Clinical Considerations for Special Populations

What to know

  • There are additional considerations for specific people diagnosed with COVID-19.

People who are moderately or severely immunocompromised

Risk

People with immunocompromising conditions and people who take immunosuppressive medications or therapies are at increased risk for severe outcomes from COVID-19 [1, 2]including:

  • Hospitalization
  • Intensive care unit admission
  • Mechanical ventilation
  • Death

Studies show that people with hematologic or solid organ cancer, with hematopoietic stem cell or solid organ transplant, and who are taking immunosuppressive medications can experience lower vaccine effectiveness than those who are immunocompetent.[3, 4, 5] However, studies suggest administering a third vaccine dose as part of the initial series and more than one dose of an updated COVID-19 vaccine, can increase immune response and protection against severe illness. [6, 7, 8]

Additional protection

Pre-exposure prophylaxis (prevention) medication is available for some people who are moderately or severely immunocompromised. Pre-exposure prophylaxis helps prevent COVID-19 but does not take the place of vaccination in people who are eligible to receive an updated COVID-19 vaccine. Everyone ages 6 months and older should stay up-to-date with their COVID-19 vaccines.

Pemivibart (Pemgarda™) is a monoclonal antibody for COVID-19 pre-exposure prophylaxis for people who:

  • Are moderately or severely immunocompromised,
  • Unlikely to mount an adequate immune response to COVID-19 vaccination, and
  • Meet the FDA-authorized conditions for use

Pemivibart may provide another layer of protection against COVID-19 in addition to the protection provided through vaccination. It can be given at least 2 weeks after receiving a COVID-19 vaccine.

Pemivibart is administered as a single intravenous infusion, over 60 minutes at a doctor's office or healthcare facility. If continued protection is needed, additional doses should be administered every 3 months. Pemivibart is still being studied and there is limited information about the safety and effectiveness of Pemivibart in preventing COVID-19. Healthcare providers should consult the Pemivibart EUA Fact Sheet and EUA Frequently Asked Questions for the FDA-authorized conditions under which Pemivibart may be used. CDC is monitoring variants and how commonly they occur to understand if they might affect how well Pemivibart works. The FDA will provide additional updates to the EUA materials, as appropriate, if new information emerges. This is the only preventive option available for COVID-19 for the immunocompromised community, as described above, at the present time.

Treatment

There are several therapeutics available, including:

These therapeutics are beneficial in this population for early treatment of COVID-19. Treatment is best initiated as soon as possible after diagnosis and within 5 to 7 days after illness onset.

The FDA has issued an emergency use authorization (EUA) for COVID-19 convalescent plasma (CP) with high titers of anti-SARS-CoV-2 antibodies for the treatment of COVID-19. CP is recommended for patients with immunosuppressive disease or patients receiving immunosuppressive treatment. CP may be administered in an outpatient or inpatient setting. For more information, please see the FDA Fact Sheet for Providers.

Management

Recommendations on who should be considered for CP and clinical information on treating patients with CP who have immunocompromising conditions, can be found in the Infectious Diseases Society of America (IDSA) Guidelines on the Treatment and Management of Patients with COVID-19. There are additional guidelines about COVID-19 vaccines, and prioritization for therapies specific to this population.

Pregnancy and recent pregnancy

Risk

Pregnant and recently pregnant people (at least 6 weeks following the end of pregnancy) are at increased risk of severe illness from COVID-19, 12including:

  • Hospital admission
  • Intensive care unit admission
  • Receipt of invasive mechanical ventilation
  • Extracorporeal membrane oxygenation

Race and ethnicity, 234older maternal age, working in a healthcare setting, and number and type of underlying conditions are associated with severe COVID-19 illness among pregnant people. 256

Data from meta-analyses 78910and observational studies 61112suggest that, compared to pregnant people without COVID-19, pregnant people with COVID-19 are at increased risk of preterm birth and stillbirth and might be at increased risk of pregnancy complications, including pre-eclampsia.

In addition, compared to recently pregnant people without COVID-19, those with COVID-19 are at increased risk for postpartum complications, including hospital readmission. 1314 However, methods for defining the period of recent pregnancy vary from study to study. While some include people with COVID-19 immediately after delivery, others include people with COVID-19 up to at least 6 weeks after a live birth or pregnancy loss.

Treatment

It is not recommended to withhold COVID-19 treatment from pregnant or lactating individuals because of theoretical safety concerns. For more information on treating COVID-19 in pregnant people, see the IDSA guidelines on initiating remdesivir and nirmatrelvir/ritonavir (Paxlovid).

