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Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–October 3, 2020

Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed... Morbidity and Mortality Weekly Report Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–October 3, 2020 1, 1, 1 1 1 1 Laura D. Zambrano, PhD *; Sascha Ellington, PhD *; Penelope Strid, MPH ; Romeo R. Galang, MD ; Titilope Oduyebo, MD ; Van T. Tong, MPH ; 1 1 1 1 1 Kate R. Woodworth, MD ; John F. Nahabedian III, MS ; Eduardo Azziz-Baumgartner, MD ; Suzanne M. Gilboa, PhD ; Dana Meaney-Delman, MD ; CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team On November 2, 2020, this report was posted as an MMWR Data on laboratory-confirmed and probable COVID-19 Early Release on the MMWR website (https://www.cdc.gov/mmwr). cases were electronically reported to CDC using a standardized § ¶ Studies suggest that pregnant women might be at increased case report form or NNDSS as part of COVID-19 surveil- risk for severe illness associated with coronavirus disease 2019 lance efforts. Data are reported by health departments and can (COVID-19) (1,2). This report provides updated information be updated by health departments as new information becomes about symptomatic women of reproductive age (15–44 years) available. This analysis included cases initially reported to with laboratory-confirmed infection with SARS-CoV-2, CDC during January 22–October 3, 2020, with data updated the virus that causes COVID-19. During January 22– as of October 28, 2020. Cases were limited to those in symp- October 3, CDC received reports through national COVID-19 tomatic women aged 15–44 years in the United States with case surveillance or through the National Notifiable Diseases laboratory-confirmed infection (detection of SARS-CoV-2 Surveillance System (NNDSS) of 1,300,938 women aged RNA in a clinical specimen using a molecular amplification 15–44 years with laboratory results indicative of acute infection detection test). Information on demographic characteristics, with SARS-CoV-2. Data on pregnancy status were available for pregnancy status, underlying medical conditions, symptoms, 461,825 (35.5%) women with laboratory-confirmed infection, and outcomes was collected. Pregnancy status was ascertained 409,462 (88.7%) of whom were symptomatic. Among symp- by a pregnancy field on the COVID-19 case report form tomatic women, 23,434 (5.7%) were reported to be pregnant. or through records linked to the Surveillance for Emerging After adjusting for age, race/ethnicity, and underlying medical Threats to Mothers and Babies Network (SET-NET) optional ,†† conditions, pregnant women were significantly more likely than (3). CDC ascertained symptom status COVID-19 module** were nonpregnant women to be admitted to an intensive care either through a reported symptom status variable (symptom- unit (ICU) (10.5 versus 3.9 per 1,000 cases; adjusted risk ratio atic, asymptomatic, or unknown) or based on the presence of at [aRR] = 3.0; 95% confidence interval [CI] = 2.6–3.4), receive least one specific symptom on the case report form. Outcomes invasive ventilation (2.9 versus 1.1 per 1,000 cases; aRR = 2.9; with missing data were assumed not to have occurred. Crude 95% CI  =  2.2–3.8), receive extracorporeal membrane and adjusted RRs and 95% CIs were calculated using modi- oxygenation (ECMO) (0.7 versus 0.3 per 1,000 cases; fied Poisson regression. Overall and stratified risk ratios were aRR = 2.4; 95% CI = 1.5–4.0), and die (1.5 versus 1.2 per adjusted for age (in years), race/ethnicity, and presence of 1,000 cases; aRR = 1.7; 95% CI = 1.2–2.4). Stratifying these diabetes, cardiovascular disease (including hypertension), and analyses by age and race/ethnicity highlighted disparities chronic lung disease. SAS (version 9.4; SAS Institute) was used in risk by subgroup. Although the absolute risks for severe to conduct all analyses. This activity was reviewed by CDC outcomes for women were low, pregnant women were at and was conducted consistent with applicable federal law and §§ increased risk for severe COVID-19–associated illness. To CDC policy. reduce the risk for severe illness and death from COVID-19, During January 22–October 3, a total of 5,003,041 pregnant women should be counseled about the importance laboratory-confirmed cases of SARS-CoV-2 infection were of seeking prompt medical care if they have symptoms reported to CDC as part of national COVID-19 case and measures to prevent SARS-CoV-2 infection should be surveillance, including 1,300,938 (26.0%) cases in women strongly emphasized for pregnant women and their families https://wwwn.cdc.gov/nndss/conditions/coronavirus-disease-2019-covid-19/ during all medical encounters, including prenatal care visits. case-definition/2020/08/05/. Understanding COVID-19–associated risks among pregnant https://www.cdc.gov/coronavirus/2019-ncov/downloads/pui-form.pdf. https://wwwn.cdc.gov/nndss/covid-19-response.html. women is important for prevention counseling and clinical ** https://www.cdc.gov/coronavirus/2019-ncov/downloads/cases-updates/case- care and treatment. report-form-pregnancy-module.pdf. †† https://www.researchsquare.com/article/rs-90329/v1. §§ * These authors contributed equally to this report. 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq. US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 6, 2020 / Vol. 69 / No. 44 1641 Morbidity and Mortality Weekly Report aged 15–44 years. Data on pregnancy status were available for Discussion 461,825 (35.5%) women aged 15–44 years, 30,415 (6.6%) Although the absolute risks for severe COVID-19–associated of whom were pregnant and 431,410 (93.4%) of whom outcomes among women were low, pregnant women were at were nonpregnant. Among all women aged 15–44 years with significantly higher risk for severe outcomes compared with known pregnancy status, 409,462 (88.7%) were symptomatic, nonpregnant women. This finding might be related to physi- including 23,434 pregnant women, accounting for 5.7% of all ologic changes in pregnancy, including increased heart rate symptomatic women with laboratory-confirmed COVID-19, and oxygen consumption, decreased lung capacity, a shift and 386,028 nonpregnant women. Pregnant women were away from cell-mediated immunity, and increased risk for more frequently Hispanic/Latina (Hispanic) (29.7%) and thromboembolic disease (4,5). Compared with the initial less frequently non-Hispanic White (White) (23.5%) report of these data (1), in which increased risk for ICU admis- compared with nonpregnant women (22.6% Hispanic and sions and invasive ventilation among pregnant women was 31.7% White). Among all women, cough, headache, muscle reported, this analysis includes nearly five times the number aches, and fever were the most frequently reported signs and of symptomatic women and a higher proportion of women symptoms; most symptoms were reported less frequently by with known pregnancy status (36% versus 28%). Further, to pregnant women than by nonpregnant women (Table 1). avoid including pregnant women who were tested as part of Compared with nonpregnant women, pregnant women asymptomatic screening practices at the delivery hospitaliza- more frequently were admitted to an ICU (10.5 versus 3.9 tion, this analysis was limited to symptomatic women. In this per 1,000 cases; aRR = 3.0; 95% CI = 2.6–3.4), received analysis 5.7% of symptomatic women aged 15–44 years with invasive ventilation (2.9 versus 1.1 per 1,000 cases; aRR = 2.9; COVID-19 were pregnant, corresponding to the anticipated 95% CI = 2.2–3.8) and received ECMO (0.7 versus 0.3 per ¶¶, *** proportion of 5% of the population at any point in time. 1,000 cases; aRR = 2.4; 95% CI = 1.5–4.0). Thirty-four deaths Whereas increased risk for severe disease related to pregnancy (1.5 per 1,000 cases) were reported among 23,434 symptomatic was apparent in nearly all stratified analyses, pregnant women pregnant women, and 447 (1.2 per 1,000 cases) were reported aged 35–44 years with COVID-19 were nearly four times among 386,028 nonpregnant women, reflecting a 70% as likely to require invasive ventilation and twice as likely to increased risk for death associated with pregnancy (aRR = 1.7; die than were nonpregnant women of the same age. Among 95% CI = 1.2–2.4). Irrespective of pregnancy status, ICU symptomatic pregnant women with COVID-19 for whom admissions, receipt of invasive ventilation, and death occurred race/ethnicity was reported, 30% were Hispanic and 24% more often among women aged 35–44 years than among those were White, differing from the overall reported racial/ethnic aged 15–24 years (Table 2). Whereas non-Hispanic Black or distribution of women who gave birth in 2019 (24% Hispanic African American (Black) women made up 14.1% of women ††† Pregnant Asian and Native Hawaiian/ and 51% White). included in this analysis, they represented 176 (36.6%) Pacific Islander women appeared to be at disproportionately deaths overall, including nine of 34 (26.5%) deaths among greater risk for ICU admission. Hispanic pregnant women pregnant women and 167 of 447 (37.4%) deaths among of any race not only experienced a disproportionate risk nonpregnant women. for SARS-CoV-2 infection but also a higher risk for death Increased risk for ICU admission among pregnant women compared with nonpregnant Hispanic women. Regardless of was observed for all strata but was particularly notable pregnancy status, non-Hispanic Black women experienced a among non-Hispanic Asian (Asian) women (aRR  =  6.6; disproportionate number of deaths relative to their distribu- 95% CI  =  4.0–11.0) and non-Hispanic Native Hawaiian/ tion among reported cases. This analysis highlights racial and Pacific Islander women (aRR  =  3.7; 95% CI  =  1.3–10.1). ethnic disparities in both risk for infection and disease severity Risk for receiving invasive ventilation among pregnant among pregnant women, indicating a need to address potential women aged 15–24 years was 3.0 times that of nonpregnant drivers of risk in these populations. women (95% CI = 1.6–5.7), and among pregnant women The findings in this report are subject to at least three limita- aged 35–44 years was 3.6 times that of nonpregnant women tions. First, national case surveillance data for COVID-19 are (95% CI = 2.4–5.4). In addition, among Hispanic women, voluntarily reported to CDC and rely on health care providers pregnancy was associated with 2.4 times the risk for death and jurisdictional public health agencies to share information (95% CI = 1.3-4.3) (Table 2). ¶¶ https://data.census.go v/cedsci/table?q=U nited%20 States&tid=ACSST1Y2019.S0101&hidePreview=false. *** https://www.cdc.gov/reproductivehealth/emergency/docs/Geographic- Calculator-for-Pregnant-Women_508.xlsx. ††† https://www.cdc.gov/nchs/data/vsrr/vsrr-8-508.pdf. 1642 MMWR / November 6, 2020 / Vol. 69 / No. 44 US Department of Health and Human Services/Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. Demographic characteristics, signs and symptoms, and underlying medical conditions among symptomatic women of reproductive ,† age with laboratory-confirmed SARS-CoV-2 infection (N = 409,462),* by pregnancy status — United States, January 22–October 3, 2020 No. (%) of symptomatic women Pregnant Nonpregnant Total Characteristic (n = 23,434) (n = 386,028) (N = 409,462) Age group, yrs 15–24 6,463 (27.6) 133,032 (34.5) 139,495 (34.1) 25–34 12,951 (55.3) 131,835 (34.2) 144,786 (35.4) 35–44 4,020 (17.2) 121,161 (31.4) 125,181 (30.6) Race/Ethnicity Hispanic or Latina, any race 6,962 (29.7) 85,618 (22.2) 92,580 (22.6) AI/AN, non-Hispanic 113 (0.5) 1,652 (0.4) 1,765 (0.4) Asian, non-Hispanic 560 (2.4) 8,605 (2.2) 9,165 (2.2) Black, non-Hispanic 3,387 (14.5) 54,185 (14.0) 57,572 (14.1) NHPI, non-Hispanic 119 (0.5) 1,526 (0.4) 1,645 (0.4) White, non-Hispanic 5,508 (23.5) 124,305 (32.2) 129,813 (31.7) Multiple or other race, non-Hispanic 726 (3.1) 12,341 (3.2) 13,067 (3.2) Signs and symptoms Known status of individual signs and symptoms 10,404 174,198 184,602 Cough 5,230 (50.3) 89,422 (51.3) 94,652 (51.3) Fever** 3,328 (32.0) 68,536 (39.3) 71,864 (38.9) Muscle aches 3,818 (36.7) 78,725 (45.2) 82,543 (44.7) Chills 2,537 (24.4) 50,836 (29.2) 53,373 (28.9) Headache 4,447 (42.7) 95,713 (54.9) 100,160 (54.3) Shortness of breath 2,692 (25.9) 43,234 (24.8) 45,926 (24.9) Sore throat 2,955 (28.4) 60,218 (34.6) 63,173 (34.2) Diarrhea 1,479 (14.2) 38,165 (21.9) 39,644 (21.5) Nausea or vomiting 2,052 (19.7) 28,999 (16.6) 31,051 (16.8) Abdominal pain 870 (8.4) 16,123 (9.3) 16,993 (9.2) Runny nose 1,328 (12.8) 22,750 (13.1) 24,078 (13.0) †† New loss of taste or smell 2,234 (21.5) 43,256 (24.8) 45,490 (24.6) Fatigue 1,404 (13.5) 29,788 (17.1) 31,192 (16.9) Wheezing 172 (1.7) 3,743 (2.1) 3,915 (2.1) Chest pain 369 (3.5) 7,079 (4.1) 7,448 (4.0) Underlying medical conditions §§ Known underlying medical condition status 7,795 160,065 167,860 Diabetes mellitus 427 (5.5) 6,119 (3.8) 6,546 (3.9) Cardiovascular disease 304 (3.9) 7,703 (4.8) 8,007 (4.8) Chronic lung disease 506 (6.5) 9,185 (5.7) 9,691 (5.8) Chronic renal disease 18 (0.2) 680 (0.4) 698 (0.4) Chronic liver disease 17 (0.2) 350 (0.2) 367 (0.2) Immunocompromised condition 124 (1.6) 2,496 (1.6) 2,620 (1.6) Neurologic disorder, neurodevelopmental disorder, or intellectual disability 44 (0.6) 1,097 (0.7) 1,141 (0.7) Psychiatric disorder 62 (0.8) 1,139 (0.7) 1,201 (0.7) Autoimmune disorder 26 (0.3) 515 (0.3) 541 (0.3) ¶¶ Severe obesity 174 (2.2) 1,810 (1.1) 1,984 (1.2) Abbreviations: AI/AN = American Indian or Alaska Native; NHPI = Native Hawaiian or Other Pacific Islander. * Women with known pregnancy status, representing 52% of 783,072 total cases among symptomatic women aged 15–44 years. All statistical comparisons were significant at α <0.01, with the exception of the comparison of prevalence of neurologic disorders between pregnant and nonpregnant women (p = 0.307). Race/ethnicity was missing for 6,059 (26%) of symptomatic pregnant women and 97,796 (26%) of symptomatic nonpregnant women. Data on individual symptoms were known for 10,404 (44%) of pregnant women and 174,198 (45%) of nonpregnant women. Individual symptoms were considered known if any of the following symptoms were noted as present or absent on the CDC’s Human Infection with 2019 Novel Coronavirus Case Report Form: fever (measured >100.4°F [38°C] or subjective), cough, shortness of breath, wheezing, difficulty breathing, chills, rigors, myalgia, rhinorrhea, sore throat, chest pain, nausea or vomiting, abdominal pain, headache, fatigue, diarrhea (three or more loose stools in a 24-hour period), new olfactory or taste disorder, or other symptom not otherwise specified on the form. ** Patients were included if they had information for either measured or subjective fever variables and were considered to have a fever if “yes” was indicated for either variable. †† New olfactory and taste disorder has only been included on the CDC’s Human Infection with 2019 Novel Coronavirus Case Report Form since May 5, 2020. Therefore, data might be underreported for this symptom. §§ Status was classified as “known” if any of the following conditions were noted as present or absent on the CDC’s Human Infection with 2019 Novel Coronavirus Case Report Form: diabetes mellitus, cardiovascular disease (including hypertension), severe obesity (body mass index ≥40 kg/m ), chronic renal disease, chronic liver disease, chronic lung disease, immunosuppressive condition, autoimmune condition, neurologic condition (including neurodevelopmental, intellectual, physical, visual, or hearing impairment), psychological/psychiatric condition, and other underlying medical condition not otherwise specified. ¶¶ 2 Defined as body mass index ≥40 kg/m . US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 6, 2020 / Vol. 69 / No. 44 1643 Morbidity and Mortality Weekly Report TABLE 2. Intensive care unit (ICU) admissions, receipt