during the ongoing response to Zika virus and in the next emergent threat to maternal and child health. Birth Defects Research 109:372-378, 2017. © 2017 Wiley Periodicals, Inc.

National and State Trends in Sudden Unexpected Infant Death: 1990-2015

BACKGROUND

Sharp declines in sudden unexpected infant death (SUID) in the 1990s and a diagnostic shift from sudden infant death syndrome (SIDS) to unknown cause and accidental suffocation and strangulation in bed (ASSB) in 1999-2001 have been documented. We examined trends in SUID and SIDS, unknown cause, and ASSB from 1990 to 2015 and compared state-specific SUID rates to identify significant trends that may be used to inform SUID prevention efforts.

METHODS

We used data from US mortality files to evaluate national and state-specific SUID rates (deaths per 100 000 live births) for 1990-2015. SUID included infants with an underlying cause of death, SIDS, unknown cause, or ASSB. To examine overall US rates for SUID and SUID subtypes, we calculated the percent change by fitting Poisson regression models. We report state differences in SUID and compared state-specific rates from 2000-2002 to 2013-2015 by calculating the percent change.

RESULTS

SUID rates declined from 154.6 per 100 000 live births in 1990 to 92.4 in 2015, declining 44.6% from 1990 to 1998 and 7% from 1999 to 2015. From 1999 to 2015, SIDS rates decreased 35.8%, ASSB rates increased 183.8%, and there was no significant change in unknown cause rates. SUID trends among states varied widely from 41.5 to 184.3 in 2000-2002 and from 33.2 to 202.2 in 2013-2015.

CONCLUSIONS

Reductions in SUID rates since 1999 have been minimal, and wide variations in state-specific rates remain. States with significant declines in SUID rates might have SUID risk-reduction programs that could serve as models for other states.

Full-Term Small-for-Gestational-Age Newborns in the U.S.: Characteristics, Trends, and Morbidity

Objectives The magnitude, characteristics, and morbidity of term (≥37 weeks gestation) newborns that are small-for-gestational-age (SGA) in the U.S. are underexplored. We sought to examine characteristics and trends for SGA-coded term newborns in the U.S. Methods Data were obtained from the Nationwide Inpatient Sample, a nationally representative database of hospital stays in the U.S. from 2002 to 2011. Term, singleton newborns with SGA codes were identified and examined over the study period. Demographic characteristics were compared for term newborns according to presence of SGA codes using χ² tests. Odds ratios (OR) were calculated to compare morbidities between the two groups, adjusting for relevant demographic and clinical variables. Results In 2011, 15 per 1000 term newborns in the U.S. were coded as SGA, a 29.9 % increase since 2002. Compared with other term newborns, SGA term newborns were significantly (p < 0.05) more likely to be female, receive public insurance, and reside in lower income zip codes. Comorbidities, including perinatal complications, metabolic disorders, central nervous system diseases, infection, and neonatal abstinence syndrome were more common among SGA-coded term newborns. These newborns also had higher odds of in-hospital death (OR = 3.0 95 % confidence interval: 2.0, 4.4), longer mean length of stay (3.7 vs. 2.3 days, p < 0.001), and higher mean hospital charges ($12,621 vs. $5012, p < 0.001). Conclusions for practice Term newborns coded as SGA have higher morbidity, mortality, and incur higher hospital charges than other term newborns. More research is needed to understand causes of SGA so its incidence and effects can be reduced.

Public Health Approach to Addressing the Needs of Children Affected by Congenital Zika Syndrome

