Pandemic influenza and pregnant women: summary of a meeting of experts

Systematic Review of Avian Influenza Virus Infection and Outcomes during Pregnancy

Human cases of avian influenza A(H5N2) and A(H5N1) viruses associated with outbreaks in birds and mammals are increasing globally, raising concerns about the possibility of a future avian influenza pandemic. We conducted a systematic review examining 30 reported cases of avian influenza in pregnant women. We found high mortality rates for mothers (90.0%, 27/30) and their babies (86.7%, 26/30) when women were infected with avian influenza virus during pregnancy. Despite being a high-risk population and having worse health outcomes across multiple pandemics, pregnant women are often excluded from vaccine trials. However, as the risk for a new pandemic increases and human vaccines against avian influenza are developed, early inclusion of pregnant women in clinical trials can inform the risk-benefit analysis for both the mother and their newborn infant. Early inclusion of pregnant women in public health vaccination programs is vital for protecting this high-risk population.

Influenza in Pregnancy: Maternal, Obstetric, and Fetal Implications, Diagnosis, and Management

Influenza(flu) in pregnancy is associated with higher rates of hospitalization, ICU admission, and death and with increased odds of congenital anomalies and stillbirth, but not preterm birth. Clinical manifestations of flu in pregnancy are the same as nonpregnant patients. Pregnant individuals with flu-like symptoms or flu exposure should be treated with antivirals. Diagnostic testing is not needed. Oseltamivir is the mainstay of treatment(and prophylaxis), and when given within 48 hours of symptom onset, it decreases morbidity and mortality. Influenza is associated with worse maternal, obstetric, and neonatal outcomes. These risks are mitigated by early oseltamivir treatment and maternal vaccination; hence the recommendation for universal vaccination in pregnancy.

Viral infections in pregnancy and impact on offspring neurodevelopment: mechanisms and lessons learned

Pregnant individuals with viral illness may experience significant morbidity and have higher rates of pregnancy and neonatal complications. With the growing number of viral infections and new viral pandemics, it is important to examine the effects of infection during pregnancy on both the gestational parent and the offspring. Febrile illness and inflammation during pregnancy are correlated with risk for autism, attention deficit/hyperactivity disorder, and developmental delay in the offspring in human and animal models. Historical viral epidemics had limited follow-up of the offspring of affected pregnancies. Infants exposed to seasonal influenza and the 2009 H1N1 influenza virus experienced increased risks of congenital malformations and neuropsychiatric conditions. Zika virus exposure in utero can lead to a spectrum of abnormalities, ranging from severe microcephaly to neurodevelopmental delays which may appear later in childhood and in the absence of Zika-related birth defects. Vertical infection with severe acute respiratory syndrome coronavirus-2 has occurred rarely, but there appears to be a risk for developmental delays in the infants with antenatal exposure. Determining how illness from infection during pregnancy and specific viral pathogens can affect pregnancy and neurodevelopmental outcomes of offspring can better prepare the community to care for these children as they grow. IMPACT: Viral infections have impacted pregnant people and their offspring throughout history. Antenatal exposure to maternal fever and inflammation may increase risk of developmental and neurobehavioral disorders in infants and children. The recent SARS-CoV-2 pandemic stresses the importance of longitudinal studies to follow pregnancies and offspring neurodevelopment.

Inflammatory and Immune Responses during SARS-CoV-2 Infection in Vaccinated and Non-Vaccinated Pregnant Women and Their Newborns

BACKGROUND

Pregnant women are more susceptible to severe disease associated with SARS-CoV-2 infection. We performed a prospective study to analyze the inflammatory and immune profile after SARS-CoV-2 infection occurring in vaccinated or non-vaccinated pregnant women and their newborns.

METHODS

Twenty-five pregnant women with SARS-CoV-2 infection were enrolled, and sixteen cord blood samples were obtained at delivery.

RESULTS

We observed that IL-1β, TNF-α, Eotaxin, MIB-1β, VEGF, IL-15, IL-2, IL-5, IL-9, IL-10 and IL-1ra levels were significantly higher in vaccinated than non-vaccinated mothers. Furthermore, the newborns of the vaccinated mothers produced higher levels of IL-7, IL-5 and IL-12 compared to the newborns of non-vaccinated mothers. Anti-Spike (S) IgG levels were significantly higher in all vaccinated mothers and their newborns compared to the non-vaccinated group. We found that 87.5% of vaccinated women and 66.6% of non-vaccinated women mounted an S-specific T-cell response quantified by ELISpot assay. Moreover, 75.0% of vaccinated mothers and 38.4% of non-vaccinated mothers showed S-specific CD4⁺ T-cell proliferative response. The T-helper subset response was restricted to CD4⁺ T_h1 in both vaccinated and non-vaccinated women.

CONCLUSION

A higher level of cytokines, IgG antibodies and memory T cells was noted in the vaccinated women. Furthermore, the maternal IgG antibody trans-placental transfer occurred more frequently in vaccinated mothers and may protect the newborn.

Curcumin-Loaded Oil-Free Self-Assembled Micelles Inhibit the Influenza A Virus Activity and the Solidification of Curcumin-Loaded Micelles for Pharmaceutical Applications

Curcumin, a well-known natural lipophilic phenolic compound, plays a vital role in inhibiting the influenza infection. Currently, many kinds of formulations for the enhancement of a water dispersion of curcumin have been developed; however, the anti-influenza abilities of formulated curcumin have been much less investigated. In this study, the optimized self-assembled micelles of RH 40/Tween 80 loaded with curcumin (Cur-M) in an oil-free-based system were spherical with a hydrodynamic size at 13.55 nm ± 0.208 and polydispersity at 0.144 characterized by atomic force microscopy and dynamic light scattering, respectively. Additionally, Cur-M significantly increased the bioactivity/stability of curcumin and effectively inhibited the influenza A virus infection and its replication after viral entry, indicating the alteration of the inhibition mechanisms of curcumin against virus infection via RH 40/Tween 80 micelle formulation. Furthermore, a solid formulation (Cur-SM) of Cur-M was successfully developed by a one-pot physical adsorption method using a small amount of adsorbent and ~50% of curcumin/Cur-M that could be burst released from Cur-SM in 1 h, facilitating the fast-releasing applications. Ultimately, all of the results show that Cur-SM acts as a good nano-formulation of curcumin with improved solubility/dispersity in aqueous solutions and demonstrate new anti-influenza mechanisms of curcumin for pharmaceutical development.

