Temporal trends and spatial clusters of high risk for maternal death due to COVID-19 pre and during COVID-19 vaccination in Brazil: a national population-based ecological study.

OBJECTIVE: This study comprehensively analyzed the temporal and spatial dynamics of COVID-19 cases and deaths within the obstetric population in Brazil, comparing the periods before and during mass COVID-19 vaccination. We explored the trends and geographical patterns of COVID-19 cases and maternal deaths over time. We also examined their correlation with the SARS-CoV-2 variant circulating and the social determinants of health. STUDY DESIGN: This is a nationwide population-based ecological study. METHODS: We obtained data on COVID-19 cases, deaths, socioeconomic status, and vulnerability information for Brazil's 5570 municipalities for both the pre-COVID-19 vaccination and COVID-19 vaccination periods. A Bayesian model was used to mitigate indicator fluctuations. The spatial correlation of maternal cases and fatalities with socioeconomic and vulnerability indicators was assessed using bivariate Moran. RESULTS: From March 2020 to June 2023, a total of 23,823 cases and 1991 maternal fatalities were recorded among pregnant and postpartum women. The temporal trends in maternal incidence and mortality rates fluctuated over the study period, largely influenced by widespread COVID-19 vaccination and the dominant SARS-CoV-2 variant. There was a significant reduction in maternal mortality due to COVID-19 following the introduction of vaccination. The geographical distribution of COVID-19 cases and maternal deaths exhibited marked heterogeneity in both periods, with distinct spatial clusters predominantly observed in the North, Northeast, and Central West regions. Municipalities with the highest Human Development Index reported the highest incidence rates, while those with the highest levels of social vulnerability exhibited elevated mortality and fatality rates. CONCLUSION: Despite the circulation of highly transmissible variants of concern, maternal mortality due to COVID-19 was significantly reduced following the mass vaccination. There was a heterogeneous distribution of cases and fatalities in both periods (before and during mass vaccination). Smaller municipalities and those grappling with social vulnerability issues experienced the highest rates of maternal mortality and fatalities.

Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021.

BACKGROUND: Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic. METHODS: The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic. FINDINGS: Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021. INTERPRETATION: Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades. FUNDING: Bill & Melinda Gates Foundation.

Perinatal outcomes and sinopharm BBIBP-CorV vaccination during pregnancy.

BACKGROUND: After the outbreak of COVID-19, a huge part of the health care services was dedicated to preventing and treating this disease. In case of COVID-19 infection, severe COVID-19 is reported more in pregnant individuals. Afterward, Vaccination against SARS-CoV-2 became a hot topic due to known effects in preventing severe COVID-19 during pregnancy. Vaccination of pregnant individuals started in August 2021 with the Sinopharm vaccine in Iran. The aim of current study was to determine the incidence of perinatal outcomes in women who were vaccinated during pregnancy. METHOD: This retrospective cohort study included 129,488 singleton births from March 21, 2021, until March 21, 2022, in Tehran, Iran. The data was obtained from the Iranian Maternal and Neonatal (IMaN) Network and the Maternal Vaccination Registry. Adverse perinatal outcomes investigated in this study include preterm birth, extremely preterm birth, low birth weight, very low birth weight, intrauterine growth restriction, stillbirth, neonatal intensive care unit admission, congenital anomaly, neonatal death and low 5-minute Apgar score. The risk of all perinatal outcomes was evaluated using multiple logistic regression. The analysis was done using STATA version 14. RESULTS: Of all 129,488 singleton births included in this study, 17,485 (13.5%) were vaccinated against SARS-CoV-2 (all with Sinopharm (BBIBP-CorV)). The exposure to the Sinopharm vaccine during pregnancy caused a significant decrease in the incidence of preterm birth (P =0.006, OR=0.91 [95% CI, 0.85 to 0.97]), extremely preterm birth (P =<0.001,OR=0.55 [95% CI, 0.45 to 0.66]), and stillbirth (P =<0.001, OR=0.60 [95% CI, 0.47 to 0.76]). Exposure to vaccination during the first trimester was associated with an increased risk of preterm birth (P =0.01, OR=1.27 [95% CI, 1.04 to 1.55]) Maternal vaccination during pregnancy was not associated with an increased risk of other adverse perinatal outcomes included in this study. CONCLUSION: The finding of this population-based study indicated no adverse pregnancy outcome due to vaccination with the Sinopharm vaccine during the second and third trimesters of pregnancy. Overall risk of adverse pregnancy outcomes were lower in the vaccinated individuals compared to the unvaccinated group. Also, vaccination during the first trimester was associated with an increased risk of preterm birth.

Case report: Complex evaluation of coagulation, fibrinolysis and inflammatory cytokines in a SARS-CoV-2 infected pregnant woman with fetal loss.