We have learned much about the short-term sequelae of congenital Zika virus (ZIKV) infection since the Centers for Disease Control and Prevention activated its ZIKV emergency response in January 2016. Nevertheless, gaps remain in our understanding of the full spectrum of adverse health outcomes related to congenital ZIKV infection and how to optimize health in those who are affected. To address the remaining knowledge gaps, support affected children so they can reach their full potential, and make the best use of available resources, a carefully planned public health approach in partnership with pediatric health care providers is needed. An essential step is to use population-based data captured through surveillance systems to describe congenital Zika syndrome. Another key step is using collected data to investigate why some children exhibit certain sequelae during infancy and beyond, whereas others do not, and to describe the clustering of anomalies and the timing of when these anomalies occur, among other research questions. The final critical step in the public health framework for congenital Zika syndrome is an intervention strategy with evidence-based best practices for longer-term monitoring and care. Adherence to recommended evaluation and management procedures for infants with possible congenital ZIKV infection, including for those with less obvious developmental and medical needs at birth, is essential. It will take many years to fully understand the effects of ZIKV on those who are congenitally infected; however, the lifetime medical and educational costs as well as the emotional impact on affected children and families are likely to be substantial.

Variations in Cause-of-Death Determination for Sudden Unexpected Infant Deaths

OBJECTIVES

To quantify and describe variation in cause-of-death certification of sudden unexpected infant deaths (SUIDs) among US medical examiners and coroners.

METHODS

From January to November 2014, we conducted a nationally representative survey of US medical examiners and coroners who certify infant deaths. Two-stage unequal probability sampling with replacement was used. Medical examiners and coroners were asked to classify SUIDs based on hypothetical scenarios and to describe the evidence considered and investigative procedures used for cause-of-death determination. Frequencies and weighted percentages were calculated.

RESULTS

Of the 801 surveys mailed, 60% were returned, and 377 were deemed eligible and complete. Medical examiners and coroners classification of infant deaths varied by scenario. For 3 scenarios portraying potential airway obstruction and negative autopsy findings, 61% to 69% classified the death as suffocation/asphyxia. In the last scenario, which portrayed a healthy infant in a safe sleep environment with negative autopsy findings, medical examiners and coroners classified the death as sudden infant death syndrome (38%) and SUID (30%). Reliance on investigative procedures to determine cause varied, but 94% indicated using death scene investigations, 88% full autopsy, 85% toxicology analyses, and 82% medical history review.

CONCLUSIONS

US medical examiners and coroners apply variable practices to classify and investigate SUID, and thus, they certify the same deaths differently. This variability influences surveillance and research, impacts true understanding of infant mortality causes, and inhibits our ability to accurately monitor and ultimately prevent future deaths. Findings may inform future strategies for promoting standardized practices for SUID classification.

Racial and Ethnic Trends in Sudden Unexpected Infant Deaths: United States, 1995-2013

BACKGROUND AND OBJECTIVES

Immediately after the 1994 Back-to-Sleep campaign, sudden unexpected infant death (SUID) rates decreased dramatically, but they have remained relatively stable (93.4 per 100 000 live births) since 2000. In this study, we examined trends in SUID rates and disparities by race/ethnicity since the Back-to-Sleep campaign.

METHODS

We used 1995-2013 US period-linked birth-infant death data to evaluate SUID rates per 100 000 live births by non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander racial/ethnic groupings. To examine racial/ethnic disparities, we calculated rate ratios with NHWs as the referent group. Unadjusted linear regression was used to evaluate trends (P < .05) in rates and rate ratios. The distribution and rates of SUID by demographic and birth characteristics were compared for 1995-1997 and 2011-2013, and χ2 tests were used to evaluate significance.

RESULTS

From 1995 to 2013, SUID rates were consistently highest for American Indian/Alaska Natives, followed by NHBs. The rate for NHBs decreased significantly, whereas the rate for NHWs also declined, but not significantly. As a result, the disparity between NHWs and NHBs narrowed slightly. The SUID rates for Hispanics and Asian/Pacific Islanders were lower than the rates for NHWs and showed a significant decrease, resulting in an increase in their advantage over NHWs.

CONCLUSIONS

Each racial/ethnic group showed a unique trend in SUID rates since the Back-to-Sleep campaign. When implementing risk-reduction strategies, it is important to consider these trends in targeting populations for prevention and developing culturally appropriate approaches for racial/ethnic communities.

Vital Signs: Update on Zika Virus-Associated Birth Defects and Evaluation of All U.S. Infants with Congenital Zika Virus Exposure - U.S. Zika Pregnancy Registry, 2016

Background

In collaboration with state, tribal, local, and territorial health departments, CDC established the U.S. Zika Pregnancy Registry (USZPR) in early 2016 to monitor pregnant women with laboratory evidence of possible recent Zika virus infection and their infants.