Anesthesia management in a post Covid-19 obstetric patient-What we need to know

The outbreak of the coronavirus disease (COVID)-19 pandemic has led to unprecedented challenges globally. At the outset of the receding second wave and third wave of COVID-19, many patients who have recovered from the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are coming for elective/emergency surgery. This demands a noteworthy emphasis on the post-COVID-19 obstetric patients. The administration of quality and safe obstetric anesthesia are quite challenging in this mentioned subset due to the overlap of signs and symptoms of COVID-19 with the constitutional signs and symptoms of pregnancy. The physiological changes in normal pregnancy and vascular, metabolic alterations in high-risk pregnancy may affect or exacerbate the pathogenesis or clinical presentation of COVID-19, respectively. This article highlights the specific concerns in recovered COVID-19 pregnant patients with associated comorbidity posted for surgery and their repercussions on anesthesia management.

Pregnant people's responses to the COVID-19 pandemic: a mixed-methods, descriptive study

BACKGROUND

Given the extent of the COVID-19 pandemic and uncertainty around the timing of its containment, understanding the experiences and responses of the perinatal population is essential for planning responsive maternity care both during and after the pandemic. The aim of this study was to explore the experiences of pregnant people and their responses to the COVID-19 pandemic, and to identify how health care providers can support this population.

METHODS

This was a mixed-methods, descriptive study with cross-sectional and qualitative descriptive components. We conducted the study between Mar. 20 and May 31, 2020, in British Columbia, Canada. Any pregnant person at any gestational age living in BC was eligible to participate. We collected quantitative data using online survey tools, including the Edinburgh Postnatal Depression Scale (EPDS) and the 7-item Generalized Anxiety Disorder questionnaire (GAD-7). We collected qualitative data using open-ended questions to explore people's thoughts, feelings and experiences during the pandemic. Participants were recruited using study posters distributed via prenatal care clinics and classes, LifeLabs and social media across the province. We used thematic and descriptive analyses to analyze the data, and we integrated the qualitative and quantitative findings at the interpretation level.

RESULTS

The study sample included 96 participants with mean (± standard deviation) maternal and gestational ages of 32 ± 3.92 years and 22.73 ± 8.93 weeks, respectively. Most (93%; n = 89) identified as female. Of the participants, 54% (n = 50) and 35% (n = 34) reported anxiety and depressive symptoms, as measured by the GAD-7 and EPDS, respectively. Overarching themes that emerged from the qualitative data included uncertainty about birth plans and setting, added burden to existing health and social disparities, perceived or projected lack of support or limited support, concerns about early development, and struggle over managing multiple demands. Perceived maternity care needs included mental health support, maintaining prenatal care, frequent and proactive check-ins to build rapport, and recommendations specific to the pandemic.

INTERPRETATION

We found that the impact of the COVID-19 pandemic on the pregnant population has been substantial. The findings of this mixed-methods study can be used to help plan informed and evidence-based health care interventions to mitigate adverse effects and support mothers and families.

Lessons learned from the A (H1N1) influenza pandemic

Influenza in pregnancy is a common condition that is associated with an increased risk of hospital admission. Women with comorbidities are at a greater risk of severe outcomes. There are substantial gaps in our knowledge of the impact of severe influenza on perinatal outcomes, particularly in low- and middle-income countries, but preterm birth, fetal death, infant respiratory infection and hospital admission may be increased. Thus, influenza is a major burden on health services. Immunisation is cost-effective, safe and effective in preventing influenza in pregnant women and their infants but policies and uptake vary worldwide. Operational challenges and concern over the safety, efficacy and necessity of immunisation are common, and there is a lack of evidence on how to overcome these barriers. This review identifies learning points that are relevant to the current coronavirus disease-2019 pandemic through describing the epidemiology and impact of seasonal and A(H1N1)pdm09 influenza in pregnancy, alongside the effectiveness and use of immunisation.

Inclusion of pregnant women in COVID-19 treatment trials: a review and global call to action

Inclusion of pregnant women in COVID-19 clinical trials would allow evaluation of effective therapies that might improve maternal health, pregnancy, and birth outcomes, and avoid the delay of developing treatment recommendations for pregnant women. We explored the inclusion of pregnant women in treatment trials of COVID-19 by reviewing ten international clinical trial registries at two timepoints in 2020. We identified 155 COVID-19 treatment studies of non-biological drugs for the April 7–10, 2020 timepoint, of which 124 (80%) specifically excluded pregnant women. The same registry search for the July 10–15, 2020 timepoint, yielded 722 treatment studies, of which 538 (75%) specifically excluded pregnant women. We then focused on studies that included at least one of six drugs (remdesivir, lopinavir–ritonavir, interferon beta, corticosteroids, chloroquine and hydroxychloroquine, and ivermectin) under evaluation for COVID-19. Of 176 such studies, 130 (74%) listed pregnancy as an exclusion criterion. Of 35 studies that evaluated high-dose vitamin treatment for COVID-19, 27 (77%) excluded pregnant women. Despite the surge in treatment studies for COVID-19, the proportion excluding pregnant women remains consistent. Exclusion was not well justified as many of the treatments being evaluated have no or low safety concerns during pregnancy. Inclusion of pregnant women in clinical treatment trials is urgently needed to identify effective COVID-19 treatment for this population.

Viral Pandemics of the Last Four Decades: Pathophysiology, Health Impacts and Perspectives

The twenty-first century has witnessed some of the deadliest viral pandemics with far-reaching consequences. These include the Human Immunodeficiency Virus (HIV) (1981), Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) (2002), Influenza A virus subtype H1N1 (A/H1N1) (2009), Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (2012) and Ebola virus (2013) and the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) (2019-present). Age- and gender-based characterizations suggest that SARS-CoV-2 resembles SARS-CoV and MERS-CoV with regard tohigher fatality rates in males, and in the older population with comorbidities. The invasion-mechanism of SARS-CoV-2 and SARS-CoV, involves binding of its spike protein with angiotensin-converting enzyme 2 (ACE2) receptors; MERS-CoV utilizes dipeptidyl peptidase 4 (DPP4), whereas H1N1 influenza is equipped with hemagglutinin protein. The viral infections-mediated immunomodulation, and progressive inflammatory state may affect the functions of several other organs. Although no effective commercial vaccine is available for any of the viruses, those against SARS-CoV-2 are being developed at an unprecedented speed. Until now, only Pfizer/BioNTech's vaccine has received temporary authorization from the UK Medicines and Healthcare products Regulatory Agency. Given the frequent emergence of viral pandemics in the 21st century, proper understanding of their characteristics and modes of action are essential to address the immediate and long-term health consequences.

