Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
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Query Trace: Petersen EE[original query] |
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Pregnancy-Related Mortality Due to Cardiovascular Conditions: Maternal Mortality Review Committees in 32 U.S. States, 2017 to 2019
Briller J , Trost SL , Busacker A , Joseph NT , Davis NL , Petersen EE , Goodman DA , Hollier LM . JACC Advances 2024 3 (12) Background: Cardiomyopathy (CM) and other cardiovascular conditions (OCVs) are among the most frequent causes of pregnancy-related death in the United States. Objectives: The purpose of this paper was to report demographic and clinical characteristics, preventability, contributing factors, and Maternal Mortality Review Committee (MMRC) recommendations among pregnancy-related deaths with underlying causes of CM, OCVs, and the 2 combined (cardiovascular conditions, CV). Methods: We analyzed pregnancy-related death data from MMRCs in 32 states, occurring during 2017 to 2019, with MMRC-determined underlying causes of CVs. We describe distributions of demographic characteristics, present the most frequent contributing factor classes, and provide example MMRC prevention recommendations. Results: Among 210 pregnancy-related deaths due to CVs, 84 (40%) were due to CM and 126 (60%) to OCVs. More than half (51.2%) of CM deaths were among non-Hispanic Black persons. Two-thirds (66%) of all CV deaths occurred among people <35 years old. Approximately 53% of CM deaths and 31% of OCV deaths occurred 43 to 365 days postpartum. Over 75% of pregnancy-related deaths due to CVs were determined by MMRCs to be preventable. The 5 most frequent contributing factor classes accounted for 50% of the total MMRC-identified contributing factors. MMRC prevention recommendations occur at multiple levels. Conclusions: Most pregnancy-related deaths due to CM and OCV are preventable. Example MMRC recommendations provided in this report illustrate prevention opportunities that address contributing factors, including broader awareness of urgent warning signs, improved handoffs for care coordination and continuity, and expanded accessibility of community-based comprehensive and integrated care services. © 2024 The Authors |
Pregnancy-related deaths by Hispanic origin, United States, 2009-2018
Parker-Collins W , Njie F , Goodman DA , Cox S , Chang J , Petersen EE , Beauregard JL . J Womens Health (Larchmt) 2023 32 (12) 1320-1327 Objective: To describe pregnancy-related mortality among Hispanic people by place of origin (country or region of Hispanic ancestry), 2009-2018. Materials and Methods: We conducted a cross-sectional descriptive study of pregnancy-related deaths among Hispanic people, stratified by place of origin (Central or South America, Cuba, Dominican Republic, Mexico, Puerto Rico, Other and Unknown Hispanic), using Pregnancy Mortality Surveillance System data, 2009-2018. We describe distributions of pregnancy-related deaths and pregnancy-related mortality ratios (number of pregnancy-related deaths per 100,000 live births) overall and by place of origin for select demographic and clinical characteristics. Results: For 2009-2018, the overall pregnancy-related mortality ratio among Hispanic people was 11.5 pregnancy-related deaths per 100,000 live births (95% confidence intervals [CI]: 10.8-12.2). In general, pregnancy-related mortality ratios were higher among older age groups (i.e., 35 years and older) and lower among those with higher educational attainment (i.e., college degree or higher). Approximately two in five pregnancy-related deaths among Hispanic people occurred on the day of delivery through 6 days postpartum. Place of origin-specific pregnancy-related mortality ratios ranged from 9.6 (95% CI: 5.8-15.0) among people of Cuban origin to 15.3 (95% CI: 12.4-18.3) among people of Puerto Rican origin. Hemorrhage and infection were the most frequent causes of pregnancy-related deaths overall among Hispanic people. People of Puerto Rican origin had a higher proportion of deaths because of cardiomyopathy. Conclusions: We identified differences in pregnancy-related mortality by place of origin among Hispanic people that can help inform prevention of pregnancy-related deaths. |
Identifying deaths during and after pregnancy: New approaches to a perennial challenge
Trost SL , Beauregard J , Petersen EE , Cox S , Chandra G , St Pierre A , Rodriguez M , Goodman D . Public Health Rep 2022 138 (4) 333549221110487 Maternal mortality is increasingly recognized as a public health crisis in the United States, with growing attention on the 3 major systems of national surveillance. National maternal mortality statistics are reported by the Centers for Disease Control and Prevention’s (CDC’s) National Vital Statistics System (NVSS)1 within the National Center for Health Statistics (NCHS) and the Pregnancy Mortality Surveillance System (PMSS)2 within the Division of Reproductive Health (DRH). Comprehensive surveillance data at the state and local level are also available from maternal mortality review committees (MMRCs) via the Maternal Mortality Review Information Application (MMRIA).3 Each surveillance system has inherent strengths and limitations, but all rely on valid, accurate, and timely case identification via vital statistics data. We outline recent innovations to improve identification and ensure robust and accurate surveillance of maternal mortality in the United States. |
County-level associations between pregnancy-related mortality ratios and contextual sociospatial indicators
Barrera CM , Kramer MR , Merkt PT , Petersen EE , Brantley MD , Eckhaus L , Beauregard JL , Goodman DA . Obstet Gynecol 2022 139 (5) 855-865 OBJECTIVE: To characterize county-level differences in pregnancy-related mortality as a function of sociospatial indicators. METHODS: We conducted a cross-sectional multilevel analysis of all pregnancy-related deaths and all live births with available ZIP code or county data in the Pregnancy Mortality Surveillance System during 2011-2016 for non-Hispanic Black, Hispanic (all races), and non-Hispanic White women aged 15-44 years. The exposures included 31 conceptually-grounded, county-specific sociospatial indicators that were collected from publicly available data sources and categorized into domains of demographic; general, reproductive, and behavioral health; social capital and support; and socioeconomic contexts. We calculated the absolute difference of county-level pregnancy-related mortality ratios (deaths per 100,000 live births) per 1-unit increase in the median absolute difference between women living in counties with higher compared with lower levels of each sociospatial indicator overall and stratified by race and ethnicity. RESULTS: Pregnancy-related mortality varied across counties and by race and ethnicity. Many sociospatial indicators were associated with county-specific pregnancy-related mortality ratios independent of maternal age, population size, and Census region. Across domains, the most harmful indicators were percentage of low-birth-weight births (absolute ratio difference [RD] 6.44; 95% CI 5.36-7.51), percentage of unemployed adults (RD 4.98; 95% CI 3.91-6.05), and food insecurity (RD 4.92; 95% CI 4.14-5.70). The most protective indicators were higher median household income (RD -2.76; 95% CI -3.28 to -2.24), percentage of college-educated adults (RD -2.28; 95% CI -2.81 to -1.75), and percentage of owner-occupied households (RD -1.66; 95% CI -2.29 to -1.03). The magnitude of these associations varied by race and ethnicity. CONCLUSION: This analysis identified sociospatial indicators of pregnancy-related mortality and showed an association between pregnancy-related deaths and place of residence overall and stratified by race and ethnicity. Understanding county-level context associated with pregnancy-related mortality may be an important step towards building public health evidence to inform action to reduce pregnancy-related mortality at local levels. |
Abortion Surveillance - United States, 2019
Kortsmit K , Mandel MG , Reeves JA , Clark E , Pagano HP , Nguyen A , Petersen EE , Whiteman MK . MMWR Surveill Summ 2021 70 (9) 1-29 PROBLEM/CONDITION: CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States. PERIOD COVERED: 2019. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2019, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2010-2019. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2018 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS). RESULTS: A total of 629,898 abortions for 2019 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2010-2019, in 2019, a total of 625,346 abortions were reported, the abortion rate was 11.4 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 195 abortions per 1,000 live births. From 2018 to 2019, the total number of abortions increased 2% (from 614,820 total abortions), the abortion rate increased 0.9% (from 11.3 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 3% (from 189 abortions per 1,000 live births). From 2010 to 2019, the total number of reported abortions, abortion rate, and abortion ratio decreased 18% (from 762,755), 21% (from 14.4 abortions per 1,000 women aged 15-44 years), and 13% (from 225 abortions per 1,000 live births), respectively. In 2019, women in their 20s accounted for more than half of abortions (56.9%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (27.6% and 29.3%, respectively) and had the highest abortion rates (19.0 and 18.6 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.7 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2019 were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years. Abortion rates decreased from 2010 to 2019 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2018 to 2019, abortion rates decreased or did not change among women aged ≤24 years; however, the abortion rate increased among those aged ≥25 years. Abortion ratios also decreased or did not change from 2010 to 2019 for all age groups, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2018 to 2019, abortion ratios increased for all age groups, except adolescents aged <15 years. In 2019, 79.3% of abortions were performed at ≤9 weeks' gestation, and nearly all (92.7%) were performed at ≤13 weeks' gestation. During 2010-2019, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.0%). In 2019, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks' gestation (49.0%), followed by early medical abortion at ≤9 weeks' gestation (42.3%), surgical abortion at >13 weeks' gestation (7.2%), and medical abortion at >9 weeks' gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 53.7% of abortions were early medical abortions. In 2018, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women died as a result of complications from legal induced abortion. INTERPRETATION: Among the 48 areas that reported data continuously during 2010-2019, overall decreases were observed during 2010-2019 in the total number, rate, and ratio of reported abortions; however, from 2018 to 2019, 1%-3% increases were observed across all measures. PUBLIC HEALTH ACTION: Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies. |
Receipt of mRNA Covid-19 Vaccines and Risk of Spontaneous Abortion.
