Reviewed by Rebekah Moehring, MD, MPH, FSHEA, Duke University Hospital, and James “Brad” Cutrell. MD, FIDSA, UT Southwestern Medical Center
As the US passed the 200,000 COVID-19 related deaths threshold, several MMWR articles highlight special populations who may get overlooked when discussing pandemic impact: pediatrics and pregnant women. Despite a lower mortality rates in these populations compared to older adults, we are reminded that this virus can still be cause severe health complications in populations felt to be at “lower” risk.
MMWR investigators described a total of 121 deaths in individuals aged <21 from February to July 2020 among 391,814 cases of confirmed or probable COVID-19 or multisystem inflammatory syndrome in children (MIS-C) through US case-based surveillance. There were 120 (99%) deaths in confirmed or probable COVID-19, 15 (12%) deaths in MIS-C, and 14 (12%) who met both case definitions. Twelve (10%) deaths occurred in infants aged <1 year, 24 (20%) in aged 1–9, and 85 (70%) aged 10–20 years, with a median age at death of 16 years (IQR 7–19.) While 30 (25%) were previously healthy, 91 (75%) had at least one underlying medical condition, and 54 (45%) had two or more underlying medical conditions including pulmonary, obesity, neurologic, and cardiovascular diseases, most commonly. Among 94 with known illness onset, median interval from symptom onset until death was 11 days (IQR = 6–24 days). As in other reports, there were obvious racial disparities observed among young people that died: Hispanic, Black, and Native American accounted for approximately 75% of deaths. Using case-based surveillance likely underestimates COVID-19 deaths due to incomplete reporting. These observations warrant discussion during school reopening planning since the fatality rate among children is not zero.
Two MMWR reports reported COVID-19 outcomes in pregnancy. First, investigators accessed data from the Vaccine Surveillance Datalink (VSD) from March to May 2020 at 8 US healthcare centers to identify 105 (2.4%) hospitalized pregnant women with COVID-19 out of 4,408 persons hospitalized at VSD sites. Notably, 43 (41%) of COVID-19 positive pregnant women were hospitalized for COVID-19 while 62 (59%) were hospitalized for obstetric reasons. Of the latter group, most (50, 81%) were asymptomatic. For those admitted due to COVID-19 illness, 13 (30%) required ICU admission, 6 (14%) required mechanical ventilation, and one death reported. Pre-pregnancy obesity and gestational diabetes were more prevalent in those hospitalized due to COVID-19 compared to those hospitalized for obstetric indications. Preterm delivery and stillbirths were 1.7- and 5.3-foldhigher, respectively, in COVID-19 infected pregnant women than the baseline rate in the VSD cohort over this period.
Second, COVID-NET, which covers 13 US states, reported 598 hospitalized pregnant women with COVID-19 between March and August 22, 2020, representing about a quarter of hospitalized women aged 15-49 with COVID-19 in this network. Of the 272 (45.5%) pregnant women admitted with symptomatic COVID-19, 16.2% required ICU admission, 8.5% required mechanical ventilation, and two deaths were reported. Of women who completed their pregnancy prior to discharge (n=458), there were 56 (12.2%) with preterm delivery and 10 (2.2%) who experienced pregnancy loss. The proportion of hospitalized pregnant women with COVID-19 who were Hispanic (42.5%) and Black (26.5%) was higher than the general COVID-NET catchment population (15.3% and 19.5%, respectively). Limitations of both studies include small sample size, incomplete chart data abstraction, varied COVID-19 screening practices of asymptomatic pregnant women at different sites, and limited data on other comorbidities or risk factors for severe disease or negative birth outcomes. Still, pregnant women with COVID-19 appear to suffer higher rates of negative clinical and pregnancy outcomes. Further understanding of racial disparities and birth outcomes in this population is needed to inform patient care and counseling for pregnant women.
Bixler D, Miller AD, Mattison CP, et al. SARS-CoV-2–Associated Deaths Among Persons Aged <21 Years — United States, February 12–July 31, 2020. MMWR Morb Mortal Wkly Rep. ePub: 15 September 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6937e4
Panagiotakopoulos L, Myers TR, Gee J, et al. SARS-CoV-2 Infection Among Hospitalized Pregnant Women: Reasons for Admission and Pregnancy Characteristics—Eight US Health Care Centers March 1-May 30, 2020. MMWR Morb Mortal Wkly Rep. ePub: 16 September 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6938e2
Delahoy MJ, Whitaker M, O’Halloran A, et al. Characteristics and Maternal and Birth Outcomes of Pregnant Women with Laboratory-Confirmed COVID-19—COVID-NET, 13 States, March 1- August 22, 2020. MMWR Morb Mortal Wkly Rep. ePub: 16 Setpember 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6938e1