Background: SARS-CoV-2 infection during pregnancy increases the risk of severe obstetrical complications. Detailed evaluation of COVID-19-associated coagulopathy in a pregnancy with stillbirth hasn't been described so far. Besides knowledge gaps in the pathomechanism leading to stillbirth in COVID-19 pregnancies, currently, no prognostic biomarker is available to identify pregnant patients who are at imminent risk of COVID-19-associated maternal and fetal complications, requiring immediate medical attention. Case: Here we report the case of a 28-year-old SARS-CoV-2 infected pregnant patient, admitted to our hospital at 28 weeks of gestation with intrauterine fetal loss. The presence of SARS-CoV-2 placentitis was confirmed by immunohistological evaluation of the placenta. She had only mild upper respiratory symptoms and her vital signs were within reference throughout labor and postpartum. The stillborn infant was delivered per vias naturales. Fibrinogen concentrate was administered before and after labor due to markedly decreased fibrinogen levels (1.49 g/l) at admission and excessive bleeding during and after delivery. Although coagulation screening tests were not alarming at admission, the balance of hemostasis was strikingly distorted in the patient. As compared to healthy age- and gestational age-matched pregnant controls, increased D-dimer, low FVIII activity, low FXIII level, marked hypocoagulability as demonstrated by the thrombin generation assay, together with shortened clot lysis and decreased levels of fibrinolytic proteins were observed. These alterations most likely have contributed to the increased bleeding observed during labor and in the early postpartum period. Interestingly, at the same time, only moderately altered inflammatory cytokine levels were found at admission. Serum ACE2 activity did not differ in the patient from that of age- and gestational age-matched healthy controls, suggesting that despite previous speculations in the literature, ACE2 may not be used as a potential biomarker for the prediction of COVID-19 placentitis and threatening fetal loss in SARS-CoV-2-infected pregnancies. Conclusions: Although based on this case report no prognostic biomarker could be identified for use in pregnant patients with imminent risk of fetal loss associated with COVID-19 placentitis, the above-described hemostasis alterations warrant awareness of postpartum hemorrhagic complications and could be helpful to identify patients requiring intensified medical attention.

Factors associated with hospitalizations and deaths of pregnant women from Paraná due to COVID-19: a cross-sectional study.

OBJECTIVE: To analyze the factors associated with hospitalization in the ward and intensive care unit (ICU), and with death from COVID-19 in pregnant women with confirmed cases. METHODS: Observational, cross-sectional study, carried out with data from pregnant women with a confirmed case of COVID-19 from the Influenza Epidemiological Surveillance Information System and the Paraná's state COVID-19 notification system. The association between the independent and dependent variables (hospitalization in the ward and ICU, and death) was investigated using the Poisson regression model with robust variance. RESULTS: 4,719 pregnant women comprised the study population. 9.6 and 5.1% were hospitalized in wards and ICU, respectively. 1.9% died. There was an association between advanced maternal age and hospitalization in wards (PR=1.36; 95%CI 1.10-1.62) and ICU (PR=2.25; 95%CI 1.78-2.71), and death (PR=3.22; 95%CI 2.30-4.15). An association was found between the third trimester and hospitalization in wards (PR=5.06; 95%CI 2.82-7.30) and ICU (PR=6.03; 95%CI 3.67-8.39) and death (PR=13.56; 95%CI 2.90-24.23). The second trimester was associated with ICU admission (PR=2.67; 95%CI 1.36-3.99). Pregnant women with cardiovascular disease had a higher frequency of hospitalization in wards (PR=2.24; 95%CI 1.43-3.05) and ICU (PR=2.66; 95%CI 1.46-3.87). Obesity was associated with ICU admission (PR=3.79; 95%CI 2.71-4.86) and death (PR=5.62; 95%CI 2.41-8.83). CONCLUSIONS: Advanced maternal age, the end of the gestational period and comorbidities were associated with severe COVID-19.

Maternal COVID-19 infection and intrauterine fetal death: Impact on the placenta and fetus.

BACKGROUND: Placental damage due to viral infections increases risk of adverse perinatal outcomes. Histopathologic examination of placenta can provide information regarding association between infection and outcome. There is paucity of data describing placental pathology with respect to intrauterine fetal death (IUFD) in pregnant mothers affected with COVID-19. METHODS: 4 fetuses and 10 placentas, including one twin placenta from 9 women with history of IUFD and SARS-CoV-2 infection underwent evaluation. These findings were contrasted with 3 fetuses and 21 gestational age matched placentas from non-infected women with history of IUFD. RESULTS: Extensive gross placental lesions, mixture of histologic features (maternal/ fetal vascular malperfusion) and isolated cases of massive perivillous fibrin depositon and chronic intervillositis were observed in COVID-IUFD group. There were no distinguishing histologic findings when compared to control. Three fetuses showed signs of intraventricular/intraparenchymal hemorrhage in autopsy. CONCLUSION: These findings demonstrate that IUFD does not correspond with maternal symptoms and lacks distinctive lesion. However, there was significant placental damage which developed rapidly. These results show that SARS-CoV-2 infection results in rapid placental deterioration and fetal death. This information can be used to educate infected mothers and remind medical professionals, value of monitoring placental function especially following diagnosis of infection.