Methods

This report includes an analysis of completed pregnancies (which include live births and pregnancy losses, regardless of gestational age) in the 50 U.S. states and the District of Columbia (DC) with laboratory evidence of possible recent Zika virus infection reported to the USZPR from January 15 to December 27, 2016. Birth defects potentially associated with Zika virus infection during pregnancy include brain abnormalities and/or microcephaly, eye abnormalities, other consequences of central nervous system dysfunction, and neural tube defects and other early brain malformations.

Results

During the analysis period, 1,297 pregnant women in 44 states were reported to the USZPR. Zika virus–associated birth defects were reported for 51 (5%) of the 972 fetuses/infants from completed pregnancies with laboratory evidence of possible recent Zika virus infection (95% confidence interval [CI] = 4%–7%); the proportion was higher when restricted to pregnancies with laboratory-confirmed Zika virus infection (24/250 completed pregnancies [10%, 95% CI = 7%–14%]). Birth defects were reported in 15% (95% CI = 8%–26%) of fetuses/infants of completed pregnancies with confirmed Zika virus infection in the first trimester. Among 895 liveborn infants from pregnancies with possible recent Zika virus infection, postnatal neuroimaging was reported for 221 (25%), and Zika virus testing of at least one infant specimen was reported for 585 (65%).

Conclusions and Implications for Public Health Practice

These findings highlight why pregnant women should avoid Zika virus exposure. Because the full clinical spectrum of congenital Zika virus infection is not yet known, all infants born to women with laboratory evidence of possible recent Zika virus infection during pregnancy should receive postnatal neuroimaging and Zika virus testing in addition to a comprehensive newborn physical exam and hearing screen. Identification and follow-up care of infants born to women with laboratory evidence of possible recent Zika virus infection during pregnancy and infants with possible congenital Zika virus infection can ensure that appropriate clinical services are available.

Baseline Prevalence of Birth Defects Associated with Congenital Zika Virus Infection - Massachusetts, North Carolina, and Atlanta, Georgia, 2013-2014

Zika virus infection during pregnancy can cause serious brain abnormalities, but the full range of adverse outcomes is unknown (1). To better understand the impact of birth defects resulting from Zika virus infection, the CDC surveillance case definition established in 2016 for birth defects potentially related to Zika virus infection* (2) was retrospectively applied to population-based birth defects surveillance data collected during 2013-2014 in three areas before the introduction of Zika virus (the pre-Zika years) into the World Health Organization's Region of the Americas (Americas) (3). These data, from Massachusetts (2013), North Carolina (2013), and Atlanta, Georgia (2013-2014), included 747 infants and fetuses with one or more of the birth defects meeting the case definition (pre-Zika prevalence = 2.86 per 1,000 live births). Brain abnormalities or microcephaly were the most frequently recorded (1.50 per 1,000), followed by neural tube defects and other early brain malformations^† (0.88), eye abnormalities without mention of a brain abnormality (0.31), and other consequences of central nervous system (CNS) dysfunction without mention of brain or eye abnormalities (0.17). During January 15-September 22, 2016, the U.S. Zika Pregnancy Registry (USZPR) reported 26 infants and fetuses with these same defects among 442 completed pregnancies (58.8 per 1,000) born to mothers with laboratory evidence of possible Zika virus infection during pregnancy (2). Although the ascertainment methods differed, this finding was approximately 20 times higher than the proportion of one or more of the same birth defects among pregnancies during the pre-Zika years. These data demonstrate the importance of population-based surveillance for interpreting data about birth defects potentially related to Zika virus infection.

