Publications by authors named "Denise J Jamieson"

493 Publications

Validation of Hypertensive Disorders During Pregnancy: ICD-10 Codes in a High-burden Southeastern United States Hospital.

Epidemiology 2021 Jul;32(4):591-597

Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, GA.

Background: Identification of hypertensive disorders in pregnancy research often uses hospital International Classification of Diseases v. 10 (ICD-10) codes meant for billing purposes, which may introduce misclassification error relative to medical records. We estimated the validity of ICD-10 codes for hypertensive disorders during pregnancy overall and by subdiagnosis, compared with medical record diagnosis, in a Southeastern United States high disease burden hospital.

Methods: We linked medical record data with hospital discharge records for deliveries between 1 July 2016, and 30 June 2018, in an Atlanta, Georgia, public hospital. For any hypertensive disorder (with and without unspecified codes) and each subdiagnosis (hemolysis, elevated liver enzymes, and low platelet count [HELLP] syndrome, eclampsia, preeclampsia with and without severe features, chronic hypertension, superimposed preeclampsia, and gestational hypertension), we calculated positive predictive value (PPV), negative predictive value (NPV) sensitivity, and specificity for ICD-10 codes compared with medical record diagnoses (gold standard).

Results: Thirty-seven percent of 3,654 eligible pregnancies had a clinical diagnosis of any hypertensive disorder during pregnancy. Overall, ICD-10 codes identified medical record diagnoses well (PPV, NPV, specificity >90%; sensitivity >80%). PPV, NPV, and specificity were high for all subindicators (>80%). Sensitivity estimates were high for superimposed preeclampsia, chronic hypertension, and gestational hypertension (>80%); moderate for eclampsia (66.7%; 95% confidence interval [CI] = 22.3%, 95.7%), HELLP (75.0%; 95% CI = 50.9%, 91.3%), and preeclampsia with severe features (58.3%; 95% CI = 52.6%, 63.8%); and low for preeclampsia without severe features (3.2%; 95% CI, 1.4%, 6.2%).

Conclusions: We provide bias parameters for future US-based studies of hypertensive outcomes during pregnancy in high-burden populations using hospital ICD-10 codes.
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http://dx.doi.org/10.1097/EDE.0000000000001343DOI Listing
July 2021

Zika Prevention Behaviors Among Women of Reproductive Age in Puerto Rico, 2016.

Am J Prev Med 2021 May 2. Epub 2021 May 2.

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia.

Introduction: Zika virus is primarily transmitted through mosquito bites. Because Zika virus infection during pregnancy can cause serious birth defects, reproductive-aged women need protection from Zika virus infection. This report describes Zika virus prevention behaviors among women aged 18-49 years and assesses whether pregnancy status and healthcare provider counseling increases Zika virus prevention behaviors.

Methods: A population-based cell phone survey of women aged 18-49 years living in Puerto Rico was conducted in July-November 2016. Data were analyzed in 2018-2019. Prevalence estimates and 95% CIs were calculated for Zika virus prevention behaviors. Adjusted prevalence ratios were estimated to examine the association of pregnancy status with healthcare provider counseling on Zika virus prevention behaviors, controlling for age, education, and health insurance status.

Results: Most women reported using screens on open doors/windows (87.7%) and eliminating standing water in/around their homes (92.3%). Other Zika virus prevention behaviors were less common (<33%). In adjusted analysis, pregnant women were more likely than women not at risk for unintended pregnancy to report using mosquito repellent every/most days (adjusted prevalence ratio=1.44, 95% CI=1.13, 1.85). Healthcare provider counseling was associated with receiving professional spraying/larvicide treatment (adjusted prevalence ratio=1.42, 95% CI=1.17, 1.74), sleeping under a bed net (adjusted prevalence ratio=2.37, 95% CI=1.33, 4.24), using mosquito repellent (adjusted prevalence ratio=1.57, 95% CI=1.40, 1.77), and wearing long sleeves/pants (adjusted prevalence ratio=1.32, 95% CI=1.12, 1.55).

Conclusions: Receipt of healthcare provider counseling was more consistently associated with Zika virus prevention behaviors than pregnancy status. Healthcare provider counseling is an important strategy for increasing the uptake of Zika virus prevention behaviors among women aged 18-49 years.
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http://dx.doi.org/10.1016/j.amepre.2021.03.004DOI Listing
May 2021

Maternal Antibody Response, Neutralizing Potency, and Placental Antibody Transfer After Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) Infection.