COVID-19 and Women's Health: A Low- and Middle-Income Country Perspective

Corona Virus Disease (COVID-19), a contagious disease, is a global pandemic affecting the lives and health of individuals across borders, genders and races. Much of what is known about the effects of natural disasters and disease outbreaks on women's health in particular, is based on studies conducted in high-income countries. The evolving evidence suggests that COVID-19 has a profound negative impact on the perinatal mental health of women. It is also clear that global pandemics such as COVID-19 disproportionately affect the less affluent, including individuals living in low- and middle-income countries. The purpose of this review is to summarize and critically discuss extant knowledge on COVID-19 as it relates to the perinatal health of women in low and middle-income countries, using Pakistan as a case example. We specifically highlight the effects on perinatal mental health, preterm birth, and timing of the COVID-19 exposure. Our review suggests that it is essential to consider the effects of COVID-19 within this cultural context and that findings from high-income countries do not necessarily translate to the situation in low and middle-income countries.

Redesigning routine antenatal care in low resource setting during COVID-19 pandemic

Obstetric population because of its unique and varying needs specific for different gestations justifies for distinctive considerations in times of pandemic like COVID-19. Healthcare facilities providing obstetric care need to develop contingency plans for minimizing antenatal visits to limit exposure of both healthy pregnant women and care providers from ill people. However, to mitigate any potential adverse effects of reduced antenatal visits, intelligent and smart use of evolving telemedicine capabilities can provide the continuum of care despite overwhelming burden due to pandemic. A collaborative work-model involving health workers in the community and the regional levels of health centres also has the potential to prevent the catastrophic collapse of obstetric care services during any pandemic like COVID-19.

SARS-CoV-2 Infection and COVID-19 During Pregnancy: A Multidisciplinary Review

The global pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), has been associated with worse outcomes in several patient populations, including the elderly and those with chronic comorbidities. Data from previous pandemics and seasonal influenza suggest that pregnant women may be at increased risk for infection-associated morbidity and mortality. Physiologic changes in normal pregnancy and metabolic and vascular changes in high-risk pregnancies may affect the pathogenesis or exacerbate the clinical presentation of COVID-19. Specifically, SARS-CoV-2 enters the cell via the angiotensin-converting enzyme 2 (ACE2) receptor, which is upregulated in normal pregnancy. Upregulation of ACE2 mediates conversion of angiotensin II (vasoconstrictor) to angiotensin-(1-7) (vasodilator) and contributes to relatively low blood pressures, despite upregulation of other components of the renin-angiotensin-aldosterone system. As a result of higher ACE2 expression, pregnant women may be at elevated risk for complications from SARS-CoV-2 infection. Upon binding to ACE2, SARS-CoV-2 causes its downregulation, thus lowering angiotensin-(1-7) levels, which can mimic/worsen the vasoconstriction, inflammation, and pro-coagulopathic effects that occur in preeclampsia. Indeed, early reports suggest that, among other adverse outcomes, preeclampsia may be more common in pregnant women with COVID-19. Medical therapy, during pregnancy and breastfeeding, relies on medications with proven safety, but safety data are often missing for medications in the early stages of clinical trials. We summarize guidelines for medical/obstetric care and outline future directions for optimization of treatment and preventive strategies for pregnant patients with COVID-19 with the understanding that relevant data are limited and rapidly changing.

Factors that influence vaccination decision-making among pregnant women: A systematic review and meta-analysis

BACKGROUND

The most important factor influencing maternal vaccination uptake is healthcare professional (HCP) recommendation. However, where data are available, one-third of pregnant women remain unvaccinated despite receiving a recommendation. Therefore, it is essential to understand the significance of other factors and distinguish between vaccines administered routinely and during outbreaks. This is the first systematic review and meta-analysis (PROSPERO: CRD 42019118299) to examine the strength of the relationships between identified factors and maternal vaccination uptake.

METHODS

We searched MEDLINE, Embase Classic & Embase, PsycINFO, CINAHL Plus, Web of Science, IBSS, LILACS, AfricaWideInfo, IMEMR, and Global Health databases for studies reporting factors that influence maternal vaccination. We used random-effects models to calculate pooled odds ratios (OR) of being vaccinated by vaccine type.

FINDINGS

We screened 17,236 articles and identified 120 studies from 30 countries for inclusion. Of these, 49 studies were eligible for meta-analysis. The odds of receiving a pertussis or influenza vaccination were ten to twelve-times higher among pregnant women who received a recommendation from HCPs. During the 2009 influenza pandemic an HCP recommendation increased the odds of antenatal H1N1 vaccine uptake six times (OR 6.76, 95% CI 3.12-14.64, I2 = 92.00%). Believing there was potential for vaccine-induced harm had a negative influence on seasonal (OR 0.22, 95% CI 0.11-0.44 I2 = 84.00%) and pandemic influenza vaccine uptake (OR 0.16, 95% CI 0.09-0.29, I2 = 89.48%), reducing the odds of being vaccinated five-fold. Combined with our qualitative analysis the relationship between the belief in substantial disease risk and maternal seasonal and pandemic influenza vaccination uptake was limited.

CONCLUSIONS

The effect of an HCP recommendation during an outbreak, whilst still powerful, may be muted by other factors. This requires further research, particularly when vaccines are novel. Public health campaigns which centre on the protectiveness and safety of a maternal vaccine rather than disease threat alone may prove beneficial.

Clinical Manifestation and Neonatal Outcomes of Pregnant Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China

Background

Clinical manifestation and neonatal outcomes of pregnant women with coronavirus disease 2019 (COVID-19) were unclear in Wuhan, China.

