Pregnancy-associated deaths will increase in the COVID-19 era

Maternal mortality due to partner violence, suicide, and substance overdoses will increase due to COVID-19.

Do blog da Maternal Health Task Force

 

By: Kathryn Mishkin, DrPH, MPH, MA, Associate Director of Evaluation, March of Dimes; Rahul Gupta, MD, MPH, MBA, FACP, Chief Medical & Health Officer, SVP, March of Dimes; Roland Estrella, MS, MBA, Senior Director of Science, Data, and Evaluation, March of Dimes

 

COVID-19 has devastated the lives of the American people with over 250,000 deaths to date, and this impact is going to extend to pregnant and postpartum women.

This is terrifying considering that the United States entered the pandemic with the infamous status of having the highest maternal mortality rate among all developed nations. Already, researchers are concerned about an increase in maternal morbidity and mortality due to COVID-19’s effect on pregnant women’s immune systems, its contribution to cardiopulmonary complications, and the higher rates of hospitalizations and ICU visits among pregnant women with COVID. It is feared that Black women will be particularly affected, and this is troubling considering that Black women were already four times more likely to die in the maternal period compared to White women pre-COVID.

It is clear that COVID-19 will adversely affect pregnant and postpartum women’s physical health.

However, current predictions have not yet painted a full picture of how COVID-19 may contribute to an increase in maternal mortality in the United States. It is essential that we expand our discussion beyond medical causes of death to include maternal deaths due to suicide, substance overdose, and homicide as a result of partner violence.

We expect pregnant and postpartum women to die more frequently from these causes because we are seeing this happen in the general population. Since January, drug overdoses have spiked according to the Office of National Drug Control Policy. A physician in California says he has seen more deaths from suicide than COVID-19, with a year’s worth of suicide deaths occurring in just four weeks. The United Nations Population Fund predicts IPV rates will increase by 20% during a three-month quarantine. Physical distancing, while protective against COVID-19, exacerbates the risk of being abused and suffering from mental illness because of social isolation and increased stress. From a social perspective, women are now facing the brunt of increased responsibility for domestic responsibilities that comes with the “new normal”, and this added stress will have an impact on their health.

Furthermore, we know that pregnant and postpartum women were dying from these causes before the pandemic. A global study revealed that 13-36% of maternal deaths are due to suicide. In 2016, Philadelphia’s maternal mortality review reported that nearly half of pregnancy-associated deaths were due to injuries including homicide, suicide, and drug overdoses. In California, research shows that drug-related and suicide deaths are the second and seventh leading cause of maternal deaths, respectively, constituting 18% of all maternal deaths.

We also know that certain populations are at higher risk for these types of deaths. People living with underlying mental illness are at higher risk for dying from suicide and substance overdose deaths and women experiencing IPV are more likely to have a mental illness. Measures taken to limit the spread of the virus will result in reduced access to and use of care and support for some at-risk populations.

In sum, pregnant and postpartum women were already experiencing IPV, suffering from mental illness, and using substances, and COVID-19 will exacerbate these issues.

We call on public health leaders to join the #Blanket Change movement to raise awareness about the urgent health crisis moms and babies are facing in order to ramp up prevention and care and support documentation of these deaths.

Prevention of death due to these causes is possible but requires an effective and efficient health care and social support system. The American College of Obstetricians and Gynecologists provides recommendations for screening for substance use, IPV, and depression. In spite of this, screening appears to be lacking. For example, a recent report by the Centers for Disease Control and Prevention stated that 20% of women were not asked by their health care provider about depression symptoms in the prenatal period and 12.5% were not asked in the postpartum period, with a wide discrepancy in rates depending on where a woman was living.  We call on health care providers to improve screening for mental illness, IPV, and substance use to improve the health of moms and babies.