The Sudden Death in the Young Case Registry: Collaborating to Understand and Reduce Mortality

Knowledge gaps persist about the incidence of and risk factors for sudden death in the young (SDY). The SDY Case Registry is a collaborative effort between the National Institutes of Health, the Centers for Disease Control and Prevention, and the Michigan Public Health Institute. Its goals are to: (1) describe the incidence of SDY in the United States by using population-based surveillance; (2) compile data from SDY cases to create a resource of information and DNA samples for research; (3) encourage standardized approaches to investigation, autopsy, and categorization of SDY cases; (4) develop partnerships between local, state, and federal stakeholders toward a common goal of understanding and preventing SDY; and (5) support families who have lost loved ones to SDY by providing resources on bereavement and medical evaluation of surviving family members. Built on existing Child Death Review programs and as an expansion of the Sudden Unexpected Infant Death Case Registry, the SDY Case Registry achieves its goals by identifying SDY cases, providing guidance to medical examiners/coroners in conducting comprehensive autopsies, evaluating cases through child death review and an advanced review by clinical specialists, and classifying cases according to a standardized algorithm. The SDY Case Registry also includes a process to obtain informed consent from next-of-kin to save DNA for research, banking, and, in some cases, diagnostic genetic testing. The SDY Case Registry will provide valuable incidence data and will enhance understanding of the characteristics of SDY cases to inform the development of targeted prevention efforts.

Differences in Infant Care Practices and Smoking among Hispanic Mothers Living in the United States

OBJECTIVE

To assess the association between maternal birth country and adherence to the American Academy of Pediatrics safe sleep recommendations in a national sample of Hispanic mothers, given that data assessing the heterogeneity of infant care practices among Hispanics are lacking.

STUDY DESIGN

We used a stratified, 2-stage, clustered design to obtain a nationally representative sample of mothers from 32 US intrapartum hospitals. A total of 907 completed follow-up surveys (administered 2-6 months postpartum) were received from mothers who self-identified as Hispanic/Latina, forming our sample, which we divided into 4 subpopulations by birth country (US, Mexico, Central/South America, and Caribbean). Prevalence estimates and aORs were determined for infant sleep position, location, breastfeeding, and maternal smoking.

RESULTS

When compared with US-born mothers, we found that mothers born in the Caribbean (aOR 4.56) and Central/South America (aOR 2.68) were significantly more likely to room share without bed sharing. Caribbean-born mothers were significantly less likely to place infants to sleep supine (aOR 0.41). Mothers born in Mexico (aOR 1.67) and Central/South America (aOR 2.57) were significantly more likely to exclusively breastfeed; Caribbean-born mothers (aOR 0.13) were significantly less likely to do so. Foreign-born mothers were significantly less likely to smoke before and during pregnancy.

CONCLUSIONS

Among US Hispanics, adherence to American Academy of Pediatrics safe sleep recommendations varies widely by maternal birth country. These data illustrate the importance of examining behavioral heterogeneity among ethnic groups and have potential relevance for developing targeted interventions for safe infant sleep.

Birth Defects Among Fetuses and Infants of US Women With Evidence of Possible Zika Virus Infection During Pregnancy

IMPORTANCE

Understanding the risk of birth defects associated with Zika virus infection during pregnancy may help guide communication, prevention, and planning efforts. In the absence of Zika virus, microcephaly occurs in approximately 7 per 10 000 live births.

OBJECTIVE

To estimate the preliminary proportion of fetuses or infants with birth defects after maternal Zika virus infection by trimester of infection and maternal symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Completed pregnancies with maternal, fetal, or infant laboratory evidence of possible recent Zika virus infection and outcomes reported in the continental United States and Hawaii from January 15 to September 22, 2016, in the US Zika Pregnancy Registry, a collaboration between the CDC and state and local health departments.

EXPOSURES

Laboratory evidence of possible recent Zika virus infection in a maternal, placental, fetal, or infant sample.

MAIN OUTCOMES AND MEASURES

Birth defects potentially Zika associated: brain abnormalities with or without microcephaly, neural tube defects and other early brain malformations, eye abnormalities, and other central nervous system consequences.