Zauche LH , Wallace B , Smoots AN , Olson CK , Oduyebo T , Kim SY , Petersen EE , Ju J , Beauregard J , Wilcox AJ , Rose CE , Meaney-Delman DM , Ellington SR . N Engl J Med 2021 385 (16) 1533-1535 Pregnant persons are at risk for severe coronavirus disease 2019 (Covid-19), and infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy is associated with increased risks of preterm birth and other adverse maternal and neonatal outcomes.1 Although spontaneous abortion (pregnancy loss occurring at less than 20 weeks of gestation) is a common pregnancy outcome affecting 11 to 22% of recognized pregnancies (see Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org),2-4 data to inform estimates of the risk of spontaneous abortion after receipt of an mRNA Covid-19 vaccine either before conception (30 days before the first day of the last menstrual period through 14 days after) or during pregnancy are limited. |
Urban-Rural Differences in Pregnancy-Related Deaths, United States, 2011-2016
Merkt PT , Kramer MR , Goodman DA , Brantley MD , Barrera CM , Eckhaus L , Petersen EE . Am J Obstet Gynecol 2021 225 (2) 183 e1-183 e16 BACKGROUND: The U.S. pregnancy-related mortality ratio has not improved over the past decade and includes striking disparities by race/ethnicity and by state. Understanding differences in pregnancy-related mortality across and within urban and rural areas can guide the development of interventions for preventing future pregnancy-related deaths. OBJECTIVE: We sought to compare pregnancy-related mortality across and within urban and rural counties by race/ethnicity and age. STUDY DESIGN: We conducted a descriptive analysis of 3,747 pregnancy-related deaths during 2011-2016 (the most recent available) with available ZIP code or county data in the Pregnancy Mortality Surveillance System, among Hispanic and non-Hispanic White, Black, American Indian/Alaska Native, and Asian/Pacific Islander women ages 15-44 years. We aggregated data by U.S. county and grouped counties per the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. We used R statistical software, epitools, to calculate the pregnancy-related mortality ratio (number of pregnancy-related deaths per 100,000 live births) for each urban-rural grouping, obtain 95% confidence intervals, and perform exact tests of ratio comparisons using the Poisson distribution. RESULTS: Of the total 3,747 pregnancy-related deaths analyzed, 52% occurred in large metro counties and 7% occurred in noncore (rural) counties. Large metro counties had the lowest pregnancy-related mortality ratio (14.8, 95% CI: 14.2-15.5) while noncore counties had the highest (24.1, 95% CI: 21.4-27.1), including for most race/ethnicity and age groups. Pregnancy-related mortality ratio age disparities increased with rurality. Women ages 25-34 years and ages 35-44 years living in noncore counties had pregnancy-related mortality ratios 1.5 and 3 times higher, respectively, than women of the same age groups in large metro counties. Within each urban-rural category, pregnancy-related mortality ratios were higher among non-Hispanic Black women compared to non-Hispanic White women. Non-Hispanic American Indian/Alaska Native pregnancy-related mortality ratios in small metro, micropolitan, and noncore counties were 2-3 times that of non-Hispanic White women in the same areas. CONCLUSION: Although more than half of pregnancy-related deaths occurred in large metro counties, the pregnancy-related mortality ratio rose with increasing rurality. Disparities existed among urban-rural categories, including by age group and by race/ethnicity. Geographic location is an important context for initiatives to prevent future deaths and eliminate disparities. Further research is needed to better understand reasons for the observed urban-rural differences and to guide a multifactorial response to reduce pregnancy-related deaths. |
Using supervised learning methods to develop a list of prescription medications of greatest concern during pregnancy
Ailes EC , Zimmerman J , Lind JN , Fan F , Shi K , Reefhuis J , Broussard CS , Frey MT , Cragan JD , Petersen EE , Polen KD , Honein MA , Gilboa SM . Matern Child Health J 2020 24 (7) 901-910 ![]() INTRODUCTION: Women and healthcare providers lack adequate information on medication safety during pregnancy. While resources describing fetal risk are available, information is provided in multiple locations, often with subjective assessments of available data. We developed a list of medications of greatest concern during pregnancy to help healthcare providers counsel reproductive-aged and pregnant women. METHODS: Prescription drug labels submitted to the U.S. Food and Drug Administration with information in the Teratogen Information System (TERIS) and/or Drugs in Pregnancy and Lactation by Briggs & Freeman were included (N = 1,186 medications; 766 from three data sources, 420 from two). We used two supervised learning methods ('support vector machine' and 'sentiment analysis') to create prediction models based on narrative descriptions of fetal risk. Two models were created per data source. Our final list included medications categorized as 'high' risk in at least four of six models (if three data sources) or three of four models (if two data sources). RESULTS: We classified 80 prescription medications as being of greatest concern during pregnancy; over half were antineoplastic agents (n = 24), angiotensin converting enzyme inhibitors (n = 10), angiotensin II receptor antagonists (n = 8), and anticonvulsants (n = 7). DISCUSSION: This evidence-based list could be a useful tool for healthcare providers counseling reproductive-aged and pregnant women about medication use during pregnancy. However, providers and patients may find it helpful to weigh the risks and benefits of any pharmacologic treatment for both pregnant women and the fetus when managing medical conditions before and during pregnancy. |
Hospitalizations and deaths associated with EVALI
Werner AK , Koumans EH , Chatham-Stephens K , Salvatore PP , Armatas C , Byers P , Clark CR , Ghinai I , Holzbauer SM , Navarette KA , Danielson ML , Ellington S , Moritz ED , Petersen EE , Kiernan EA , Baldwin GT , Briss P , Jones CM , King BA , Krishnasamy V , Rose DA , Reagan-Steiner S . N Engl J Med 2020 382 (17) 1589-1598 BACKGROUND: As of January 7, 2020, a total of 2558 hospitalized patients with nonfatal cases and 60 patients with fatal cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC). METHODS: In a national study, we compared the characteristics of patients with fatal cases of EVALI with those of patients with nonfatal cases to improve the ability of clinicians to identify patients at increased risk for death from the condition. Health departments reported cases of EVALI to the CDC and included, when available, data from medical-record abstractions and patient interviews. Analyses included all the patients with fatal or nonfatal cases of EVALI that were reported to the CDC as of January 7, 2020. We also present three case reports of patients who died from EVALI to illustrate the clinical characteristics common among such patients. RESULTS: Most of the patients with fatal or nonfatal cases of EVALI were male (32 of 60 [53%] and 1666 of 2498 [67%], respectively). The proportion of patients with fatal or nonfatal cases was higher among those who were non-Hispanic white (39 of 49 [80%] and 1104 of 1818 [61%], respectively) than among those in other race or ethnic groups. The proportion of patients with fatal cases was higher among those 35 years of age or older (44 of 60 [73%]) than among those younger than 35 years, but the proportion with nonfatal cases was lower among those 35 years of age or older (551 of 2514 [22%]). Among the patients who had an available medical history, a higher proportion of those with fatal cases than those with nonfatal cases had a history of asthma (13 of 57 [23%] vs. 102 of 1297 [8%]), cardiac disease (26 of 55 [47%] vs. 115 of 1169 [10%]), or a mental health condition (32 of 49 [65%] vs. 575 of 1398 [41%]). A total of 26 of 50 patients (52%) with fatal cases had obesity. Half the patients with fatal cases (25 of 54 [46%]) were seen in an outpatient setting before hospitalization or death. CONCLUSIONS: Chronic conditions, including cardiac and respiratory diseases and mental health conditions, were common among hospitalized patients with EVALI. |
Update: Characteristics of patients in a national outbreak of e-cigarette, or vaping, product use-associated lung injuries - United States, October 2019
