Pandemic influenza and pregnant women

Maternal Influenza A Virus Infection Restricts Fetal and Placental Growth and Adversely Affects the Fetal Thymic Transcriptome

Maternal influenza A viral infections in humans are associated with low birth weight, increased risk of pre-term birth, stillbirth and congenital defects. To examine the effect of maternal influenza virus infection on placental and fetal growth, pregnant C57BL/6 mice were inoculated intranasally with influenza A virus A/CA/07/2009 pandemic H1N1 or phosphate-buffered saline (PBS) at E3.5, E7.5 or E12.5, and the placentae and fetuses collected and weighed at E18.5. Fetal thymuses were pooled from each litter. Placentae were examined histologically, stained by immunohistochemistry (IHC) for CD34 (hematopoietic progenitor cell antigen) and vascular channels quantified. RNA from E7.5 and E12.5 placentae and E7.5 fetal thymuses was subjected to RNA sequencing and pathway analysis. Placental weights were decreased in litters inoculated with influenza at E3.5 and E7.5. Placentae from E7.5 and E12.5 inoculated litters exhibited decreased labyrinth development and the transmembrane protein 150A gene was upregulated in E7.5 placentae. Fetal weights were decreased in litters inoculated at E7.5 and E12.5 compared to controls. RNA sequencing of E7.5 thymuses indicated that 957 genes were downregulated ≥2-fold including Mal, which is associated with Toll-like receptor signaling and T cell differentiation. There were 28 upregulated genes. It is concluded that maternal influenza A virus infection impairs fetal thymic gene expression as well as restricting placental and fetal growth.

Desire for parenthood at the time of COVID-19 pandemic: an insight into the Italian situation

Purpose: To evaluate the impact of the COVID-19 pandemic lifestyle change on couples of reproductive age and on their desire for parenthood.Materials and methods: A quantitative correlational research study, based on a web survey, was conducted among Italian men and women in heterosexual stable relationships, aged between 18 and 46 years. The self-administered Italian version questionnaire was created using Google Forms and posted on chats and social networks.The mood of participants before and during the quarantine was assessed using a scale from 1 to 10 (1 = no wellbeing; 10 = total wellbeing). Couples' quality of life and their reproductive desire were evaluated.Results: 1482 respondents were included: 944 women (63.7%) and 538 men (36.3%). A significant trend toward reduced mean wellbeing scores during the quarantine, compared to before, was found (p < .01). From 18.1% participants who were planning to have a child before the pandemic, 37.3% abandoned the intention, related to worries of future economic difficulties (58%) and consequences on pregnancy (58%). Of 81.9% who did not intend to conceive, 11.5% revealed a desire for parenthood during quarantine than before (p < .01), related to will for change (50%) and need for positivity (40%). 4.3% of these actually tried to get pregnant. Stratifying by age, a trend toward older ages was found in the desire for parenthood before and during the COVID-19 pandemic (p < .05).Conclusions: COVID-19 pandemic is impacting on the desire for parenthood. It is unknown whether these findings will result in a substantial modification of birth rate in the near future.

A Systematic Review of Treatment and Outcomes of Pregnant Women With COVID-19-A Call for Clinical Trials

BACKGROUND

Data pertaining to COVID-19 in pregnancy are limited; to better inform clinicians, we collated data from COVID-19 cases during pregnancy and summarized clinical trials enrolling this population.

METHODS

We performed a systematic literature review of PubMed/MEDLINE to identify cases of COVID-19 in pregnancy or the postpartum period and associated outcomes. We then evaluated the proportion of COVID-19 clinical trials (from ClinicalTrials.gov) excluding pregnant or breastfeeding persons (both through June 29, 2020).

RESULTS

We identified 11 308 published cases of COVID-19 during pregnancy. Of those reporting disease severity, 21% (416/1999) were severe/critical. Maternal and neonatal survival were reassuring (98% [10 437/10 597] and 99% [1155/1163], respectively). Neonatal disease was rare, with only 41 possible cases of infection reported in the literature. Of 2351 ongoing COVID-19 therapeutic clinical trials, 1282 were enrolling persons of reproductive age and 65% (829/1282) excluded pregnant persons. Pregnancy was an exclusion criterion for 69% (75/109) of chloroquine/hydroxychloroquine, 80% (28/35) of lopinavir/ritonavir, and 48% (44/91) of convalescent plasma studies. We identified 48 actively recruiting or completed drug trials reporting inclusion of this population.

CONCLUSIONS

There are limited published reports of COVID-19 in pregnancy despite more than 14 million cases worldwide. To date, clinical outcomes appear reassuring, but data related to important long-term outcomes are missing or not yet reported. The large number of clinical trials excluding pregnant persons, despite interventions with safety data in pregnancy, is concerning. In addition to observational cohort studies, pregnancy-specific adaptive clinical trials could be designed to identify safe and effective treatments.

Risk Communication Initiatives amid COVID-19 in India: Analyzing Message Effectiveness of Videos on National Television

Communication for all hazards including widespread public health emergencies is a massive task. The crucial element is to reach and cover maximum people in a timely manner. This article is based on a systematic content analysis of videos on coronavirus disease (COVID-19) on National Television by Indian Public Service Broadcaster and Ministry of Health and Family Welfare. A total of 36 videos were telecasted on National Television channel Doordarshan from 3 March to 21 April 2020 in between programme breaks.

The article analyses the presentation characteristics of these videos with respect to timing, duration, language, characters, format and key message content of communication videos on COVID-19. The article deliberates about the manner in which the chronology of the communication messages synced with the external events of the trajectory of the pandemic and thereby information-need of the community in India. All the messages which evolved in these videos (real and animated) were built on each other and depicted an information hierarchy (e.g., washing hands to social distancing) which could be viewed as an empowering tool for the community.

The videos were analysed based on the nine constructs of conceptual model of emergency risk communication given by Seeger et al. (2018) . The key preventive messages in these videos focused on generating awareness, which was the fundamental necessity in view of the new type of pandemic like COVID-19. The summated scores show that 36 videos were appropriate up to 79 per cent times for the nine constructs, indicating the effectiveness of the messages in communicating the intended message as per the assessed construct. Limitations of the messages were primarily related to the inability to design communication messages with respect to specific understanding, needs and culture of the community.