RESULTS

Among 442 completed pregnancies in women (median age, 28 years; range, 15-50 years) with laboratory evidence of possible recent Zika virus infection, birth defects potentially related to Zika virus were identified in 26 (6%; 95% CI, 4%-8%) fetuses or infants. There were 21 infants with birth defects among 395 live births and 5 fetuses with birth defects among 47 pregnancy losses. Birth defects were reported for 16 of 271 (6%; 95% CI, 4%-9%) pregnant asymptomatic women and 10 of 167 (6%; 95% CI, 3%-11%) symptomatic pregnant women. Of the 26 affected fetuses or infants, 4 had microcephaly and no reported neuroimaging, 14 had microcephaly and brain abnormalities, and 4 had brain abnormalities without microcephaly; reported brain abnormalities included intracranial calcifications, corpus callosum abnormalities, abnormal cortical formation, cerebral atrophy, ventriculomegaly, hydrocephaly, and cerebellar abnormalities. Infants with microcephaly (18/442) represent 4% of completed pregnancies. Birth defects were reported in 9 of 85 (11%; 95% CI, 6%-19%) completed pregnancies with maternal symptoms or exposure exclusively in the first trimester (or first trimester and periconceptional period), with no reports of birth defects among fetuses or infants with prenatal exposure to Zika virus infection only in the second or third trimesters.

CONCLUSIONS AND RELEVANCE

Among pregnant women in the United States with completed pregnancies and laboratory evidence of possible recent Zika infection, 6% of fetuses or infants had evidence of Zika-associated birth defects, primarily brain abnormalities and microcephaly, whereas among women with first-trimester Zika infection, 11% of fetuses or infants had evidence of Zika-associated birth defects. These findings support the importance of screening pregnant women for Zika virus exposure.

Explaining the recent decrease in US infant mortality rate, 2007-2013

BACKGROUND

The US infant mortality rate has been steadily decreasing in recent years as has the preterm birth rate; preterm birth is a major factor associated with death during the first year of life. The degree to which changes in gestational age-specific mortality and changes in the distribution of births by gestational age have contributed to the decrease in the infant mortality rate requires clarification.

OBJECTIVE

The objective of the study was to better understand the major contributors to the 2007-2013 infant mortality decline for the total population and for infants born to non-Hispanic black, non-Hispanic white, and Hispanic women.

STUDY DESIGN

We identified births and infant deaths from 2007 and 2013 Centers for Disease Control and Prevention National Vital Statistics System's period linked birth and infant death files. We included all deaths and births for which there was a reported gestational age at birth on the birth certificate of 22 weeks or greater. The decrease in the infant mortality rate was disaggregated such that all of the change could be attributed to improvements in gestational age-specific infant mortality rates and changes in the distribution of gestational age, by week of gestation, using the Kitagawa method. Sensitivity analyses were performed to account for records in which the obstetric estimate of gestational age was missing and for deaths and births less than 22 weeks' gestation. Maternal race and ethnicity information was obtained from the birth certificate.

RESULTS

The infant mortality rates after exclusions were 5.72 and 4.92 per 1000 live births for 2007 and 2013, respectively, with an absolute difference of -0.80 (14% decrease). Infant mortality rates declined by 11% for non-Hispanic whites, by 19% for non-Hispanic blacks, and by 14% for Hispanics during the period. Compared with 2007, the proportion of births in each gestational age category was lower in 2013 with the exception of 39 weeks during which there was an increase in the proportion of births from 30.1% in 2007 to 37.5% in 2013. Gestational age-specific mortality decreased for each gestational age category between 2007 and 2013 except 33 weeks and >42 weeks. About 31% of the decrease in the US infant mortality rate from 2007 through 2013 was due to changes in the gestational age distribution, and 69% was due to improvements in gestational age-specific survival. Improvements in the gestational age distribution from 2007 through 2013 benefited infants of non-Hispanic white women (48%) the most, followed by infants of non-Hispanic black (31%) and Hispanic (14%) women.

CONCLUSION

Infant mortality improved between 2007 and 2013 as a result of both improvements in the distribution of gestational age at birth and improvements in survival after birth. The differential contribution of improvements in the gestational age distribution at birth by race and ethnicity suggests that preconception and antenatal health and health care aimed at preventing or delaying preterm birth may not be reaching all populations.