Incidence, Determinants, and Outcomes of Spontaneous Preterm Birth at Tertiary Hospitals in Enugu, Southeast, Nigeria: A Cross-Sectional Study.

BACKGROUND: In the past five years, observational evidence suggests that the rates and determinants of preterm birth may have changed due to the effect of the coronavirus disease 2019 (COVID-19) pandemic and other humanitarian crises in our environment. AIM: This study aimed to determine the incidence, associated factors, and outcomes of preterm birth in tertiary hospitals in Enugu, southeastern Nigeria. METHODS: This cross-sectional study included 238 pregnant women from the University of Nigeria Teaching Hospital (UNTH), Enugu State University of Science and Technology Teaching Hospital (ESUT-TH) Parklane, and Mother of Christ Specialist Hospital (MOCSH), Enugu, from April 2022 to March 2023. Eligible and consenting participants were recruited from 28-36 weeks +6 days of gestational age and followed up until delivery. Relevant outcome variables, such as sociodemographic characteristics, gestational age at delivery, and pregnancy outcomes, were recorded in a pro forma. These data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) statistics for Windows, version 22.0, Armonk, NY: IBM Corp. RESULTS: The incidence of preterm birth was 16.6% (37/223), with spontaneous preterm birth constituting 24 of 37 (64.5%) cases. The mean age of participants was 30.3 ± 4.8 years. Advanced maternal age (>35 years) (P = 0.01, adjusted odds ratio (AOR) =0.01, confidence interval (CI): 0.00-0.144), low socioeconomic status (P = 0.04, AOR = 0.40, CI: 0.11-1.46), and history of miscarriage (P = 0.02, AOR = 0.06, CI: 0.01-0.59) were the factors associated with spontaneous preterm birth. Neonatal death occurred in 21.6% (8/37) of cases within the first 24 hours. Rates of cesarean section and low birth weight were 73% (27/37) each. CONCLUSIONS: The incidence of preterm birth is high in Enugu, and associated factors were advanced maternal age, low socioeconomic status, and a history of miscarriage.

Description of maternal and neonatal adverse events in pregnant people immunised with COVID-19 vaccines during pregnancy in the CLAP NETWORK of sentinel sites. Nested case-control analysis of the immunization-associated risk: A study protocol.

INTRODUCTION: COVID-19 is associated with higher morbimortality in pregnant people compared with non-pregnant people. At present, the benefits of maternal immunisation are considered to outweigh the risks, and therefore, vaccination is recommended during pregnancy. However, additional information is needed on the safety of the vaccines in this population. METHODS AND ANALYSIS: This a retrospective cohort nested case-control study in pregnant people who attended maternity hospitals from eight Latin American and Caribbean countries. A perinatal electronic clinical history database with neonatal and obstetric information will be used. The proportion of pregnant people immunised with COVID-19 vaccines of the following maternal and neonatal events will be described: preterm infant, small for gestational age, low birth weight, stillbirth, neonatal death, congenital malformations, maternal near miss and maternal death. Moreover, the risk of prematurity, small for gestational age and low birth weight associated with exposure to COVID-19 vaccines will be estimated. Each case will be matched with two groups of three randomly selected controls. Controls will be matched by hospital and mother's age (±3 years) with an additional matching by delivery date and conception time in the first and second control groups, respectively. The estimated required sample size for the main analysis (exposure to any vaccine) concerning 'non-use' is at least 1009 cases (3027 controls) to detect an increased probability of vaccine-associated event risk of 30% and at least 650 cases (1950 controls) to detect 30% protection. Sensitivity and secondary analyses considering country, type of vaccine, exposure windows and completeness of immunisation will be reported. ETHICS: The study protocol was reviewed by the Ethical Review Committee on Research of the Pan American Health Organization. Patient informed consent was waived due to the retrospective design and the utilisation of anonymised data (Ref. No: PAHOERC.0546.01). Results will be disseminated in open access journals.

The mental health of Australians bereaved during the first two years of the COVID-19 pandemic: a latent class analysis.

BACKGROUND: The COVID-19 pandemic disrupted many areas of life, including culturally accepted practices at end-of-life care, funeral rites, and access to social, community, and professional support. This survey investigated the mental health outcomes of Australians bereaved during this time to determine how these factors might have impacted bereavement outcomes. METHODS: An online survey indexing pandemic and bereavement experiences, levels of grief, depression, anxiety, and health, work, and social impairment. Latent class analysis (LCA) was used to identify groups of individuals who shared similar symptom patterns. Multinomial regressions identified pandemic-related, loss-related, and sociodemographic correlates of class membership. RESULTS: 1911 Australian adults completed the survey. The LCA identified four classes: low symptoms (46.8%), grief (17.3%), depression/anxiety (17.7%), and grief/depression/anxiety (18.2%). The latter group reported the highest levels of health, work, and social impairment. The death of a child or partner and an inability to care for the deceased due to COVID-19 public health measures were correlated with grief symptoms (with or without depression and anxiety). Preparedness for the person's death and levels of pandemic-related loneliness and social isolation differentiated all four classes. Unemployment was associated with depression/anxiety (with or without grief). CONCLUSIONS: COVID-19 had profound impacts for the way we lived and died, with effects that are likely to ricochet through society into the foreseeable future. These lessons learned must inform policymakers and healthcare professionals to improve bereavement care and ensure preparedness during and following future predicted pandemics to prevent negative impacts.