of invasive ventilation, receipt of extracorporeal membrane oxygenation (ECMO), and deaths among symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 (N = 409,462), by pregnancy status, age, race/ ethnicity, and underlying health conditions — United States, January 22–October 3, 2020 No. (per 1,000 cases) of symptomatic women Risk ratio (95% CI) Pregnant Nonpregnant † †,§ Outcome*/Characteristic (n = 23,434) (n = 386,028) Crude Adjusted ICU admission All 245 (10.5) 1,492 (3.9) 2.7 (2.4–3.1) 3.0 (2.6–3.4) Age group, yrs 15–24 49 (7.6) 244 (1.8) 4.1 (3.0–5.6) 3.9 (2.8–5.3) 25–34 118 (9.1) 467 (3.5) 2.6 (2.1–3.1) 2.4 (2.0–3.0) 35–44 78 (19.4) 781 (6.4) 3.0 (2.4–3.8) 3.2 (2.5–4.0) Race/Ethnicity Hispanic or Latina 89 (12.8) 429 (5.0) 2.6 (2.0–3.2) 2.8 (2.2–3.5) AI/AN, non-Hispanic 0 (0) 13 (7.9) NA NA Asian, non-Hispanic 20 (35.7) 52 (6.0) 5.9 (3.6–9.8) 6.6 (4.0–11.0) Black, non-Hispanic 46 (13.6) 334 (6.2) 2.2 (1.6–3.0) 2.8 (2.0–3.8) NHPI, non-Hispanic 5 (42.0) 22 (14.4) 2.9 (1.1–7.6) 3.7 (1.3–10.1) White, non-Hispanic 31 (5.6) 348 (2.8) 2.0 (1.4–2.9) 2.3 (1.6–3.3) Multiple or other race, non-Hispanic 8 (11.0) 37 (3.0) 3.7 (1.7–7.9) 4.1 (1.9–8.9) Unknown/Not reported 46 (7.6) 257 (2.6) 2.9 (2.1–3.9) 3.4 (2.5–4.7) Underlying health conditions Diabetes 25 (58.5) 274 (44.8) 1.3 (0.9–1.9) 1.5 (1.0–2.2) CVD** 13 (42.8) 247 (32.1) 1.3 (0.8–2.3) 1.5 (0.9–2.6) Chronic lung disease 15 (29.6) 179 (19.5) 1.5 (0.9–2.6) 1.7 (1.0–2.8) †† Invasive ventilation All 67 (2.9) 412 (1.1) 2.7 (2.1–3.5) 2.9 (2.2–3.8) Age group, yrs §§ 15–24 11 (1.7) 68 (0.5) 3.3 (1.8–6.3) 3.0 (1.6–5.7) §§ 25–34 30 (2.3) 123 (0.9) 2.5 (1.7–3.7) 2.5 (1.6–3.7) 35–44 26 (6.5) 221 (1.8) 3.5 (2.4–5.3) 3.6 (2.4–5.4) Race/Ethnicity Hispanic or Latina 33 (4.7) 143 (1.7) 2.8 (1.9–4.1) 3.0 (2.1–4.5) AI/AN, non-Hispanic 0 (0) 5 (3.0) NA NA Asian, non-Hispanic 4 (7.1) 19 (2.2) NA NA Black, non-Hispanic 10 (3) 86 (1.6) 1.9 (1.0–3.6) 2.5 (1.3–4.9) NHPI, non-Hispanic 4 (33.6) 10 (6.6) NA NA White, non-Hispanic 12 (2.2) 102 (0.8) 2.7 (1.5–4.8) 3.0 (1.7–5.6) Multiple or other race, non-Hispanic 0 (0) 8 (0.6) NA NA Unknown/Not reported 4 (0.7) 39 (0.4) NA NA Underlying health conditions Diabetes 10 (23.4) 98 (16.0) 1.5 (0.8–2.8) 1.7 (0.9–3.3) ¶¶ CVD** 6 (19.7) 82 (10.6) 1.9 (0.8–4.2) 1.9 (0.8–4.5) Chronic lung disease 4 (7.9) 50 (5.4) NA NA ECMO*** All 17 (0.7) 120 (0.3) 2.3 (1.4–3.9) 2.4 (1.5–4.0) Age group,yrs ††† 15–24 6 (0.9) 31 (0.2) 4.0 (1.7–9.5) NA §§ 25–34 7 (0.5) 35 (0.3) 2.0 (0.9–4.6) 2.0 (0.9–4.4) 35–44 4 (1.0) 54 (0.4) NA NA Race/Ethnicity Hispanic or Latina 6 (0.9) 35 (0.4) 2.1 (0.9–5.0) 2.4 (1.0–5.9) AI/AN, non-Hispanic 0 (0) 1 (0.6) NA NA Asian, non-Hispanic 0 (0) 1 (0.1) NA NA Black, non-Hispanic 5 (1.5) 30 (0.6) 2.7 (1.0–6.9) 2.9 (1.1–7.3) NHPI, non-Hispanic 0 (0) 2 (1.3) NA NA White, non-Hispanic 4 (0.7) 29 (0.2) NA NA Multiple or other race, non-Hispanic 0 (0) 3 (0.2) NA NA Unknown/Not reported 2 (0.3) 19 (0.2) NA NA See table footnotes on the next page. 1644 MMWR / November 6, 2020 / Vol. 69 / No. 44 US Department of Health and Human Services/Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. (Continued) Intensive care unit (ICU) admissions, receipt of invasive ventilation, receipt of extracorporeal membrane oxygenation (ECMO), and deaths among symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 (N = 409,462), by pregnancy status, age, race/ethnicity, and underlying health conditions — United States, January 22–October 3, 2020 No. (per 1,000 cases) of symptomatic women Risk ratio (95% CI) Pregnant Nonpregnant † †,§ Outcome*/Characteristic (n = 23,434) (n = 386,028) Crude Adjusted Underlying health conditions Diabetes 1 (2.3) 13 (2.1) NA NA CVD** 1 (3.3) 20 (2.6) NA NA Chronic lung disease 1 (2.0) 20 (2.2) NA NA §§§ Death All 34 (1.5) 447 (1.2) 1.3 (0.9–1.8) 1.7 (1.2–2.4) Age group, yrs 15–24 2 (0.3) 40 (0.3) NA NA 25–34 15 (1.2) 125 (0.9) 1.2 (0.7–2.1) 1.2 (0.7–2.1) 35–44 17 (4.2) 282 (2.3) 1.8 (1.1–3.0) 2.0 (1.2–3.2) Race/Ethnicity Hispanic or Latina 14 (2.0) 87 (1.0) 2.0 (1.1–3.5) 2.4 (1.3–4.3) AI/AN, non-Hispanic 0 (0) 5 (3.0) NA NA Asian, non-Hispanic 1 (1.8) 11 (1.3) NA NA Black, non-Hispanic 9 (2.7) 167 (3.1) 0.9 (0.4–1.7) 1.4 (0.7–2.7) NHPI, non-Hispanic 2 (16.8) 6 (3.9) NA NA White, non-Hispanic 3 (0.5) 83 (0.7) NA NA Multiple or other race, non-Hispanic 0 (0) 12 (1.0) NA NA Unknown/Not reported 5 (0.8) 76 (0.8) 1.1 (0.4–2.6) 1.4 (0.6–3.6) Underlying health conditions ¶¶¶ Diabetes 6 (14.1) 78 (12.7) 1.1 (0.5–2.5) 1.5 (0.6–3.5) CVD** 7 (23.0) 89 (11.6) 2.0 (0.9–4.3) 2.2 (1.0–4.8)**** Chronic lung disease 1 (2.0) 37 (4.0) NA NA Abbreviations: AI/AN  =  American Indian/Alaska Native; CI  =  confidence interval; CVD  =  cardiovascular disease; NA = not applicable; NHPI = Native Hawaiian or Other Pacific Islander. * Percentages calculated among total in pregnancy status group. Crude and adjusted risk ratios were not calculated for cell sizes <5. Adjusted for age (continuous variable, in years), categorical race/ethnicity variable, and dichotomous indicators for diabetes, cardiovascular disease, and chronic lung disease. A total of 17,007 (72.6%) symptomatic pregnant women and 291,539 (75.5%) symptomatic nonpregnant women were missing information on ICU admission status; however, while hospital admission status was not separately analyzed, hospitalization status was missing for 2,393 (10.2%) symptomatic pregnant women and 35,624 (9.2%) of symptomatic nonpregnant women, and no hospital admission was reported for 16,672 (71.1%) pregnant and 337,414 (87.4%) nonpregnant women. Therefore, in the absence of reported hospital admissions, women with missing ICU admission information were assumed to have not been admitted to the ICU. ** Cardiovascular disease also accounts for presence of hypertension. †† A total of 17,903 (76.4%) pregnant women and 299,413 (77.6%) nonpregnant women were missing information regarding receipt of invasive ventilation and were assumed to have not received it. §§ Adjusted for the presence of diabetes, CVD, and chronic lung disease only, and removed race/ethnicity from adjustment set because of model convergence issues. ¶¶ Adjusted for the presence of diabetes and chronic lung disease and age as a continuous covariate only and removed race/ethnicity from adjustment set because of model convergence issues. *** A total of 18,246 (77.9%) pregnant women and 298,608 (77.4%) nonpregnant women were missing information for receipt of ECMO and were assumed to have not received ECMO. ††† Model failed to converge even after adjustment for a reduced set of covariates. §§§ A total of 5,152 (22.0%) pregnant women and 66,346 (17.2%) nonpregnant women were missing information on death and were assumed to have survived. ¶¶¶ Adjusted for the presence of CVD and chronic lung disease and age as a continuous variable. **** Adjusted for presence of diabetes and chronic lung disease and age as a continuous variable. for patients who meet standard case definitions. The mecha- status was missing for over one half (64.5%) of reported cases, nism used to report cases and the capacity to investigate cases and among those with known pregnancy status, data on race/ §§§ varies across jurisdictions. Thus, case information is limited ethnicity were missing for approximately 25% of cases, and or unavailable for a portion of detected COVID-19 cases, and information on symptoms and underlying conditions was reported case data might be updated at any time. This analysis missing for approximately one half. Second, when estimating was restricted to women with known age; however, pregnancy the proportion of cases with severe outcomes, the observational §§§ https://www.cdc.gov/coronavirus/2019-ncov/covid-data/faq-surveillance.html. US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 6, 2020 / Vol. 69 / No. 44 1645 Morbidity and Mortality Weekly Report Understanding the risk posed by SARS-CoV-2 infec- Summary tion in pregnant women can inform clinical practice, risk What is already known about this topic? communication, and medical countermeasure allocation. Limited information suggests that pregnant women with Pregnant women should be informed of their risk for severe COVID-19 might be at increased risk for severe illness compared COVID-19–associated illness and the warning signs of with nonpregnant women. severe COVID-19.