Moritz ED , Zapata LB , Lekiachvili A , Glidden E , Annor FB , Werner AK , Ussery EN , Hughes MM , Kimball A , DeSisto CL , Kenemer B , Shamout M , Garcia MC , Reagan-Steiner S , Petersen EE , Koumans EH , Ritchey MD , King BA , Jones CM , Briss PA , Delaney L , Patel A , Polen KD , Sives K , Meaney-Delman D , Chatham-Stephens K . MMWR Morb Mortal Wkly Rep 2019 68 (43) 985-989 CDC, the Food and Drug Administration, state and local health departments, and other public health and clinical stakeholders are investigating a national outbreak of electronic-cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) (1). As of October 22, 2019, 49 states, the District of Columbia (DC), and the U.S. Virgin Islands have reported 1,604 cases of EVALI to CDC, including 34 (2.1%) EVALI-associated deaths in 24 states. Based on data collected as of October 15, 2019, this report updates data on patient characteristics and substances used in e-cigarette, or vaping, products (2) and describes characteristics of EVALI-associated deaths. The median age of EVALI patients who survived was 23 years, and the median age of EVALI patients who died was 45 years. Among 867 (54%) EVALI patients with available data on use of specific e-cigarette, or vaping, products in the 3 months preceding symptom onset, 86% reported any use of tetrahydrocannabinol (THC)-containing products, 64% reported any use of nicotine-containing products, and 52% reported use of both. Exclusive use of THC-containing products was reported by 34% of patients and exclusive use of nicotine-containing products by 11%, and for 2% of patients, no use of either THC- or nicotine-containing products was reported. Among 19 EVALI patients who died and for whom substance use data were available, 84% reported any use of THC-containing products, including 63% who reported exclusive use of THC-containing products; 37% reported any use of nicotine-containing products, including 16% who reported exclusive use of nicotine-containing products. To date, no single compound or ingredient used in e-cigarette, or vaping, products has emerged as the cause of EVALI, and there might be more than one cause. Because most patients reported using THC-containing products before symptom onset, CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific compound or ingredient causing lung injury is not yet known, and while the investigation continues, persons should consider refraining from the use of all e-cigarette, or vaping, products. |
Pregnant Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors
Catalano A , Davis NL , Petersen EE , Harrison C , Kieltyka L , You M , Conrey EJ , Ewing AC , Callaghan WM , Goodman D . Am J Obstet Gynecol 2019 222 (3) 269 e1-269 e8 BACKGROUND: Maternal mortality rates in the United States appear to be increasing. One potential reason may be increased identification of maternal deaths after the addition of a pregnancy checkbox to the death certificate. In 2016, four state health departments (Georgia, Louisiana, Michigan, Ohio) implemented a pregnancy checkbox quality assurance pilot, with technical assistance provided by the Centers for Disease Control and Prevention. The pilot aimed to improve accuracy of the pregnancy checkbox on death certificates and resultant state maternal mortality estimates. OBJECTIVE(S): To estimate the validity of the pregnancy checkbox on the death certificate and describe characteristics associated with errors using 2016 data from a four state quality assurance pilot. STUDY DESIGN: Potential pregnancy-associated deaths were identified by linking death certificates with birth or fetal death certificates from within a year preceding death or by pregnancy checkbox status. Death certificates which indicated the decedent was pregnant within a year of death via the pregnancy checkbox, but that did not link to a birth or fetal death certificate, were referred for active follow-up to confirm pregnancy status by either death certifier confirmation or medical record review. Descriptive statistics and 95% confidence intervals were used to examine the distributions of demographic characteristics by pregnancy confirmation category (i.e., confirmed pregnant, confirmed not pregnant, and unable to confirm). We compared the proportion confirmed pregnant and confirmed not pregnant within age, race/ethnicity, pregnancy checkbox category, and certifier type categories using a Wald test of proportions. Binomial and Poisson regression models were used to estimate prevalence ratios for having an incorrect pregnancy checkbox (false positive, false negative) by age group, race/ethnicity, pregnancy checkbox category, and certifier type. RESULTS: Among 467 potential pregnancy-associated deaths, 335 (72%) were confirmed pregnant either via linkage to a birth or fetal death certificate, certifier confirmation, or review of medical records. Ninety-seven (21%) women were confirmed not pregnant (false positives) and 35 (7%) were unable to be confirmed. Women confirmed pregnant were significantly younger than women confirmed not pregnant (p<.001). Deaths certified by coroners and medical examiners were more likely to be confirmed pregnant than confirmed not pregnant (p=0.04). The association between decedent age category and false positive status followed a dose-response relationship (p<0.001), with increasing prevalence ratios for each increase in age category. Death certificates of non-Hispanic black women were more likely to be false positives, compared with non-Hispanic white women [prevalence ratio (PR) 1.41, 95% confidence interval (CI) 1.01, 1.96]. The sensitivity of the pregnancy checkbox among these four states in 2016 was 62% and the positive predictive value was 68%. CONCLUSION(S): We provide a multi-state analysis of the validity of the pregnancy checkbox and highlight a need for more accurate reporting of pregnancy status on death certificates. States and other jurisdictions may increase the accuracy of their data used to calculate maternal mortality rates by implementing quality assurance processes. |
Update: Interim guidance for health care providers evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung injury - United States, October 2019
Siegel DA , Jatlaoui TC , Koumans EH , Kiernan EA , Layer M , Cates JE , Kimball A , Weissman DN , Petersen EE , Reagan-Steiner S , Godfred-Cato S , Moulia D , Moritz E , Lehnert JD , Mitchko J , London J , Zaki SR , King BA , Jones CM , Patel A , Meaney Delman D , Koppaka R . MMWR Morb Mortal Wkly Rep 2019 68 (41) 919-927 Forty-nine states, the District of Columbia, and one U.S. territory have reported 1,299 cases of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. Twenty-six deaths have been reported from 21 states. Based on the most current data, CDC's updated interim guidance provides a framework for health care providers in their initial assessment, evaluation, management, and follow-up of persons with symptoms of e-cigarette, or vaping, product use associated lung injury (EVALI). Rapid recognition by health care providers of patients with EVALI and an increased understanding of treatment considerations could reduce morbidity and mortality associated with this injury. |
Racial/ethnic disparities in pregnancy-related deaths - United States, 2007-2016
Petersen EE , Davis NL , Goodman D , Cox S , Syverson C , Seed K , Shapiro-Mendoza C , Callaghan WM , Barfield W . MMWR Morb Mortal Wkly Rep 2019 68 (35) 762-765 Approximately 700 women die in the United States each year as a result of pregnancy or its complications, and significant racial/ethnic disparities in pregnancy-related mortality exist (1). Data from CDC's Pregnancy Mortality Surveillance System (PMSS) for 2007-2016 were analyzed. Pregnancy-related mortality ratios (PRMRs) (i.e., pregnancy-related deaths per 100,000 live births) were analyzed by demographic characteristics and state PRMR tertiles (i.e., states with lowest, middle, and highest PRMR); cause-specific proportionate mortality by race/ethnicity also was calculated. Over the period analyzed, the U.S. overall PRMR was 16.7 pregnancy-related deaths per 100,000 births. Non-Hispanic black (black) and non-Hispanic American Indian/Alaska Native (AI/AN) women experienced higher PRMRs (40.8 and 29.7, respectively) than did all other racial/ethnic groups. This disparity persisted over time and across age groups. The PRMR for black and AI/AN women aged >/=30 years was approximately four to five times that for their white counterparts. PRMRs for black and AI/AN women with at least some college education were higher than those for all other racial/ethnic groups with less than a high school diploma. Among state PRMR tertiles, the PRMRs for black and AI/AN women were 2.8-3.3 and 1.7-3.3 times as high, respectively, as those for non-Hispanic white (white) women. Significant differences in cause-specific proportionate mortality were observed among racial/ethnic populations. Strategies to address racial/ethnic disparities in pregnancy-related deaths, including improving women's health and access to quality care in the preconception, pregnancy, and postpartum periods, can be implemented through coordination at the community, health facility, patient, provider, and system levels. |