Pertussis Infections Among Pregnant Women in the United States, 2012–2017

Background

Little is known about pertussis among pregnant women, a population at increased risk for severe morbidity from respiratory infections such as influenza. We used the Centers for Disease Control and Prevention’s Enhanced Pertussis Surveillance (EPS) system to describe pertussis epidemiology among pregnant and nonpregnant women of childbearing age.

Methods

Pertussis cases in women aged 18–44 years with cough onset between 1 January 2012 and 31 December 2017 were identified in 7 EPS states. Surveillance data were collected through patient and provider interviews and immunization registries. Bridged-race, intercensal population data and live birth estimates were used as denominators.

Results

We identified 1582 pertussis cases among women aged 18–44 years; 5.1% (76/1499) of patients with a known pregnancy status were pregnant at cough onset. Of the pregnant patients with complete information, 81.7% (49/60) reported onset during the second or third trimester. The median ages of pregnant and nonpregnant patients were 29.0 and 33.0 years, respectively. Most pregnant and nonpregnant patients were White (78.3% vs. 86.4%, respectively; P = .09) and non-Hispanic (72.6% vs. 77.3%, respectively; P = .35). The average annual incidence of pertussis was 7.7/100000 among pregnancy women and 7/3/100000 among nonpregnant women. Compared to nonpregnant patients, more pregnant patients reported whoop (41.9% vs. 31.3%, respectively), posttussive vomiting (58.1% vs. 47.9%, respectively), and apnea (37.3% vs. 29.0%, respectively); however, these differences were not statistically significant (P values &gt; .05 for all). A similar proportion of pregnant and nonpregnant patients reported ever having received Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine; 31.6% vs. 32.7%, respectively; P = .84).

Conclusions

Our analysis suggests that incidence of pertussis and clinical characteristics of disease are similar among pregnant and nonpregnant women. Continued monitoring is important to further define pertussis epidemiology in pregnant women.

Is the Host Viral Response and the Immunogenicity of Vaccines Altered in Pregnancy?

The intricacy of the maternal immune system arises from its ability to prevent a maternal immune response against a semi-allogenic fetus, while protecting the mother against harmful pathogens. However, these immunological adaptations may also make pregnant women vulnerable to developing adverse complications from respiratory viral infections. While the influenza and SARS pandemics support this theory, there is less certainty regarding the clinical impact of SARS-CoV-2 in pregnancy. In the current COVID-19 pandemic, vaccine development is key to public preventative strategies. Whilst most viral vaccines are able to induce a seroprotective antibody response, in some high-risk individuals this may not correlate with clinical protection. Some studies have shown that factors such as age, gender, and chronic illnesses can reduce their effectiveness and in this review, we discuss how pregnancy may affect the efficacy and immunogenicity of vaccines. We present literature to support the hypothesis that pregnant women are more susceptible to respiratory viral infections and may not respond to vaccines as effectively. In particular, we focus on the clinical implications of important respiratory viral infections such as influenza during pregnancy, and the pregnancy induced alterations in important leukocytes such as TFH, cTFH and B cells, which play an important role in generating long-lasting and high-affinity antibodies. Finally, we review how this may affect the efficacy of vaccines against influenza in pregnancy and highlight areas that require further research.

Redox control in the pathophysiology of influenza virus infection

Triggered in response to external and internal ligands in cells and animals, redox homeostasis is transmitted via signal molecules involved in defense redox mechanisms through networks of cell proliferation, differentiation, intracellular detoxification, bacterial infection, and immune reactions. Cellular oxidation is not necessarily harmful per se, but its effects depend on the balance between the peroxidation and antioxidation cascades, which can vary according to the stimulus and serve to maintain oxygen homeostasis. The reactive oxygen species (ROS) that are generated during influenza virus (IV) infection have critical effects on both the virus and host cells. In this review, we outline the link between viral infection and redox control using IV infection as an example. We discuss the current state of knowledge on the molecular relationship between cellular oxidation mediated by ROS accumulation and the diversity of IV infection. We also summarize the potential anti-IV agents available currently that act by targeting redox biology/pathophysiology.

Impact of influenza virus during pregnancy: from disease severity to vaccine efficacy

Pregnant women are among the individuals at the highest risk for severe influenza virus infection. Infection of the mother during pregnancy increases the probability of adverse fetal outcomes such as small for gestational age, preterm birth and fetal death. Animal models of syngeneic and allogeneic mating can recapitulate the increased disease severity observed in pregnant women and are used to define the mechanism(s) of that increased severity. This review focuses on influenza A virus pathogenesis, the unique immunological landscape during pregnancy, the impact of maternal influenza virus infection on the fetus and the immune responses at the maternal–fetal interface. Finally, we summarize the importance of immunization and antiviral treatment in this population and highlight issues that warrant further investigation.

Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019-positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019-associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).

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

OBJECTIVES

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

DESIGN

Systematic review/meta-analysis.

DATA SOURCES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

REGISTRATION

PROSPERO CRD42018102776.

Immunobiological aspects of vaccines in pregnancy: Maternal perspective

Immunization during pregnancy is an efficient strategy to protect both the mother and the newborn infant against infectious pathogens. Pregnant women have an increased susceptibility to severe infections caused by some pathogens, but the mechanisms involved remain poorly understood. Pregnancy is associated with dynamic changes in maternal immune system that are critical for tolerance of the fetus. These changes could also play an important role in shaping maternal immune components that are transferred to the newborn infant following natural infection or vaccination to prevent infectious diseases in early life. As the momentum for maternal immunization is growing, there is a need to increase our understanding of the immunobiology of maternal immunization in order to better prevent infectious diseases in the pregnant women and the young infant.

Pregnancy-Induced Alterations in NK Cell Phenotype and Function

Pregnant women are particularly susceptible to complications of influenza A virus infection, which may result from pregnancy-induced changes in the function of immune cells, including natural killer (NK) cells. To better understand NK cell function during pregnancy, we assessed the ability of the two main subsets of NK cells, CD56^dim, and CD56^bright NK cells, to respond to influenza-virus infected cells and tumor cells. During pregnancy, CD56^dim and CD56^bright NK cells displayed enhanced functional responses to both infected and tumor cells, with increased expression of degranulation markers and elevated frequency of NK cells producing IFN-γ. To better understand the mechanisms driving this enhanced function, we profiled CD56^dim and CD56^bright NK cells from pregnant and non-pregnant women using mass cytometry. NK cells from pregnant women displayed significantly increased expression of several functional and activation markers such as CD38 on both subsets and NKp46 on CD56^dim NK cells. NK cells also displayed diminished expression of the chemokine receptor CXCR3 during pregnancy. Overall, these data demonstrate that functional and phenotypic shifts occur in NK cells during pregnancy that can influence the magnitude of the immune response to both infections and tumors.