Obstet Gynecol 2021 Apr 28. Epub 2021 Apr 28.

From the Departments of Gynecology and Obstetrics, Pathology and Laboratory Medicine, Nell Hodgson Woodruff School of Nursing, and Pediatrics, Emory University School of Medicine, Biostatistics and Bioinformatics, Emory Rollins School of Public Health, and the Division of Microbiology and Immunology, Emory Yerkes National Primate Research Center, Emory University, Atlanta, Georgia.

Objective: To characterize maternal immune response after severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection during pregnancy and quantify the efficiency of transplacental antibody transfer.

Methods: We conducted a prospective cohort study of pregnant patients who tested positive for SARS CoV-2 infection at any point in pregnancy and collected paired maternal and cord blood samples at the time of delivery. An enzyme-linked immunosorbent assay (ELISA) and neutralization assays were performed to measure maternal plasma and cord blood concentrations and neutralizing potency of immunoglobulin (Ig)G, IgA, and IgM antibodies directed against the SARS-CoV-2 spike protein. Differences in concentrations according to symptomatic compared with asymptomatic infection and time from positive polymerase chain reaction (PCR) test result to delivery were analyzed using nonparametric tests of significance. The ratio of cord to maternal anti-receptor-binding domain IgG titers was analyzed to assess transplacental transfer efficiency.

Results: Thirty-two paired samples were analyzed. Detectable anti-receptor-binding domain IgG was detected in 100% (n=32) of maternal and 91% (n=29) of cord blood samples. Functional neutralizing antibody was present in 94% (n=30) of the maternal and 25% (n=8) of cord blood samples. Symptomatic infection was associated with a significant difference in median (interquartile range) maternal anti-receptor-binding domain IgG titers compared with asymptomatic infection (log 3.2 [3.5-2.4] vs log 2.7 [2.9-1.4], P=.03). Median (interquartile range) maternal anti-receptor-binding domain IgG titers were not significantly higher in patients who delivered more than 14 days after a positive PCR test result compared with those who delivered within 14 days (log 3.3 [3.5-2.4] vs log 2.67 [2.8-1.6], P=.05). Median (range) cord/maternal antibody ratio was 0.81 (0.67-0.88).

Conclusions: These results demonstrate robust maternal neutralizing and anti-receptor-binding domain IgG response after SARS-CoV-2 infection, yet a lower-than-expected efficiency of transplacental antibody transfer and a significant reduction in neutralization between maternal blood and cord blood. Maternal infection does confer some degree of neonatal antibody protection, but the robustness and durability of protection require further study.
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http://dx.doi.org/10.1097/AOG.0000000000004440DOI Listing
April 2021

Chronic Stress and Preconception Health Among Latina Women in Metro Atlanta.

Matern Child Health J 2021 Jul 28;25(7):1147-1155. Epub 2021 Apr 28.

Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA, 30322, USA.

Background: Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta.

Design: We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma.

Results: Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)).

Conclusions: Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.
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http://dx.doi.org/10.1007/s10995-021-03164-wDOI Listing
July 2021

Evaluating Differences in Whole Blood, Serum, and Urine Screening Tests for Zika Virus, Puerto Rico, USA, 2016.

Emerg Infect Dis 2021 May;27(5):1505-1508

We evaluated nucleic acid amplification testing (NAAT) for Zika virus on whole-blood specimens compared with NAAT on serum and urine specimens among asymptomatic pregnant women during the 2015-2016 Puerto Rico Zika outbreak. Using NAAT, more infections were detected in serum and urine than in whole blood specimens.
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http://dx.doi.org/10.3201/eid2705.203960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084515PMC
May 2021

Modification of the association between diabetes and birth defects by obesity, National Birth Defects Prevention Study, 1997-2011.

Birth Defects Res 2021 Apr 19. Epub 2021 Apr 19.

National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: Maternal pregestational diabetes and obesity are risk factors for birth defects. Diabetes and obesity often occur together; it is unclear whether their co-occurrence compounds birth defect risk.

Methods: We analyzed 1997-2011 data on 29,671 cases and 10,963 controls from the National Birth Defects Prevention Study, a multisite case-control study. Mothers self-reported height, pregestational weight, and diabetes (pregestational and gestational; analyzed separately). We created four exposure groups: no obesity or diabetes (referent), obesity only, diabetes only, and both obesity and diabetes. We estimated odds ratios (ORs) using logistic regression and the relative excess risk due to interaction (RERI).