Risk for Complicated Grief After the COVID-19 Death of a Marital Partner in Late Life.

OBJECTIVE: To identify 1) complicated grief symptom clusters among acutely-bereaved older adults who have lost a spouse to COVID-19 and 2) if spousal death due to COVID-19 increased risk of developing probable PGD METHODS: Eighty adults participating in a randomized controlled trial for depression prevention (mean age [± SD] = 70.4 [6.6]) completed the Inventory of Complicated Grief, every 3 months over a maximum of 15 months. Twenty-four percent (n = 19) of participants lost a spouse to COVID-19; 76% (n = 61) lost a spouse to other causes of death. Adjusted linear regression examined the associations between COVID-19 bereavement and six symptom clusters: yearning and preoccupation, anger and bitterness, shock and disbelief, estrangement from others, hallucinations, and behavior change. RESULTS: Compared to the non-COVID-19 group, the COVID-19 bereaved group reported greater shock and disbelief, hallucinations of the deceased, and estrangement from others. COVID-19 death was also associated with higher risk for probable prolonged grief disorder (PGD) at 12 months (odds ratio = 4.38, p = 0.027). CONCLUSIONS: Older adults who have lost a spouse to COVID-19 present with specific symptoms of distress and may eventually require clinical care for PGD.

SARS-CoV-2-Placental effects and association with stillbirth.

SARS-CoV-2 has had a significant impact on pregnancy outcomes due to the effects of the virus and the altered healthcare environment. Stillbirth has been relatively hidden during the COVID-19 pandemic, but a clear link between SARS-CoV-2 and poor fetal outcome emerged in the Alpha and Delta waves. A small minority of women/birthing people who contracted COVID-19 developed SARS-CoV-2 placentitis. In many reported cases this was linked to intrauterine fetal death, although there are cases of delivery just before imminent fetal demise and we shall discuss how some cases are sub-clinical. What is surprising, is that SARS-CoV-2 placentitis is often not associated with severe maternal COVID-19 infection and this makes it difficult to predict. The worst outcomes seem to be with diffuse placental disease which occurs within 21 days of COVID-19 diagnosis. Poor outcomes are often pre-dated by reduced fetal movements but are not associated with ultrasound changes. In some cases, there has also been maternal thrombocytopenia, or coagulation abnormalities, which may provide a clue as to which pregnancies are at risk of fetal demise if a further variant of concern is to emerge. In future, multidisciplinary collaboration and cross-boundary working must be prioritised, to identify quickly such a phenomenon and provide clinicians with clear guidance for reducing fetal death and associated poor outcomes. While we wait to see if COVID-19 brings a future variant of concern, we must focus on appropriate future management of women who have had SARS-CoV-2 placentitis. As a placental condition with an infectious aetiology, SARS-CoV-placentitis is unlikely to recur in a subsequent pregnancy and thus a measured approach to subsequent pregnancy management is needed.

Factors associated with hospitalizations and deaths of pregnant women from Paraná due to COVID-19: a cross-sectional study / Fatores associados a hospitalizações e óbitos de gestantes paranaenses por COVID-19: estudo transversal

ABSTRACT Objective: To analyze the factors associated with hospitalization in the ward and intensive care unit (ICU), and with death from COVID-19 in pregnant women with confirmed cases. Methods: Observational, cross-sectional study, carried out with data from pregnant women with a confirmed case of COVID-19 from the Influenza Epidemiological Surveillance Information System and the Paraná's state COVID-19 notification system. The association between the independent and dependent variables (hospitalization in the ward and ICU, and death) was investigated using the Poisson regression model with robust variance. Results: 4,719 pregnant women comprised the study population. 9.6 and 5.1% were hospitalized in wards and ICU, respectively. 1.9% died. There was an association between advanced maternal age and hospitalization in wards (PR=1.36; 95%CI 1.10-1.62) and ICU (PR=2.25; 95%CI 1.78-2.71), and death (PR=3.22; 95%CI 2.30-4.15). An association was found between the third trimester and hospitalization in wards (PR=5.06; 95%CI 2.82-7.30) and ICU (PR=6.03; 95%CI 3.67-8.39) and death (PR=13.56; 95%CI 2.90-24.23). The second trimester was associated with ICU admission (PR=2.67; 95%CI 1.36-3.99). Pregnant women with cardiovascular disease had a higher frequency of hospitalization in wards (PR=2.24; 95%CI 1.43-3.05) and ICU (PR=2.66; 95%CI 1.46-3.87). Obesity was associated with ICU admission (PR=3.79; 95%CI 2.71-4.86) and death (PR=5.62; 95%CI 2.41-8.83). Conclusions: Advanced maternal age, the end of the gestational period and comorbidities were associated with severe COVID-19.