Management

In general, the therapeutic management of pregnant people with COVID-19 is the same as management of people who are not pregnant.

Multisystem Inflammatory Syndrome

About MIS‎

MIS is a rare but serious condition associated with COVID-19 that can affect children (MIS-C) and adults (MIS-A). Read more:



- About MIS (for general public)
- About MIS (for healthcare professionals)

Pediatric populations

Risk

The initial clinical presentation of COVID-19 in children can include:

  • Fever
  • Cough
  • Other respiratory symptoms

Many children also experience gastrointestinal symptoms 1516including:

  • Nausea
  • Vomiting
  • Diarrhea

Viral tests are recommended for diagnosing COVID-19 in children. Children who develop severe illness can develop abnormal vital signs and markers of severe inflammation once hospitalized. 17A study of over 10,000 hospitalized children found that lower blood pressure, higher heart and respiratory rates, and abnormal markers of inflammation, including D-dimers and ferritin, were associated with severe illness in children. 17

Studies suggest that most children experience asymptomatic, mild, or moderate COVID-19 illness, but some children can experience severe illness requiring admission to the hospital or ICU, or use of invasive mechanical ventilation, and some die. 1819Like adults, children with one or more underlying medical conditions, including obesity, diabetes, and cardiac, lung, and neurologic disorders, have increased risk of severe COVID-19. 1718202122

While increasing age is the strongest risk factor for severe COVID-19 illness in adults, being <12 months of age is the strongest risk factor in children. 2324In addition to individual risk factors, the COVID-19 variant circulating at the time of infection may also impact disease severity. Compared to prior periods, studies of COVID-19 in the pediatric population during the Delta predominant period found increased rates of hospitalization. 2526Increases in overall number of pediatric hospitalizations were observed during the Omicron predominant period, particularly for children under the age of 5 years. However, pediatric patients experienced less severe disease during the Omicron period than in previous waves. 242728

Treatment and Management

Some of the medications authorized for the treatment of COVID-19 in adults have been authorized for use in children. For information on medications that are authorized for use in children in ambulatory and hospital settings, see IDSA Guidelines on the Treatment and Management of Patients with COVID-19.

For information on recommendations for clinical management, see the American Academy of Pediatrics Management Strategies in Children and Adolescents with Mild to Moderate COVID-19.