Hormone receptor expression of colorectal cancer diagnosed during the peri-partum period

BACKGROUND

Colorectal carcinoma (CRC) during the peri-partum period is challenging to diagnose due to the overlapping symptoms of CRC and pregnancy. This is the first case series to investigate clinicopathologic, hormonal and molecular features of CRC diagnosed during the peri-partum period. We hypothesized that advanced presentations of CRC could possibly be mitigated by pregnancy-related hormonal factors.

METHODS

We conducted a retrospective review of five women diagnosed with CRC during the peri-partum period and studied the clinical and molecular features of their cancer.

RESULTS

All patients presented with stage IV CRC at diagnosis; three had primary tumors in the rectum and two had primary tumors in the sigmoid colon. The liver was the most common metastatic site (three of five women). Immunohistochemistry stains were negative for estrogen receptors alpha (ERα) and beta (ERβ), and one tumor demonstrated low-level positivity for PR (1%). Formalin-fixed and paraffin-embedded (FFPE) biopsies from each case were tested with next-generation sequencing and found that all tumors were mismatch repair (MMR) proficient, and three harbored a KRAS mutation. Germline testing showed no predisposition to CRC; however, several somatic variants of undetermined significance (VUS) were identified.

DISCUSSION

CRC in the peri-partum period poses significant risk factors for presentations with advanced disease due to diagnostic challenges. While our study provides no evidence that pathogenesis of CRC during pregnancy is driven by elevated estrogen and/or progesterone levels during pregnancy, additional putative etiologic factors, including placental growth factors, the immunosuppressive state of pregnancy and other physiologic processes during pregnancy, warrant future study.

Why Should We Advocate Maternal Immunization?

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

Influenza A Viral Infection with Septic Shock in Pregnancy

The influenza virus is RNA virus and is classified into four subtypes, influenza A, influenza B, influenza C, and influenza D. One of the subtypes of influenza A, the H1N1 strain, also known as swine flu, is especially of high risk for development of complications in pregnant women. The influenza A virus infection is difficult to diagnose clinically because its presenting symptoms are similar to those of the common cold but are more severe, last longer, and can be potentially life-threatening. This case also presented with common cold symptoms but her condition worsened later. Fortunately, obstetric health providers were vigilant enough to address the developing infection and its related complications. It was the cooperative effort of multidisciplinary team care which resulted in a favourable outcome in both mother and baby.

Enhancing uptake of influenza maternal vaccine

INTRODUCTION

Influenza vaccination during pregnancy can offer many benefits to both mother and infant. Despite recommendations from the Advisory Committee on Immunization Practices, vaccine coverage rates among pregnant women during pregnancy are below 40% in the United States. There is a need for a greater understanding of what interventions can improve vaccine uptake among pregnant women.

AREAS COVERED

This review synthesizes the existing evidence on the effectiveness of interventions to improve maternal influenza vaccine uptake. These interventions are examined within the framework of the three psychological propositions: thoughts and feelings, social processes and changing behavior directly.

EXPERT COMMENTARY

A number of promising and effective interventions were identified in this review. Nudge-based interventions that build on favorable intentions to vaccinate such as provider prompts and standing orders have demonstrated significant success in improving influenza vaccine uptake. However, substantial gaps in the literature still exist. Provider recommendations are the most important predictor of vaccine receipt among pregnant women, yet few studies evaluated intervening to improve the dialogue between patient and provider. With the potential for even more vaccines to be added to the maternal immunization schedule, it is vitally important to understand how to improve uptake.

Estimating Vaccine Effectiveness Against Hospitalized Influenza During Pregnancy: Multicountry Protocol for a Retrospective Cohort Study

Background

Although pregnant women are believed to have elevated risks of severe influenza infection and are targeted for influenza vaccination, no study to date has examined influenza vaccine effectiveness (IVE) against laboratory-confirmed influenza-associated hospitalizations during pregnancy, primarily because this outcome poses many methodological challenges.

Objective

The Pregnancy Influenza Vaccine Effectiveness Network (PREVENT) was formed in 2016 as an international collaboration with the Centers for Disease Control and Prevention; Abt Associates; and study sites in Australia, Canada, Israel, and the United States. The primary goal of this collaboration is to estimate IVE in preventing acute respiratory or febrile illness (ARFI) hospitalizations associated with laboratory-confirmed influenza virus infection during pregnancy. Secondary aims include (1) describing the incidence, clinical course, and severity of influenza-associated ARFI hospitalization during pregnancy; (2) comparing the characteristics of ARFI-hospitalized pregnant women who were tested for influenza with those who were not tested; (3) describing influenza vaccination coverage in pregnant women; and (4) comparing birth outcomes among women with laboratory-confirmed influenza-associated hospitalization versus other noninfluenza ARFI hospitalizations.

Methods

For an initial assessment of IVE, sites identified a retrospective cohort of pregnant women aged from 18 to 50 years whose pregnancies overlapped with local influenza seasons from 2010 to 2016. Pregnancies were defined as those that ended in a live birth or stillbirth of at least 20 weeks gestation. The analytic sample for the primary IVE analysis was restricted to pregnant women who were hospitalized for ARFI during site-specific influenza seasons and clinically tested for influenza virus infection using real-time reverse transcription polymerase chain reaction.

Results

We identified approximately 2 million women whose pregnancies overlapped with influenza seasons; 550,344 had at least one hospitalization during this time. After restricting to women who were hospitalized for ARFI and tested for influenza, the IVE analytic sample included 1005 women.

Conclusions

In addition to addressing the primary question about the effectiveness of influenza vaccination, PREVENT data will address other important knowledge gaps including understanding the incidence, clinical course, and severity of influenza-related hospitalizations during pregnancy. The data infrastructure and international partnerships created for these analyses may be useful and informative for future influenza studies.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11333

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Natality Decline and Spatial Variation in Excess Death Rates During the 1918-1920 Influenza Pandemic in Arizona, United States

A large body of epidemiologic research has concentrated on the 1918 influenza pandemic, but more work is needed to understand spatial variation in pandemic mortality and its effects on natality. We collected and analyzed 35,151 death records from Arizona for 1915–1921 and 21,334 birth records from Maricopa county for 1915–1925. We estimated the number of excess deaths and births before, during, and after the pandemic period, and we found a significant decline in the number of births occurring 9–11 months after peak pandemic mortality. Moreover, excess mortality rates were highest in northern Arizona counties, where Native Americans were historically concentrated, suggesting a link between ethnic and/or sociodemographic factors and risk of pandemic-related death. The relationship between birth patterns and pandemic mortality risk should be further studied at different spatial scales and in different ethnic groups.