Methods

We retrospectively analyzed clinical characteristics of pregnant and nonpregnant women with COVID-19 aged from 20 to 40, admitted between January 15 and March 15, 2020 at Union Hospital, Wuhan, and symptoms of pregnant women with COVID-19 and compared the clinical characteristics and symptoms to historic data previously reported for H1N1.

Results

Among 64 patients, 34 (53.13%) were pregnant, with higher proportion of exposure history (29.41% vs 6.67%) and more pulmonary infiltration on computed tomography test (50% vs 10%) compared to nonpregnant women. Of pregnant patients, 27 (79.41%) completed pregnancy, 5 (14.71%) had natural delivery, 18 (52.94%) had cesarean section, and 4 (11.76%) had abortion; 5 (14.71%) patients were asymptomatic. All 23 newborns had negative reverse-transcription polymerase chain results, and an average 1-minute Apgar score was 8-9 points. Pregnant and nonpregnant patients show differences in symptoms such as fever, expectoration, and fatigue and on laboratory tests such as neurophils, fibrinogen, D-dimer, and erythrocyte sedimentation rate. Pregnant patients with COVID-19 tend to have more milder symptoms than those with H1N1.

Conclusions

Clinical characteristics of pregnant patients with COVID-19 are less serious than nonpregnant. No evidence indicated that pregnant women may have fetal infection through vertical transmission of COVID-19. Pregnant patients with H1N1 had more serious condition than those with COVID-19.

Epidemiological and clinical profile of Influenza A(H1N1) pdm09 in Odisha, eastern India

Epidemic of flu is highly contagious and it spreads through air. In 2009 H1N1 influenza virus emerged after reassortment of North American TRIG and Eurasia Avian like virus of swine and started epidemic in Mexico. The first cases were reported from Hyderabad city on 16th May 2009 in India that spread rapidly within a short span of time. During this period large population of Odisha situated at the eastern side of India was also affected and incidences of H1N1 cases were recorded through state Government surveillance system. In this study real time RT-PCR based diagnosis was conducted for the throat swabs collected from suspected H1N1 cases in Odisha during 2009–2017. A total of 2872 throat swabs were received from 23 different Government and private hospitals and 21.1% positivity was confirmed. The disease affected mostly 46–60 years age group, males (50.6%) being more affected. The clinical features had shown that fever with cough (89.6%) was the most common symptom followed by shortness of breath (72.7%). Post monsoon was the peak season in which most of the cases were reported. Neurological signs, pregnancy, diabetes and hypertension were found to be risk factors for H1N1. The case fatality rate (CFR) was 15%.

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.

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.

Value of inventory information in allocating a limited supply of influenza vaccine during a pandemic

Objective

To understand the value of information on vaccine inventory levels during an influenza pandemic, we propose a simulation study to compare vaccine allocation strategies using: (i) only population information (pro-rata, or population-based, PB), (ii) both population and vaccine inventory information (population and inventory-based, PIB).

Methods

We adapt an agent-based simulation model to predict the spread of the disease both geographically and temporally. We study PB and PIB when uptake rates vary geographically. The simulation study is done from 2015 to 2017, using population and commuting data from the state of Georgia from the United States census.

Findings

Compared to PB under reasonable scenarios, PIB reduces the infection attack rate from 23.4% to 22.4%, decreases the amount of leftover inventory from 827 to 152 thousand, and maintains or increases the percentage of vaccinated population.

Conclusions

Our results indicate the need for greater vaccine inventory visibility in public health supply chains, especially when supply is limited, and uptake rates vary geographically. Such visibility has a potential to decrease the number of infections, help identify locations with low uptake rates and to motivate public awareness efforts.

Treatment of infections during pregnancy: Progress and challenges

BACKGROUND

Emergence of Zika virus as a pathogen with important implications for perinatal outcomes highlights the need to identify safe and effective strategies for prevention and treatment of maternal infections.

METHODS

While substantial progress has been made in this area in recent years, significant regulatory and health systems barriers must still be overcome to identify and deliver evidence-based drug therapies for pregnant women.

RESULTS

We review progress and outstanding challenges associated with the identification and implementation of new treatment options for maternal infections.

CONCLUSION

We describe several strategies in use to optimize the application of existing evidence.Birth Defects Research 109:387-390, 2017.© 2017 Wiley Periodicals, Inc.

Seropositivity of influenza A H1NI in mothers and infants following maternal vaccination with trivalent seasonal influenza vaccine after the 2009 pandemic

OBJECTIVE

To assess H1N1 antibody titers between vaccinated and nonvaccinated maternal and cord blood sera after the 2009 pandemic.

MATERIALS AND METHODS

Antibody titers were measured in maternal blood and cord sera from three groups of pregnant women in this prospective study. Group 1 comprised women who received a trivalent seasonal influenza vaccine before conception, Group 2 comprised women who received a single injection of monovalent H1N1 vaccine during pregnancy, and Group 3 comprised women who were nonvaccinated. A seropositive or seroprotective hemagglutination inhibition (HAI) assay was defined as titer ≥ 1:40.

RESULTS

In this study, 500 healthy women were enrolled, of which 44 women were in the trivalent seasonal influenza vaccine group, 41 women were in the monovalent vaccine group, and 415 women were in the nonvaccinated group. The seropositive HAI titers in the three groups of mothers were 48%, 78%, and 12%, respectively. The HAI titers in the vaccinated groups were significantly higher than those in the nonvaccinated group. The HAI titers of the cord blood samples of the three groups were comparable to their respective maternal samples.

CONCLUSION

Seroprotection after the 2009 HIN1 pandemic was generally low in pregnant women. Vaccination during pregnancy yielded best seropositivity, whereas receiving a trivalent seasonal influenza vaccine before conception can offer better seroprotection to mothers and newborns than no vaccination.

Impact of maternal respiratory infections on low birth weight - a community based longitudinal study in an urban setting in Pakistan

Background

The health of mothers and their newborns is intricately related. The weight of the infant at birth is a powerful predictor of infant growth and survival, and is considered to be partly dependent on maternal health and nutrition during pregnancy. We conducted a longitudinal study in an urban community within Karachi to determine maternal predictors of newborn birth weight.