RESUMO Objetivo: Analisar os fatores associados à hospitalização em enfermaria e unidade de terapia intensiva (UTI), e ao óbito pela COVID-19 em gestantes com caso confirmado. Métodos: Pesquisa observacional, transversal, realizada com dados de gestantes com caso confirmado para COVID-19 provenientes do Sistema de Informação de Vigilância Epidemiológica da Gripe e do Sistema Estadual Notifica COVID-19, do Paraná. Investigou-se a associação entre variáveis independentes e dependentes (hospitalização em enfermaria e UTI, e óbito) pelo modelo de regressão de Poisson com variância robusta. Resultados: 4.719 gestantes compuseram a população do estudo; 9,6 e 5,1% foram hospitalizadas em enfermaria e UTI, respectivamente; 1,9% evoluíram para óbito. Houve associação entre a idade materna avançada e internação em enfermaria (RP=1,36; IC95% 1,10-1,62) e UTI (RP=2,25; IC95% 1,78-2,71), e óbito (RP=3,22; IC95% 2,30-4,15). Verificou-se associação entre o terceiro trimestre gestacional e hospitalização em enfermaria (RP=5,06; IC95% 2,82-7,30) e UTI (RP=6,03; IC95% 3,67-8,39) e óbito (RP=13,56; IC95% 2,90-24,23). O segundo trimestre associou-se à internação em UTI (RP=2,67; IC95% 1,36-3,99). Gestantes com cardiopatia apresentaram maior frequência de hospitalização em enfermaria (RP=2,24; IC95% 1,43-3,05) e UTI (RP=2,66; IC95% 1,46-3,87). A obesidade foi associada à admissão em UTI (RP=3,79; IC95% 2,71-4,86) e ao óbito (RP=5,62; IC95% 2,41-8,83). Conclusão: A idade materna avançada, o final do período gestacional e comorbidades foram fatores associados a quadros graves de COVID-19.

Pre-Delta, Delta, and Omicron Periods of the Coronavirus Disease 2019 (COVID-19) Pandemic and Health Outcomes During Delivery Hospitalization.

OBJECTIVE: To examine the relationship between coronavirus disease 2019 (COVID-19) diagnosis at delivery and adverse maternal health and pregnancy outcomes during pre-Delta, Delta, and Omicron variant predominance, with a focus on the time period of Omicron variant predominance. METHODS: We conducted a cross-sectional observational study with data from delivery hospitalizations in the Premier Healthcare Database from February 2020 to August 2023. The pre-Delta (February 2020-June 2021), Delta (July 2021-December 2021), and Omicron (January 2022-August 2023) periods of variant predominance were examined. Exposure to COVID-19 was identified by having a diagnostic code for COVID-19 during the delivery hospitalization. Adjusted prevalence ratios (aPRs) were calculated to compare the risks of adverse maternal and pregnancy outcomes for women with and without COVID-19 diagnoses at the time of delivery for each variant period. RESULTS: Among 2,990,973 women with delivery hospitalizations, 1.9% (n=56,618) had COVID-19 diagnoses noted at delivery admission discharge, including 26,053 during the Omicron period. Across all variant time periods, the prevalence of many adverse maternal and pregnancy outcomes during the delivery hospitalization was significantly higher for pregnant women with COVID-19 compared with pregnant women without COVID-19. In adjusted models, COVID-19 during the Omicron period was associated with significant increased risks for maternal sepsis (COVID-19: 0.4% vs no COVID-19: 0.1%; aPR 3.32, 95% CI, 2.70-4.08), acute respiratory distress syndrome (0.6% vs 0.1%; aPR 6.19, 95% CI, 5.26-7.29), shock (0.2% vs 0.1%; aPR 2.14, 95% CI, 1.62-2.84), renal failure (0.5% vs 0.2%; aPR 2.08, 95% CI, 1.73-2.49), intensive care unit admission (2.7% vs 1.7%; aPR 1.64, 95% CI, 1.52-1.77), mechanical ventilation (0.3% vs 0.1%; aPR 3.15, 95% CI, 2.52-3.93), in-hospital death (0.03% vs 0.01%; aPR 5.00, 95% CI, 2.30-10.90), stillbirth (0.7% vs 0.6%; aPR 1.17, 95% CI, 1.01-1.36), and preterm delivery (12.3% vs 9.6%; aPR 1.28, 95% CI, 1.24-1.33). CONCLUSION: Despite the possibility of some level of immunity due to previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, vaccination, or testing differences, risks of adverse outcomes associated with COVID-19 diagnosis at delivery remained elevated during the Omicron variant time period.

Association Between COVID-19 During Pregnancy and Preterm Birth by Trimester of Infection: A Retrospective Cohort Study Using Longitudinal Social Media Data.

