{"id":47327,"date":"2020-04-28T15:11:25","date_gmt":"2020-04-28T14:11:25","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=47327"},"modified":"2020-04-30T12:03:03","modified_gmt":"2020-04-30T11:03:03","slug":"covid-19-the-time-to-shield-all-pregnant-frontline-workers-is-now","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/04\/28\/covid-19-the-time-to-shield-all-pregnant-frontline-workers-is-now\/","title":{"rendered":"Covid-19: The time to shield all pregnant frontline workers is now"},"content":{"rendered":"<p class=\"standfirst\">Recent outbreaks of influenza, Ebola, and Zika viruses have taught us that pregnant women are uniquely vulnerable to emerging infectious threats. Let\u2019s not fail pregnant frontline workers during the covid-19 pandemic, say Elizabeth B Brickley and Enny S Paix\u00e3o<\/p>\n<p><!--more--><span style=\"font-weight: 400\">Last month the Royal College of Obstetricians and Gynaecologists introduced <\/span><a href=\"https:\/\/www.rcog.org.uk\/globalassets\/documents\/guidelines\/2020-04-21-occupational-health-advice-for-employers-and-pregnant-women.pdf\"><span style=\"font-weight: 400\">new guidance<\/span><\/a><span style=\"font-weight: 400\"> on covid-19 and occupational health, asserting that for pregnant healthcare workers after 28 weeks\u2019 gestation and those with underlying health conditions, \u201ca more precautionary approach is advised. Women in this category should be recommended to stay at home.\u201d This precautionary approach to limiting occupational risks of infection should be extended to all pregnant workers <\/span><span style=\"font-weight: 400\">on the frontline of the covid-19 response, including those in non-medical roles.<\/span><\/p>\n<p><span style=\"font-weight: 400\">To accommodate and protect the developing fetus, pregnancy exerts new pressures on a woman\u2019s respiratory and cardiovascular systems and induces profound changes to her immune system. Pregnant women are at increased risk during gestation of developing hypertension and diabetes, both <\/span><a href=\"https:\/\/www.nejm.org\/doi\/10.1056\/NEJMoa2002032\"><span style=\"font-weight: 400\">newly recognised risk factors for severe covid-19<\/span><\/a><span style=\"font-weight: 400\">.\u00a0 Compared with their non-pregnant peers, pregnant women may also have markedly altered immune responses when they encounter new infectious agents like the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) that causes covid-19.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Few pregnant women have had confirmed cases of covid-19 to date, and the evidence base on the consequences of <\/span><a href=\"https:\/\/doi.org\/10.1016\/S0140-6736(20)30360-3\"><span style=\"font-weight: 400\">SARS-CoV-2 infection in pregnancy<\/span><\/a><span style=\"font-weight: 400\"> is scant. Vital comparisons of the <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7182016\/\"><span style=\"font-weight: 400\">clinical course of covid-19<\/span><\/a><span style=\"font-weight: 400\"> between pregnant and non-pregnant women of child bearing age are, unfortunately, lacking. Vertical transmission remains an open question. The relative risks of adverse pregnancy outcomes, including miscarriages, intrauterine growth restrictions, stillbirths, congenital anomalies, and preterm births, between SARS-CoV-2-infected and uninfected pregnant women are also unknown.\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Looking back to recent emerging infectious disease outbreaks, we have good reasons to be concerned about pregnant frontline professionals.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Past outbreaks teach us that pregnant women may be at heightened risk of severe complications from respiratory infections. In 2009, a pandemic strain of influenza A (H1N1) emerged and rapidly spread across the globe. When researchers collated 120 studies investigating the risks of <\/span><a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0002937810025172\"><span style=\"font-weight: 400\">influenza A (H1N1)pdm09 in pregnancy<\/span><\/a><span style=\"font-weight: 400\">, they concluded that infections were associated with higher risks of hospitalization, intensive care unit admission, and death. Further pieces of evidence, from both the <\/span><a href=\"https:\/\/link.springer.com\/article\/10.1007\/s10654-020-00600-z\"><span style=\"font-weight: 400\">2009<\/span><\/a><span style=\"font-weight: 400\"> and <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3203382\/pdf\/jir510.pdf\"><span style=\"font-weight: 400\">1918<\/span><\/a><span style=\"font-weight: 400\"> pandemics, indicate that infection with influenza during the first trimester is associated with increased risks of fetal loss. Analogous reports of severe pregnancy complications and fetal demise can also be found in the more limited literature on the coronaviruses that caused epidemics of<\/span><a href=\"https:\/\/www.ajog.org\/article\/S0002-9378(03)02039-8\/pdf\"> <span style=\"font-weight: 400\">SARS<\/span><\/a><span style=\"font-weight: 400\"> and<\/span><a href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S168411821830152X?via%3Dihub\"> <span style=\"font-weight: 400\">MERS.<\/span><\/a><span style=\"font-weight: 400\">\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Past outbreaks also show us that, despite facing disproportionately high risks, pregnant women may be systematically excluded from trials of potentially lifesaving vaccines and therapeutics. Consider, for example, the 2013-16 Ebola virus outbreak in Guinea, Liberia, and Sierra Leone. <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5407292\/\"><span style=\"font-weight: 400\">Observational reports dating back to 1976<\/span><\/a> <span style=\"font-weight: 400\">suggest that Ebola virus infections and pregnancy may be a deadly combination: upwards of 80% of infected pregnant women die and virtually all lose their pregnancies. Nevertheless, when investigators examined the clinical trials of vaccines and drugs \u201cproposed, initiated, or conducted\u201d during the recent Ebola virus outbreak in west Africa,<\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5751665\/\"> <span style=\"font-weight: 400\">they found that all 14 trials failed to include pregnant women.