**** To minimize the risk for acquiring What is added by this report? SARS-CoV-2 infection, pregnant women should limit unnec- In an analysis of approximately 400,000 women aged essary interactions with persons who might have been exposed 15–44 years with symptomatic COVID-19, intensive care unit to or are infected with SARS-CoV-2, including those within admission, invasive ventilation, extracorporeal membrane †††† §§§§ their household, as much as possible. When going oxygenation, and death were more likely in pregnant women out or interacting with others, pregnant women should wear than in nonpregnant women. a mask, social distance, avoid persons who are not wearing a What are the implications for public health practice? mask, and frequently wash their hands. In addition, pregnant Pregnant women should be counseled about the risk for severe women should take measures to ensure their general health, COVID-19–associated illness including death; measures to prevent infection with SARS-CoV-2 should be emphasized for including staying up to date with annual influenza vaccination pregnant women and their families. These findings can inform and prenatal care. Providers who care for pregnant women clinical practice, risk communication, and medical should be familiar with guidelines for medical management countermeasure allocation. of COVID-19, including considerations for management ¶¶¶¶, of COVID-19 in pregnancy. ***** Additional data data collected through passive surveillance might be subject from surveillance and cohort studies on COVID-19 sever- to reporting bias, wherein preferential ascertainment of severe ity during pregnancy are necessary to inform messaging and cases is likely (6,7); therefore, the frequency of reported out- patient counseling. comes incorporates a denominator of all cases as a conservative **** https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms. estimate. Finally, severe outcomes might require additional html. time to be ascertained. To account for this, a time lag was †††† https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/care-for- incorporated, such that data reported as of October 28, 2020, someone.html#face-covering. §§§§ https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/ were used for cases reported as of October 3. pregnancy-breastfeeding.html. This analysis supports previous findings that pregnancy is ¶¶¶¶ https://www.covid19treatmentguidelines.nih.gov/. ***** https://www.acog.org/en/Topics/COVID-19. associated with increased risk for ICU admission and receipt of invasive ventilation among women of reproductive age with Acknowledgments COVID-19 (1,2). In the current report, an increased risk for State, local, and territorial health department personnel; U.S. clinical, receiving ECMO and death was also observed, which are two public health, and emergency response staff members; Kathleen E. additional important markers of COVID-19 severity that sup- Fullerton, Erin K. Stokes, CDC; CDC Epidemiology Studies Task Force port previous findings. In comparison to influenza, a recent Pregnancy and Infant Linked Outcomes Team; CDC Data, Analytics, meta-analysis found no increased risk for ICU admission or and Modeling Task Force Case Surveillance Section. death among pregnant women with seasonal influenza (8). CDC COVID-19 Response Pregnancy and Infant Linked However, data from previous influenza pandemics, including Outcomes Team 2009 H1N1, have shown that pregnant women are at increased risk for severe outcomes including death and the absolute Amanda Akosa, Eagle Global Scientific; Carolyne Bennett, Eagle Global Scientific; Veronica Burkel, Eagle Medical; Daniel Chang, Oak risks for severe outcomes were higher than in this study of Ridge Institute for Science and Education; Augustina Delaney, CDC; COVID-19 during pregnancy (9). Longitudinal surveillance Charise Fox, Oak Ridge Institute for Science and Education; Isabel and cohort studies among pregnant women with COVID-19, Griffin, Eagle Global Scientific; Jason Hsia, CDC; Katie Krause, CDC; including information about pregnancy outcomes, are neces- Elizabeth Lewis, CDC; Susan Manning, CDC; Yousra Mohamoud, sary to understand the full spectrum of maternal and neonatal CDC; Suzanne Newton, CDC; Varsha Neelam, CDC; Emily O’Malley outcomes associated with COVID-19 in pregnancy. CDC, in Olsen, CDC; Mirna Perez, CDC; Megan Reynolds, CDC; Aspen Riser, collaboration with health departments, has adapted SET-NET CDC; Maria Rivera, CDC; Nicole M. Roth, Eagle Global Scientific; to collect pregnancy-related information and pregnancy and Christina Sancken, CDC; Neha Shinde, Eagle Global Scientific; neonatal outcomes among women with COVID-19 during Ashley Smoots, CDC; Margaret Snead, CDC; Bailey Wallace, CDC; ¶¶¶ pregnancy (3). Florence Whitehill, Oak Ridge Institute for Science and Education; Erin Whitehouse, CDC; Lauren Zapata, CDC. ¶¶¶ https://www.cdc.gov/ncbddd/aboutus/pregnancy/emerging-threats.html. 1646 MMWR / November 6, 2020 / Vol. 69 / No. 44 US Department of Health and Human Services/Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Corresponding author: Sascha Ellington for the CDC COVID-19 Response 4. Vlachodimitropoulou Koumoutsea E, Vivanti AJ, Shehata N, et al. Pregnancy and Infant Linked Outcomes Team, eocevent397@cdc.gov. COVID-19 and acute coagulopathy in pregnancy. J Thromb Haemost 2020;18:1648–52. https://doi.org/10.1111/jth.14856 CDC COVID-19 Response Team. 5. Ramsey PS, Ramin KD. Pneumonia in pregnancy. Obstet Gynecol Clin North Am 2001;28:553–69. https://doi.org/10.1016/S0889-8545(05)70217-5 All authors have completed and submitted the International 6. Lipsitch M, Donnelly CA, Fraser C, et al. Potential biases in estimating Committee of Medical Journal Editors form for disclosure of potential absolute and relative case-fatality risks during outbreaks. PLoS Negl Trop conflicts of interest. No potential conflicts of interest were disclosed. Dis 2015;9:e0003846. https://doi.org/10.1371/journal.pntd.0003846 7. World Health Organization. Immunization, vaccines and biologicals: References national passive surveillance. Geneva, Switzerland: World Health Organization; 2020. https://www.who.int/immunization/monitoring_ 1. Ellington S, Strid P, Tong VT, et al. Characteristics of women of surveillance/burden/vpd/surveillance_type/passive/en reproductive age with laboratory-confirmed SARS-CoV-2 infection by 8. Mertz D, Lo CK, Lytvyn L, Ortiz JR, Loeb M; FLURISK-INVESTIGATORS. pregnancy status—United States, January 22–June 7, 2020. MMWR Pregnancy as a risk factor for severe influenza infection: an individual Morb Mortal Wkly Rep 2020;69:769–75. https://doi.org/10.15585/ participant data meta-analysis. BMC Infect Dis 2019;19:683. https:// mmwr.mm6925a1 doi.org/10.1186/s12879-019-4318-3 2. Allotey J, Stallings E, Bonet M, et al.; PregCOV-19 Living Systematic 9. Rasmussen SA, Jamieson DJ, Uyeki TM. Effects of influenza on pregnant Review Consortium. Clinical manifestations, risk factors, and maternal women and infants. Am J Obstet Gynecol 2012;207(Suppl):S3–8. https:// and perinatal outcomes of coronavirus disease 2019 in pregnancy: living doi.org/10.1016/j.ajog.2012.06.068 systematic review and meta-analysis. BMJ 2020;370:m3320. https://doi. org/10.1136/bmj.m3320 3. Woodworth KR, Olsen EO, Neelam V, et al. Birth and infant outcomes following laboratory-confirmed SARS-CoV-2 infection in pregnancy— SET-NET, 16 jurisdictions, March 29–October 14, 2020. MMWR Morb Mortal Wkly Rep 2020;69. Epub November 2, 2020. US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 6, 2020 / Vol. 69 / No. 44 1647 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Morbidity and Mortality Weekly Report Pubmed Central