In addition to effective prevention, we call for all states to document the frequency of deaths due to suicide, IPV, and substance overdose through maternal mortality review.  Full documentation on a national scale will allow us to develop a better understanding of the reasons that pregnant and postpartum women are dying. Without a comprehensive review, our ability to develop critical recommendations to prevent future deaths will remain inadequate.

Grávida de 8 meses, professora de São Caetano é internada com covid-19 após volta às aulas

Rafaela de Ávila Cardoso, professora da EMEF Luiz Olinto Tortorello, relatou que voltou a trabalhar por pressão e acabou contaminada pela covid-19

Grávida de 8 meses, a professora do ensino fundamental Rafaela está internada em terapia semi-intensiva com covid-19 – Acervo pessoal

São Paulo – Com apenas 10 dias da volta às aulas presenciais obrigatórias, a professora Rafaela de Ávila Cardoso, grávida de 8 meses, começou a apresentar sintomas de covid-19. Ela foi internada ontem (22) na Unidade de Terapia Semi-Intensiva do Hospital e Maternidade Santa Joana, em São Paulo, monitorando sinais vitais dela e de sua bebê, tomando corticoide, anticoagulante e outros medicamentos. A docente trabalha na Escola Municipal de Ensino Fundamental (Emef) Luiz Olinto Tortorello, em São Caetano do Sul, e relata que voltou à escola no dia 5 fevereiro por pressão, já que não teve seus pedidos para manter-se em home office aceitos.

“Minha bebê está bem, mas o médico decidiu pela internação, pois disse que a piora nestes casos pode ser muito rápida. Voltei a trabalhar por pressão. Não consegui preencher a Comunicação de Acidente de Trabalho (CAT), mesmo com o atestado de 14 dias com o CID de covid-19. Durante quase 11 meses estive em casa e não peguei nada. Foi só voltar duas semanas e já fiquei doente”, relatou Rafaela.

Sintomas

Segundo a professora, temendo voltar à escola em meio à pandemia de covid-19, ela solicitou à direção da unidade o afastamento no dia 5 de fevereiro, o que lhe foi negado. “Pedi para a direção da escola e eles me disseram que não seria possível nenhuma liberação a não ser que eu entrasse de licença”, afirmou. Entre os dias 5 e 10 de fevereiro, foram realizadas atividades de planejamento na escola. A partir do dia 11, a professora começou a receber alunos.

A professora diz ter sido informada que no dia 9 seria publicada uma normativa sobre o sistema de home office para servidores dos grupos de risco à covid-19. No dia 15, ela sentiu o primeiro sintoma: falta de ar, ao subir uma rampa na escola e ao ler trecho de um livro para seus alunos. No começo, ela pensou ser reflexo da própria gravidez. Nos dias seguintes, passou a sentir cansaço, dores, tosse e febre. No dia 21, já apresentando sintomas há alguns dias, a professora recebeu a confirmação do teste positivo para covid-19. A portaria que lhe garantiria a atuação em home office só foi publicada hoje (23).

Necessidade, insegurança, medo

A professora comentou que entende a necessidade de retomar as aulas presenciais, já que tem sido muito difícil manter o interesse e o aprendizado das crianças nas aulas online. Ao mesmo tempo, avalia que a volta foi cercada de insegurança e medo, já que a pandemia de covid-19 vem piorando desde o final do ano passado. Hoje, São Paulo tem o maior número de pessoas internadas em UTI com covid-19 de toda a pandemia.

“É muito difícil e cruel se sentir pressionada a fazer alguma coisa em que você está muito insegura e com medo de fazer. Voltar as aulas presenciais no momento em que estávamos de uma possível 2°onda. E, após 5 dias com os alunos e 9 dias no ambiente escolar, me vi com o que eu mais temia, testando positivo para covid-19. Com uma sensação de impotência, pois neste momento não tenho mais o que fazer a não ser tratar os sintomas e torcer que nada demais grave ocorra comigo e com minha filha. Enquanto meus amigos seguem correndo o risco em sala diariamente”, disse Rafaela.