Results: Among mothers with pregestational obesity without diabetes, modest associations (OR range: 1.1-1.5) were observed for neural tube defects, small intestinal atresia, anorectal atresia, renal agenesis/hypoplasia, omphalocele, and several congenital heart defects. Pregestational diabetes, regardless of obesity, was strongly associated with most birth defects (OR range: 2.0-75.9). Gestational diabetes and obesity had a stronger association than for obesity alone and the RERI (in parentheses) suggested additive interaction for hydrocephaly (1.2; 95% confidence interval [CI]: -0.1, 2.5), tetralogy of Fallot (0.9; 95% CI: -0.01, 1.8), atrioventricular septal defect (1.1; 95% CI: -0.1, 2.3), hypoplastic left heart syndrome (1.1; 95% CI: -0.2, 2.4), and atrial septal defect secundum or not otherwise specified (1.0; 95% CI: 0.3, 1.6; only statistically significant RERI).

Conclusions: Our results do not support a synergistic relationship between obesity and diabetes for most birth defects examined. However, there are opportunities for prevention by reducing obesity and improving glycemic control among women with pregestational diabetes before conception.
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http://dx.doi.org/10.1002/bdr2.1900DOI Listing
April 2021

Moving Beyond Breastfeeding Initiation: A Qualitative Study Unpacking Factors That Influence Infant Feeding at Hospital Discharge Among Urban, Socioeconomically Disadvantaged Women.

J Acad Nutr Diet 2021 Mar 11. Epub 2021 Mar 11.

Background: Factors that influence breastfeeding initiation and duration have been well established; however, there is limited understanding of in-hospital exclusive breastfeeding (EBF), which is critical for establishing breastfeeding. Grady Memorial Hospital, which serves a high proportion of participants receiving Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and racial/ethnic minorities, had an in-hospital EBF rate in 2018 by the Joint Commission's definition of 29% and sought contextualized evidence on how to best support breastfeeding mothers.

Objective: The objectives were to (1) identify facilitators and barriers to in-hospital EBF and (2) explore breastfeeding support available from key stakeholders across the social-ecological model.

Design: In-depth, semistructured interviews were conducted and analyzed using thematic analysis.

Participants: The sample included a total of 38 purposively sampled participants from Grady Memorial Hospital (10 EBF mothers, 10 non-EBF, and 18 key stakeholders such as clinicians, community organizations' staff, and administrators).

Results: Key themes included that maternal perception of inadequate milk supply was a barrier to in-hospital EBF at the intrapersonal level. At the interpersonal level, a personable and individualized approach to breastfeeding counseling may be most effective in supporting EBF. At the institutional level, key determinants of EBF were gaps in prenatal breastfeeding education, limited time to provide comprehensive prenatal education to high-risk patients, and practical help with latching and positioning. Community-level WIC services were perceived as a facilitator due to the additional benefits provided for EBF mothers; however, the distribution of WIC vouchers for formula to mothers while they are in the hospital undermines the promotion of EBF. Cultural norms and a diverse patient population were reported as barriers to providing support at the macrosystem level.

Conclusion: Multipronged approaches that span the social-ecological model may be required to support early EBF in hospital settings.
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http://dx.doi.org/10.1016/j.jand.2021.02.005DOI Listing
March 2021

The effects of COVID-19 on pregnancy and implications for reproductive medicine.

Fertil Steril 2021 04 1;115(4):824-830. Epub 2021 Jan 1.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

COVID-19 was officially declared a pandemic in March 2020. Since then, our understanding of its effects on pregnancy have evolved rapidly. Emerging surveillance data and large cohort studies suggest that pregnancy is associated with an increased risk of intensive care unit hospitalization, invasive ventilation, and death. Pregnancies complicated by SARS-CoV-2 infection are associated with increased likelihood of cesarean delivery and preterm birth. Intrauterine transmission occurs, but seems to be rare. Critical gaps remain, and rigorous high-quality data are needed to better ascertain pregnancy risks and to inform antenatal and obstetrical management.
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http://dx.doi.org/10.1016/j.fertnstert.2020.12.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775651PMC
April 2021

Pregnancy, Postpartum Care, and COVID-19 Vaccination in 2021.

JAMA 2021 03;325(11):1099-1100

Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia.