Methods

Four hundred pregnant women were enrolled in the study during the period 2011–2013. Data related to symptoms of acute respiratory illness (fever, cough, difficulty breathing, runny nose, sore throat, headache, chills, and myalgia/lethargy) in the pregnant women were collected weekly until delivery. Birth weight of the newborn was recorded within 14 days of delivery and the weight of <2.5 kg was classified as low birth weight (LBW).

Results

A total of 9,853 symptom episodes were recorded of fever, cough, difficulty breathing, runny nose, sore throat, headache, chills, myalgias/lethargy in the enrolled pregnant women during the study. Out of 243 pregnant women whose newborns were weighed within 14 days of birth, LBW proportion was 21% (n = 53). On multivariate analysis, independent significant risk factors noted for delivering LBW babies were early pregnancy weight of < 57.5 kg [odds ratio adjusted (OR_adj) = 5.1, 95% CI: (1.3, 19.9)] and gestational age [OR_adj = 0.3, 95% CI (0.2, 0.7) for every one week increase in gestational age]. Among mothers with high socioeconomic status (SES), every 50-unit increase in the number of episodes of respiratory illness/100 weeks of pregnancy had a trend of association with an increased risk of delivering LBW infants [OR_adj = 1.7, 95% CI: (1.0, 3.1)]. However, among mothers belonging to low SES, there was no association of the number of episodes of maternal respiratory illness during pregnancy with infants having LBW [OR_adj = 0.9, 95% CI: (0.5, 3.5)].

Conclusions

While overall respiratory illnesses during pregnancy did not impact newborn weight in our study, we found this trend in the sub-group of mothers belonging to the higher SES. Whether this is because in mothers belonging to lower SES, the effects of respiratory illnesses were overshadowed by other risk factors associated with poverty need to be further studied.

A call for science preparedness for pregnant women during public health emergencies

Science preparedness, or the ability to conduct scientific research early in a public health emergency, is essential to increase the likelihood that important research questions regarding pregnant women will be addressed during future public health emergencies while the window of opportunity for data collection is open. Science preparedness should include formulation and human subject approval of generic protocols, which could be rapidly updated at the time of the public health emergency; development of a preexisting study network to coordinate time-sensitive research during a public health emergency; and identification of mechanisms for funding these studies.

Zika Virus Infection Among U.S. Pregnant Travelers - August 2015-February 2016

After reports of microcephaly and other adverse pregnancy outcomes in infants of mothers infected with Zika virus during pregnancy, CDC issued a travel alert on January 15, 2016, advising pregnant women to consider postponing travel to areas with active transmission of Zika virus. On January 19, CDC released interim guidelines for U.S. health care providers caring for pregnant women with travel to an affected area, and an update was released on February 5. As of February 17, CDC had received reports of nine pregnant travelers with laboratory-confirmed Zika virus disease; 10 additional reports of Zika virus disease among pregnant women are currently under investigation. No Zika virus-related hospitalizations or deaths among pregnant women were reported. Pregnancy outcomes among the nine confirmed cases included two early pregnancy losses, two elective terminations, and three live births (two apparently healthy infants and one infant with severe microcephaly); two pregnancies (approximately 18 weeks' and 34 weeks' gestation) are continuing without known complications. Confirmed cases of Zika virus infection were reported among women who had traveled to one or more of the following nine areas with ongoing local transmission of Zika virus: American Samoa, Brazil, El Salvador, Guatemala, Haiti, Honduras, Mexico, Puerto Rico, and Samoa. This report summarizes findings from the nine women with confirmed Zika virus infection during pregnancy, including case reports for four women with various clinical outcomes. U.S. health care providers caring for pregnant women with possible Zika virus exposure during pregnancy should follow CDC guidelines for patient evaluation and management. Zika virus disease is a nationally notifiable condition. CDC has developed a voluntary registry to collect information about U.S. pregnant women with confirmed Zika virus infection and their infants. Information about the registry is in preparation and will be available on the CDC website.

Pregnancy-Related Mortality Resulting From Influenza in the United States During the 2009-2010 Pandemic

OBJECTIVE

To estimate the burden of pregnancy-related mortality resulting from influenza A (H1N1)pdm09 virus infection during the 2009-2010 pandemic influenza season.

METHODS

Data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System were used to identify women whose death during or shortly after pregnancy was attributed or likely attributed to the influenza A (H1N1)pdm09 virus from April 15, 2009, through June 30, 2010. We report the characteristics of these women and enumerate cases resulting in death as the pandemic began, peaked, and resolved.

RESULTS

During the pandemic season, we identified 915 pregnancy-related deaths and 4,911,297 live births. Seventy-five (8.2%) women died as a result of confirmed influenza A (H1N1)pdm09 infection deaths and 34 (3.7%) women as a result of possible influenza A (H1N1)pdm09 infection deaths. The pregnancy-related mortality ratio for confirmed and possible (combined) influenza A (H1N1)pdm09 infection deaths was 2.2 per 100,000 live births. Most deaths occurred during the 2009 calendar year with the peak of the distribution of deaths over time occurring in October 2009.

CONCLUSION

Twelve percent of pregnancy-related deaths were attributed to confirmed or possible influenza A (H1N1)pdm09 infection during the 2009-2010 pandemic season. Because prediction of pandemics is difficult, planning for prevention of influenza and care for those women affected are critical for preventing associated severe maternal morbidity and mortality.

LEVEL OF EVIDENCE

III.

Demographic and clinical characteristics of deaths associated with influenza A(H1N1) pdm09 in Central America and Dominican Republic 2009-2010

BACKGROUND

The demographic characteristics of pandemic influenza decedents among middle and low-income tropical countries are poorly understood. We explored the demographics of persons who died with influenza A (H1N1)pdm09 infection during 2009-2010, in seven countries in the American tropics.

METHODS

We used hospital-based surveillance to identify laboratory-confirmed influenza deaths in Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and Dominican Republic. An influenza death was defined as a person who died within two weeks of a severe acute respiratory infection (SARI) defined as sudden onset of fever >38 °C, cough or sore-throat, and shortness of breath, or difficulty breathing requiring hospitalization, and who tested positive for influenza A (H1N1)pdm09 virus by real time polymerase chain reaction. We abstracted the demographic and clinical characteristics of the deceased from their medical records.