Levantamento organizado pelos servidores públicos da prefeitura de São Caetano, até ontem (22), mostra que as escolas de São Caetano do Sul já registram 36 casos confirmados de covid-19. Destes, 34 professores e funcionários e dois estudantes. Além de 46 casos suspeitos, sendo 44 de docentes e funcionários e dois entre alunos. Todos os servidores tiveram de retomar suas atividades, mesmo maiores de 60 anos, doentes crônicos ou grávidas.

RBA pediu posicionamento do governo do prefeito interino Anacletto Campanella Júnior (Cidadania), mas não obteve resposta até a publicação da reportagem.

LONG-COVID IN CHILDREN – PARENTS AND FAMILIES’ PERSPECTIVES NEED TO BE HEARD

Long-COVID in Children – Parents and families’ perspectives need to be heard

Frances Simpson is a founding member of LongCovidKids and LongCovidSOS and a Lecturer in Psychology at Coventry University. She is on Twitter: @FrancesorFran

Carolyn Chew-Graham is a GP in Central Manchester and Professor of General Practice Research at Keele University; Carolyn’s main areas of interest include the primary care management of people with multiple health conditions and difficult to understand symptoms which are key components of her clinical work. She is on Twitter: @CizCG

Amali Lokugamage is a consultant in obstetrics and gynaecology, and honorary associate professor and currently has long covid. She is on Twitter: @Docamali

PARENTS HAVE BEEN STRUGGLING to obtain help and support, watching their children with persistent symptoms following acute infection with COVID-19. Early on in the pandemic, parents and children felt they were disbelieved by their general practitioners (GPs) as they witnessed an emerging phenomenon. As ‘Long-COVID’ came to be recognised in adults1 and named as such by patients2 there came to be a growing acceptance that Long-COVID can also occur in children as evidence emerged.3 Indeed, ONS statistics suggest that 12-15% of children may have symptoms lasting 5 weeks after an acute infection with COVID-19.

12-15% of children may have symptoms lasting 5 weeks after an acute infection with COVID-19.

The lack of GP awareness has led to some parents whose children have long-COVID feeling that their children’s symptoms were minimised or even ‘gaslighted’; experiences that were highlighted in the recent All Party Parliamentary Group (APPG) about Long Covid in children on 26th January 2021. Parents described desperation and fear of seeking further help, not wanting to be branded with the stigma of ‘Munchausen by proxy’. While the adult population of Long-COVID sufferers were assembling on social media groups and collecting data, children were discounted under the misconception that children did not get COVID severely, that they did not transmit COVID, that they were often asymptomatic.4 Even when the facts of paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) in children started to present themselves,5 it was understood that this was very rare. When parents started to wonder why their children were becoming ill from COVID and not making a full recovery, there was no narrative in existence that helped them to make sense of this.

Parents described desperation and fear of seeking further help.

Through desperation, mothers Frances Simpson and Sammie McFarland, whose children became sick in March 2020, joined forces to start the support group LongCovidKids. These families found themselves in a confusing place of being told that there was no proof that their childrens’ symptoms were a result of COVID, due to the lack of testing available in Spring 2020. LongCovidKids has evolved to provide support for families with Long-COVID; this now has 940 parents or carers, many of whom have more than one child with Long-COVID. Symptoms described by members of the group range from the most common symptoms of fatigue, headache, abdominal pain, dizziness and muscle pain to the most frightening to parent – electric shock-like pain in the eyes and head, nerve pain, testicular pain, liver damage, paralysis and new-onset seizures; some of their experiences are captured in a film.

Parents have noted that their children are also affected by anxiety, OCD and extremely volatile mood changes which may be associated with neuro-inflammatory processes6 as well as a natural response to being so unwell. The majority of parents would describe their child’s symptoms as fluctuating, and many describe a gap of many weeks between the acute stage and the start of Long-COVID. This variability causes further confusion when presenting the problems to a GP and often leads to diagnoses of anxiety or symptoms attributed to the effects of lockdown or home-schooling.