The long-run effects of pandemic influenza on the development of children from elite backgrounds: Evidence from industrializing Japan

This study estimates the lingering effects of fetal exposure to the 1918 influenza pandemic on the development of secondary school and girls' high school students in industrializing Japan. In order to refine the verification of the fetal origins hypothesis, we tried not only to focus on children from elite schools but also to construct the continuous influenza mortality measure using monthly variations in the number of births and influenza deaths. By utilizing a nationwide multidimensional physical examination dataset, we found that fetal exposure to influenza in the pandemic years reduced the heights of boys and girls by approximately 0.3 cm and 0.1 cm, respectively. While the strongest negative magnitude was observed in the pandemic period, the lingering relapses in the post-pandemic period still had considerable adverse effects on height. In relation to the lowest decile group which experienced normal influenza mortality in non-pandemic years, the heights of the boys and girls who experienced pandemic influenza in the womb are approximately 0.6 and 0.3 cm lower. The lingering influenza relapse in the post-pandemic period has an adverse effect on the boys' height, accounting for roughly 80% of the maximum pandemic effect.

Exploring the risk of severe outcomes and the role of seasonal influenza vaccination in pregnant women hospitalized with confirmed influenza, Spain, 2010/11-2015/16

Based on previous observations during pandemics and seasonal epidemics, pregnant women are considered at risk of developing severe influenza outcomes after influenza infection. With the aim of preventing severe influenza illness, the World Health Organization (WHO) includes pregnant women as a target group for seasonal influenza vaccination. However, influenza vaccine uptake during pregnancy remains low in many countries, including Spain. The objectives of this study were to increase the evidence of pregnancy as a risk factor for severe influenza illness and to study the potential role of seasonal influenza vaccination in the prevention of severe outcomes in infected pregnant women. Using information from the surveillance of Severe Hospitalized Confirmed Influenza Cases (SHCIC) in Spain, from seasons 2010/11 to 2015/16, we estimated that pregnant women in our study had a relative risk of hospitalization with severe influenza nearly 7.8 times higher than non-pregnant women of reproductive age. Only 5 out of 167 pregnant women with known vaccination status in our study had been vaccinated (3.6%). Such extremely low vaccination coverage only allowed obtaining crude estimates suggesting a protective effect of the vaccine against influenza complications (ICU admission or death). Our overall results support that pregnant women could benefit from seasonal influenza vaccination, in line with national and international recommendations.

Who's the Target: Mother or Baby?

Maternal immunization for prevention of morbidity and mortality of pregnant women and their neonates due to infectious diseases is ongoing worldwide. The complexity of vaccine research and development in this population is challenging. Not only do vaccines for pregnant women require evidence of immunogenicity, potency, stability, and limited reactogenicity, they must also provide efficacy in decreasing morbidity for the pregnant woman, her fetus, and the neonate, demonstrate safety or lack of evidence of harm, and offer benefit or potential benefit of vaccination during pregnancy. Since the 19th century, evidence of protective effects of vaccination during pregnancy has been documented. Pandemic influenza and pertussis outbreaks in recent years have affected a paradigm shift in vaccine research and development as well as current policy regarding immunization in pregnancy. Studies of the immune system in pregnant women and neonates have shown that immune changes associated with pregnancy in women do not interfere with maternal vaccine responses, multiple factors are important in transplacental transfer of antibodies, and maternal antibodies are beneficial to neonates. In recent years, guidelines have been developed by expert panels to help design studies for maternal vaccinations and for harmonization of data collection, analysis, and adverse event reporting. Further research into maternal and neonatal immunology, transplacental antibody transfer, and epidemiology of diseases is needed, especially as new vaccines to respiratory syncytial virus, cytomegalovirus, and Group B streptococcus are developed. Maternal vaccinations have the potential to change the epidemiology of infectious diseases in reproductive health and pediatrics and may lead to new clinical applications to improve global maternal and neonatal health.

Feasibility of Text Message Influenza Vaccine Safety Monitoring During Pregnancy

INTRODUCTION

The feasibility and accuracy of text messaging to monitor events after influenza vaccination throughout pregnancy and the neonatal period has not been studied, but may be important for seasonal and pandemic influenza vaccines and future maternal vaccines.

METHODS

This prospective observational study was conducted during 2013-2014 and analyzed in 2015-2016. Enrolled pregnant women receiving inactivated influenza vaccination at a gestational age <20 weeks were sent text messages intermittently through participant-reported pregnancy end to request fever, health events, and neonatal outcomes. Text message response rates, Day 0-2 fever (≥100.4°F), health events, and birth/neonatal outcomes were assessed.

RESULTS

Most (80.2%, n=166) eligible women enrolled. Median gestational age was 8.9 (SD=3.9) weeks at vaccination. Response rates remained high (80.0%-95.2%). Only one Day 0-2 fever was reported. Women reported via text both pregnancy- and non-pregnancy-specific health events, not all associated with medical visits. Most pregnancy-specific events in the electronic medical record (EMR) were reported via text message. Of all enrollees, 84.9% completed the study (131 reported live birth, ten reported pregnancy loss). Two losses reported via text were not medically attended; there was one additional EMR-identified loss. Gestational age and weight at birth were similar between text message-reported and EMR-abstracted data and 95% CIs were overlapping for proportions of prematurity, low birth weight, small for gestational age, and major birth defects, as identified by text message-reported versus EMR-abstracted plus text message-reported versus EMR-abstracted data only.

CONCLUSIONS

This study demonstrated the feasibility of text messaging for influenza vaccine safety surveillance sustained throughout pregnancy. In these women receiving inactivated influenza vaccination during pregnancy, post-vaccination fever was infrequent and a typical pattern of maternal and neonatal health outcomes was observed.

1918 Influenza Pandemic: In Utero Exposure in the United States and Long-Term Impact on Hospitalizations

OBJECTIVES

To explore associations between in utero exposure to the 1918 influenza pandemic and hospitalization rates in old age (≥ 70 years) in the United States.