Vital Signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017
Petersen EE , Davis NL , Goodman D , Cox S , Mayes N , Johnston E , Syverson C , Seed K , Shapiro-Mendoza CK , Callaghan WM , Barfield W . MMWR Morb Mortal Wkly Rep 2019 68 (18) 423-429 BACKGROUND: Approximately 700 women die from pregnancy-related complications in the United States every year. METHODS: Data from CDC's national Pregnancy Mortality Surveillance System (PMSS) for 2011-2015 were analyzed. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics. The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated. Detailed data on pregnancy-related deaths during 2013-2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors. RESULTS: For 2011-2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1-6 days postpartum, 21.4% 7-42 days postpartum, and 11.7% 43-365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. MMRC data indicated that multiple factors contributed to pregnancy-related deaths. Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care. CONCLUSIONS: Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. Approximately three in five pregnancy-related deaths were preventable. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Strategies to address contributing factors to pregnancy-related deaths can be enacted at the community, health facility, patient, provider, and system levels. |
Public health approach to addressing the needs of children affected by congenital Zika syndrome
Broussard CS , Shapiro-Mendoza CK , Peacock G , Rasmussen SA , Mai CT , Petersen EE , Galang RR , Newsome K , Reynolds MR , Gilboa SM , Boyle CA , Moore CA . Pediatrics 2018 141 S146-s153 We have learned much about the short-term sequelae of congenital Zika virus (ZIKV) infection since the Centers for Disease Control and Prevention activated its ZIKV emergency response in January 2016. Nevertheless, gaps remain in our understanding of the full spectrum of adverse health outcomes related to congenital ZIKV infection and how to optimize health in those who are affected. To address the remaining knowledge gaps, support affected children so they can reach their full potential, and make the best use of available resources, a carefully planned public health approach in partnership with pediatric health care providers is needed. An essential step is to use population-based data captured through surveillance systems to describe congenital Zika syndrome. Another key step is using collected data to investigate why some children exhibit certain sequelae during infancy and beyond, whereas others do not, and to describe the clustering of anomalies and the timing of when these anomalies occur, among other research questions. The final critical step in the public health framework for congenital Zika syndrome is an intervention strategy with evidence-based best practices for longer-term monitoring and care. Adherence to recommended evaluation and management procedures for infants with possible congenital ZIKV infection, including for those with less obvious developmental and medical needs at birth, is essential. It will take many years to fully understand the effects of ZIKV on those who are congenitally infected; however, the lifetime medical and educational costs as well as the emotional impact on affected children and families are likely to be substantial. |
Pregnancy outcomes after maternal Zika virus infection during pregnancy - U.S. territories, January 1, 2016-April 25, 2017
Shapiro-Mendoza CK , Rice ME , Galang RR , Fulton AC , VanMaldeghem K , Prado MV , Ellis E , Anesi MS , Simeone RM , Petersen EE , Ellington SR , Jones AM , Williams T , Reagan-Steiner S , Perez-Padilla J , Deseda CC , Beron A , Tufa AJ , Rosinger A , Roth NM , Green C , Martin S , Lopez CD , deWilde L , Goodwin M , Pagano HP , Mai CT , Gould C , Zaki S , Ferrer LN , Davis MS , Lathrop E , Polen K , Cragan JD , Reynolds M , Newsome KB , Huertas MM , Bhatangar J , Quinones AM , Nahabedian JF , Adams L , Sharp TM , Hancock WT , Rasmussen SA , Moore CA , Jamieson DJ , Munoz-Jordan JL , Garstang H , Kambui A , Masao C , Honein MA , Meaney-Delman D . MMWR Morb Mortal Wkly Rep 2017 66 (23) 615-621 Pregnant women living in or traveling to areas with local mosquito-borne Zika virus transmission are at risk for Zika virus infection, which can lead to severe fetal and infant brain abnormalities and microcephaly (1). In February 2016, CDC recommended 1) routine testing for Zika virus infection of asymptomatic pregnant women living in areas with ongoing local Zika virus transmission at the first prenatal care visit, 2) retesting during the second trimester for women who initially test negative, and 3) testing of pregnant women with signs or symptoms consistent with Zika virus disease (e.g., fever, rash, arthralgia, or conjunctivitis) at any time during pregnancy (2). To collect information about pregnant women with laboratory evidence of recent possible Zika virus infection* and outcomes in their fetuses and infants, CDC established pregnancy and infant registries (3). During January 1, 2016-April 25, 2017, U.S. territoriesdagger with local transmission of Zika virus reported 2,549 completed pregnancies section sign (live births and pregnancy losses at any gestational age) with laboratory evidence of recent possible Zika virus infection; 5% of fetuses or infants resulting from these pregnancies had birth defects potentially associated with Zika virus infection paragraph sign (4,5). Among completed pregnancies with positive nucleic acid tests confirming Zika infection identified in the first, second, and third trimesters, the percentage of fetuses or infants with possible Zika-associated birth defects was 8%, 5%, and 4%, respectively. Among liveborn infants, 59% had Zika laboratory testing results reported to the pregnancy and infant registries. Identification and follow-up of infants born to women with laboratory evidence of recent possible Zika virus infection during pregnancy permits timely and appropriate clinical intervention services (6). |
Vital Signs: Update on Zika virus-associated birth defects and evaluation of all U.S. Infants with congenital Zika virus exposure - U.S. Zika Pregnancy Registry, 2016
Reynolds MR , Jones AM , Petersen EE , Lee EH , Rice ME , Bingham A , Ellington SR , Evert N , Reagan-Steiner S , Oduyebo T , Brown CM , Martin S , Ahmad N , Bhatnagar J , Macdonald J , Gould C , Fine AD , Polen KD , Lake-Burger H , Hillard CL , Hall N , Yazdy MM , Slaughter K , Sommer JN , Adamski A , Raycraft M , Fleck-Derderian S , Gupta J , Newsome K , Baez-Santiago M , Slavinski S , White JL , Moore CA , Shapiro-Mendoza CK , Petersen L , Boyle C , Jamieson DJ , Meaney-Delman D , Honein MA . MMWR Morb Mortal Wkly Rep 2017 66 (13) 366-373 BACKGROUND: In collaboration with state, tribal, local, and territorial health departments, CDC established the U.S. Zika Pregnancy Registry (USZPR) in early 2016 to monitor pregnant women with laboratory evidence of possible recent Zika virus infection and their infants. METHODS: This report includes an analysis of completed pregnancies (which include live births and pregnancy losses, regardless of gestational age) in the 50 U.S. states and the District of Columbia (DC) with laboratory evidence of possible recent Zika virus infection reported to the USZPR from January 15 to December 27, 2016. Birth defects potentially associated with Zika virus infection during pregnancy include brain abnormalities and/or microcephaly, eye abnormalities, other consequences of central nervous system dysfunction, and neural tube defects and other early brain malformations. RESULTS: During the analysis period, 1,297 pregnant women in 44 states were reported to the USZPR. Zika virus-associated birth defects were reported for 51 (5%) of the 972 fetuses/infants from completed pregnancies with laboratory evidence of possible recent Zika virus infection (95% confidence interval [CI] = 4%-7%); the proportion was higher when restricted to pregnancies with laboratory-confirmed Zika virus infection (24/250 completed pregnancies [10%, 95% CI = 7%-14%]). Birth defects were reported in 15% (95% CI = 8%-26%) of fetuses/infants of completed pregnancies with confirmed Zika virus infection in the first trimester. Among 895 liveborn infants from pregnancies with possible recent Zika virus infection, postnatal neuroimaging was reported for 221 (25%), and Zika virus testing of at least one infant specimen was reported for 585 (65%). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: These findings highlight why pregnant women should avoid Zika virus exposure. Because the full clinical spectrum of congenital Zika virus infection is not yet known, all infants born to women with laboratory evidence of possible recent Zika virus infection during pregnancy should receive postnatal neuroimaging and Zika virus testing in addition to a comprehensive newborn physical exam and hearing screen. Identification and follow-up care of infants born to women with laboratory evidence of possible recent Zika virus infection during pregnancy and infants with possible congenital Zika virus infection can ensure that appropriate clinical services are available. |
Baseline prevalence of birth defects associated with congenital Zika virus infection - Massachusetts, North Carolina, and Atlanta, Georgia, 2013-2014
Cragan JD , Mai CT , Petersen EE , Liberman RF , Forestieri NE , Stevens AC , Delaney A , Dawson AL , Ellington SR , Shapiro-Mendoza CK , Dunn JE , Higgins CA , Meyer RE , Williams T , Polen KN , Newsome K , Reynolds M , Isenburg J , Gilboa SM , Meaney-Delman DM , Moore CA , Boyle CA , Honein MA . MMWR Morb Mortal Wkly Rep 2017 66 (8) 219-222 Zika virus infection during pregnancy can cause serious brain abnormalities, but the full range of adverse outcomes is unknown (1). To better understand the impact of birth defects resulting from Zika virus infection, the CDC surveillance case definition established in 2016 for birth defects potentially related to Zika virus infection* (2) was retrospectively applied to population-based birth defects surveillance data collected during 2013-2014 in three areas before the introduction of Zika virus (the pre-Zika years) into the World Health Organization's Region of the Americas (Americas) (3). These data, from Massachusetts (2013), North Carolina (2013), and Atlanta, Georgia (2013-2014), included 747 infants and fetuses with one or more of the birth defects meeting the case definition (pre-Zika prevalence = 2.86 per 1,000 live births). Brain abnormalities or microcephaly were the most frequently recorded (1.50 per 1,000), followed by neural tube defects and other early brain malformationsdagger (0.88), eye abnormalities without mention of a brain abnormality (0.31), and other consequences of central nervous system (CNS) dysfunction without mention of brain or eye abnormalities (0.17). During January 15-September 22, 2016, the U.S. Zika Pregnancy Registry (USZPR) reported 26 infants and fetuses with these same defects among 442 completed pregnancies (58.8 per 1,000) born to mothers with laboratory evidence of possible Zika virus infection during pregnancy (2). Although the ascertainment methods differed, this finding was approximately 20 times higher than the proportion of one or more of the same birth defects among pregnancies during the pre-Zika years. These data demonstrate the importance of population-based surveillance for interpreting data about birth defects potentially related to Zika virus infection. |
Birth defects among fetuses and infants of US women with evidence of possible Zika virus infection during pregnancy
Honein MA , Dawson AL , Petersen EE , Jones AM , Lee EH , Yazdy MM , Ahmad N , Macdonald J , Evert N , Bingham A , Ellington SR , Shapiro-Mendoza CK , Oduyebo T , Fine AD , Brown CM , Sommer JN , Gupta J , Cavicchia P , Slavinski S , White JL , Owen SM , Petersen LR , Boyle C , Meaney-Delman D , Jamieson DJ . JAMA 2016 317 (1) 59-68 Importance: Understanding the risk of birth defects associated with Zika virus infection during pregnancy may help guide communication, prevention, and planning efforts. In the absence of Zika virus, microcephaly occurs in approximately 7 per 10000 live births. Objective: To estimate the preliminary proportion of fetuses or infants with birth defects after maternal Zika virus infection by trimester of infection and maternal symptoms. Design, Setting, and Participants: Completed pregnancies with maternal, fetal, or infant laboratory evidence of possible recent Zika virus infection and outcomes reported in the continental United States and Hawaii from January 15 to September 22, 2016, in the US Zika Pregnancy Registry, a collaboration between the CDC and state and local health departments. Exposures: Laboratory evidence of possible recent Zika virus infection in a maternal, placental, fetal, or infant sample. Main Outcomes and Measures: Birth defects potentially Zika associated: brain abnormalities with or without microcephaly, neural tube defects and other early brain malformations, eye abnormalities, and other central nervous system consequences. Results: Among 442 completed pregnancies in women (median age, 28 years; range, 15-50 years) with laboratory evidence of possible recent Zika virus infection, birth defects potentially related to Zika virus were identified in 26 (6%; 95% CI, 4%-8%) fetuses or infants. There were 21 infants with birth defects among 395 live births and 5 fetuses with birth defects among 47 pregnancy losses. Birth defects were reported for 16 of 271 (6%; 95% CI, 4%-9%) pregnant asymptomatic women and 10 of 167 (6%; 95% CI, 3%-11%) symptomatic pregnant women. Of the 26 affected fetuses or infants, 4 had microcephaly and no reported neuroimaging, 14 had microcephaly and brain abnormalities, and 4 had brain abnormalities without microcephaly; reported brain abnormalities included intracranial calcifications, corpus callosum abnormalities, abnormal cortical formation, cerebral atrophy, ventriculomegaly, hydrocephaly, and cerebellar abnormalities. Infants with microcephaly (18/442) represent 4% of completed pregnancies. Birth defects were reported in 9 of 85 (11%; 95% CI, 6%-19%) completed pregnancies with maternal symptoms or exposure exclusively in the first trimester (or first trimester and periconceptional period), with no reports of birth defects among fetuses or infants with prenatal exposure to Zika virus infection only in the second or third trimesters. Conclusions and Relevance: Among pregnant women in the United States with completed pregnancies and laboratory evidence of possible recent Zika infection, 6% of fetuses or infants had evidence of Zika-associated birth defects, primarily brain abnormalities and microcephaly, whereas among women with first-trimester Zika infection, 11% of fetuses or infants had evidence of Zika-associated birth defects. These findings support the importance of screening pregnant women for Zika virus exposure. |
Using insurance claims data to identify and estimate critical periods in pregnancy: An application to antidepressants
Ailes EC , Simeone RM , Dawson AL , Petersen EE , Gilboa SM . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 927-934 BACKGROUND: Health insurance claims are a rich data source to examine medication use in pregnancy. Our objective was to identify pregnant women, their pregnancy outcomes, and date of their last menstrual period (LMP), and to estimate antidepressant dispensations in pregnancy. METHODS: From a literature search, we identified diagnosis and procedure codes indicating the end of a pregnancy. Using Truven Health MarketScan(R) Commercial Claims and Encounters Databases, we identified all inpatient admissions and outpatient service claims with these codes. We developed an algorithm to assign: (1) pregnancy outcome (ectopic pregnancy, induced or spontaneous abortion, live birth, or stillbirth), and (2) estimated gestational age, to each inpatient or outpatient visit. For each pregnancy outcome, we estimated the LMP as the admission (for inpatient visits) or service (for outpatient visits) date minus the gestational age. To differentiate visits associated with separate pregnancies, we required ≥ 2 months between one pregnancy outcomes and the LMP of the next pregnancy. We used this algorithm to identify pregnancies in 2013 and to estimate the proportion of women who filled a prescription for an antidepressant from an outpatient pharmacy at various time points in pregnancy. RESULTS: We identified 488,887 pregnancies in 2013; 79% resulted in a live birth. A prescription for an antidepressant was filled in 6.2% of pregnancies. Dispensations varied throughout pregnancy and were lowest (3.1%) during the second trimester. CONCLUSION: This work will inform future efforts to estimate medication dispensations during critical periods of preconception, interconception, and pregnancy using health insurance claims data. |