Children are also affected by anxiety, OCD and extremely volatile mood changes which may be associated with neuro-inflammatory processes.

The combination of an often mild or asymptomatic acute illness, followed by delayed debilitating symptoms of Long-COVID, lack of testing and limited awareness amongst GPs about the syndrome has meant that in the UK it is currently difficult to assess the prevalence of Long-COVID in children. The ONS data has now given us some estimation and the recent European data helps to validate this emerging condition in children.3

NHS England now recognises that Long COVID in children needs urgent evaluation and as this official recognition, epidemiological evidence and long-COVID paediatric services evolve, it is hoped that GPs will be provided the resources they need to support families where children are affected by Long-COVID.

In consultations with parents and children, it is preferable to admit to the limitations of knowledge, whilst being interested in the experiences of the family, believing in presented problems and offering support, help and referral. Parents who are frightened for their child need to feel listened to, and the child needs their experiences to be validated. After all, their lived experiences are also valuable evidence.

 

References

  1. Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ2020;370:m3026. doi:10.1136/bmj.m3026 pmid:32784198
  2. Body Politic COVID-19 Support Group. Report: what does covid-19 recovery actually look like? 2020. https://patientresearchcovid19.com/research/report-1/
  3. Buonsenso D, Munblit D, De Rose C et al; Preliminary Evidence on Long COVID in children. medRxiv 2021.01.23.21250375; doi: https://doi.org/10.1101/2021.01.23.21250375
  4. Zimmermann P, Curtis N. Why is COVID-19 less severe in children? A review of the proposed mechanisms underlying the age-related difference in severity of SARS-CoV-2 infectionsArchives of Disease in Childhood Published Online First: 01 December 2020. doi: 10.1136/archdischild-2020-320338
  5. Harwood R, Allin B, Jones CE et al; PIMS-TS National Consensus Management Study Group. A national consensus management pathway for paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS): results of a national Delphi process. Lancet Child Adolesc Health. 2021 Feb;5(2):133-141. doi: 10.1016/S2352-4642(20)30304-7. Epub 2020 Sep 18. Erratum in: Lancet Child Adolesc Health. 2021 Feb;5(2):e5. PMID: 32956615; PMCID: PMC7500943.
  6. Mazza MG, De Lorenzo R, Conte C et al; COVID-19 BioB Outpatient Clinic Study group, Benedetti F. Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors. Brain Behav Immun. 2020 Oct;89:594-600. doi: 10.1016/j.bbi.2020.07.037. Epub 2020 Jul 30. PMID: 32738287; PMCID: PMC7390748.

 

Featured photo by Kat J on Unsplash

Grávidas correm risco 70% maior de infecção por Covid-19, diz estudo

Equipe de pesquisa coletou dados de 240 pacientes grávidas com Covid-19 em 35 hospitais e clínicas nos Estados Unidos

Mulher grávida
Estudo americano ressalta a prioridade de vacinas para gestantes
Foto: Divulgação / Pixabay

Um estudo publicado na terça-feira (16), no Jornal Americano de Obstetrícia e Ginecologia, mostra que a taxa de infecção de Covid-19 entre mulheres grávidas, no estado de Washington, nos Estados Unidos, foi 70% maior do que em adultos com idades semelhantes, no mesmo estado.

O estudo também descobriu que as taxas de infecção entre mulheres negras grávidas eram, de duas a quatro vezes, maiores do que o esperado.

“As mulheres grávidas não foram protegidas da Covid-19 nos primeiros meses da pandemia, com o maior índice de infecções ocorrendo em quase todos os grupos de minorias raciais / étnicas”, escreveram os pesquisadores em seu relatório.