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http://dx.doi.org/10.1001/jama.2021.1683DOI Listing
March 2021

Inclusion of Pregnant and Lactating Persons in COVID-19 Vaccination Efforts.

Ann Intern Med 2021 05 26;174(5):701-702. Epub 2021 Jan 26.

Emory University School of Medicine, Atlanta, Georgia (D.J.J.).

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http://dx.doi.org/10.7326/M21-0173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875205PMC
May 2021

The need for inclusion of pregnant women in COVID-19 vaccine trials.

Vaccine 2021 02 11;39(6):868-870. Epub 2021 Jan 11.

Center for Immunization Research, Department of International Health, Johns Hopkins Bloomberg School of Public Health, United States.

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http://dx.doi.org/10.1016/j.vaccine.2020.12.074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798437PMC
February 2021

Coronavirus Disease 2019 (COVID-19) Vaccines and Pregnancy: What Obstetricians Need to Know.

Obstet Gynecol 2021 03;137(3):408-414

Departments of Pediatrics, Obstetrics and Gynecology, and Epidemiology, University of Florida College of Medicine and College of Public Health and Health Professions, Gainesville, Florida; and the Division of Infectious Diseases and the Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, the Grady Healthcare System, Infectious Diseases Program, Atlanta, and the Hope Clinic of the Emory Vaccine Center, Decatur, Georgia.

Coronavirus disease 2019 (COVID-19) vaccines have begun to be distributed across the United States and to be offered initially to priority groups including health care personnel and persons living in long-term care facilities. Guidance regarding whether pregnant persons should receive a COVID-19 vaccine is needed. Because pregnant persons were excluded from the initial phase 3 clinical trials of COVID-19 vaccines, limited data are available on their efficacy and safety during pregnancy. After developmental and reproductive toxicology studies are completed, some companies are expected to conduct clinical trials in pregnant persons. Until then, pregnant persons and their obstetricians will need to use available data to weigh the benefits and risks of COVID-19 vaccines. Issues to be considered when counseling pregnant persons include data from animal studies and inadvertently exposed pregnancies during vaccine clinical trials when available, potential risks to pregnancy of vaccine reactogenicity, timing of vaccination during pregnancy, evidence for safety of other vaccines during pregnancy, risk of COVID-19 complications due to pregnancy and the pregnant person's underlying conditions, and risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and potential for risk mitigation. The Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine have each issued guidance supportive of offering COVID-19 vaccine to pregnant persons. As additional information from clinical trials and from data collected on vaccinated pregnant persons becomes available, it will be critical for obstetricians to keep up to date with this information.
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http://dx.doi.org/10.1097/AOG.0000000000004290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884084PMC
March 2021

Protecting Pregnant Women and Their Infants From COVID-19: Clues From Maternal Viral Loads, Antibody Responses, and Placentas.

JAMA Netw Open 2020 12 1;3(12):e2030564. Epub 2020 Dec 1.

Department of Pediatrics, Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.30564DOI Listing
December 2020

Chagas Disease Screening Using Point-of-Care Testing in an At-Risk Obstetric Population.

Am J Trop Med Hyg 2020 Dec 21. Epub 2020 Dec 21.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia.

Congenital transmission is the most important mode of transmission of Chagas disease (CD) in non-endemic countries. Identifying CD in reproductive-aged women is essential to reduce the risk of transmitting the disease to their children and offer treatment to women and their children, which could cure the disease. We evaluated the use of point-of-care (POC) testing for CD in postpartum patients. In our patient population, 16.7% (23/138) tested positive by POC testing, but confirmatory testing was negative for all patients. Among those considered high risk, 30% declined participation. Our results suggest limited utility of the point-of-care test used in our study and identify an opportunity for improvement to broaden diagnostic testing options. Our study also highlights the need to develop strategies to increase subject participation in future research.
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http://dx.doi.org/10.4269/ajtmh.20-0517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941822PMC
December 2020

Validation of ICD-10 Codes for Gestational and Pregestational Diabetes During Pregnancy in a Large, Public Hospital.

Epidemiology 2021 03;32(2):277-281

From the Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA.