Update: Interim guidance for preconception counseling and prevention of sexual transmission of Zika virus for persons with possible Zika virus exposure - United States, September 2016
Petersen EE , Meaney-Delman D , Neblett-Fanfair R , Havers F , Oduyebo T , Hills SL , Rabe IB , Lambert A , Abercrombie J , Martin SW , Gould CV , Oussayef N , Polen KN , Kuehnert MJ , Pillai SK , Petersen LR , Honein MA , Jamieson DJ , Brooks JT . MMWR Morb Mortal Wkly Rep 2016 65 (39) 1077-1081 CDC has updated its interim guidance for persons with possible Zika virus exposure who are planning to conceive and interim guidance to prevent transmission of Zika virus through sexual contact, now combined into a single document. Guidance for care for pregnant women with possible Zika virus exposure was previously published. Possible Zika virus exposure is defined as travel to or residence in an area of active Zika virus transmission (http://www.cdc.gov/zika/geo/index.html), or sex without a condom with a partner who traveled to or lived in an area of active transmission. Based on new though limited data, CDC now recommends that all men with possible Zika virus exposure who are considering attempting conception with their partner, regardless of symptom status, section sign wait to conceive until at least 6 months after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic). Recommendations for women planning to conceive remain unchanged: women with possible Zika virus exposure are recommended to wait to conceive until at least 8 weeks after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic). Couples with possible Zika virus exposure, who are not pregnant and do not plan to become pregnant, who want to minimize their risk for sexual transmission of Zika virus should use a condom or abstain from sex for the same periods for men and women described above. Women of reproductive age who have had or anticipate future Zika virus exposure who do not want to become pregnant should use the most effective contraceptive method that can be used correctly and consistently. These recommendations will be further updated when additional data become available. |
Update: Interim guidance for the evaluation and management of infants with possible congenital zika virus infection - United States, August 2016
Russell K , Oliver SE , Lewis L , Barfield WD , Cragan J , Meaney-Delman D , Staples JE , Fischer M , Peacock G , Oduyebo T , Petersen EE , Zaki S , Moore CA , Rasmussen SA . MMWR Morb Mortal Wkly Rep 2016 65 (33) 870-878 CDC has updated its interim guidance for U.S. health care providers caring for infants born to mothers with possible Zika virus infection during pregnancy. Laboratory testing is recommended for 1) infants born to mothers with laboratory evidence of Zika virus infection during pregnancy and 2) infants who have abnormal clinical or neuroimaging findings suggestive of congenital Zika syndrome and a maternal epidemiologic link suggesting possible transmission, regardless of maternal Zika virus test results. Congenital Zika syndrome is a recently recognized pattern of congenital anomalies associated with Zika virus infection during pregnancy that includes microcephaly, intracranial calcifications or other brain anomalies, or eye anomalies, among others. Recommended infant laboratory evaluation includes both molecular (real-time reverse transcription-polymerase chain reaction [rRT-PCR]) and serologic (immunoglobulin M [IgM]) testing. Initial samples should be collected directly from the infant in the first 2 days of life, if possible; testing of cord blood is not recommended. A positive infant serum or urine rRT-PCR test result confirms congenital Zika virus infection. Positive Zika virus IgM testing, with a negative rRT-PCR result, indicates probable congenital Zika virus infection. In addition to infant Zika virus testing, initial evaluation of all infants born to mothers with laboratory evidence of Zika virus infection during pregnancy should include a comprehensive physical examination, including a neurologic examination, postnatal head ultrasound, and standard newborn hearing screen. Infants with laboratory evidence of congenital Zika virus infection should have a comprehensive ophthalmologic exam and hearing assessment by auditory brainstem response (ABR) testing before 1 month of age. Recommendations for follow-up of infants with laboratory evidence of congenital Zika virus infection depend on whether abnormalities consistent with congenital Zika syndrome are present. Infants with abnormalities consistent with congenital Zika syndrome should have a coordinated evaluation by multiple specialists within the first month of life; additional evaluations will be needed within the first year of life, including assessments of vision, hearing, feeding, growth, and neurodevelopmental and endocrine function. Families and caregivers will also need ongoing psychosocial support and assistance with coordination of care. Infants with laboratory evidence of congenital Zika virus infection without apparent abnormalities should have ongoing developmental monitoring and screening by the primary care provider; repeat hearing testing is recommended. This guidance will be updated when additional information becomes available. |
Prolonged detection of Zika virus RNA in pregnant women
Meaney-Delman D , Oduyebo T , Polen KN , White JL , Bingham AM , Slavinski SA , Heberlein-Larson L , St George K , Rakeman JL , Hills S , Olson CK , Adamski A , Culver Barlow L , Lee EH , Likos AM , Munoz JL , Petersen EE , Dufort EM , Dean AB , Cortese MM , Santiago GA , Bhatnagar J , Powers AM , Zaki S , Petersen LR , Jamieson DJ , Honein MA . Obstet Gynecol 2016 128 (4) 724-730 ![]() ![]() OBJECTIVE: Zika virus infection during pregnancy is a cause of microcephaly and other fetal brain abnormalities. Reports indicate that the duration of detectable viral RNA in serum after symptom onset is brief. In a recent case report involving a severely affected fetus, Zika virus RNA was detected in maternal serum 10 weeks after symptom onset, longer than the duration of RNA detection in serum previously reported. This report summarizes the clinical and laboratory characteristics of pregnant women with prolonged detection of Zika virus RNA in serum that were reported to the U.S. Zika Pregnancy Registry. METHODS: Data were obtained from the U.S. Zika Pregnancy Registry, an enhanced surveillance system of pregnant women with laboratory evidence of confirmed or possible Zika virus infection. For this case series, we defined prolonged detection of Zika virus RNA as Zika virus RNA detection in serum by real-time reverse transcription-polymerase chain reaction (RT-PCR) 14 or more days after symptom onset or, for women not reporting signs or symptoms consistent with Zika virus disease (asymptomatic), 21 or more days after last possible exposure to Zika virus. RESULTS: Prolonged Zika virus RNA detection in serum was identified in four symptomatic pregnant women up to 46 days after symptom onset and in one asymptomatic pregnant woman 53 days postexposure. Among the five pregnancies, one pregnancy had evidence of fetal Zika virus infection confirmed by histopathologic examination of fetal tissue, three pregnancies resulted in live births of apparently healthy neonates with no reported abnormalities, and one pregnancy is ongoing. CONCLUSION: Zika virus RNA was detected in the serum of five pregnant women beyond the previously estimated timeframe. Additional real-time RT-PCR testing of pregnant women might provide more data about prolonged detection of Zika virus RNA and the possible diagnostic, epidemiologic, and clinical implications for pregnant women. |
