Employers should be aware of the pandemic’s effects on maternal wellbeing

Cases continue to fall throughout the U.S., down by about two-thirds over the last two weeks with hospitalizations down over 40%. Deaths per day are finally below 2,000, and under 2% of counties currently appear to be at risk of hospital-bed shortages.

Daily trends in number of COVID-19 cases and new patients admitted to hospital in the U.S.

Source: Centers for Disease Control and Prevention (CDC)

Implications for employers:

• Risk of returning remote workers to the office continues to decline, although community transmission rates remain high.
• Employers should be fully prepared for workplace exposures and infections.
• Workplaces with high vaccination rates face the lowest risk.
• Employers should continue to mitigate risk for those employees, customers and visitors who are immunocompromised.

Maternal mortality increased by 20% during the pandemic

The CDC published data showing that maternal deaths in 2020 were higher than in previous years. The mortality among developed countries and the pandemic has worsened the situation. This could be from COVID-19 as well as decreased access to prenatal care. Closure of more rural hospitals, leading to longer distances to care, hasn’t helped. Increases in death rates were higher among Black and Hispanic people than among whites. The pandemic only affected nine months of 2020, so the statistics for 2021 may look even worse. Vaccination protects against severe complications of COVID-19, but we have low vaccination rates among pregnant women in the U.S.

Among Blacks: 37.3 in 2018 to 55.3 in 2020; Hispanics 11.2 in 2018 to 18.2 in 2020.

U.S. maternal mortality rates per 100,000 births

Source: National Center for Health Statistics

Implications for employers:

• About 60,000 women a year suffer severe complications from pregnancy. This is a widespread problem that predated the pandemic, which has worsened the situation.
• Racial disparities in pregnancy outcomes continue to be appalling, and we need better ways to address the increased pregnancy risk faced by Black women. This can include increasing access to doulas, midwives and early prenatal care.
• Employers can continue to require reporting from carriers regarding their efforts to improve maternal quality and safety. Improved care must begin in clinical practices and hospital labor and delivery facilities – carriers can demand explicit efforts to improve care for the most vulnerable women.
• Employers can also encourage carriers to provide incentives to hospitals to participate in collaboratives like the Alliance for Improvement in Maternal Health and California Maternal Quality Care Collaborative. Implementing care pathways and safety bundles has been shown to decrease maternal mortality, but the majority of hospitals performing deliveries do not participate in these efforts.
• Getting more young women vaccinated can address the current increase in maternal deaths, but underlying barriers to quality maternity care remain. Employers can help focus more attention on this important issue.

The CDC updates mask recommendations and releases data on mask effectiveness

Many governors have announced plans to discontinue mask mandates, and the CDC has published data supporting mask effectiveness at preventing COVID-19 transmission.

A study released by the CDC, showed that those who reported they regularly wore respirators (N95 or KN95 masks) were dramatically less likely to contract COVID-19 than those who remained largely unmasked. Cloth masks were much less helpful, and the study had a small number of participants using respirators. Real-world studies of mask usage like this are always fraught, because those who report regularly using masks might be more cautious in other ways. Nonetheless, the evidence of effectiveness of masks remains good.

Effectiveness of face mask use in indoor public settings

Another study, from an economist affiliated with Johns Hopkins, concludes that “lockdowns” (defined broadly as regulations enforcing almost any pandemic protection, including mask requirements, social distancing and vaccine requirements) did not decrease COVID-19 infections. This paper has been widely criticized because it looked for impact on COVID-19 case counts from the moment the restriction was put in place, rather than two to four weeks later.

The CDC recently issued new mask guidelines.

The CDC will now assess geographic risk based on rate of new community infections, portion of hospital beds occupied by people with COVID-19 and number of new COVID-19 hospital admissions each week.

This places about a third of the country at low risk (indoor masks not recommended), medium risk (indoor masks recommended for those who are immunocompromised) and high risk (indoor well-fitting masks recommended for all, and respirators [KN-95 or N-95] recommended for those who are immunocompromised). The new guidance emphasizes that people can wear a mask in communities with any level of risk based on personal preference informed by personal level of risk, and that those with symptoms, a positive test or exposure to COVID-19 should wear a mask.

Implications for employers:

• Many employers will be able to lift their mask mandates in communities that have no shortage of hospital beds and where COVID-19 cases are declining.
• Those who are immunocompromised, live in a household where others have weakened immune systems or who simply feel safer wearing a mask should feel comfortable doing so.
• Employers should be prepared to reinstitute mask mandates if case rates increase in the future, and evidence supports requiring and providing KN95 or better masks.
• Our Global Benefits Attitudes Survey (9,600 respondents, fielded December 1, 2021, to January 3, 2022) showed a high level of employee support for mandates. Sixty-five percent supported mask mandates, while 15% opposed them.

New vaccinations on the way

Sanofi and GSK announced results of their protein-based COVID-19 vaccination, which was highly effective at preventing severe cases and hospitalizations from COVID-19. They plan to seek emergency use authorization for primary and booster vaccinations. This vaccine doesn’t use mRNA. It is based on a more common, traditional approach, an engineered protein, which is similar to how Novavax’s vaccine works.

The mRNA vaccines are exceptionally safe and effective, but perhaps some of those who have opposed the currently available vaccines will decide to proceed with one of these new vaccines after they are authorized.

The CDC also quietly changed recommendations for the primary series of COVID-19 mRNA vaccines; the new recommendation is an interval of eight weeks between the first and second shot. This could decrease the already small risk of heart inflammation after the second dose.

Implications for employers:

• More available vaccines is good news. This will lead to greater availability – including in less developed countries, which could prevent some variants from emerging globally. This could also lead to more competition and lower prices in the future, as employers will bear the financial cost of vaccines when the pandemic emergency ends and the government stops providing all vaccines without charge.
• There is no reason for employers or pharmacy benefit managers to have a “formulary” preferring some vaccination brands over others, since there is no vaccine acquisition cost for any of the vaccines at this point.
• Employers with vaccine mandates in place should incorporate the new CDC intervals into their requirements.

New data show prolonged effectiveness of three doses of mRNA vaccine against hospitalization

Data from Nature Medicine show that those who have had three doses of mRNA vaccine provides less protection against Omicron than previous variants, as expected. Nonetheless, three shots of vaccine prevented more than 99% of hospitalizations. This study covered over 26,000 cases of COVID-19.

A separate study published in the New England Journal of Medicine showed that two doses of mRNA vaccine were over 99% effective at preventing hospitalizations among those ages 12 to 17. Those who were hospitalized despite vaccination were four times less likely to land in intensive care, and all seven deaths in the study were in unvaccinated teens.

Implications for employers:

• Continue to encourage boosters for those who are eligible.
• Continue to encourage employees to vaccinate their eligible children.

Paxlovid decreases hospitalization risk by 89%

The New England Journal of Medicine published data earlier this month showing the effectiveness of Paxlovid in decreasing hospitalization risk by 89%. We knew this number from a Pfizer press release last fall, but it’s reassuring to see the full report. Effective antiviral drugs lower the viral load, so they might decrease risk of long COVID, too.

Implications for employers:

• This drug, which appears effective regardless of variant, is an important element of our “off ramp” from the pandemic.
• Paxlovid is still relatively hard to find, and so use is generally limited to those at highest risk. Supply is supposed to be substantially improved by later this spring.
• The federal government is paying for this medication now, and the cost per course of therapy is over $500.
• As costs decline, we might carry home tests and a course of this medication on trips to developing countries, much like many carry antidiarrheal or antimalarial drugs.

Author

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Jeff Levin-Scherz, MD

Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.

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