METHODS

We identified individuals exposed (mild and deadly waves) and unexposed in utero to the 1918 influenza pandemic (a natural experiment) by using birth dates from the Asset and Health Dynamics Among the Oldest Old survey. We analyzed differences in hospitalization rates by exposure status with multivariate linear regression.

RESULTS

In utero exposure to the deadly wave of the 1918 influenza pandemic increased the number of hospital visits by 10.0 per 100 persons. For those exposed in utero to the deadliest wave of the influenza pandemic, high rates of functional limitations are shown to drive the higher rates of hospitalizations in old age.

CONCLUSIONS

In utero exposure to the influenza pandemic increased functional limitations and hospitalization rates in old age. Public Health Implications. To determine investments in influenza pandemic prevention programs that protect fetal health, policymakers should include long-term reductions in hospitalizations in their cost-benefit evaluations.

Emerging Infectious Diseases in Pregnancy

It has been recognized for centuries that pregnant women have unique susceptibilities to many infectious diseases that predispose them to untoward outcomes compared with the general adult population. It is thought a combination of adaptive alterations in immunity to allow for the fetal allograft combined with changes in anatomy and physiology accompanying pregnancy underlie these susceptibilities. Emerging infectious diseases are defined as those whose incidence in humans has increased in the past two decades or threaten to increase in the near future. The past decade alone has witnessed many such outbreaks, each with its own unique implications for pregnant women and their unborn fetuses as well as lessons for the health care community regarding response and mitigation. Examples of such outbreaks include, but are not limited to, severe acute respiratory syndrome, the 2009 H1N1 pandemic influenza, Ebola virus, and, most recently, the Zika virus. Although each emerging pathogen has unique features requiring specific considerations, there are many underlying principles that are shared in the recognition, communication, and mitigation of such infectious outbreaks. Some of these key principles include disease-specific delineation of transmission dynamics, understanding of pathogen-specific effects on both mothers and fetuses, and advance planning and contemporaneous management that prioritize communication among public health experts, clinicians, and patients. The productive and effective working collaboration among the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine has been a key partnership in the successful communication and management of such outbreaks for women's health care providers and patients alike. Going forward, the knowledge gained over the past decade will undoubtedly continue to inform future responses and will serve to optimize the education and care given to pregnant women in the face of current and future emerging infectious disease outbreaks.

Influenza vaccine effectiveness among high-risk groups: A systematic literature review and meta-analysis of case-control and cohort studies

Vaccination represents the most effective intervention to prevent infection, hospitalization and mortality due to influenza. This meta-analysis quantifies data reporting influenza vaccine effectiveness (VE) on influenza visits and hospitalizations of case-control and cohort studies among high-risk groups.

A systematic literature review including original articles published between 2007 and 2016, using a protocol registered on Prospero with No. 42017054854, and a meta-analysis were conducted.

For 3 high-risk groups (subjects with underlying health conditions, pregnant women and health care workers) only a qualitative evaluation was performed. The VE quantitative analysis demonstrated a clear significant overall effect of 39% (95%CI: 32–46%) for visits and 57% (95%CI: 30–74%) for hospitalization among children. Considering the elderly influenza VE had a clear effect of 25% (95%CI: 6–40%) for visits and 14% (95%CI: 7–21%; p<0.001) for hospitalization.

This study showed the high VE of influenza vaccination among high-risk groups, representing a tool for public health decision-makers to develop evidence-based preventive interventions to avoid influenza outcomes.

Lifetime Modulation of the Pain System via Neuroimmune and Neuroendocrine Interactions

Chronic pain is a debilitating condition that still is challenging both clinicians and researchers. Despite intense research, it is still not clear why some individuals develop chronic pain while others do not or how to heal this disease. In this review, we argue for a multisystem approach to understand chronic pain. Pain is not only to be viewed simply as a result of aberrant neuronal activity but also as a result of adverse early-life experiences that impact an individual's endocrine, immune, and nervous systems and changes which in turn program the pain system. First, we give an overview of the ontogeny of the central nervous system, endocrine, and immune systems and their windows of vulnerability. Thereafter, we summarize human and animal findings from our laboratories and others that point to an important role of the endocrine and immune systems in modulating pain sensitivity. Taking "early-life history" into account, together with the past and current immunological and endocrine status of chronic pain patients, is a necessary step to understand chronic pain pathophysiology and assist clinicians in tailoring the best therapeutic approach.

Birth outcomes for Australian mother-infant pairs who received an influenza vaccine during pregnancy, 2012-2014: The FluMum study

INTRODUCTION

In Australia, influenza vaccination is recommended for all women who will be pregnant during the influenza season. Vaccine safety and effectiveness are key concerns and influencers of uptake for both vaccine providers and families. We assessed the safety of receiving an influenza vaccination during any trimester of pregnancy with respect to preterm births and infant birthweight.

METHODS

We conducted a nested retrospective cohort study of 'FluMum' participants (2012-2014). Our primary exposure of interest was influenza vaccination during pregnancy. The primary outcomes of interest were infant birthweight and weeks' gestation at birth for live singleton infants. Analyses included comparisons of these birth outcomes by vaccination status and trimester of pregnancy an influenza vaccine was given. We calculated means, proportions, and relative risks and performed multivariable logistic regression for potential confounding factors.

RESULTS

In the 7126 mother-infant pairs enrolled in this study, mean maternal age at infant birth was 31.7years. Influenza vaccine uptake in pregnancy was 34%. Most mothers with a known date of vaccination received a vaccine in the second trimester (51%). Those mothers with a co-morbidity or risk factor were 13% more likely to have influenza vaccine during pregnancy compared to other mothers (RR 1.13, 95% CI 1.04-1.24, p=0.007). Mean weeks' gestation at birth was 38.7 for the vaccinated and 38.8 for the unvaccinated group (p=0.051). Infants in the vaccinated group weighed 15g less in birthweight compared to the unvaccinated infants (95% CI -12.8 to 42.2, p=0.29).

CONCLUSION

Results arising from this large Australian cohort study are reassuring with respect to two critical safety outcomes; preterm births and low infant birthweights. Studies examining a broader range of birth outcomes following influenza vaccination during pregnancy are required, particularly now that maternal vaccination in pregnancy has expanded to include pertussis as well as influenza.