Background: The use of billing codes (ICD-10) to identify and track cases of gestational and pregestational diabetes during pregnancy is common in clinical quality improvement, research, and surveillance. However, specific diagnoses may be misclassified using ICD-10 codes, potentially biasing estimates. The goal of this study is to provide estimates of validation parameters (sensitivity, specificity, positive predictive value, and negative predictive value) for pregestational and gestational diabetes diagnosis using ICD-10 diagnosis codes compared with medical record abstraction at a large public hospital in Atlanta, Georgia.

Methods: This study includes 3,654 deliveries to Emory physicians at Grady Memorial Hospital in Atlanta, Georgia, between 2016 and 2018. We linked information abstracted from the medical record to ICD-10 diagnosis codes for gestational and pregestational diabetes during the delivery hospitalization. Using the medical record as the gold standard, we calculated sensitivity, specificity, positive predictive value, and negative predictive value for each.

Results: For both pregestational and gestational diabetes, ICD-10 codes had a high-negative predictive value (>99%, Table 3) and specificity (>99%). For pregestational diabetes, the sensitivity was 85.9% (95% CI = 78.8, 93.0) and positive predictive value 90.8% (95% CI = 85, 97). For gestational diabetes, the sensitivity was 95% (95% CI = 92, 98) and positive predictive value 86% (95% CI = 81, 90).

Conclusions: In a large public hospital, ICD-10 codes accurately identified cases of pregestational and gestational diabetes with low numbers of false positives.
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http://dx.doi.org/10.1097/EDE.0000000000001311DOI Listing
March 2021

Coronavirus disease 2019 and pregnancy.

Am J Obstet Gynecol 2021 04 17;224(4):420-421. Epub 2020 Nov 17.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA.

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http://dx.doi.org/10.1016/j.ajog.2020.11.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670926PMC
April 2021

Assessing Influenza Vaccination Behaviors Among Medically Underserved Obstetric Patients.

J Womens Health (Larchmt) 2021 01 23;30(1):52-60. Epub 2020 Oct 23.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA.

Despite recommendations, maternal influenza vaccine acceptance has stagnated around 50%. A prospective cohort study was conducted of pregnant women seen in the clinic from September 2018 to April 2019. Primary outcomes included influenza vaccine uptake and reasons for vaccine refusal, categorized based on the Health Belief Model. We compared characteristics between three vaccination groups (never refused, refused and vaccinated, and refused and not vaccinated) by using chi-square and one-way analysis of variance. We used multivariate logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between patient characteristics and vaccine acceptance. Mixed-effects logistic regression models were used to explore the impact of provider-patient race concordance on influenza vaccine uptake. Among 1666 women, 902 (54.1%) were vaccinated. Of these, 183 (20.3%) initially refused. Those who refused and were never vaccinated were more likely to be non-Hispanic black (aOR: 1.64, 95% CI: 1.05-2.56) and less likely to be Hispanic (aOR: 0.44, 95% CI: 0.24-0.81). Overall, perceived barriers were the most common reason for refusal (52.4%). Women who refused consistently were more likely to cite reasons related to perceived benefits (38.5% vs. 7.6%). Those who eventually accepted were more likely to cite cue to action (22.4% vs. 12.6%). Women who were race discordant with their provider were more likely to be vaccinated compared with those who were race concordant (57.9% vs. 52.9%, aOR: 1.16, 95% CI: 1.07-1.27). Women who refuse influenza vaccination in pregnancy may later choose to be vaccinated. Continued promotion of vaccination throughout pregnancy is crucial for vaccine uptake.
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http://dx.doi.org/10.1089/jwh.2020.8582DOI Listing
January 2021

Preventing Vector-Borne Transmission of Zika Virus Infection During Pregnancy, Puerto Rico, USA, 2016-2017.

Emerg Infect Dis 2020 11;26(11):2717-2720

We examined pregnant women's use of personal protective measures to prevent mosquito bites during the 2016-2017 Zika outbreak in Puerto Rico. Healthcare provider counseling on recommended measures was associated with increased use of insect repellent among pregnant women but not with wearing protective clothing.
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http://dx.doi.org/10.3201/eid2611.201614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588518PMC
November 2020

Sociodemographic Predictors of SARS-CoV-2 Infection in Obstetric Patients, Georgia, USA.

Emerg Infect Dis 2020 Nov 13;26(11):2787-2789. Epub 2020 Oct 13.