“Nossos dados indicam que as mulheres grávidas não evitaram a pandemia como esperávamos, e as comunidades de cor carregaram o maior fardo”, disse a Dra. Kristina Adams Waldorf, uma obstetra da Escola de Medicina da Universidade de Washington e o autor sênior do relatório.

De acordo com o estudo, a taxa de infecção de Covid-19 em mulheres grávidas no estado de Washington foi de 13,9 em cada 1.000 partos, em comparação com uma taxa geral de 7,3 em cada 1.000 para jovens de 20 a 39 anos no estado.

“As taxas de infecção mais altas em pacientes grávidas podem ser devido à representação excessiva de mulheres em muitas profissões e setores considerados essenciais durante a pandemia Covid-19 – incluindo saúde, educação, setores de serviços”, disse a autora principal, Dra. Erica Lokken, em um comunicado à imprensa.

Os pesquisadores sugerem que as gestantes devem ser amplamente priorizadas para a vacinação contra Covid-19.

“Mulheres grávidas estão excluídas da priorização de alocação em cerca de metade dos estados dos EUA. Muitos estados nem mesmo estão vinculando seus planos de alocação de vacina Covid-19 às condições médicas de alto risco listadas pelos Centros para Controle e Prevenção de Doenças, que inclui gravidez “, disse Waldorf.

Pfizer begins coronavirus vaccine trial in pregnant women

Do The Hill

 

Pfizer begins coronavirus vaccine trial in pregnant women
© Getty Images

Pfizer and BioNTech on Thursday announced a new trial aiming to test the safety and efficacy of its coronavirus vaccine among pregnant women.

The companies, which together produced one of the two COVID-19 vaccines the Food and Drug Administration approved for emergency use in the U.S., said in a press release that it had given doses to its first group of participants in the new study, which aims to provide clear data on any impacts the inoculation may have for expectant mothers and their newborn children.

William Gruber, senior vice president of Vaccine Clinical Research and Development at Pfizer, said in a statement along with the press release, “We are proud to start this study in pregnant women and continue to gather the evidence on safety and efficacy to potentially support the use of the vaccine by important subpopulations.”

Gruber went on to say, “Pregnant women have an increased risk of complications and developing severe COVID-19, which is why it is critical that we develop a vaccine that is safe and effective for this population.”

According to the Centers for Disease Control and Prevention (CDC), pregnant women who are infected with COVID-19 have a higher chance of severe illnesses, including “ICU admission, mechanical ventilation, and death compared with non-pregnant women of reproductive age.”

Pregnant women were excluded from the initial Pfizer-BioNTech clinical trials, and the most updated CDC guidance states that it is a “personal choice” for pregnant women on whether to get the coronavirus vaccine.

Pfizer’s new trial will include about 4,000 healthy pregnant volunteers ages 18 and older who are anywhere from 24 to 34 weeks into their pregnancy, according to Thursday’s press release.

Pfizer and BioNTech said the trial will “evaluate the safety, tolerability, and immunogenicity of two doses” of the vaccine 21 days apart, with half of the participants receiving the actual inoculation and half getting a placebo.

Each woman is expected to participate in the study for seven to 10 months, with researchers looking for any side effects in women, including miscarriage.

The researchers will also monitor the infants until they reach approximately 6 months of age to detect any adverse reactions, as well as the possibility of a vaccinated mother transferring protective antibody to the child while in the womb.

The press release added that those mothers given the placebo will have the opportunity after the study to receive the vaccine.

The additional trial comes as Pfizer, as well as Moderna and AstraZeneca, all have clinical trials underway to determine the safety and efficacy of vaccinations among children, as the inoculations have largely been tested and approved by countries for emergency use for people as young as 16.