<\/span><\/a><span style=\"font-weight: 400\"> Much hope is currently pinned on the development of a vaccine for SARS-CoV-2, but it remains uncertain to what extent such a vaccine would benefit pregnant women.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Finally, past outbreaks illustrate the devastating costs of delays in protecting pregnant women. The 2015-17 Zika virus outbreak, and the ensuing epidemic of children born with microcephaly and other congenital birth defects, provide perhaps the most striking example of the potential dangers of failing to shield pregnant women from emerging viral threats.\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">After the cluster of microcephaly was first recognised in northeast Brazil, epidemiologists swiftly made the<\/span><a href=\"https:\/\/www.thelancet.com\/journals\/laninf\/article\/PIIS1473-3099(17)30727-2\/fulltext\"> <span style=\"font-weight: 400\">causal connection to the seemingly benign Zika virus<\/span><\/a><span style=\"font-weight: 400\"> and recognised the elevated risks of infection during the<\/span><a href=\"https:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1602412\"> <span style=\"font-weight: 400\">first trimester<\/span><\/a><span style=\"font-weight: 400\">. For many women, the evidence came too late. Although there are currently no reports of birth defects associated with SARS-CoV-2, case reports by <\/span><a href=\"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2763853\"><span style=\"font-weight: 400\">Dong et al<\/span><\/a><span style=\"font-weight: 400\"> and <\/span><a href=\"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2763854\"><span style=\"font-weight: 400\">Zeng et al<\/span><\/a><span style=\"font-weight: 400\"> of three neonates born with elevated IgM antibodies to the virus have raised new concerns of the possibility of congenital infection.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The covid-19 pandemic has only been unfolding for five months, and the full impact of SARS-CoV-2 infections during pregnancy is yet to be seen. Nevertheless, the lack of evidence is not a reason to wait before we act. Pregnancy is a unique, but fleeting season of many women\u2019s lives. In this unprecedented public health crisis, we can afford to offer pregnant workers in essential public service roles the opportunity to step back temporarily from their frontline professional duties. Failing to adopt protective measures now could place pregnant women and their offspring at unnecessary risk.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Government officials around the world should take action today to shield all pregnant frontline workers from exposure to SARS-CoV-2. We need to respect pregnant women\u2019s autonomy to choose whether or not to continue working during the pandemic. We should provide pregnant workers in conventionally public facing roles with alternative means to contribute, such as through teleworking opportunities. When that is not possible, we must ensure pregnant workers, regardless of gestational stage, have the option of a viable temporary off-ramp from professional duties, comprising an early paid maternity leave with stable healthcare coverage, and a clear path to career re-entry.\u00a0<\/span><\/p>\n<p><i><span style=\"font-weight: 400\"><strong><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-47331 alignleft\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2020\/04\/elizabeth_brickley.jpg\" alt=\"\" width=\"120\" height=\"120\" \/>Elizabeth B Brickley<\/strong> is an assistant professor of infectious disease epidemiology at the London School of Hygiene &amp; Tropical Medicine.\u00a0 She studies health equity, epidemic preparedness, and vaccines. Twitter <a href=\"https:\/\/twitter.com\/ebbrickley\">@ebbrickley<\/a><\/span><\/i><\/p>\n<p><span style=\"font-weight: 400\"><strong>Competing interests:<\/strong> None declared.<\/span><\/p>\n<p><i><span style=\"font-weight: 400\"><strong><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-47330 alignleft\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2020\/04\/enny-bmj-copy.jpg\" alt=\"\" width=\"119\" height=\"120\" \/>Enny S Paix\u00e3o<\/strong>\u00a0is a Sir Henry Wellcome postdoctoral fellow at the London School of Hygiene &amp; Tropical Medicine.\u00a0 She studies infections during pregnancy, data record linkage, and health equity.\u00a0 Twitter <a href=\"https:\/\/twitter.com\/Enny04762857\">@Enny04762857<\/a><\/span><\/i><\/p>\n<p><span style=\"font-weight: 400\"><strong>Competing interests:<\/strong> None declared.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Recent outbreaks of influenza, Ebola, and Zika viruses have taught us that pregnant women are uniquely vulnerable to emerging infectious threats. Let\u2019s not fail pregnant frontline workers during the covid-19 [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2020\/04\/28\/covid-19-the-time-to-shield-all-pregnant-frontline-workers-is-now\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":47329,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[223],"tags":[],"class_list":["post-47327","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-guest-bloggers"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Covid-19: The time to shield all pregnant frontline workers is now - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2020\/04\/28\/covid-19-the-time-to-shield-all-pregnant-frontline-workers-is-now\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Covid-19: The time to shield all pregnant frontline workers is now - The BMJ\" \/>\n<meta property=\"og:description\" content=\"Recent outbreaks of influenza, Ebola, and Zika viruses have taught us that pregnant women are uniquely vulnerable to emerging infectious threats. 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