We conducted a cohort study to determine sociodemographic risk factors for severe acute respiratory syndrome coronavirus 2 infection among obstetric patients in 2 urban hospitals in Atlanta, Georgia, USA. Prevalence of infection was highest among women who were Hispanic, were uninsured, or lived in high-density neighborhoods.
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http://dx.doi.org/10.3201/eid2611.203091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588535PMC
November 2020

Clinical Presentation of Coronavirus Disease 2019 (COVID-19) in Pregnant and Recently Pregnant People.

Obstet Gynecol 2020 12;136(6):1117-1125

Departments of Obstetrics and Gynecology and Pediatrics, University of California, Los Angeles, Los Angeles, California; the Departments of Obstetrics, Gynecology, and Reproductive Sciences, Pediatrics, Epidemiology and Biostatistics, and Medicine, University of California, San Francisco, San Francisco, California; the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania; the Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts; the Department of Obstetrics and Gynecology, University of Iowa, Iowa City, Iowa; the Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York; and the Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia.

Objective: To describe the clinical presentation, symptomology, and disease course of coronavirus disease 2019 (COVID-19) in pregnancy.

Methods: The PRIORITY (Pregnancy CoRonavIrus Outcomes RegIsTrY) study is an ongoing nationwide prospective cohort study of people in the United States who are pregnant or up to 6 weeks postpregnancy with known or suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed the clinical presentation and disease course of COVID-19 in participants who tested positive for SARS-CoV-2 infection and reported symptoms at the time of testing.

Results: Of 991 participants enrolled from March 22, 2020, until July 10, 2020, 736 had symptoms of COVID-19 at the time of testing; 594 tested positive for SARS-CoV-2 infection and 142 tested negative in this symptomatic group. Mean age was 31.3 years (SD 5.1), and 37% will nulliparous. Ninety-five percent were outpatients. Participants who tested positive for SARS-CoV-2-infection were a geographically diverse cohort: 34% from the Northeast, 25% from the West, 21% from the South, and 18% from the Midwest. Thirty-one percent of study participants were Latina, and 9% were Black. The average gestational age at enrollment was 24.1 weeks, and 13% of participants were enrolled after pregnancy. The most prevalent first symptoms in the cohort of patients who tested positive for SARS-CoV-2 infection were cough (20%), sore throat (16%), body aches (12%), and fever (12%). Median time to symptom resolution was 37 days (95% CI 35-39). One quarter (25%) of participants who tested positive for SARS-CoV-2 infection had persistent symptoms 8 or more weeks after symptom onset.

Conclusion: COVID-19 has a prolonged and nonspecific disease course during pregnancy and in the 6 weeks after pregnancy.

Clinical Trial Registration: ClinicalTrials.gov, NCT04323839.
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http://dx.doi.org/10.1097/AOG.0000000000004178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673633PMC
December 2020

Delaying Pregnancy during a Public Health Crisis - Examining Public Health Recommendations for Covid-19 and Beyond.

N Engl J Med 2020 Nov 30;383(22):2097-2099. Epub 2020 Sep 30.

From the Departments of Pediatrics, Obstetrics and Gynecology, and Epidemiology, University of Florida College of Medicine, and the College of Public Health and Health Professions, Gainesville (S.A.R.); the Center for Bioethics and Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill (A.D.L.); and the Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta (D.J.J.).

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http://dx.doi.org/10.1056/NEJMp2027940DOI Listing
November 2020

In Reply.

Obstet Gynecol 2020 10;136(4):851

American College of Obstetricians and Gynecologists, Washington, DC.

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http://dx.doi.org/10.1097/AOG.0000000000004114DOI Listing
October 2020

Infant Outcomes Following Maternal Infection with SARS-CoV-2: First Report from the PRIORITY Study.

Clin Infect Dis 2020 Sep 18. Epub 2020 Sep 18.

University of California San Francisco.

Infant outcomes after maternal SARS-CoV-2 infection are not well-described. In a prospective U.S. registry of 263 infants born to mothers testing positive or negative for SARS-CoV-2, SARS-CoV-2 status was not associated with birth weight, difficulty breathing, apnea or upper or lower respiratory infection through 8 weeks of age.
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http://dx.doi.org/10.1093/cid/ciaa1411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543372PMC
September 2020

Reply.

Am J Obstet Gynecol 2020 12 25;223(6):957-958. Epub 2020 Aug 25.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA.

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http://dx.doi.org/10.1016/j.ajog.2020.08.060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446610PMC
December 2020

Teratogen update: Zika virus and pregnancy.

Birth Defects Res 2020 09 23;112(15):1139-1149. Epub 2020 Aug 23.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA.