Increased Proinflammatory Responses of Monocytes and Plasmacytoid Dendritic Cells to Influenza A Virus Infection During Pregnancy

Pregnancy-induced alterations in immunity may contribute to the increased morbidity associated with influenza A virus infection during pregnancy. We characterized the immune response of monocytes and plasmacytoid dendritic cells (pDCs) to influenza A virus infection in 21 pregnant and 21 nonpregnant women. In pregnant women, monocytes and pDCs exhibit an exaggerated proinflammatory immune response to 2 strains of influenza A virus, compared with nonpregnant women, characterized by increased expression of major histocompatibility complex class II (approximately 2.0-fold), CD69 (approximately 2.2-fold), interferon γ-induced protein 10 (approximately 2.0-fold), and macrophage inflammatory protein 1β (approximately 1.5-fold). This enhanced innate inflammatory response during pregnancy could contribute to pulmonary inflammation following influenza A virus infection.

Perceptions of influenza vaccination during pregnancy in Korean women of childbearing age

The rate of maternal influenza vaccination in Korea is much lower than the general population. We evaluated the influenza vaccination rate during pregnancy and assessed women's perceptions of the influenza vaccine. One thousand women of childbearing age were surveyed from April through May 2014, using a questionnaire about vaccination history, general understanding of influenza vaccination and that examined factors that influence decisions about influenza vaccination. We also conducted an intervention to evaluate potential improvement in vaccination behavior. The influenza vaccination rate during pregnancy was 37.3%. The common reasons listed in support of vaccination included the perception of the risk of influenza infection, recommendations from health care providers, and belief in the effectiveness of the influenza vaccine. The most common reasons for not vaccinating included concern about harmful effects and the lack of recommendation from health care providers. Based on the results of the questionnaire and intervention, it is important to provide accurate information and for health care providers to recommend the influenza vaccine to pregnant women. It is also necessary for the government to encourage women to receive the influenza vaccination as a healthcare policy.

Safety of the 2011-12, 2012-13, and 2013-14 seasonal influenza vaccines in pregnancy: Preterm delivery and specific malformations, a study from the case-control arm of VAMPSS

BACKGROUND

Pregnant women have higher risks of influenza complications, but vaccine coverage is incomplete. Because concern about fetal harm limits uptake, we investigated risks for preterm delivery (PTD) and specific birth defects following vaccination in the 2011-12 through 2013-14 influenza seasons.

METHODS

We used data from the Slone Epidemiology Center's Birth Defects Study. For PTD, propensity score-adjusted time-varying hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for exposure anytime in pregnancy and for each trimester. For 42 specific major birth defects or birth defect categories, propensity score-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated.

RESULTS

For PTD (1803 fullterm deliveries, 107 PTD for all seasons combined), an elevated adjusted risk was observed for only the 2nd trimester of the 2011-12 season (HR=2.60, 95% CI 1.21, 5.61) - a reduction in gestational length of <2days. For the 42 specific defects or categories of defects (2866 cases, 1411 controls for all seasons combined) most adjusted risks were close to 1.0; the highest was 2.38 for omphalocele and the lowest was 0.50 for atrioventricular canal defects. None had lower confidence bounds >1.0. For each season separately, only one elevated OR had a lower 95% CI >1.0: omphalocele in 2011-12 (OR=5.19, 95% CI 1.44, 18.7).

CONCLUSIONS

Our results regarding risks for PTD and birth defects are generally reassuring. The few risks that were observed are compatible with chance, but warrant testing in other data. Given that vaccine components and manufacturing processes vary, continuing studies are needed to evaluate risks and safety of each season's vaccine and specific products.

Influenza pathogenicity during pregnancy in women and animal models

Pregnant women are at the highest risk to develop severe and even fatal influenza. The high vulnerability of women against influenza A virus infections during pregnancy was repeatedly highlighted during influenza pandemics including the pandemic of this century. In 2009, mortality rates were particularly high among otherwise healthy pregnant women. However, our current understanding of the molecular mechanisms involved in severe disease development during pregnancy is still very limited. In this review, we summarize the knowledge on the clinical observations in influenza A virus-infected pregnant women. In addition, knowledge obtained from few existing experimental infections in pregnant animal models is discussed. Since clinical data do not provide in-depth information on the pathogenesis of severe influenza during pregnancy, adequate animal models are urgently required that mimic clinical findings. Studies in pregnant animal models will allow the dissection of involved molecular disease pathways that are key to improve patient management and care.

The Effect of Influenza Vaccination on Birth Outcomes in a Cohort of Pregnant Women in Lao PDR, 2014-2015

BACKGROUND

Some studies suggest that maternal influenza vaccination can improve birth outcomes. However, there are limited data from tropical settings, particularly Southeast Asia. We conducted an observational study in Laos to assess the effect of influenza vaccination in pregnant women on birth outcomes.

METHODS

We consented and enrolled a cohort of pregnant woman who delivered babies at 3 hospitals during April 2014-February 2015. We collected demographic and clinical information on mother and child. Influenza vaccination status was ascertained by vaccine card. Primary outcomes were the proportion of live births born small for gestational age (SGA) or preterm and mean birth weight. Multivariate models controlled for differences between vaccinated and unvaccinated women and influenza virus circulation.

RESULTS

We enrolled 5103 women (2172 [43%] were vaccinated). Among the 4854 who had a live birth, vaccinated women were statistically significantly less likely than unvaccinated women to have an infant born preterm during the period of high influenza virus circulation (risk ratio [RR] = 0.56, 95% confidence interval [CI], .45-.70), and the effect remained after adjusting for covariates (adjusted RR, 0.69; 95% CI, .55-.87). There was no effect of vaccine on mean birth weight. Vaccinated mothers had a statistically significant elevated risk of having an infant born SGA (adjusted RR, 1.25; 95% CI, 1.11–1.41).

CONCLUSIONS

In this observational study, we found indirect evidence of influenza vaccine safety during pregnancy, and women who received vaccine had a reduced risk of delivering a preterm infant during times of high influenza virus circulation. Vaccination may prevent 1 in 5 preterm births that occur during periods of high influenza circulation.

Lack of Availability of Antenatal Vaccination Information on Obstetric Care Practice Web Sites

OBJECTIVE

To estimate the proportion of obstetric practice web sites in the United States providing information on antenatal influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination.

METHODS

Using www.healthgrades.com, a national random sample of 1,003 obstetric practice web sites was examined for provision of information on antenatal vaccination and other preventive prenatal health topics. Data were collected for this cross-sectional study between September 25, 2014, and November 12, 2014. χ tests and odds ratios were calculated to determine significance and magnitude of associations between provision of antenatal vaccination information and other practice characteristics.