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Morbidity and Mortality Weekly Report Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–October 3, 2020 1, 1, 1 1 1 1 Laura D. Zambrano, PhD *; Sascha Ellington, PhD *; Penelope Strid, MPH ; Romeo R. Galang, MD ; Titilope Oduyebo, MD ; Van T. Tong, MPH ; 1 1 1 1 1 Kate R. Woodworth, MD ; John F. Nahabedian III, MS ; Eduardo Azziz-Baumgartner, MD ; Suzanne M. Gilboa, PhD ; Dana Meaney-Delman, MD ; CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team On November 2, 2020, this report was posted as an MMWR Data on laboratory-confirmed and probable COVID-19 Early Release on the MMWR website (https://www.cdc.gov/mmwr). cases were electronically reported to CDC using a standardized § ¶ Studies suggest that pregnant women might be at increased case report form or NNDSS as part of COVID-19 surveil- risk for severe illness associated with coronavirus disease 2019 lance efforts. Data are reported by health departments and can (COVID-19) (1,2). This report provides updated information be updated by health departments as new information becomes about symptomatic women of reproductive age (15–44 years) available. This analysis included cases initially reported to with laboratory-confirmed infection with SARS-CoV-2, CDC during January 22–October 3, 2020, with data updated the virus that causes COVID-19. During January 22– as of October 28, 2020. Cases were limited to those in symp- October 3, CDC received reports through national COVID-19 tomatic women aged 15–44 years in the United States with case surveillance or through the National Notifiable Diseases laboratory-confirmed infection (detection of SARS-CoV-2 Surveillance System (NNDSS) of 1,300,938 women aged RNA in a clinical specimen using a molecular amplification 15–44 years with laboratory results indicative of acute infection detection test). Information on demographic characteristics, with SARS-CoV-2. Data on pregnancy status were available for pregnancy status, underlying medical conditions, symptoms, 461,825 (35.5%) women with laboratory-confirmed infection, and outcomes was collected. Pregnancy status was ascertained 409,462 (88.7%) of whom were symptomatic. Among symp- by a pregnancy field on the COVID-19 case report form tomatic women, 23,434 (5.7%) were reported to be pregnant. or through records linked to the Surveillance for Emerging After adjusting for age, race/ethnicity, and underlying medical Threats to Mothers and Babies Network (SET-NET) optional ,†† conditions, pregnant women were significantly more likely than (3). CDC ascertained symptom status COVID-19 module** were nonpregnant women to be admitted to an intensive care either through a reported symptom status variable (symptom- unit (ICU) (10.5 versus 3.9 per 1,000 cases; adjusted risk ratio atic, asymptomatic, or unknown) or based on the presence of at [aRR] = 3.0; 95% confidence interval [CI] = 2.6–3.4), receive least one specific symptom on the case report form. Outcomes invasive ventilation (2.9 versus 1.1 per 1,000 cases; aRR = 2.9; with missing data were assumed not to have occurred. Crude 95% CI  =  2.2–3.8), receive extracorporeal membrane and adjusted RRs and 95% CIs were calculated using modi- oxygenation (ECMO) (0.7 versus 0.3 per 1,000 cases; fied Poisson regression. Overall and stratified risk ratios were aRR = 2.4; 95% CI = 1.5–4.0), and die (1.5 versus 1.2 per adjusted for age (in years), race/ethnicity, and presence of 1,000 cases; aRR = 1.7; 95% CI = 1.2–2.4). Stratifying these diabetes, cardiovascular disease (including hypertension), and analyses by age and race/ethnicity highlighted disparities chronic lung disease. SAS (version 9.4; SAS Institute) was used in risk by subgroup. Although the absolute risks for severe to conduct all analyses. This activity was reviewed by CDC outcomes for women were low, pregnant women were at and was conducted consistent with applicable federal law and §§ increased risk for severe COVID-19–associated illness. To CDC policy. reduce the risk for severe illness and death from COVID-19, During January 22–October 3, a total of 5,003,041 pregnant women should be counseled about the importance laboratory-confirmed cases of SARS-CoV-2 infection were of seeking prompt medical care if they have symptoms reported to CDC as part of national COVID-19 case and measures to prevent SARS-CoV-2 infection should be surveillance, including 1,300,938 (26.0%) cases in women strongly emphasized for pregnant women and their families https://wwwn.cdc.gov/nndss/conditions/coronavirus-disease-2019-covid-19/ during all medical encounters, including prenatal care visits. case-definition/2020/08/05/. Understanding COVID-19–associated risks among pregnant https://www.cdc.gov/coronavirus/2019-ncov/downloads/pui-form.pdf. https://wwwn.cdc.gov/nndss/covid-19-response.html. women is important for prevention counseling and clinical ** https://www.cdc.gov/coronavirus/2019-ncov/downloads/cases-updates/case- care and treatment. report-form-pregnancy-module.pdf. †† https://www.researchsquare.com/article/rs-90329/v1. §§ * These authors contributed equally to this report. 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq. US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 6, 2020 / Vol. 69 / No. 44 1641 Morbidity and Mortality Weekly Report aged 15–44 years. Data on pregnancy status were available for Discussion 461,825 (35.5%) women aged 15–44 years, 30,415 (6.6%) Although the absolute risks for severe COVID-19–associated of whom were pregnant and 431,410 (93.4%) of whom outcomes among women were low, pregnant women were at were nonpregnant. Among all women aged 15–44 years with significantly higher risk for severe outcomes compared with known pregnancy status, 409,462 (88.7%) were symptomatic, nonpregnant women. This finding might be related to physi- including 23,434 pregnant women, accounting for 5.7% of all ologic changes in pregnancy, including increased heart rate symptomatic women with laboratory-confirmed COVID-19, and oxygen consumption, decreased lung capacity, a shift and 386,028 nonpregnant women. Pregnant women were away from cell-mediated immunity, and increased risk for more frequently Hispanic/Latina (Hispanic) (29.7%) and thromboembolic disease (4,5). Compared with the initial less frequently non-Hispanic White (White) (23.5%) report of these data (1), in which increased risk for ICU admis- compared with nonpregnant women (22.6% Hispanic and sions and invasive ventilation among pregnant women was 31.7% White). Among all women, cough, headache, muscle reported, this analysis includes nearly five times the number aches, and fever were the most frequently reported signs and of symptomatic women and a higher proportion of women symptoms; most symptoms were reported less frequently by with known pregnancy status (36% versus 28%). Further, to pregnant women than by nonpregnant women (Table 1). avoid including pregnant women who were tested as part of Compared with nonpregnant women, pregnant women asymptomatic screening practices at the delivery hospitaliza- more frequently were admitted to an ICU (10.5 versus 3.9 tion, this analysis was limited to symptomatic women. In this per 1,000 cases; aRR = 3.0; 95% CI = 2.6–3.4), received analysis 5.7% of symptomatic women aged 15–44 years with invasive ventilation (2.9 versus 1.1 per 1,000 cases; aRR = 2.9; COVID-19 were pregnant, corresponding to the anticipated 95% CI = 2.2–3.8) and received ECMO (0.7 versus 0.3 per ¶¶, *** proportion of 5% of the population at any point in time. 1,000 cases; aRR = 2.4; 95% CI = 1.5–4.0). Thirty-four deaths Whereas increased risk for severe disease related to pregnancy (1.5 per 1,000 cases) were reported among 23,434 symptomatic was apparent in nearly all stratified analyses, pregnant women pregnant women, and 