RESULTS

During May 2009-June 2010, we identified 183 influenza deaths. Their median age was 32 years (IQR 18-46 years). One-hundred and one (55 %) were female of which 20 (20 %) were pregnant and 7 (7 %) were in postpartum. One-hundred and twelve decedents (61 %) had pre-existing medical conditions, (15 % had obesity, 13 % diabetes, 11 % asthma, 8 % metabolic disorders, 5 % chronic obstructive pulmonary disease, and 10 % neurological disorders). 65 % received oseltamivir but only 5 % received it within 48 h of symptoms onset.

CONCLUSIONS

The pandemic killed young adults, pregnant women and those with pre-existing medical conditions. Most sought care too late to fully benefit from oseltamivir. We recommend countries review antiviral treatment policies for people at high risk of developing complications.

Pandemic influenza A (H1N1) infection in pregnant and nonpregnant women in Spain (2009-2010)

The present study aimed to compare the main features of infection with pandemic influenza A virus in pregnant and nonpregnant women admitted to hospitals in Spain during the first waves of the 2009-2010 influenza pandemic. This was a prospective (November 2009 to June 2010), multicenter observational study. All cases were women of reproductive age who had not been vaccinated against seasonal or pandemic influenza A. Influenza infection was confirmed by reverse transcription-polymerase chain reaction (RT-PCR). The sociodemographic and clinical data of all cases were reviewed. A total of 219 inpatients, including 49 pregnant women and 170 nonpregnant women, were enrolled in the study upon admission to participating hospitals. The most substantially different symptoms between the groups were respiratory distress and unilobar consolidation, both of which were more frequent among nonpregnant women. Antibiotics and systemic corticosteroids were more frequently used in nonpregnant women; however, there were no differences in the rates of treatment with antivirals. Our findings indicated that the compared with nonpregnant women, pregnant women in this study did not have significantly different symptoms and were not at increased risk of complications from pandemic influenza virus infection.

Vaccination during the 2013-2014 influenza season in pregnant Japanese women

This questionnaire survey was conducted at 11 hospitals in Japan to determine vaccination coverage against seasonal influenza and the prevalence rate of influenza among pregnant Japanese women. Of 2,808 postpartum women who gave birth at the 11 hospitals during the study period from March 1, 2014, to July 31, 2014, 1,713 (61 %) participated in this study and 876 (51 %) reported having received vaccination against influenza in or after October 2013. Women aged <25 years had a significantly lower vaccination rate than those aged ≥25 years (31 % vs. 53 %, respectively; p = 0.0000). Eighty-seven (5.1 %) and 1,626 (94.9 %) women did and did not contract influenza, respectively. Although prior birth did not affect overall vaccination coverage (50 % for primiparous vs. 53 % for multiparous), multiparous women had a significantly higher rate of contracting influenza than primiparous women, irrespective of vaccination status (5.6 % vs. 2.2 % [p = 0.0216] and 9.7 % vs. 3.5 % [p = 0.0003] for women with and without vaccination, respectively). The 2013-2014 vaccination program significantly reduced the influenza infection rate by 35 % (3.9 % vs. 6.3 % for women with and without vaccination, respectively; p = 0.0272). Seventy-two (83 %) of the 87 women took antiviral agents for the treatment of influenza and two (2.3 %) required hospitalization. These results suggested that pregnant Japanese women had a high level of concern regarding seasonal influenza. However, campaigns targeting young pregnant Japanese women, as well as multiparous women, for vaccination are needed in order to further reduce the incidence of influenza among pregnant Japanese women.

Influenza and its treatment during pregnancy: A review

The influenza viral infection has dramatic effects during pregnancy on the mother and the fetus. We present a review article on the prevention and treatment recommendations of influenza infection in pregnant women, and the effects of antiviral medications on maternal-fetal outcomes. This viral infection not only leads to miscarriages, preterm deliveries and a high maternal mortality rate, but it also poses negative risks to the fetus including small-for-gestational age infants, and admissions to neonatal intensive care units. Vaccination is the most effective strategy for preventing influenza infection during pregnancy whereby can protect both maternal and fetal immunities. The safety profiles of antiviral drugs during pregnancy are limited. Available risk-benefit evidence has indicated that pregnant women with suspected or confirmed influenza should receive prompt antiviral therapy where these medications reduce the risk of complications among pregnant women, and attenuate the teratogenic effects of the influenza infection. Post-exposure prophylaxis is not recommended for most pregnant women, but it may be prescribed in pandemic settings, particularly to non-vaccinated women. Although some ex vivo models for pharmacokinetic studies have revealed that the transplacental transfer of oseltamivir to fetal circuits may occur, there is no evidence of adverse fetal outcomes as a result of most in utero exposures to neuraminidase inhibitors. Due to the large number of confounding variables, large, population-based studies are needed to assess the association between in utero oseltamivir exposure and fetal outcome.

Prevention and management of influenza in pregnancy

Influenza infections are an important global source of morbidity and mortality. Pregnant and postpartum women are at increased risk for serious disease, related complications, and death from influenza infection. This increased risk is thought to be mostly caused by the altered physiologic and immunologic specifics of pregnancy. The morbidity of influenza infection during pregnancy is compounded by the potential for adverse obstetric, fetal, and neonatal outcomes. Importantly, influenza vaccination to prevent or minimize the severity of influenza infection during pregnancy (and the neonatal period) is recommended for all women who are or will be pregnant during influenza season.

General influenza infection control policies and practices during the 2009 H1N1 influenza pandemic: a survey of women's health, obstetric, and neonatal nurses

BACKGROUND

An evaluation of infection control practices was conducted following the release of the Centers for Disease Control and Prevention (CDC) guidance regarding the care of pregnant women during the 2009 H1N1 influenza pandemic. This paper describes 9 general hospital practices.

METHODS

A questionnaire was distributed electronically to 12,612 members of the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN). Respondents (N = 2,304) who reported working in obstetric or neonatal settings during the pandemic completed the questionnaire.