RESULTS

Of 1,003 web sites examined, 229 (22.8%) posted information pertaining to antenatal vaccinations. Only 105 web sites (10.5%) provided up-to-date information about both antenatal influenza and Tdap vaccination. Compared with the proportion posting on antenatal vaccination, significantly more web sites posted on safe foods (40.8%; P<.001), safe medications (36.9%; P<.001), and safe exercise (38.5%; P<.001) during pregnancy. When compared with web sites not mentioning these other prenatal health topics, web sites mentioning these topics were more likely to also mention antenatal vaccination (safe foods: 45.7% compared with 7.1%; odds ratio [OR] 11.07, 95% confidence interval [CI] 7.65-16.01; safe medications: 45.4% compared with 9.6%; OR 7.8, CI 5.58-10.89; safe exercise: 45.9% compared with 8.4%; OR 9.2, CI 6.5-13.03).

CONCLUSION

A majority of obstetric care practice web sites do not provide information on antenatal vaccinations. Obstetric practices should consider using their web sites to provide reliable information on antenatal vaccinations as many already do for other prenatal health topics.

Influenza vaccination in high-risk groups: a revision of existing guidelines and rationale for an evidence-based preventive strategy

Influenza, an infectious respiratory disease, is one of the main causes of excess winter deaths (EWDs) in Europe. Annual flu epidemics are associated with high morbidity and mortality rates, especially among the elderly, those with underlying health conditions and pregnant women. Health Care Workers (HCWs) are also considered at high risk of both contracting influenza and spreading the virus to vulnerable patients. During the 2014/2015 season, the excess winter mortality rates observed in countries of the northern hemisphere (EuroMOMO network) and in Italy (+13%) were strongly related to the intensity of influenza circulation. Influenza vaccination is the most important public health intervention to prevent seasonal influenza transmission and infection. However, to date, influenza vaccination coverage reported in Europe (including high-risk groups) is still largely unsatisfactory. This study analyzes some international and European guidelines on influenza vaccination and the rationale that underlies evidence- based public health intervention for the prevention of influenza among the principal high-risk groups: a) the elderly (subjects aged 65 years or older); b) subjects with underlying health conditions; c) pregnant women; d) healthcare workers. Only by achievement recommended influenza vaccination coverage among high-risk groups in all European countries can we reduce the burden of disease.

Replication of influenza A virus in swine umbilical cord epithelial stem-like cells

In this study, we describe the isolation and characterization of epithelial stem-like cells from the swine umbilical cord and their susceptibility to influenza virus infection. Swine umbilical cord epithelial stem cells (SUCECs) expressed stem cell and pluripotency associated markers such as SSEA-1, SSEA-4, TRA 1-60 and TRA 1-81 and Oct4. Morphologically, cells displayed polygonal morphology and were found to express epithelial markers; pancytokeratin, cytokeratin-18 and occludin; mesenchymal cell markers CD44, CD90 and haematopoietic cell marker CD45 were not detected on these cells. The cells had extensive proliferation and self- renewal properties. The cells also possessed immunomodulatory activity and inhibited the proliferation of T cells. Also, higher levels of anti-inflammatory cytokine IL-10 were detected in SUCEC-T cell co-cultures. The cells were multipotent and differentiated into lung epithelial cells when cultured in epithelial differentiation media. We also examined if SUCECs are susceptible to infection with influenza virus. SUCECs expressed sialic acid receptors, used by influenza virus for binding to cells. The 2009 pandemic influenza virus and swine influenza virus replicated in these cells. SUCECs due to their differentiation and immunoregulatory properties will be useful as cellular therapy in a pig model for human diseases. Additionally, our data indicate that influenza virus can infect SUCECs and may transmit influenza virus from mother to fetus through umbilical cord and transplantation of influenza virus-infected stem cells may transmit infection to recipients. Therefore, we propose that umbilical cord cells, in addition to other agents, should also be tested for influenza virus before cryopreservation for future use as a cell therapy for disease conditions.

Inflammation and preterm birth

Preterm birth is the leading cause of neonatal morbidity and mortality. Although the underlying causes of pregnancy-associated complication are numerous, it is well established that infection and inflammation represent a highly significant risk factor in preterm birth. However, despite the clinical and public health significance, infectious agents, molecular trigger(s), and immune pathways underlying the pathogenesis of preterm birth remain underdefined and represent a major gap in knowledge. Here, we provide an overview of recent clinical and animal model data focused on the interplay between infection-driven inflammation and induction of preterm birth. Furthermore, here, we highlight the critical gaps in knowledge that warrant future investigations into the interplay between immune responses and induction of preterm birth.

Acute respiratory failure and mechanical ventilation in pregnant patient: A narrative review of literature

Physiological changes of pregnancy imposes higher risk of acute respiratory failure (ARF) with even a slight insult and remains an important cause of maternal and fetal morbidity and mortality. Although pregnant women have different respiratory physiology and different causes of ARF, guidelines specific to ventilatory settings, goals of oxygenation and weaning process could not be framed due to lack of large-scale randomized controlled trials. During the 2009 H1N1 pandemic, pregnant women had higher morbidity and mortality compared to nonpregnant women. During this period, alternative strategies of ventilation such as high-frequency oscillatory ventilation, inhalational of nitric oxide, prone positioning, and extra corporeal membrane oxygenation were increasingly used as a desperate measure to rescue pregnant patients with severe hypoxemia who were not improving with conventional mechanical ventilation. This article highlights the causes of ARF and recent advances in invasive, noninvasive and alternative strategies of ventilation used during pregnancy.

Clinical chorioamnionitis at term V: umbilical cord plasma cytokine profile in the context of a systemic maternal inflammatory response

OBJECTIVE

Microbial invasion of the fetus due to intra-amniotic infection can lead to a systemic inflammatory response characterized by elevated concentrations of cytokines in the umbilical cord plasma/serum. Clinical chorioamnionitis represents the maternal syndrome often associated with intra-amniotic infection, although other causes of this syndrome have been recently described. The objective of this study was to characterize the umbilical cord plasma cytokine profile in neonates born to mothers with clinical chorioamnionitis at term, according to the presence or absence of bacteria and/or intra-amniotic inflammation.