Zika virus was first identified in Uganda in 1947 but received little attention until 2015 when a large outbreak of Zika virus illness followed by an increased number of babies born with microcephaly occurred in Brazil. Zika virus spread rapidly throughout the Americas, and in 2016 was identified as a cause of microcephaly and other serious birth defects. Since that time, much has been learned about the Zika virus. The virus is primarily spread by the bite of Aedes species mosquitoes; however, other forms of transmission (e.g., sexual and intrauterine) have been recognized. Although postnatal Zika virus infection typically causes mild or no symptoms, effects on infants born to prenatally infected mothers can be severe and include structural birth defects and neurodevelopmental effects. The risk of a structural birth defect among infants born to mothers with confirmed or suspected Zika virus infection during pregnancy has ranged from 5 to 10%. The timing of Zika infection during pregnancy affects risk, with higher risks with the first-trimester infection. Neurodevelopmental effects are seen even in infants who appear normal in the newborn period. Although cases of Zika virus infection have fallen in the Americas, the Zika virus remains an active threat in some regions of the world. The development of a Zika vaccine will require continued focus and investment. Until a Zika vaccine is available, prevention efforts for pregnant women include avoidance of travel to areas with active Zika transmission, avoidance of mosquito bites for those living in or traveling to areas with Zika transmission, and protection against sexual transmission.
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http://dx.doi.org/10.1002/bdr2.1781DOI Listing
September 2020

Zika Virus Disease and Pregnancy Outcomes in Colombia.

N Engl J Med 2020 08;383(6):537-545

From Instituto Nacional de Salud (M.L.O., M.G., M.M., A.J.R, A.R., L.P., G.A., S.G., F.P., O.P.), Bogota, Colombia; and the Centers for Disease Control and Prevention (V.T.T., D.V., S.M.G., S.C.T., C.M.W., J.D.T., J.M.V., D.M.D., M.A.H.) and the Department of Gynecology and Obstetrics, Emory University School of Medicine (D.J.J.), Atlanta.

Background: In 2015 and 2016, Colombia had a widespread outbreak of Zika virus. Data from two national population-based surveillance systems for symptomatic Zika virus disease (ZVD) and birth defects provided complementary information on the effect of the Zika virus outbreak on pregnancies and infant outcomes.

Methods: We collected national surveillance data regarding cases of pregnant women with ZVD that were reported during the period from June 2015 through July 2016. The presence of Zika virus RNA was identified in a subgroup of these women on real-time reverse-transcriptase-polymerase-chain-reaction (rRT-PCR) assay. Brain or eye defects in infants and fetuses and other adverse pregnancy outcomes were identified among the women who had laboratory-confirmed ZVD and for whom data were available regarding pregnancy outcomes. We compared the nationwide prevalence of brain and eye defects during the outbreak with the prevalence both before and after the outbreak period.

Results: Of 18,117 pregnant women with ZVD, the presence of Zika virus was confirmed in 5926 (33%) on rRT-PCR. Of the 5673 pregnancies with laboratory-confirmed ZVD for which outcomes had been reported, 93 infants or fetuses (2%) had brain or eye defects. The incidence of brain or eye defects was higher among pregnancies in which the mother had an onset of ZVD symptoms in the first trimester than in those with an onset during the second or third trimester (3% vs. 1%). A total of 172 of 5673 pregnancies (3%) resulted in pregnancy loss; after the exclusion of pregnancies affected by birth defects, 409 of 5426 (8%) resulted in preterm birth and 333 of 5426 (6%) in low birth weight. The prevalence of brain or eye defects during the outbreak was 13 per 10,000 live births, as compared with a prevalence of 8 per 10,000 live births before the outbreak and 11 per 10,000 live births after the outbreak.

Conclusions: In pregnant women with laboratory-confirmed ZVD, brain or eye defects in infants or fetuses were more common during the Zika virus outbreak than during the periods immediately before and after the outbreak. The frequency of such defects was increased among women with a symptom onset early in pregnancy. (Funded by the Colombian Instituto Nacional de Salud and the Centers for Disease Control and Prevention.).
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http://dx.doi.org/10.1056/NEJMoa1911023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480270PMC
August 2020

Diversity of the hepatitis C virus NS5B gene during HIV co-infection.

PLoS One 2020 4;15(8):e0237162. Epub 2020 Aug 4.

Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America.

Viral diversity is an important feature of hepatitis C virus (HCV) infection and an important predictor of disease progression and treatment response. HIV/HCV co-infection is associated with enhanced HCV replication, increased fibrosis, and the development of liver disease. HIV also increases quasispecies diversity of HCV structural genes, although limited data are available regarding the impact of HIV on non-structural genes of HCV, particularly in the absence of direct-acting therapies. The genetic diversity and presence of drug resistance mutations within the RNA-dependent RNA polymerase (NS5B) gene were examined in 3 groups of women with HCV genotype 1a infection, including those with HCV mono-infection, antiretroviral (ART)-naïve women with HIV/HCV co-infection and CD4 cell count <350 cells/mm3, and ART-naïve women with HIV/HCV co-infection and CD4 cell count ≥350 cells/mm3. None had ever been treated for HCV infection. There was evidence of significant diversity across the entire NS5B gene in all women. There were several nucleotides and amino acids with distinct distributions across the three study groups, although no obvious clustering of NS5B sequences was observed based on HIV co-infection or CD4 cell count. Polymorphisms at amino acid positions associated with resistance to dasabuvir and sofosbuvir were limited, although the Q309R variant associated with ribavirin resistance was present in 12 individuals with HCV mono-infection, 8 HIV/HCV co-infected individuals with CD4 <350 cells/mm3, and 12 HIV/HCV co-infected individuals with CD4 ≥350 cells/mm3. Previously reported fitness altering mutations were rare. CD8+ T cell responses against the human leukocyte antigen (HLA) B57-restricted epitopes NS5B2629-2637 and NS5B2936-2944 are critical for HCV control and were completely conserved in 44 (51.8%) and 70 (82.4%) study participants. These data demonstrate extensive variation across the NS5B gene. Genotypic variation may have a profound impact on HCV replication and pathogenesis and deserves careful evaluation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237162PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402467PMC
October 2020

Public Health Decision Making during Covid-19 - Fulfilling the CDC Pledge to the American People.

N Engl J Med 2020 Sep 29;383(10):901-903. Epub 2020 Jul 29.

From the Department of Pediatrics, University of Florida College of Medicine, and the Department of Epidemiology, University of Florida College of Public Health and Health Professions and College of Medicine, Gainesville (S.A.R.); and the Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta (D.J.J.). Both authors were employed by the U.S. federal government until 2017 (D.J.J.) and 2018 (S.A.R.); both are currently unpaid guest researchers at the CDC.

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http://dx.doi.org/10.1056/NEJMp2026045DOI Listing
September 2020

Hypertensive Disorders of Pregnancy, Cesarean Delivery, and Severe Maternal Morbidity in an Urban Safety-Net Population.

Am J Epidemiol 2020 12;189(12):1502-1511

Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM), yet mediation by cesarean delivery is largely unexplored. We investigated the association between HDP and SMM in a cohort of deliveries at a safety-net institution in Atlanta, Georgia, during 2016-2018. Using multivariable generalized linear models, we estimated adjusted risk differences, adjusted risk ratios, and 95% confidence intervals for the association between HDP and SMM. We examined interactions with cesarean delivery and used mediation analysis with 4-way decomposition to estimate excess relative risks. Among 3,723 deliveries, the SMM rate for women with and without HDP was 124.4 per 1,000 and 52.0 per 1,000, respectively. The adjusted risk ratio for the total effect of HDP on SMM was 2.55 (95% confidence interval (CI): 2.15, 3.39). Approximately 55.2% (95% CI: 25.7, 68.5) of excess relative risk was due to neither interaction nor mediation, 24.9% (95% CI: 15.4, 50.0) was due to interaction between HDP and cesarean delivery, 9.6% (95% CI: 3.4, 15.2) was due to mediation, and 10.3% (95% CI: 5.4, 20.3) was due to mediation and interaction. HDP are a potentially modifiable risk factor for SMM; implementing evidence-based interventions for the prevention and treatment of HDP is critical for reducing SMM risk.
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http://dx.doi.org/10.1093/aje/kwaa135DOI Listing
December 2020

In Reply.

Obstet Gynecol 2020 07;136(1):192-193

Departments of Pediatrics and Epidemiology, University of Florida College of Medicine & College of Public Health and Health Professions, Gainesville, Florida.

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http://dx.doi.org/10.1097/AOG.0000000000003964DOI Listing
July 2020