Background: Preterm birth, defined as birth at <37 weeks of gestation, is the leading cause of neonatal death globally and, together with low birthweight, the second leading cause of infant mortality in the United States. There is mounting evidence that COVID-19 infection during pregnancy is associated with an increased risk of preterm birth; however, data remain limited by trimester of infection. The ability to study COVID-19 infection during the earlier stages of pregnancy has been limited by available sources of data. The objective of this study was to use self-reports in large-scale, longitudinal social media data to assess the association between trimester of COVID-19 infection and preterm birth. Methods: In this retrospective cohort study, we used natural language processing and machine learning, followed by manual validation, to identify pregnant Twitter users and to search their longitudinal collection of publicly available tweets for reports of COVID-19 infection during pregnancy and, subsequently, a preterm birth or term birth (i.e., a gestational age ≥37 weeks) outcome. Among the users who reported their pregnancy on Twitter, we also identified a 1:1 age-matched control group, consisting of users with a due date prior to January 1, 2020-that is, without COVID-19 infection during pregnancy. We calculated the odds ratios (ORs) with 95% confidence intervals (CIs) to compare the overall rates of preterm birth for pregnancies with and without COVID-19 infection and by timing of infection: first trimester (weeks 1-13), second trimester (weeks 1427), or third trimester (weeks 28-36). Results: Through August 2022, we identified 298 Twitter users who reported COVID-19 infection during pregnancy, a preterm birth or term birth outcome, and maternal age: 94 (31.5%) with first-trimester infection, 110 (36.9%) second-trimester infection, and 95 (31.9%) third-trimester infection. In total, 26 (8.8%) of these 298 users reported preterm birth: 8 (8.5%) were infected during the first trimester, 7 (6.4%) were infected during the second trimester, and 12 (12.6%) were infected during the third trimester. In the 1:1 age-matched control group, 13 (4.4%) of the 298 users reported preterm birth. Overall, the risk of preterm birth was significantly higher for pregnancies with COVID-19 infection compared to those without (OR 2.1, 95% CI 1.06-4.16). In particular, the risk of preterm birth was significantly higher for pregnancies with COVID-19 infection during the third trimester (OR 3.17, CI 1.39-7.21). Conclusion: The results of our study suggest that COVID-19 infection particularly during the third trimester is associated with an increased risk of preterm birth.

Deaths: Leading Causes for 2020.

Objectives-This report presents final 2020 data on the 10 leading causes of death in the United States by age, race and Hispanic origin, and sex. Leading causes of infant, neonatal, and postneonatal death are also presented. This report supplements "Deaths: Final Data for 2020," the National Center for Health Statistics' annual report of final mortality statistics. Methods-Data in this report are based on information from all death certificates filed in the 50 states and the District of Columbia in 2020. Causes of death classified by the International Classification of Diseases, 10th Revision (ICD-10) are ranked according to the number of deaths. Cause-of-death statistics are based on the underlying cause of death. Race and Hispanicorigin data are based on the Office of Management and Budget's 1997 standards for reporting race and Hispanic origin. Results-In 2020, many of the 10 leading causes of death changed rank order due to the emergence of COVID-19 as a leading cause of death in the United States. The 10 leading causes of death in 2020 were, in rank order: Diseases of heart; Malignant neoplasms; COVID-19; Accidents (unintentional injuries); Cerebrovascular diseases; Chronic lower respiratory diseases; Alzheimer disease; Diabetes mellitus; Influenza and pneumonia; and Nephritis, nephrotic syndrome and nephrosis. They accounted for 74.1% of all deaths occurring in the United States. Differences in the rankings are evident by age, race and Hispanic origin, and sex. Leading causes of infant death for 2020 were, in rank order: Congenital malformations, deformations and chromosomal abnormalities; Disorders related to short gestation and low birth weight, not elsewhere classified; Sudden infant death syndrome; Accidents (unintentional injuries); Newborn affected by maternal complications of pregnancy; Newborn affected by complications of placenta, cord and membranes; Bacterial sepsis of newborn; Respiratory distress of newborn; Diseases of the circulatory system; and Neonatal hemorrhage.

Review of short-term and long-term adverse effects of covid-19 vaccination during pregnancy.

BACKGROUND: The covid-19 pandemic sparked a debate about the safety of vaccines during pregnancy. However, pregnant women were excluded from the Pfizer-BioNTech vaccine phase 3 trials. As two years have passed since the first Covid-19 vaccine and more studies have been conducted, we want to evaluate the scientific literature to determine any actual risks in taking the vaccine during pregnancy. METHODS: We conducted literature research using PubMed and Google Scholar databases from January to April 2023. As the review considers short- and long-term adverse effects it was divided into two parts. The first part was conducted as a systematic review. The second concerning long-term negative effects due to lack of research is a literature review. The inclusion criteria for the systematic review part were singleton pregnancies, women vaccinated during pregnancy, and studies from 2020 and later. The most common short-term pregnancy adverse effects were included in the search: preterm delivery, small gestation age, intrauterine death, congenital defects, stillborn, fetal growth retardation, spontaneous abortion. Maternal immune activation was the primary concern for the long-term adverse effects and whether vaccination could cause it. The search terms included maternal immune activation, fetal neurodevelopment, neuropsychiatric disorders and the studies used were from 2019. RESULTS: Most studies showed no significant difference in short-term adverse effects between vaccinated and non-vaccinated women and their fetuses. However, the literature is insufficient to evaluate possible long-term adverse effects. CONCLUSION: Available evidence supports the safety of administering SARS-CoV-2 vaccines to pregnant women, but further systematic reviews and meta-analyses are essential. Maternal immune activation caused by vaccination may impact a child's neurodevelopment and should be a concern for future studies.