447 (1.2 per 1,000 cases) were reported aged 35–44 years with COVID-19 were nearly four times among 386,028 nonpregnant women, reflecting a 70% as likely to require invasive ventilation and twice as likely to increased risk for death associated with pregnancy (aRR = 1.7; die than were nonpregnant women of the same age. Among 95% CI = 1.2–2.4). Irrespective of pregnancy status, ICU symptomatic pregnant women with COVID-19 for whom admissions, receipt of invasive ventilation, and death occurred race/ethnicity was reported, 30% were Hispanic and 24% more often among women aged 35–44 years than among those were White, differing from the overall reported racial/ethnic aged 15–24 years (Table 2). Whereas non-Hispanic Black or distribution of women who gave birth in 2019 (24% Hispanic African American (Black) women made up 14.1% of women ††† Pregnant Asian and Native Hawaiian/ and 51% White). included in this analysis, they represented 176 (36.6%) Pacific Islander women appeared to be at disproportionately deaths overall, including nine of 34 (26.5%) deaths among greater risk for ICU admission. Hispanic pregnant women pregnant women and 167 of 447 (37.4%) deaths among of any race not only experienced a disproportionate risk nonpregnant women. for SARS-CoV-2 infection but also a higher risk for death Increased risk for ICU admission among pregnant women compared with nonpregnant Hispanic women. Regardless of was observed for all strata but was particularly notable pregnancy status, non-Hispanic Black women experienced a among non-Hispanic Asian (Asian) women (aRR  =  6.6; disproportionate number of deaths relative to their distribu- 95% CI  =  4.0–11.0) and non-Hispanic Native Hawaiian/ tion among reported cases. This analysis highlights racial and Pacific Islander women (aRR  =  3.7; 95% CI  =  1.3–10.1). ethnic disparities in both risk for infection and disease severity Risk for receiving invasive ventilation among pregnant among pregnant women, indicating a need to address potential women aged 15–24 years was 3.0 times that of nonpregnant drivers of risk in these populations. women (95% CI = 1.6–5.7), and among pregnant women The findings in this report are subject to at least three limita- aged 35–44 years was 3.6 times that of nonpregnant women tions. First, national case surveillance data for COVID-19 are (95% CI = 2.4–5.4). In addition, among Hispanic women, voluntarily reported to CDC and rely on health care providers pregnancy was associated with 2.4 times the risk for death and jurisdictional public health agencies to share information (95% CI = 1.3-4.3) (Table 2). ¶¶ https://data.census.go v/cedsci/table?q=U nited%20 States&tid=ACSST1Y2019.S0101&hidePreview=false. *** https://www.cdc.gov/reproductivehealth/emergency/docs/Geographic- Calculator-for-Pregnant-Women_508.xlsx. ††† https://www.cdc.gov/nchs/data/vsrr/vsrr-8-508.pdf. 1642 MMWR / November 6, 2020 / Vol. 69 / No. 44 US Department of Health and Human Services/Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. Demographic characteristics, signs and symptoms, and underlying medical conditions among symptomatic women of reproductive ,† age with laboratory-confirmed SARS-CoV-2 infection (N = 409,462),* by pregnancy status — United States, January 22–October 3, 2020 No. (%) of symptomatic women Pregnant Nonpregnant Total Characteristic (n = 23,434) (n = 386,028) (N = 409,462) Age group, yrs 15–24 6,463 (27.6) 133,032 (34.5) 139,495 (34.1) 25–34 12,951 (55.3) 131,835 (34.2) 144,786 (35.4) 35–44 4,020 (17.2) 121,161 (31.4) 125,181 (30.6) Race/Ethnicity Hispanic or Latina, any race 6,962 (29.7) 85,618 (22.2) 92,580 (22.6) AI/AN, non-Hispanic 113 (0.5) 1,652 (0.4) 1,765 (0.4) Asian, non-Hispanic 560 (2.4) 8,605 (2.2) 9,165 (2.2) Black, non-Hispanic 3,387 (14.5) 54,185 (14.0) 57,572 (14.1) NHPI, non-Hispanic 119 (0.5) 1,526 (0.4) 1,645 (0.4) White, non-Hispanic 5,508 (23.5) 124,305 (32.2) 129,813 (31.7) Multiple or other race, non-Hispanic 726 (3.1) 12,341 (3.2) 13,067 (3.2) Signs and symptoms Known status of individual signs and symptoms 10,404 174,198 184,602 Cough 5,230 (50.3) 89,422 (51.3) 94,652 (51.3) Fever** 3,328 (32.0) 68,536 (39.3) 71,864 (38.9) Muscle aches 3,818 (36.7) 78,725 (45.2) 82,543 (44.7) Chills 2,537 (24.4) 50,836 (29.2) 53,373 (28.9) Headache 4,447 (42.7) 95,713 (54.9) 100,160 (54.3) Shortness of breath 2,692 (25.9) 43,234 (24.8) 45,926 (24.9) Sore throat 2,955 (28.4) 60,218 (34.6) 63,173 (34.2) Diarrhea 1,479 (14.2) 38,165 (21.9) 39,644 (21.5) Nausea or vomiting 2,052 (19.7) 28,999 (16.6) 31,051 (16.8) Abdominal pain 870 (8.4) 16,123 (9.3) 16,993 (9.2) Runny nose 1,328 (12.8) 22,750 (13.1) 24,078 (13.0) †† New loss of taste or smell 2,234 (21.5) 43,256 (24.8) 45,490 (24.6) Fatigue 1,404 (13.5) 29,788 (17.1) 31,192 (16.9) Wheezing 172 (1.7) 3,743 (2.1) 3,915 (2.1) Chest pain 369 (3.5) 7,079 (4.1) 7,448 (4.0) Underlying medical conditions §§ Known underlying medical condition status 7,795 160,065 167,860 Diabetes mellitus 427 (5.5) 6,119 (3.8) 6,546 (3.9) Cardiovascular disease 304 (3.9) 7,703 (4.8) 8,007 (4.8) Chronic lung disease 506 (6.5) 9,185 (5.7) 9,691 (5.8) Chronic renal disease 18 (0.2) 680 (0.4) 698 (0.4) Chronic liver disease 17 (0.2) 350 (0.2) 367 (0.2) Immunocompromised condition 124 (1.6) 2,496 (1.6) 2,620 (1.6) Neurologic disorder, neurodevelopmental disorder, or intellectual disability 44 (0.6) 1,097 (0.7) 1,141 (0.7) Psychiatric disorder 62 (0.8) 1,139 (0.7) 1,201 (0.7) Autoimmune disorder 26 (0.3) 515 (0.3) 541 (0.3) ¶¶ Severe obesity 174 (2.2) 1,810 (1.1) 1,984 (1.2) Abbreviations: AI/AN = American Indian or Alaska Native; NHPI = Native Hawaiian or Other Pacific Islander. * Women with known pregnancy status, representing 52% of 783,072 total cases among symptomatic women aged 15–44 years. All statistical comparisons were significant at α <0.01, with the exception of the comparison of prevalence of neurologic disorders between pregnant and nonpregnant women (p = 0.307). Race/ethnicity was missing for 6,059 (26%) of symptomatic pregnant women and 97,796 (26%) of symptomatic nonpregnant women. Data on individual symptoms were known for 10,404 (44%) of pregnant women and 174,198 (45%) of nonpregnant women. Individual symptoms were considered known if any of the following symptoms were noted as present or absent on the CDC’s Human Infection with 2019 Novel Coronavirus Case Report Form: fever (measured >100.4°F [38°C] or subjective), cough, shortness of breath, wheezing, difficulty breathing, chills, rigors, myalgia, rhinorrhea, sore throat, chest pain, nausea or vomiting, abdominal pain, headache, fatigue, diarrhea (three or more loose stools in a 24-hour period), new olfactory or taste disorder, or other symptom not otherwise specified on the form. ** Patients were included if they had information for either measured or subjective fever variables and were considered to have a fever if “yes” was indicated for either variable. †† New olfactory and taste disorder has only been included on the CDC’s Human Infection with 2019 Novel Coronavirus Case Report Form since May 5, 2020. Therefore, data might be underreported for this symptom. §§ Status was classified as “known” if any of the following conditions were noted as present or absent on the CDC’s Human Infection with 2019 Novel Coronavirus Case Report Form: diabetes mellitus, cardiovascular disease (including hypertension), severe obesity (body mass index ≥40 kg/m ), chronic renal disease, chronic liver disease, chronic lung disease, immunosuppressive condition, autoimmune condition, neurologic condition (including neurodevelopmental, intellectual, physical, visual, or hearing impairment), psychological/psychiatric condition, and other underlying medical condition not otherwise specified. ¶¶ 2 Defined as body mass index ≥40 kg/m . US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 6, 2020 / Vol. 69 / No. 44 1643 Morbidity and Mortality Weekly Report TABLE 2. Intensive care unit (ICU) admissions, receipt of invasive ventilation, receipt of extracorporeal membrane oxygenation (ECMO), and deaths among symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 (N = 409,462), by pregnancy status, age, race/ ethnicity, and underlying health conditions — United States, January 22–October 3, 2020 No. (per 1,000 cases) of symptomatic women Risk ratio (95% CI) Pregnant Nonpregnant † †,§ Outcome*/Characteristic (n = 23,434) (n = 386,028) Crude Adjusted ICU admission All 245 (10.5) 1,492 (3.9) 2.7 (2.4–3.1) 3.0 (2.6–3.4) Age group, yrs 15–24 49 (7.6) 244 (1.8) 4.1 (3.0–5.6) 3.9 (2.8–5.3) 25–34 118 (9.1) 467 (3.5) 2.6 (2.1–3.1) 2.4 (2.0–3.0) 35–44 78 (19.4) 781 (6.4) 3.0 (2.4–3.8) 3.2 (2.5–4.0) Race/Ethnicity Hispanic or Latina 89 (12.8) 429 (5.0) 2.6 (2.0–3.2) 2.8 (2.2–3.5) AI/AN, non-Hispanic 0 (0) 13 (7.9) NA NA Asian, non-Hispanic 20 (35.7) 52 (6.0) 5.9 (3.6–9.8) 6.6 (4.0–11.0) Black, non-Hispanic 46 (13.6) 334 (6.2) 2.2 (1.6–3.0) 2.8 (2.0–3.8) NHPI, non-Hispanic 5 (42.0) 22 (14.4) 2.9 (1.1–7.6) 3.7 (1.3–10.1) White, non-Hispanic 31 (5.6) 348 (2.8) 2.0 (1.4–2.9) 2.3 (1.6–3.3) Multiple or other race, non-Hispanic 8 (11.0) 37 (3.0) 3.7 (1.7–7.9) 4.1 (1.9–8.9) Unknown/Not reported 46 (7.6) 257 (2.6) 2.9 (2.1–3.9) 3.4 (2.5–4.7) Underlying health conditions Diabetes 25 (58.5) 274 (44.8) 1.3 (0.9–1.9) 1.5 (1.0–2.2) CVD** 13 (42.8) 247 (32.1) 1.3 (0.8–2.3) 1.5 (0.9–2.6) Chronic lung disease 15 (29.6) 179 (19.5) 1.5 (0.9–2.6) 1.7 (1.0–2.8) †† Invasive ventilation All 67 (2.9) 412 (1.1) 2.7 (2.1–3.5) 2.9 (2.2–3.8) Age group, yrs §§ 15–24 11 (1.7) 68 (0.5) 3.3 (1.8–6.3) 3.0 (1.6–5.7) §§ 25–34 30 (2.3) 123 (0.9) 2.5 (1.7–3.7) 2.5 (1.6–3.7) 35–44 26 (6.5) 221 (1.8) 3.5 (2.4–5.3) 3.6 (2.4–5.4) Race/Ethnicity Hispanic or Latina 33 (4.7) 143 (1.7) 2.8 (1.9–4.1) 3.0 (2.1–4.5) AI/AN, non-Hispanic 0 (0) 5 (3.0) NA NA Asian, non-Hispanic 4 (7.1) 19 (2.2) NA NA Black, non-Hispanic 10 (3) 86 (1.6) 1.9 (1.0–3.6) 2.5 (1.3–4.9) NHPI, non-Hispanic 4 (33.6) 10 (6.6) NA NA White, non-Hispanic 12 (2.2) 102 (0.8) 2.7 (1.5–4.8) 3.0 (1.7–5.6) Multiple or other race, non-Hispanic 0 (0) 8 (0.6) NA NA Unknown/Not reported 4 (0.7) 39 (0.4) NA NA Underlying health conditions Diabetes 10 (23.4) 98 (16.0) 1.5 (0.8–2.8) 1.7 (0.9–3.3) ¶¶ CVD** 6 (19.7) 82 (10.6) 1.9 (0.8–4.2) 1.9 (0.8–4.5) Chronic lung disease 4 (7.9) 50 (5.4) NA NA ECMO*** All 17 (0.7) 120 (0.3) 2.3 (1.4–3.9) 2.4 (1.5–4.0) Age group,yrs ††† 15–24 6 (0.9) 31 (0.2) 4.0 (1.7–9.5) NA §§ 25–34 7 (0.5) 35 (0.3) 2.0 (0.9–4.6) 2.0 (0.9–4.4) 35–44 4 (1.0) 54 (0.4) NA NA Race/Ethnicity Hispanic or Latina 6 (0.9) 35 (0.4) 2.1 (0.9–5.0) 2.4 (1.0–5.9) AI/AN, non-Hispanic 0 (0) 1 (0.6) NA NA Asian, non-Hispanic 0 (0) 1 (0.1) NA NA Black, non-Hispanic 5 (1.5) 30 (0.6) 2.7 (1.0–6.9) 2.9 (1.1–7.3) NHPI, non-Hispanic 0 (0) 2 (1.3) NA NA White, non-Hispanic 4 (0.7) 29 (0.2) NA NA Multiple or other race, non-Hispanic 0 (0) 3 (0.2) NA NA Unknown/Not reported 2 (0.3) 19 (0.2) NA NA See table footnotes on the next page. 1644 MMWR / November 6, 2020 / Vol. 69 / No. 44 US Department of Health and Human Services/Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. (Continued) Intensive care unit (ICU) admissions, receipt of invasive ventilation, receipt of extracorporeal membrane oxygenation (ECMO), and deaths among symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 (N = 409,462), by pregnancy status, age, race/ethnicity, and underlying health conditions — United States, January 22–October 3, 2020 No. (per 1,000 cases) of symptomatic women Risk ratio (95% CI) Pregnant Nonpregnant † †,§ Outcome*/Characteristic (n = 23,434) (n = 386,028) Crude Adjusted Underlying health conditions Diabetes 1 (2.3) 13 (2.1) NA NA CVD** 1 (3.3) 20 (2.6) NA NA Chronic lung disease 1 (2.0) 20 (2.2) NA NA §§§ Death All 34 (1.5) 447 (1.2) 1.3 (0.9–1.8) 1.7 (1.2–2.4) Age group, yrs 15–24 2 (0.3) 40 (0.3) NA NA 25–34 15 (1.2) 125 (0.9) 1.2 (0.7–2.1) 1.2 (0.7–2.1) 35–44 17 (4.2) 282 (2.3) 1.8 (1.1–3.0) 2.0 (1.2–3.2) Race/Ethnicity Hispanic or Latina 14 (2.0) 87 (1.0) 2.0 (1.1–3.5) 2.4 (1.3–4.3) AI/AN, non-Hispanic 0 (0) 5 (3.0) NA NA Asian, non-Hispanic 1 (1.8) 11 (1.3) NA NA Black, non-Hispanic 9 (2.7) 167 (3.1) 0.9 (0.4–1.7) 1.4 (0.7–2.7) NHPI, non-Hispanic 2 (16.8) 6 (3.9) NA NA White, non-Hispanic 3 (0.5) 83 (0.7) NA NA Multiple or other race, non-Hispanic 0 (0) 12 (1.0) NA NA Unknown/Not reported 5 (0.8) 76 (0.8) 1.1 (0.4–2.6) 1.4 (0.6–3.6) Underlying health conditions ¶¶¶ Diabetes 6 (14.1) 78 (12.7) 1.1 (0.5–2.5) 1.5 (0.6–3.5) CVD** 7 (23.0) 89 (11.6) 2.0 (0.9–4.3) 2.2 (1.0–4.8)**** Chronic lung disease 1 (2.0) 37 (4.0) NA NA Abbreviations: AI/AN  =  American Indian/Alaska Native; CI  =  confidence interval; CVD  =  cardiovascular disease; NA = not applicable; NHPI = Native Hawaiian or Other Pacific Islander. * Percentages calculated among total in pregnancy status group. Crude and adjusted risk ratios were not calculated for cell sizes <5. Adjusted for age (continuous variable, in years), categorical race/ethnicity variable, and dichotomous indicators for diabetes, cardiovascular disease, and chronic lung disease. A total of 17,007 (72.6%) symptomatic pregnant women and 291,539 (75.5%) symptomatic nonpregnant women were missing information on ICU admission status; however, while hospital admission status was not separately analyzed, hospitalization status was missing for 2,393 (10.2%) symptomatic pregnant women and 35,624 (9.2%) of symptomatic nonpregnant women, and no hospital admission was reported for 16,672 (71.1%) pregnant and 337,414 (87.4%) nonpregnant women. Therefore, in the absence of reported hospital admissions, women with missing ICU admission information were assumed to have not been admitted to the ICU. ** Cardiovascular disease also accounts for presence of hypertension. †† A total of 17,903 (76.4%) pregnant women and 299,413 (77.6%) nonpregnant women were missing information regarding receipt of invasive ventilation and were assumed to have not received it. §§ Adjusted for the presence of diabetes, CVD, and chronic lung disease only, and removed race/ethnicity from adjustment set because of model convergence issues. ¶¶ Adjusted for the presence of diabetes and chronic lung disease and age as a continuous covariate only and removed race/ethnicity from adjustment set because of model convergence issues. *** A total of 18,246 (77.9%) pregnant women and 298,608 (77.4%) nonpregnant women were missing information for receipt of ECMO and were assumed to have not received ECMO. ††† Model failed to converge even after adjustment for a reduced set of covariates. §§§ A total of 5,152 (22.0%) pregnant women and 66,346 (17.2%) nonpregnant women were missing information on death and were assumed to have survived. ¶¶¶ Adjusted for the presence of CVD and chronic lung disease and age as a continuous variable. **** Adjusted for presence of diabetes and chronic lung disease and age as a continuous variable. for patients who meet standard case definitions. The mecha- status was missing for over one half (64.5%) of reported cases, nism used to report cases and the capacity to investigate cases and among those with known pregnancy status, data on race/ §§§ varies across jurisdictions. Thus, case information is limited ethnicity were missing for approximately 25% of cases, and or unavailable for a portion of detected COVID-19 cases, and information on symptoms and underlying conditions was reported case data might be updated at any time. This analysis missing for approximately one half. Second, when estimating was restricted to women with known age; however, pregnancy the proportion of cases with severe outcomes, the observational §§§ https://www.cdc.gov/coronavirus/2019-ncov/covid-data/faq-surveillance.html. US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 6, 2020 / Vol. 69 / No. 44 1645 Morbidity and Mortality Weekly Report Understanding the risk posed by SARS-CoV-2 infec- Summary tion in pregnant women can inform clinical practice, risk What is already known about this topic? communication, and medical countermeasure allocation. Limited information suggests that pregnant women with Pregnant women should be informed of their risk for severe COVID-19 might be at increased risk for severe illness compared COVID-19–associated illness and the warning signs of with nonpregnant women. severe COVID-19.