RESULTS

Most (73%) respondents considered the Centers for Disease Control and Prevention's guidance very useful. Significantly more reported a written hospital policy for each practice during versus before the pandemic. Six of the 9 practices were implemented most of the time by at least 70% of respondents; the practices least often implemented were mandatory vaccination of health care personnel involved (52%) and not involved (34%) in direct patient care and offering vaccination to close contacts of newborns prior to discharge (22%). The most consistent factor associated with implementation was the presence of a written policy supporting the practice at the respondent's hospital.

CONCLUSION

We offer a descriptive account of general hospital infection control policies and practices during the 2009 H1N1 pandemic. Factors associated with reported implementation may be useful to inform planning to protect women and children for future public health emergencies.

Seroprevalence of influenza A H1N1 and seroconversion of mothers and infants induced by a single dose of monovalent vaccine

OBJECTIVE

To determine the prevalence of preexisting antibodies against the pandemic 2009 Influenza A (H1N1) virus in pregnant women and to evaluate the seroprotection of the mothers and infants by a single injection of monovalent vaccine during the pandemic.

MATERIALS AND METHODS

Seropositivity rate of H1N1 among the nonvaccinated were compared with the vaccinated women. A single dose of vaccine, either nonadjuvanted AdimFlu-S or MF59-adjuvanted vaccine, was injected to the voluntarily vaccinated group. Maternal and cord blood sera were collected to evaluate the antibody response of the H1N1 virus. Seropositivity was defined as a hemagglutination inhibition titer to H1N1 (A/Taiwan/126/09) ≥ 1:40.

RESULTS

A total of 210 healthy, singleton, pregnant women were enrolled between January 2010 and May 2010. Seropositivity (≥ 1:40) of maternal hemagglutination inhibition was significantly higher in the vaccinated group (78%) than the nonvaccinated group (9.5%); 41.6% (20/48) of seropositive titers were >1:80. In nine vaccinated cases resulting in negative serum titers (<1:40), the prevalence of negative titer in the women received AdimFlu-S (14.8%, 4/31) was lower (p = 0.025) than those received MF59-adjuvanted vaccine (50%, 5/10).

CONCLUSIONS

Subclinical infection against H1N1 was low in Taiwanese pregnant women in the pandemic 2009. Seropositivity >75% could be achieved in the paired maternal and cord serum samples by a single injection of monovalent H1N1 vaccine.

Early prophylactic treatment in pregnant women during the 2009-2010 H1N1 pandemic: obstetric and neonatal outcomes

The aim of the study was to estimate the risk factors associated with the 2009 H1N1 influenza infection, during pregnancy; to describe complications and obstetric and perinatal outcomes of pregnancies during the H1N1 pandemic in 2009; to identify if there is teratogenicity at birth after antiviral treatment. Medical records of 168 pregnant women treated in Reina Sofia University Hospital (Cordoba, Spain) for suspected influenza A H1N1 from September 2009 to February 2010 were analysed. Using the PCR test, 76 pregnant women were diagnosed with H1N1 + infection, and infection was ruled out in the remaining 92. To manage the pandemic, recommendations of the Centres for Disease Control and Prevention were followed. Results showed that the majority of pregnant women were attended at the hospital between October and December 2009 (91.27%). Most of them were in the third-quarter of pregnancy (42.9%). In our sample, being aged between 29 and 37 years reduces the risk of acquiring infection (odds ratio, OR 0.379, 95% confidence interval, CI 0.188-0.763). However, in pregnant women who have required hospitalisation, the risk of infection increased five-fold (OR = 4.999; 95% CI = 1.178-21.212). No differences were found between obstetric and perinatal outcomes of both affected and unaffected or treated and untreated cohorts. No teratogenicity was observed at birth. It was concluded that maternal age and 3rd trimester pregnancy were found related to the risk of acquiring H1N1. No differences in obstetric outcomes or worse perinatal outcomes were found in patients affected by the pandemic. Early prophylactic treatment may be related to better maternal-fetal results.

Influenza infection control practices in labor and delivery units during the 2009 H1N1 influenza pandemic

OBJECTIVE

To assess the presence and usefulness of written policies and practices on infection control consistent with the Center for Disease Control and Prevention's (CDC) guidance in hospital labor and delivery (L&D) units during the 2009 H1N1 influenza pandemic.

SETTING

Online survey.

PARTICIPANTS

Of 11,845 eligible nurses, 2,641 (22%) participated. This analysis includes a subset of 1,866 nurses who worked exclusively in L&D units.

METHODS

A cross-sectional descriptive evaluation was sent to 12,612 members from the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) who reported working in labor, delivery, postpartum, or newborn care settings during the 2009 H1N1 influenza pandemic.

RESULTS

Respondents (73.8%) reported that CDC guidance was very useful for infection control in L&D settings during the pandemic. We assessed the presence of the following infection control written policies, consistent with CDC's guidance in hospital L&D units, during the 2009 H1N1 influenza pandemic and their rate of implementation most of the time: questioning women upon arrival about recent flu-like symptoms (89.4%, 89.9%), immediate initiation of antiviral medicines if flu suspected or confirmed (65.2%, 49%), isolating ill women from healthy women immediately (90.7%, 84.7%), ask ill women to wear masks during L&D (67%, 57.7%), immediately separating healthy newborns from ill mothers (50.9%, 42.4%), and bathing healthy infants when stable (58.4%, 56.9%). Reported written policies for five of the six practices increased during the pandemic. Five of six written policies remained above baseline after the pandemic.

CONCLUSIONS

Respondents considered CDC guidance very useful. The presence of written policies is important for the implementation of infection control practices by L&D nurses.

Postpartum and neonatal nursing care during the 2009 H1N1 influenza pandemic

We describe select influenza infection control policies and practices related to postpartum and newborn care during the 2009 H1N1 pandemic. In an online survey of obstetric and neonatal nurses, significantly more nurses indicated a written hospital policy supporting each of the practices during versus before the pandemic. The two practices least often implemented were temporary separation of healthy newborns from ill mothers (37.7 percent) and testing newborns for influenza virus infection if signs of influenza were observed (31.4 percent). Presence of written hospital policies increased implementation of practices. Findings may be useful to guide planning for future pandemics or other public health emergencies.

Vaccination rates for pandemic influenza among pregnant women: An early observation from Chennai, South India

Context:

World Health organization considers pregnancy as an important risk factor for severe illness due to pandemic influenza and recommends better vaccination coverage for them.