Inactivated COVID-19 vaccines in peri-pregnancy period: Evaluation of safety for both pregnant women and neonates.

BACKGROUND: Pregnant women have been excluded from vaccination of COVID-19 due to the lack of strong clinical evidence, which may place pregnant women at greater risk of contracting COVID-19. We conducted this study in China to investigate the maternal and neonatal safety of inactivated COVID-19 vaccination administered during the peri-pregnancy period. METHODS: This prospective observational cohort study enrolled pregnant women who received pregnancy care between January 1, 2021, and December 31, 2021. Pregnant women were categorized into vaccine group (n = 60) and control group (n = 60) based on whether they had received an inactivated COVID-19 vaccine within peri-pregnancy period. The primary outcomes were the incidence of maternal premature rupture of membranes (PROM) and neonatal adverse events, including induced labor/death, premature birth, low birth weight, and neonatal intensive care unit (NICU) admission and several secondary outcomes related to pregnant women and neonates. Inverse probability treatment weighting (IPTW) was employed to adjust for baseline covariates. Linear and logistic regression models were established after IPTW for continuous and binary outcomes, respectively. In sensitivity analysis, E-values were calculated and propensity score matching analysis and multivariate regression analysis used to demonstrate the robustness of IPTW results. Moreover, vaccination time subgroup analysis and medication subgroup analysis were conducted. RESULTS: Out of 120 neonates delivered, there was no significant difference in PROM (25.42 % vs. 19.67 %, p = 0.438) or neonatal adverse events (11.86 % vs. 4.92 %, p = 0.148) between the vaccine and control groups. Moreover, among the secondary outcomes only serum alanine transaminase (ALT) at first trimester had a statistically significant difference between the groups, ALT levels were significantly higher in the vaccine group during the first trimester (20.67 ± 20.34 vs. 13.05 ± 9.43; RR: 5.38; p = 0.04). In sensitivity analysis, the E-values calculated for the primary outcomes PROM and neonatal adverse events are 2.04 and 5.00 respectively. PSM analysis and multivariate regression analysis reached the same conclusion. The results of primary outcomes are both consistent across the vaccination time subgroup and medication subgroup. CONCLUSION: The sensitivity analysis illustrates the robustness of our results, so we can conclude that the vaccination of inactivated COVID-19 vaccine during the peri-pregnancy period is safe for both the pregnant woman and neonates no matter what time of vaccination and the use of medication. In addition, it is recommended to monitor ALT levels throughout the first trimester of pregnancy.

Postpartum Depression Among Mothers of Infants Hospitalized in the Neonatal Intensive Care Unit During the COVID-19 Pandemic.

Background Neonatal intensive care unit (NICU) hospitalization of newborn babies has been shown to have a negative impact on the mental health of postpartum women. The mental health of new mothers may be further burdened by the effects of the coronavirus disease 2019 (COVID-19) pandemic on social, economic, and psychological dimensions. This study aimed to evaluate postpartum depression and related factors in mothers of infants hospitalized in NICU during two distinct COVID-19 pandemic periods and examine any additional effects of the pandemic on the mental health of postpartum women. Methodology The Edinburgh Postpartum Depression Scale (EPDS) was applied to 250 NICU mothers during the COVID-19 pandemic. The first 125 women's children were hospitalized during a period of high number of cases and deaths when restrictions were in place for NICU parental visits (November 2021 to February 2022, the early group). The remaining 125 women completed the scale when there was a lower number of cases and restrictions had been eased (March to June 2022, the late group). Results In the early group, the EPDS scores were statistically higher (7.53.9 vs. 5.63.4; p < 0.001), smoking and NICU stay duration were significantly higher (p = 0.01), whereas the duration of marriage was significantly lower (p = 0.01). Women in the late group with EPDS scores ≥13 were statistically less educated (p = 0.01). EPDS scores ≥13 were significantly associated with depression during pregnancy and with a history of abortion/stillbirth/neonatal death (odds ratio (OR) = 5.240, 95% confidence interval (CI) 1.114 to 27.967, p = 0.03 and OR = 1.641, 95% CI = 1.009 to 2.669, p = 0.04, respectively). Conclusions NICU admission is a significant maternal risk factor for postpartum depression due to the disruption of maternal-infant bonding, and this risk may be exacerbated during times of global public health crises such as the COVID-19 pandemic. Depression during pregnancy and the presence of a perinatal loss may also contribute to worse postpartum mental outcomes in NICU mothers.

Educational Attainment and US Drug Overdose Deaths.