**** To minimize the risk for acquiring What is added by this report? SARS-CoV-2 infection, pregnant women should limit unnec- In an analysis of approximately 400,000 women aged essary interactions with persons who might have been exposed 15–44 years with symptomatic COVID-19, intensive care unit to or are infected with SARS-CoV-2, including those within admission, invasive ventilation, extracorporeal membrane †††† §§§§ their household, as much as possible. When going oxygenation, and death were more likely in pregnant women out or interacting with others, pregnant women should wear than in nonpregnant women. a mask, social distance, avoid persons who are not wearing a What are the implications for public health practice? mask, and frequently wash their hands. In addition, pregnant Pregnant women should be counseled about the risk for severe women should take measures to ensure their general health, COVID-19–associated illness including death; measures to prevent infection with SARS-CoV-2 should be emphasized for including staying up to date with annual influenza vaccination pregnant women and their families. These findings can inform and prenatal care. Providers who care for pregnant women clinical practice, risk communication, and medical should be familiar with guidelines for medical management countermeasure allocation. of COVID-19, including considerations for management ¶¶¶¶, of COVID-19 in pregnancy. ***** Additional data data collected through passive surveillance might be subject from surveillance and cohort studies on COVID-19 sever- to reporting bias, wherein preferential ascertainment of severe ity during pregnancy are necessary to inform messaging and cases is likely (6,7); therefore, the frequency of reported out- patient counseling. comes incorporates a denominator of all cases as a conservative **** https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms. estimate. Finally, severe outcomes might require additional html. time to be ascertained. To account for this, a time lag was †††† https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/care-for- incorporated, such that data reported as of October 28, 2020, someone.html#face-covering. §§§§ https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/ were used for cases reported as of October 3. pregnancy-breastfeeding.html. This analysis supports previous findings that pregnancy is ¶¶¶¶ https://www.covid19treatmentguidelines.nih.gov/. ***** https://www.acog.org/en/Topics/COVID-19. associated with increased risk for ICU admission and receipt of invasive ventilation among women of reproductive age with Acknowledgments COVID-19 (1,2). In the current report, an increased risk for State, local, and territorial health department personnel; U.S. clinical, receiving ECMO and death was also observed, which are two public health, and emergency response staff members; Kathleen E. additional important markers of COVID-19 severity that sup- Fullerton, Erin K. Stokes, CDC; CDC Epidemiology Studies Task Force port previous findings. In comparison to influenza, a recent Pregnancy and Infant Linked Outcomes Team; CDC Data, Analytics, meta-analysis found no increased risk for ICU admission or and Modeling Task Force Case Surveillance Section. death among pregnant women with seasonal influenza (8). CDC COVID-19 Response Pregnancy and Infant Linked However, data from previous influenza pandemics, including Outcomes Team 2009 H1N1, have shown that pregnant women are at increased risk for severe outcomes including death and the absolute Amanda Akosa, Eagle Global Scientific; Carolyne Bennett, Eagle Global Scientific; Veronica Burkel, Eagle Medical; Daniel Chang, Oak risks for severe outcomes were higher than in this study of Ridge Institute for Science and Education; Augustina Delaney, CDC; COVID-19 during pregnancy (9). Longitudinal surveillance Charise Fox, Oak Ridge Institute for Science and Education; Isabel and cohort studies among pregnant women with COVID-19, Griffin, Eagle Global Scientific; Jason Hsia, CDC; Katie Krause, CDC; including information about pregnancy outcomes, are neces- Elizabeth Lewis, CDC; Susan Manning, CDC; Yousra Mohamoud, sary to understand the full spectrum of maternal and neonatal CDC; Suzanne Newton, CDC; Varsha Neelam, CDC; Emily O’Malley outcomes associated with COVID-19 in pregnancy. CDC, in Olsen, CDC; Mirna Perez, CDC; Megan Reynolds, CDC; Aspen Riser, collaboration with health departments, has adapted SET-NET CDC; Maria Rivera, CDC; Nicole M. Roth, Eagle Global Scientific; to collect pregnancy-related information and pregnancy and Christina Sancken, CDC; Neha Shinde, Eagle Global Scientific; neonatal outcomes among women with COVID-19 during Ashley Smoots, CDC; Margaret Snead, CDC; Bailey Wallace, CDC; ¶¶¶ pregnancy (3). Florence Whitehill, Oak Ridge Institute for Science and Education; Erin Whitehouse, CDC; Lauren Zapata, CDC. ¶¶¶ https://www.cdc.gov/ncbddd/aboutus/pregnancy/emerging-threats.html. 1646 MMWR / November 6, 2020 / Vol. 69 / No. 44 US Department of Health and Human Services/Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Corresponding author: Sascha Ellington for the CDC COVID-19 Response 4. Vlachodimitropoulou Koumoutsea E, Vivanti AJ, Shehata N, et al. Pregnancy and Infant Linked Outcomes Team, eocevent397@cdc.gov. COVID-19 and acute coagulopathy in pregnancy. J Thromb Haemost 2020;18:1648–52. https://doi.org/10.1111/jth.14856 CDC COVID-19 Response Team. 5. Ramsey PS, Ramin KD. Pneumonia in pregnancy. Obstet Gynecol Clin North Am 2001;28:553–69. https://doi.org/10.1016/S0889-8545(05)70217-5 All authors have completed and submitted the International 6. Lipsitch M, Donnelly CA, Fraser C, et al. Potential biases in estimating Committee of Medical Journal Editors form for disclosure of potential absolute and relative case-fatality risks during outbreaks. PLoS Negl Trop conflicts of interest. No potential conflicts of interest were disclosed. Dis 2015;9:e0003846. https://doi.org/10.1371/journal.pntd.0003846 7. World Health Organization. Immunization, vaccines and biologicals: References national passive surveillance. Geneva, Switzerland: World Health Organization; 2020. https://www.who.int/immunization/monitoring_ 1. Ellington S, Strid P, Tong VT, et al. Characteristics of women of surveillance/burden/vpd/surveillance_type/passive/en reproductive age with laboratory-confirmed SARS-CoV-2 infection by 8. Mertz D, Lo CK, Lytvyn L, Ortiz JR, Loeb M; FLURISK-INVESTIGATORS. pregnancy status—United States, January 22–June 7, 2020. MMWR Pregnancy as a risk factor for severe influenza infection: an individual Morb Mortal Wkly Rep 2020;69:769–75. https://doi.org/10.15585/ participant data meta-analysis. BMC Infect Dis 2019;19:683. https:// mmwr.mm6925a1 doi.org/10.1186/s12879-019-4318-3 2. Allotey J, Stallings E, Bonet M, et al.; PregCOV-19 Living Systematic 9. Rasmussen SA, Jamieson DJ, Uyeki TM. Effects of influenza on pregnant Review Consortium. Clinical manifestations, risk factors, and maternal women and infants. Am J Obstet Gynecol 2012;207(Suppl):S3–8. https:// and perinatal outcomes of coronavirus disease 2019 in pregnancy: living doi.org/10.1016/j.ajog.2012.06.068 systematic review and meta-analysis. BMJ 2020;370:m3320. https://doi. org/10.1136/bmj.m3320 3. Woodworth KR, Olsen EO, Neelam V, et al. Birth and infant outcomes following laboratory-confirmed SARS-CoV-2 infection in pregnancy— SET-NET, 16 jurisdictions, March 29–October 14, 2020. MMWR Morb Mortal Wkly Rep 2020;69. Epub November 2, 2020. 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