Update: interim guidance for health care providers caring for pregnant women with possible Zika virus exposure - United States, July 2016
Oduyebo T , Igbinosa I , Petersen EE , Polen KN , Pillai SK , Ailes EC , Villanueva JM , Newsome K , Fischer M , Gupta PM , Powers AM , Lampe M , Hills S , Arnold KE , Rose LE , Shapiro-Mendoza CK , Beard CB , Munoz JL , Rao CY , Meaney-Delman D , Jamieson DJ , Honein MA . MMWR Morb Mortal Wkly Rep 2016 65 (29) 739-44 CDC has updated its interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure, to include the emerging data indicating that Zika virus RNA can be detected for prolonged periods in some pregnant women. To increase the proportion of pregnant women with Zika virus infection who receive a definitive diagnosis, CDC recommends expanding real-time reverse transcription-polymerase chain reaction (rRT-PCR) testing. Possible exposures to Zika virus include travel to or residence in an area with active Zika virus transmission, or sex* with a partner who has traveled to or resides in an area with active Zika virus transmission without using condoms or other barrier methods to prevent infection.(dagger) Testing recommendations for pregnant women with possible Zika virus exposure who report clinical illness consistent with Zika virus disease( section sign) (symptomatic pregnant women) are the same, regardless of their level of exposure (i.e., women with ongoing risk for possible exposure, including residence in or frequent travel to an area with active Zika virus transmission, as well as women living in areas without Zika virus transmission who travel to an area with active Zika virus transmission, or have unprotected sex with a partner who traveled to or resides in an area with active Zika virus transmission). Symptomatic pregnant women who are evaluated <2 weeks after symptom onset should receive serum and urine Zika virus rRT-PCR testing. Symptomatic pregnant women who are evaluated 2-12 weeks after symptom onset should first receive a Zika virus immunoglobulin (IgM) antibody test; if the IgM antibody test result is positive or equivocal, serum and urine rRT-PCR testing should be performed. Testing recommendations for pregnant women with possible Zika virus exposure who do not report clinical illness consistent with Zika virus disease (asymptomatic pregnant women) differ based on the circumstances of possible exposure. For asymptomatic pregnant women who live in areas without active Zika virus transmission and who are evaluated <2 weeks after last possible exposure, rRT-PCR testing should be performed. If the rRT-PCR result is negative, a Zika virus IgM antibody test should be performed 2-12 weeks after the exposure. Asymptomatic pregnant women who do not live in an area with active Zika virus transmission, who are first evaluated 2-12 weeks after their last possible exposure should first receive a Zika virus IgM antibody test; if the IgM antibody test result is positive or equivocal, serum and urine rRT-PCR should be performed. Asymptomatic pregnant women with ongoing risk for exposure to Zika virus should receive Zika virus IgM antibody testing as part of routine obstetric care during the first and second trimesters; immediate rRT-PCR testing should be performed when IgM antibody test results are positive or equivocal. This guidance also provides updated recommendations for the clinical management of pregnant women with confirmed or possible Zika virus infection. These recommendations will be updated when additional data become available. |
Possible Zika virus infection among pregnant women - United States and Territories, May 2016
Simeone RM , Shapiro-Mendoza CK , Meaney-Delman D , Petersen EE , Galang RR , Oduyebo T , Rivera-Garcia B , Valencia-Prado M , Newsome KB , Perez-Padilla J , Williams TR , Biggerstaff M , Jamieson DJ , Honein MA , Ahmed F , Anesi S , Arnold KE , Barradas D , Barter D , Bertolli J , Bingham AM , Bollock J , Bosse T , Bradley KK , Brady D , Brown CM , Bryan K , Buchanan V , Bullard PD , Carrigan A , Clouse M , Cook S , Cooper M , Davidson S , DeBarr A , Dobbs T , Dunams T , Eason J , Eckert A , Eggers P , Ellington SR , Feldpausch A , Fredette CR , Gabel J , Glover M , Gosciminski M , Gay M , Haddock R , Hand S , Hardy J , Hartel ME , Hennenfent AK , Hills SL , House J , Igbinosa I , Im L , Jeff H , Khan S , Kightlinger L , Ko JY , Koirala S , Korhonen L , Krishnasamy V , Kurkjian K , Lampe M , Larson S , Lee EH , Lind L , Lindquist S , Long J , Macdonald J , MacFarquhar J , Mackie DP , Mark-Carew M , Martin B , Martinez-Quinones A , Matthews-Greer J , McGee SA , McLaughlin J , Mock V , Muna E , Oltean H , O'Mallan J , Pagano HP , Park SY , Peterson D , Polen KN , Porse CC , Rao CY , Ropri A , Rinsky J , Robinson S , Rosinger AY , Ruberto I , Schiffman E , Scott-Waldron C , Semple S , Sharp T , Short K , Signs K , Slavinski SA , Stevens T , Sweatlock J , Talbot EA , Tonzel J , Traxler R , Tubach S , Van Houten C , VinHatton E , Viray M , Virginie D , Warren MD , Waters C , White P , Williams T , Winters AI , Wood S , Zaganjor I . MMWR Morb Mortal Wkly Rep 2016 65 (20) 514-9 Zika virus is a cause of microcephaly and brain abnormalities (1), and it is the first known mosquito-borne infection to cause congenital anomalies in humans. The establishment of a comprehensive surveillance system to monitor pregnant women with Zika virus infection will provide data to further elucidate the full range of potential outcomes for fetuses and infants of mothers with asymptomatic and symptomatic Zika virus infection during pregnancy. In February 2016, Zika virus disease and congenital Zika virus infections became nationally notifiable conditions in the United States (2). Cases in pregnant women with laboratory evidence of Zika virus infection who have either 1) symptomatic infection or 2) asymptomatic infection with diagnosed complications of pregnancy can be reported as cases of Zika virus disease to ArboNET* (2), CDC's national arboviral diseases surveillance system. Under existing interim guidelines from the Council for State and Territorial Epidemiologists (CSTE), asymptomatic Zika virus infections in pregnant women who do not have known pregnancy complications are not reportable. ArboNET does not currently include pregnancy surveillance information (e.g., gestational age or pregnancy exposures) or pregnancy outcomes. To understand the full impact of infection on the fetus and neonate, other systems are needed for reporting and active monitoring of pregnant women with laboratory evidence of possible Zika virus infection during pregnancy. Thus, in collaboration with state, local, tribal, and territorial health departments, CDC established two surveillance systems to monitor pregnancies and congenital outcomes among women with laboratory evidence of Zika virus infection(dagger) in the United States and territories: 1) the U.S. Zika Pregnancy Registry (USZPR),( section sign) which monitors pregnant women residing in U.S. states and all U.S. territories except Puerto Rico, and 2) the Zika Active Pregnancy Surveillance System (ZAPSS), which monitors pregnant women residing in Puerto Rico. As of May 12, 2016, the surveillance systems were monitoring 157 and 122 pregnant women with laboratory evidence of possible Zika virus infection from participating U.S. states and territories, respectively. Tracking and monitoring clinical presentation of Zika virus infection, all prenatal testing, and adverse consequences of Zika virus infection during pregnancy are critical to better characterize the risk for congenital infection, the performance of prenatal diagnostic testing, and the spectrum of adverse congenital outcomes. These data will improve clinical guidance, inform counseling messages for pregnant women, and facilitate planning for clinical and public health services for affected families. |
Patterns in Zika Virus Testing and Infection, by Report of Symptoms and Pregnancy Status - United States, January 3-March 5, 2016