I’m an epidemiologist. I’ll be glad to get whatever vaccine I’m offered

The rapid development of effective, safe vaccines in just under a year is something of a scientific miracle

Do Guardian

 

A nurse prepares a dose of Oxford-AstraZeneca COVID-19 vaccine
‘Even the least effective vaccine available appears to reduce the risk of the things we care about most – hospitalisation and death – by a very large amount.’ Photograph: Michael Dantas/AFP/Getty Images

At the start of the pandemic, it was very hard to predict anything. There were predictions of endless Covid-19 pain, wave upon wave of sickness and death, and fears that we would be stuck with painful trade-offs between our health and livelihoods for years to come.

But the vaccinations have changed everything. The light at the end of the tunnel is now so much closer than we could’ve hoped back in March 2020.

Few people would’ve – could’ve – predicted the speed with which we have developed vaccinations. If you had asked most scientific professionals what was a realistic timeline for effective vaccines to be rolled out, most answers would’ve run to years. And this was an understandable assumption – prior to Covid-19, the quickest vaccination development took four years, and many vaccines took far longer than that.

Covid-19 was first sequenced on 10 January 2020. The first Covid-19 vaccination not as part of a clinical trial was given on 8 December 2020 in the UK. 333 days in total to go from the most basic science to an effective, safe vaccination that is already saving lives across the world.

But with this miraculous success has come a slew of arguments. Should we be going with the most clinically efficacious vaccine that will block more transmission? What about herd immunity – which vaccine will provide us with the most protection long term?

To an extent, these discussions are important. Despite the early stage of the worldwide vaccine rollout, there is some data that certain vaccines have proven more effective in the short term against both the initial virus and its variants. If our aim is to keep Australia from having any disease outbreaks at all, as we have done so well with our Covid-19 restrictions, there’s a reasonable debate to be had about which vaccine we want to use.

But equally, it’s easy to miss the woods for the trees. Even the least effective vaccine available appears to reduce the risk of the things we care about most – hospitalisation and death – by a very large amount. While individual trials were not powered to detect a statistically significant effect, the overall impact of vaccines seems to be that they reduce your risk of getting really sick from Covid-19 even if they don’t stop you from getting the disease entirely.

On top of this, herd immunity isn’t a sure-fire bet no matter the vaccine. We can deal with variants in the short term, perhaps, but when we consider the really long term, things become inherently uncertain. If one vaccination prevents onwards transmission for 24 months, but the protection wanes and then disappears entirely over the course of a decade – similar to, for example, the whooping cough vaccine – then herd immunity would be much harder to maintain. We might be left in a situation where, similar to influenza, we all have to get vaccinated every year, except instead of it being a public health bonus it’s a national necessity because otherwise the virus will break out again in the community.

Given that the disease is unlikely to be eliminated in much of the world any time soon, we have to deal with the unwelcome fact that people will be bringing coronavirus into the country for the foreseeable future. SARS-CoV-2 will continue to mutate, and as I said at the start, making predictions is something of a fool’s game.

All that being said, we can deal with what we know now, and what we know now is that all of the approved vaccines are safe and effective. Yes, there is some debate over whether, from a public health standpoint, the long-term benefits of one immunisation over another are important. I’m not trying to stifle that conversation – it’s a discussion we need to have.

But we should take a moment and consider where we were in February 2020, and how amazingly far we’ve come since then. We may have to live with Covid-19 for a time longer, but even the least effective vaccine approved so far is a level of success that no one predicted a year ago.

In Australia two vaccines have so far received approval from the Therapeutic Goods Administration: the Pfizer vaccine, which has an efficacy rate after two doses of 95%, and the Astra Zeneca vaccine, approved on Tuesday, which has an efficacy rate of 62%. A third vaccine, Novavax, with an efficacy of 89% in phase 3 trials, has been purchased in advance by the federal government but not yet approved for use in Australia.

So which vaccine will I be getting, as an epidemiologist and public health worker? Well, I agree wholeheartedly with Nobel laureate Professor Peter Doherty on this one: I’ll take whatever I’m offered (and be glad to have it).

The best vaccine is the one that’s in your arm.

• Gideon Meyerowitz-Katz is an epidemiologist working in chronic disease