Importance: Educational attainment in the US is associated with life expectancy. As the opioid crisis worsens, it is critical to understand how overdose death rate trends evolve across education groups. Objective: To investigate the association between educational attainment and overdose death rates, with emphasis on trends during the COVID-19 pandemic. Design, Setting, and Participants: This cross-sectional study used National Vital Statistics System Mortality Multiple Cause-of-Death data describing overdose death rates in the US by educational attainment from January 1, 2000, to December 31, 2021, with a focus on 2018 to 2021. Overdose deaths were aggregated by year and educational level for decedents aged 25 years or older. Exposure: Educational attainment, categorized as no high school (HS) diploma, HS diploma (or General Educational Development) but no college, some college but no bachelor's degree, and bachelor's degree or more. Main Outcomes and Measures: The main outcomes were rates of all overdose deaths, overdose deaths involving opioids, and overdose deaths involving synthetic opioids. Results: Of 912 057 overdose deaths with education information from 2000 to 2021 (mean [SD] age at death, 44.9 [12.3] years; 64.1% male), there were 625 400 deaths (68.6%) among individuals with no college education and 286 657 deaths (31.4%) among those with at least some college. The overdose death rate was 19.9 per 100 000 population. From 2018 to 2021, there were 301 557 overdose deaths, including 58 319 (19.3%) among individuals without an HS diploma, 153 603 (50.9%) among people with an HS diploma, 64 682 (21.4%) among individuals with some college, and 24 953 (8.3%) among individuals with a bachelor's degree. There were 3324 overdose deaths (1.1%) among American Indian or Alaska Native individuals, 2968 (1.0%) among Asian American or Pacific Islander individuals, 49 152 (16.3%) among Black individuals, 31 703 (10.5%) among Hispanic individuals, 211 359 (70.1%) among White individuals, and 3051 (1.0%) among multiracial individuals. From 2018 to 2021, the overdose death rate was 33.4 per 100 000 population, the opioid-related overdose death rate was 24.2 per 100 000 population, and the synthetic opioid overdose death rate was 19.1 per 100 000 population. From 2018 to 2021, the overdose death rate for those without a HS diploma increased by 35.4 per 100 000 population compared with 1.5 per 100 000 population for those with a bachelor's degree. This differential growth was primarily due to increased rates of death involving synthetic opioids. Conclusions and Relevance: In this cross-sectional study, lower educational attainment was found to be associated with higher growth in overdose deaths. As the opioid crisis has transitioned to fentanyl and polysubstance use, overdose deaths have become more prevalent in groups with lower socioeconomic status, potentially exacerbating existing life-expectancy disparities.

Anti-Black racism and maternal death from COVID-19: what have we seen in the Pandemic? / Racismo antinegro e morte materna por COVID-19: o que vimos na Pandemia?

Anti-Black Racism traverses the lives of Black and Brown women, compromising sexual and reproductive health. Obstetric racism during pregnancy, prenatal care, childbirth, abortion, and puerperium affects these women, exposing them to harmful and often lethal maternal outcomes. This study aims to present racism and its manifestations in maternal death by COVID-19. It included data from COVID-19 notifications among pregnant women and puerperae recorded in the severe acute respiratory syndrome database (2021 and 2022). Information on race/skin color, age, region, clinical signs and symptoms, ICU, and deaths were collected. The results indicate how racism affects Black and Brown pregnant women and puerperae, who have higher lethality due to COVID-19 compared to White women (a difference of 14.02%), particularly in the puerperium. Black and Brown pregnant women least accessed the ICU. After adjustments, maternal death in the puerperium for Black women was 62% more likely than for White women (OR=1.62; 95%CI: 1.01-2.63). Racism and its manifestations (dis)organize the reproductive trajectories of Black and Brown women, whose interaction with sexism contributes to harmful and lethal maternal outcomes by COVID-19.

O racismo antinegro atravessa a vida das mulheres pretas e pardas comprometendo a saúde sexual e reprodutiva. O racismo obstétrico que ocorre durante a gravidez, pré-natal, parto, aborto e puerpério atinge estas mulheres expondo-as à desfechos maternos negativos e muitas vezes letais. Este estudo objetiva apresentar o racismo e suas manifestações na morte materna por COVID-19. Estudo transversal, com dados das notificações de COVID-19 entre gestantes e puérperas registradas na base de dados da Síndrome Respiratória Aguda Grave (2021 e 2022). Foram coletadas informações sobre raça/cor, idade, região, sinais e sintomas clínicos, UTI e óbitos. Os resultados apontam como o racismo afeta as gestantes e puérperas pretas e pardas, que apresentam maior letalidade por COVID-19 comparada às brancas (diferença que alcança os 14,02%), em particular no puerpério. Gestantes pretas e pardas são as que menos acessaram UTI. Após ajustes, a chance de óbito materno no puerpério para as mulheres pretas foi 62% maior em comparação as brancas (RC=1,62; 95%IC: 1,01-2,63). O racismo e suas manifestações (des)organizam as trajetórias reprodutivas das mulheres pretas e pardas que na sua interação com o sexismo contribuem para desfechos maternos negativos e letais por COVID-19.