Dasgupta S , Reagan-Steiner S , Goodenough D , Russell K , Tanner M , Lewis L , Petersen EE , Powers AM , Kniss K , Meaney-Delman D , Oduyebo T , O'Leary D , Chiu S , Talley P , Hennessey M , Hills S , Cohn A , Gregory C . MMWR Morb Mortal Wkly Rep 2016 65 (15) 395-9 CDC recommends Zika virus testing for potentially exposed persons with signs or symptoms consistent with Zika virus disease, and recommends that health care providers offer testing to asymptomatic pregnant women within 12 weeks of exposure. During January 3-March 5, 2016, Zika virus testing was performed for 4,534 persons who traveled to or moved from areas with active Zika virus transmission; 3,335 (73.6%) were pregnant women. Among persons who received testing, 1,541 (34.0%) reported at least one Zika virus-associated sign or symptom (e.g., fever, rash, arthralgia, or conjunctivitis), 436 (9.6%) reported at least one other clinical sign or symptom only, and 2,557 (56.4%) reported no signs or symptoms. Among 1,541 persons with one or more Zika virus-associated symptoms who received testing, 182 (11.8%) had confirmed Zika virus infection. Among the 2,557 asymptomatic persons who received testing, 2,425 (94.8%) were pregnant women, seven (0.3%) of whom had confirmed Zika virus infection. Although risk for Zika virus infection might vary based on exposure-related factors (e.g., location and duration of travel), in the current setting in U.S. states, where there is no local transmission, most asymptomatic pregnant women who receive testing do not have Zika virus infection. |
Update: interim guidance for prevention of sexual transmission of Zika virus - United States, 2016
Oster AM , Russell K , Stryker JE , Friedman A , Kachur RE , Petersen EE , Jamieson DJ , Cohn AC , Brooks JT . MMWR Morb Mortal Wkly Rep 2016 65 (12) 323-325 CDC issued interim guidance for the prevention of sexual transmission of Zika virus on February 5, 2016 (1). The following recommendations apply to men who have traveled to or reside in areas with active Zika virus transmission* and their female or male sex partners. These recommendations replace the previously issued recommendations and are updated to include time intervals after travel to areas with active Zika virus transmission or after Zika virus infection for taking precautions to reduce the risk for sexual transmission. This guidance defines potential sexual exposure to Zika virus as any person who has had sex (i.e., vaginal intercourse, anal intercourse, or fellatio) without a condom with a man who has traveled to or resides in an area with active Zika virus transmission. This guidance will be updated as more information becomes available. |
Update: interim guidance for health care providers caring for women of reproductive age with possible Zika virus exposure - United States, 2016
Petersen EE , Polen KN , Meaney-Delman D , Ellington SR , Oduyebo T , Cohn A , Oster AM , Russell K , Kawwass JF , Karwowski MP , Powers AM , Bertolli J , Brooks JT , Kissin D , Villanueva J , Munoz-Jordan J , Kuehnert M , Olson CK , Honein MA , Rivera M , Jamieson DJ , Rasmussen SA . MMWR Morb Mortal Wkly Rep 2016 65 (12) 315-322 CDC has updated its interim guidance for U.S. health care providers caring for women of reproductive age with possible Zika virus exposure (1) to include recommendations on counseling women and men with possible Zika virus exposure who are interested in conceiving. This guidance is based on limited available data on persistence of Zika virus RNA in blood and semen (2-5). Women who have Zika virus disease* should wait at least 8 weeks after symptom onset to attempt conception, and men with Zika virus disease should wait at least 6 months after symptom onset to attempt conception. Women and men with possible exposure to Zika virus but without clinical illness consistent with Zika virus disease should wait at least 8 weeks after exposure to attempt conception. Possible exposure to Zika virus is defined as travel to or residence in an area of active Zika virus transmission (http://www.cdc.gov/zika/geo/active-countries.html), or sex (vaginal intercourse, anal intercourse, or fellatio) without a condom with a man who traveled to or resided in an area of active transmission. Women and men who reside in areas of active Zika virus transmission should talk with their health care provider about attempting conception. This guidance also provides updated recommendations on testing of pregnant women with possible Zika virus exposure. These recommendations will be updated when additional data become available. |
Zika virus infection among U.S. pregnant travelers - August 2015-February 2016
Meaney-Delman D , Hills SL , Williams C , Galang RR , Iyengar P , Hennenfent AK , Rabe IB , Panella A , Oduyebo T , Honein MA , Zaki S , Lindsey N , Lehman JA , Kwit N , Bertolli J , Ellington S , Igbinosa I , Minta AA , Petersen EE , Mead P , Rasmussen SA , Jamieson DJ . MMWR Morb Mortal Wkly Rep 2016 65 (8) 211-4 After reports of microcephaly and other adverse pregnancy outcomes in infants of mothers infected with Zika virus during pregnancy, CDC issued a travel alert on January 15, 2016, advising pregnant women to consider postponing travel to areas with active transmission of Zika virus. On January 19, CDC released interim guidelines for U.S. health care providers caring for pregnant women with travel to an affected area (1), and an update was released on February 5 (2). As of February 17, CDC had received reports of nine pregnant travelers with laboratory-confirmed Zika virus disease; 10 additional reports of Zika virus disease among pregnant women are currently under investigation. No Zika virus-related hospitalizations or deaths among pregnant women were reported. Pregnancy outcomes among the nine confirmed cases included two early pregnancy losses, two elective terminations, and three live births (two apparently healthy infants and one infant with severe microcephaly); two pregnancies (approximately 18 weeks' and 34 weeks' gestation) are continuing without known complications. Confirmed cases of Zika virus infection were reported among women who had traveled to one or more of the following nine areas with ongoing local transmission of Zika virus: American Samoa, Brazil, El Salvador, Guatemala, Haiti, Honduras, Mexico, Puerto Rico, and Samoa. This report summarizes findings from the nine women with confirmed Zika virus infection during pregnancy, including case reports for four women with various clinical outcomes. U.S. health care providers caring for pregnant women with possible Zika virus exposure during pregnancy should follow CDC guidelines for patient evaluation and management (1,2). Zika virus disease is a nationally notifiable condition. CDC has developed a voluntary registry to collect information about U.S. pregnant women with confirmed Zika virus infection and their infants. Information about the registry is in preparation and will be available on the CDC website. |
Update: Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure - United States, 2016
Oduyebo T , Petersen EE , Rasmussen SA , Mead PS , Meaney-Delman D , Renquist CM , Ellington SR , Fischer M , Staples JE , Powers AM , Villanueva J , Galang RR , Dieke A , Munoz JL , Honein MA , Jamieson DJ . MMWR Morb Mortal Wkly Rep 2016 65 (5) 122-7 CDC has updated its interim guidelines for U.S. health care providers caring for pregnant women during a Zika virus outbreak (1). Updated guidelines include a new recommendation to offer serologic testing to asymptomatic pregnant women (women who do not report clinical illness consistent with Zika virus disease) who have traveled to areas with ongoing Zika virus transmission. Testing can be offered 2-12 weeks after pregnant women return from travel. This update also expands guidance to women who reside in areas with ongoing Zika virus transmission, and includes recommendations for screening, testing, and management of pregnant women and recommendations for counseling women of reproductive age (15-44 years). Pregnant women who reside in areas with ongoing Zika virus transmission have an ongoing risk for infection throughout their pregnancy. For pregnant women with clinical illness consistent with Zika virus disease,* testing is recommended during the first week of illness. For asymptomatic pregnant women residing in areas with ongoing Zika virus transmission, testing is recommended at the initiation of prenatal care with follow-up testing mid-second trimester. Local health officials should determine when to implement testing of asymptomatic pregnant women based on information about levels of Zika virus transmission and laboratory capacity. Health care providers should discuss reproductive life plans, including pregnancy intention and timing, with women of reproductive age in the context of the potential risks associated with Zika virus infection. |
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