Higher case fatality rate among obstetric patients with COVID-19 in the second year of pandemic in Brazil: do new genetic variants play a role?

Abstract

Background: In Brazil, a 20% increase in maternal mortality rate due to COVID-19 is projected for 2020. On January 4, 2021, the P.1 SARS-CoV-2 genetic variant was firstly identified in the country and recent data has indicated an association with higher hospitalization rates and mortality. The impact of P.1 variant in the obstetric population remains unclear. Methods: We carried out a preliminary analysis of sociodemographic and clinical characteristics of COVID-19 confirmed maternal deaths (between 10-50 years old) comparing cases reported to the Brazilian official severe acute respiratory syndrome (SARS) surveillance system (SS) in 2020 with those from 2021 (until April 12, 2021). This preliminary analysis employed methods described in previous reports from our group. Results: 803 maternal deaths out of 8,248 COVID-19 maternal SARS cases with a recorded outcome were reported to the SARS-SS since March 2020. Case fatality rate was significantly higher in 2021 (15.6% vs 7.4%). The first three months of 2021 already account for 46.2% of all deaths occurred in the 13-months analysed period. COVID-19 fatal cases from 2021 had a lower proportion of at least one risk factor or comorbidity as compared to 2020 but had a higher frequency of obesity. There were no significant differences in terms of age, type of residence area (urban, rural, or peri-urban), type of funding of the notification unit (public vs. private), COVID-19 diagnostic criteria, pregnancy status (pregnancy or postpartum), cardiovascular disease or diabetes. The proportion of hospitalization, ICU admission, and respiratory support before death was also not significantly different. Conclusion: Case fatality rate was increased in the three first months of 2021 when compared to 2020. Once variables related to health care access and demographics are not significantly different and women seem to be healthier in the 2021 sample, such difference may be related to the circulation of more aggressive genetic variants in the country.

Maternal mortality associated with COVID-19 in Brazil in 2020 and 2021: Comparison with non-pregnant women and men

“…Being able to compare the maternal population to other subgroups allowed us to observe that the effect of COVID-19 related mortality on pregnant and postpartum women was not equally present in the rest of the population during the 2021 pandemic year. This conclusion is different from other studies which analyze the maternal group independently [12][13][14][15][16][17][18][19][20][21][22][23][24]. Therefore, our study is unique in comparing symptoms, comorbidities, and outcomes between the maternal patients and the rest of the population and between the different pandemic years [16].…”

“…In early 2021, the maternal mortality rate seems to be even higher, even though the knowledge about the disease and the treatment tools have evolved. A recent study by Takemoto et al, demonstrated that the mortality rate was about two times higher for the maternal population in 2021 (15.6%), when compared to 2020 (7.4%) [ 15 , 16 ].…”

COVID‐19 disease and vaccination in pregnant and lactating women

“… 21 Similarly, the authors of a recent Brazilian study hypothesized that increased maternal mortality rates in 2021 relative to 2020 may be related to the rise of the Gamma variant. 22 During the period of Gamma variant predominance, a higher risk of death and severe COVID‐19 outcomes among pregnant and postpartum women was observed in Brazil. 23 …”

“…In Mississippi in the United States, an apparent increase in COVID‐19–associated deaths among pregnant women was observed after the Delta variant became the predominant strain (pre‐Delta period, five deaths per 1000 infections during pregnancy; Delta predominance period, 25 deaths per 1000) 21 . Similarly, the authors of a recent Brazilian study hypothesized that increased maternal mortality rates in 2021 relative to 2020 may be related to the rise of the Gamma variant 22 . During the period of Gamma variant predominance, a higher risk of death and severe COVID‐19 outcomes among pregnant and postpartum women was observed in Brazil 23 …”

Covid-19 treatments and vaccines must be evaluated in pregnancy

“…The numbers of pregnant and postpartum women in the UK admitted to hospital or intensive care because of covid-19 peaked over the summer 1. Maternal mortality has reached concerning levels in 2021, with case fatality rates rising in the US, doubling in Brazil, and almost tripling in India since the beginning of the pandemic 234. In Brazil, health officials even suggested avoiding pregnancy to reduce risk during the pandemic 5…”