Covid-19 re-infection in pregnancy?

Motherisk Int J 2020;1;21

 

Gideon Koren MD FRCPC FACMT, Vered Nachmias Friedler MD MBA, Renato Fusman MD, Susy Mann RN

Leumit Health Services and Adelson School of Medicine, Ariel University, Israel

 

Question

This week I have seen several media reports of Covid-19 proven- re infections. Because pregnancy appears to be a risk factor for severe Covid-19 disease, are you aware of re-infections in pregnancy?

Answer

Presently there are a handful of documented cases of re- infections. We share with you here the first such case in a young Israeli woman. Although no case has been shown yet in a pregnant woman, a new study shows that pregnant women are more likely to need intensive care. There is also mounting evidence of low or lack of measurable antibody levels among many people who recover from Covid -19.

 

After 25 million confirmed Covid 19 infections worldwide (1), a major question has been whether reinfections with this virus are possible, potentially endangering the lives of people who recovered and people who are in contact with them. It has been generally assumed that once infected, individuals mount immune response that prevents a second infection in the same individual (2).

This week the first five cases of re-infection have been described in the lay media, but these have not been peer reviewed yet (3-5). We describe a case of confirmed Covid -19 reinfection in Israel (6).

 

Case:

A 20 year 5 month old, otherwise healthy Israeli woman was diagnosed with Covid 19 on April 17, 2020. She complained of fever and cough, with no evidence of respiratory distress or other symptoms. A positive nasopharyngeal PCR swab was confirmed twice and she was sent to an isolation facility.  Between May1-10 her repeated tests were negative and she was allowed to return home.

During the first week of August 2020, after enjoying three months of complete health, some of her family members were  were tested positive by PCR, and her own tests were again positive on August 6 and 11.  She did not have symptomatology, but her pulse was 92-99/min as compared to 55-62.min during the first episode with oxygen saturation of 96%.  Viral serology on August 11 revealed positive SARS-Covid-2 IgG antibodies. She was put in isolation with other family members.

 

As of August 31, 2020, the global number Covid-19 infection was 25,387,330 with 850,600 deaths (1). The fact that till this week no viral and immunological documentation of reinfection has been published, attests to the rarity of this phenomenon.

It is conceivable  that if the immune response generated after an initial infection could not prevent a second case,  it should at least stave off more severe illness (2 ). This is what has occurred with the Hong Kong and our Israeli case. In contrast, the American and Ecuadorian cases experienced worse symptoms upon re- infection. In these 2 cases, sequenced viral samples and found them to  differ genetically, suggesting that  the re-infection stemmed  from viral mutations.

The fact that out of 25 million infected persons worldwide only a handful of re-infected cases have been identified, suggests that this is presently a rare phenomenon. It will be critical to rule out that new mutations are being introduced, which are not covered by existing immunity.

In a new study, by the PregCovid-19 Living Systematic Review Consortium, systematically reviewed 77 studies on clinical manifestations, risk  factors and maternal and perinatal outcomes following coronavirus 19  disease in pregnancy. Pregnant women were significantly more likely to need intensive care (OR 1.62, 95% confidence interval 1.33-1.96), and invasive ventilation (OR 1.88, 1.36-2.6)(6).

There is mounting evidence that in many individual Covid-19 antibody levels are borderline or even undetectable after symptoms. In general, people with more severe Covid-19 infection probably have more antibodies. Milder infections lead to fewer antibodies and could possibly provide protection to shorter time(7)

References:

  1. Statistica.com https://www.statista.com/page/covid-19-coronavirus  accessed August 31, 2020
  2. British Society of Immunology. Immune responses to viruses. https://www.immunology.org   Accessed August 31, 2020
  3. Wetsman N. A case of coronavirus reinfection shows the complexities of the pandemic. The Verge August 29, 2020
  4. Hurst L. Two cases of Covid -19 reinfection reported in Europe. Euronews, August 25, 2020
  5. CGTN: Ecuador confirms first case of COVID-19 reinfection. August 30, 2020 Nachmias V, Fusman R, Mann S, Koren G: The First Case of Documented Covid-19 Reinfection in Israel. Inf Dis Cases(Submitted for publication).
  6. Allotey J, Stalling E, Bonet M et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ 2020;370:m3320
  7. Whyte J, Greninger A. How Long Are COVID-19 Antibodies Protective? Medscape- Sep 01, 2020.