Aims:

This study was initiated to observe the vaccination rates among pregnant women in Chennai during 2 months following the availability of influenza vaccine in the region.

Settings and Design:

An urban community-based setting. Questionnaire-based observational study design.

Materials and Methods:

Pregnant women residing in Chennai selected by simple random sampling formed the study population. The study was conducted from 15^th to 30^th November 2010. Each pregnant woman was interviewed using a uniform questionnaire.

Statistical Analysis Used:

Characteristics between vaccinated and unvaccinated participants were compared using the Chi-square test or the Fisher exact test for categorical variables and Student's t-test or Mann-Whitney U test for continuous variables.

Results:

140 pregnant women were interviewed during the study period. The mean age of study participants was 25 years (range 21-35 years). 55% were less than 26 years of age and 65% were home makers. 32% had no basic school education. Of the 29 women with co-morbidities, 15 had gestational diabetes, 13 hypertension, 7 pre-eclampsia, and 7 had bronchial asthma. Fifty-eight had anemia diagnosed earlier or during current pregnancy. 32 (22.8%) were given advice to get vaccinated for pandemic influenza of which 18 (12.8%) received the vaccine.

Conclusions:

Observations on vaccination rates for pandemic influenza among pregnant women in Chennai, 2 months after the initiation of vaccination program is not encouraging.

Practices of obstetrician-gynecologists regarding nonvaccine-related public health recommendations during the 2009 H1N1 influenza pandemic

OBJECTIVE

We examined practices of obstetrician-gynecologists regarding nonvaccine-related public health recommendations during the 2009 H1N1 influenza pandemic.

STUDY DESIGN

From February to May 2010, a survey was sent to a random sample of members of the American College of Obstetricians and Gynecologists involved in obstetric care.

RESULTS

Obstetrician-gynecologists varied in their adherence to 2009 H1N1 influenza public health recommendations. Nearly all reported prescribing antiviral medications to pregnant women with suspected influenza. Most obstetrician-gynecologists reported using preventive practices in the outpatient setting to reduce exposure of well patients to ill ones. A wide range of responses was provided regarding postpartum infection control practices, suggesting lack of awareness of, disagreement with, or difficulty adhering to these recommendations.

CONCLUSION

Obstetrician-gynecologists reported that they adhered to some recommendations related to 2009 H1N1 influenza, but not to others. These data provide insight into strategies for development and dissemination of recommendations in a future pandemic.

Viral invasion of the amniotic cavity (VIAC) in the midtrimester of pregnancy

INTRODUCTION

The prevalence of viral infections in the amniotic fluid (AF) has not yet been ascertained. The aim of this study was to determine the prevalence of specific viral nucleic acids in the AF and its relationship to pregnancy outcome.

STUDY DESIGN

From a cohort of 847 consecutive women undergoing midtrimester amniocentesis, 729 cases were included in this study after exclusion of documented fetal anomalies, chromosomal abnormalities, unavailability of AF specimens and clinical outcomes. AF specimens were tested by quantitative real-time PCR for the presence of genome sequences of the following viruses: adenoviruses, herpes simplex virus (HSV), varicella zoster virus (VZV), human herpesvirus 6 (HHV6), human cytomegalovirus (HCMV), Epstein-Barr virus (EBV), parvovirus B19 and enteroviruses. Viral nucleic acid testing was also performed in maternal blood and cord blood in the population of women in whom AF was positive for viruses and in a control group of 29 women with AF negative for viral nucleic acids. The relationship between the presence of viruses and pregnancy and neonatal outcome was examined. The correlation between the presence of nucleic acids of viruses in the AF and the concentration of the cytokine interleukin-6 (IL-6) and the T cell chemokine CXCL-10 (or IP-10) in AF and maternal blood were analyzed.

RESULTS

Viral genome sequences were found in 16 of 729 (2.2%) AF samples. HHV6 was the most commonly detected virus (7 cases, 1.0%), followed by HCMV (6 cases, 0.8%), parvovirus B19 (2 cases, 0.3%) and EBV (1 case, 0.1%), while HSV, VZV, enteroviruses and adenoviruses were not found in this cohort. Corresponding viral DNA was also detected in maternal blood of six out of seven women with HHV6-positive AF and in the umbilical cord plasma, which was available in one case. In contrast, viral DNA was not detected in maternal blood of women with AF positive for parvovirus B19, HCMV, EBV or of women with AF negative for viruses. HHV6 genome copy number in AF and maternal blood was consistent with genomic integration of viral DNA and genetic infection in all women. There was no significant difference in the AF concentration of IL-6 and IP-10 between patients with and without VIAC. However, for HCMV, there was a significant relationship between viral copy number and IP-10 concentration in maternal blood and AF. The group of women with AF positive for viral DNA delivered at term healthy neonates without complications in 14 out of 16 cases. In one case of HHV6 infection in the AF, the patient developed gestational hypertension at term, and in another case of HHV6 infection in the AF, the patient delivered at 33 weeks after preterm premature rupture of membranes (PPROM).

CONCLUSION

Viral nucleic acids are detectable in 2.2% of AF samples obtained from asymptomatic women in the midtrimester. HHV6 was the most frequently detected virus in AF. Adenoviruses were not detected. Vertical transmission of HHV6 was demonstrated in one case.

Monitoring seasonal influenza vaccination coverage among pregnant women in the United States

This report describes surveillance systems used for assessing influenza vaccination coverage among pregnant women in the United States. Coverage estimates and factors associated with maternal vaccination are reviewed for internet panel surveys of pregnant women and the Pregnancy Risk Assessment Monitoring System (PRAMS); new estimates are reported from the Behavioral Risk Factor Surveillance System (BRFSS) and Internet panel surveys. Influenza vaccination coverage among pregnant women improved from 11% during the 2001-2002 influenza season to approximately 38% measured by BRFSS and 50% measured by Internet panel surveys during the 2010-2011 influenza season. Coverage varied by state, ranging from 26% to 68% among the states participating in PRAMS in 2009-2010. Provider recommendation increased a woman's likelihood of vaccination nearly 6-fold. Despite increases in influenza vaccination coverage among pregnant women, approximately half remain unvaccinated. Continued efforts are needed to ensure pregnant women receive recommendations and offers of vaccination from their health care providers.