MATERIALS AND METHODS

A cross-sectional study was conducted, including patients with clinical chorioamnionitis at term (n=38; cases) and those with spontaneous term labor without clinical chorioamnionitis (n=77; controls). Women with clinical chorioamnionitis were classified according to the results of amniotic fluid culture, broad-range polymerase chain reaction coupled with electrospray ionization mass spectrometry (PCR/ESI-MS) and amniotic fluid interleukin (IL)-6 concentration into three groups: 1) no intra-amniotic inflammation; 2) intra-amniotic inflammation without detectable microorganisms; or 3) microbial-associated intra-amniotic inflammation. A fetal inflammatory response syndrome (FIRS) was defined as an umbilical cord plasma IL-6 concentration >11 pg/mL. The umbilical cord plasma concentrations of 29 cytokines were determined with sensitive and specific V-PLEX immunoassays. Nonparametric statistical methods were used for analysis, adjusting for a false discovery rate of 5%.

RESULTS

1) Neonates born to mothers with clinical chorioamnionitis at term (considered in toto) had significantly higher median umbilical cord plasma concentrations of IL-6, IL-12p70, IL-16, IL-13, IL-4, IL-10 and IL-8, but significantly lower interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF)-α concentrations than neonates born to mothers with spontaneous term labor without clinical chorioamnionitis; 2) neonates born to mothers with clinical chorioamnionitis at term but without intra-amniotic inflammation had higher concentrations of IL-6, IL-12p70, IL-13, IL-4, IL-5, and IL-8, but lower IFN-γ, than neonates not exposed to clinical chorioamnionitis, suggesting that maternal fever in the absence of intra-amniotic inflammation leads to a change in the fetal cytokine network; 3) there were significant, positive correlations between maternal and umbilical cord plasma IL-6 and IL-8 concentrations (IL-6: Spearman correlation=0.53; P<0.001; IL-8: Spearman correlation=0.42; P<0.001), consistent with placental transfer of cytokines; 4) an elevated fetal plasma IL-6 (>11 pg/mL), the diagnostic criterion for FIRS, was present in 21% of cases (8/38), and all these neonates were born to mothers with proven intra-amniotic infection; and 5) FIRS was associated with a high concentration of umbilical cord plasma IL-8, IL-10 and monocyte chemoattractant protein (MCP)-1.

CONCLUSIONS

Neonates born to mothers with clinical chorioamnionitis at term had higher concentrations of umbilical cord plasma cytokines than those born to mothers without clinical chorioamnionitis. Even neonates exposed to clinical chorioamnionitis but not to intra-amniotic inflammation had elevated concentrations of multiple cytokines, suggesting that intrapartum fever alters the fetal immune response.

Changing perspectives of infectious causes of maternal mortality

OBJECTIVE

Infections significantly contribute to maternal mortality. There is a perceived change in the spectrum of such infections. This study aims to estimate the contribution of various types of infections to maternal mortality.

MATERIAL AND METHODS

We retrospectively reviewed records of maternal death cases that took place between 2003 and 2012 in the Christian Medical College, Vellore, India. The International Classification of Diseases-Maternal Mortality was used to classify the causes of deaths and World Health Organization near-miss criteria were used to identify organ dysfunction that occurred before death. Infections during pregnancy were divided into three groups, i.e., pregnancy-related infections, pregnancy-unrelated infections, and nosocomial infections.

RESULTS

In this study, 32.53% of maternal deaths were because of some type of infection as the primary cause. The contribution of pregnancy-related infections was comparable with that of pregnancy-unrelated infections (16.03% vs. 16.50%). Metritis with pelvic cellulitis, septic abortions, tuberculosis, malaria, scrub typhus, and H1N1 influenza (influenza A virus subtype) were among the most commonly encountered causes of maternal death due to infections. Another 7.07% of cases developed severe systemic infection during the course of illness as nosocomial infection. A significant majority of mothers were below 30 years of age, were primiparae, had advanced gestational age, and had operative delivery. Cardiovascular and respiratory system dysfunctions were the most common organ dysfunctions encountered.

CONCLUSION

The contribution of pregnancy-unrelated infections to maternal deaths is significant. Control of these diverse community-acquired infections holds the key to a reduction in maternal mortality along with the promotion of clean birthing practices. Nosocomial infections should not be underestimated as a contributor to maternal mortality.

[Current state of influenza vaccination and factors affecting vaccination rate among pregnant women]

PURPOSE

This study was done to examine the actual state of influenza vaccination among pregnant women and factors affecting vaccination rate.

METHODS

Data were collected using self-report questionnaires. Participants were pregnant women who participated in a prenatal education program at an acute care hospital in 2013. Data collected from 218 pregnant women were analyzed using the SPSS 18.0 Program.

RESULTS

Only 48.6% of the pregnant women had received vaccination when the influenza was prevalent. Statistically significant factors affecting the influenza vaccination rate among pregnant women were vaccination experience in the previous year, knowledge and attitude about vaccination, and gestation period.

CONCLUSION

Results indicate that the influenza vaccination rate among pregnant women is lower than that of elders, healthcare workers, and patients with chronic diseases, who have been considered to be the mandatory vaccination recipients. Therefore, it is necessary to develop programs and policies which provide information including safety of vaccines for pregnant women and to induce positive attitudes towards vaccination for these women, in order to ultimately improve the vaccination rate.

Post-pandemic influenza A (H1N1) 2009 virus infection in pregnant women in Ceará, Brazil

OBJECTIVE

The aim of this study was to present results of the post-pandemic phase of A(H1N1)pdm09 virus infection in pregnant women in Ceará, Brazil, during the January-June 2012 influenza season.

RESULTS

One hundred and fifty-four nasopharyngeal swab samples were collected from pregnant women admitted to hospitals with suspected severe acute respiratory infection (SARI). Fifty-three (34·4%) had laboratory-confirmed A(H1N1)pdm09 virus infection with 15 (28·3%) outpatients and 38 (71·7%) hospitalized. Five (9·4%) women were in the first trimester of pregnancy, 20 (37·7%) in the second trimester of pregnancy, and 24 (45·2%) in the third trimester of pregnancy. Three had no information about the time of pregnancy. Six samples from newborns were also analyzed, of which three were nasopharyngeal swab positive for A(H1N1)pdm09. These swabs were collected immediately after birth, with the exception of one that was collected on the day after birth.

CONCLUSION

Our findings suggest that transplacental transfer of influenza viruses could occur as a result of severe illness in pregnancy. It is therefore important to encourage women to be vaccinated against influenza in order to avoid pregnancy complications.