  1. Matar R, Alrahmani L, Monzer N, et al. Clinical Presentation and Outcomes of Pregnant Women With Coronavirus Disease 2019: A Systematic Review and Meta-analysis. Clin Infect Dis. Feb 1 2021;72(3):521-533. doi:10.1093/cid/ciaa828
  2. Dubey P, Thakur B, Reddy S, et al. Current trends and geographical differences in therapeutic profile and outcomes of COVID-19 among pregnant women – a systematic review and meta-analysis. BMC Pregnancy Childbirth. Mar 24 2021;21(1):247. doi:10.1186/s12884-021-03685-w
  3. Wei SQ, Bilodeau-Bertrand M, Liu S, Auger N. The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis. Cmaj. Apr 19 2021;193(16):E540-e548. doi:10.1503/cmaj.202604
  4. Allotey J, Stallings 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. Sep 1 2020;370:m3320. doi:10.1136/bmj.m3320
  5. DeSisto CL, Wallace B, Simeone RM, et al. Risk for Stillbirth Among Women With and Without COVID-19 at Delivery Hospitalization – United States, March 2020-September 2021. MMWR Morb Mortal Wkly Rep. Nov 26 2021;70(47):1640-1645. doi:10.15585/mmwr.mm7047e1
  6. Hcini N, Maamri F, Picone O, et al. Maternal, fetal and neonatal outcomes of large series of SARS-CoV-2 positive pregnancies in peripartum period: A single-center prospective comparative study. Eur J Obstet Gynecol Reprod Biol. Feb 2021;257:11-18. doi:10.1016/j.ejogrb.2020.11.068
  7. Prabhu M, Cagino K, Matthews KC, et al. Pregnancy and postpartum outcomes in a universally tested population for SARS-CoV-2 in New York City: a prospective cohort study. Bjog. Nov 2020;127(12):1548-1556. doi:10.1111/1471-0528.16403
  8. Siebach MK, Piedimonte G, Ley SH. COVID-19 in childhood: Transmission, clinical presentation, complications and risk factors. Pediatric Pulmonology. 2021;56(6):1342-1356. doi:10.1002/ppul.25344
  9. Rubens JH, Akindele NP, Tschudy MM, Sick-Samuels AC. Acute covid-19 and multisystem inflammatory syndrome in children. BMJ. 2021:n385. doi:10.1136/bmj.n385
  10. Martin B, Dewitt PE, Russell S, et al. Characteristics, Outcomes, and Severity Risk Factors Associated With SARS-CoV-2 Infection Among Children in the US National COVID Cohort Collaborative. JAMA Network Open. 2022;5(2):e2143151. doi:10.1001/jamanetworkopen.2021.43151
  11. Kompaniyets L, Agathis NT, Nelson JM, et al. Underlying Medical Conditions Associated With Severe COVID-19 Illness Among Children. JAMA Netw Open. Jun 1 2021;4(6):e2111182. doi:10.1001/jamanetworkopen.2021.11182
  12. Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA. 2021;325(11):1074. doi:10.1001/jama.2021.2091
  13. Wanga V, Gerdes ME, Shi DS, et al. Characteristics and Clinical Outcomes of Children and Adolescents Aged <18 Years Hospitalized with COVID-19 – Six Hospitals, United States, July-August 2021. MMWR Morb Mortal Wkly Rep. Dec 31 2021;70(5152):1766-1772. doi:10.15585/mmwr.mm705152a3
  14. Woodruff RC, Campbell AP, Taylor CA, et al. Risk Factors for Severe COVID-19 in Children. Pediatrics. 2022;149(1):e2021053418. doi:10.1542/peds.2021-053418
  15. Preston LE, Chevinsky JR, Kompaniyets L, et al. Characteristics and Disease Severity of US Children and Adolescents Diagnosed With COVID-19. JAMA Netw Open. Apr 1 2021;4(4):e215298. doi:10.1001/jamanetworkopen.2021.5298
  16. Hobbs CV, Woodworth K, Young CC, et al. Frequency, Characteristics and Complications of COVID-19 in Hospitalized Infants. Pediatr Infect Dis J. Mar 1 2022;41(3):e81-e86. doi:10.1097/inf.0000000000003435
  17. Marks KJ, Whitaker M, Agathis NT, et al. Hospitalization of Infants and Children Aged 0-4 Years with Laboratory-Confirmed COVID-19 – COVID-NET, 14 States, March 2020-February 2022. MMWR Morb Mortal Wkly Rep. Mar 18 2022;71(11):429-436. doi:10.15585/mmwr.mm7111e2
  18. Delahoy MJ, Ujamaa D, Whitaker M, et al. Hospitalizations Associated with COVID-19 Among Children and Adolescents – COVID-NET, 14 States, March 1, 2020-August 14, 2021. MMWR Morb Mortal Wkly Rep. Sep 10 2021;70(36):1255-1260. doi:10.15585/mmwr.mm7036e2
  19. Siegel DA, Reses HE, Cool AJ, et al. Trends in COVID-19 Cases, Emergency Department Visits, and Hospital Admissions Among Children and Adolescents Aged 0-17 Years – United States, August 2020-August 2021. MMWR Morb Mortal Wkly Rep. Sep 10 2021;70(36):1249-1254. doi:10.15585/mmwr.mm7036e1
  20. Cloete J, Kruger A, Masha M, et al. Paediatric hospitalisations due to COVID-19 during the first SARS-CoV-2 omicron (B.1.1.529) variant wave in South Africa: a multicentre observational study. The Lancet Child & Adolescent Health. 2022;6(5):294-302. doi:10.1016/s2352-4642(22)00027-x
  21. Torjesen I. Covid-19: Omicron variant is linked to steep rise in hospital admissions of very young children. BMJ. 2022:o110. doi:10.1136/bmj.o110
  22. Fung M, Babik JM. COVID-19 in Immunocompromised Hosts: What We Know So Far. Clin Infect Dis. Jan 27 2021;72(2):340-350. doi:10.1093/cid/ciaa863
  23. Belsky JA, Tullius BP, Lamb MG, Sayegh R, Stanek JR, Auletta JJ. COVID-19 in immunocompromised patients: A systematic review of cancer, hematopoietic cell and solid organ transplant patients. The Journal of infection. Mar 2021;82(3):329-338. doi:10.1016/j.jinf.2021.01.022
  24. Di Fusco M, Lin J, Vaghela S, et al. COVID-19 vaccine effectiveness among immunocompromised populations: a targeted literature review of real-world studies. Expert Rev Vaccines. Apr 2022;21(4):435-451. doi:10.1080/14760584.2022.2035222
  25. Lee A, Wong SY, Chai LYA, et al. Efficacy of covid-19 vaccines in immunocompromised patients: systematic review and meta-analysis. Bmj. Mar 2 2022;376:e068632. doi:10.1136/bmj-2021-068632
  26. Embi PJ, Levy ME, Naleway AL, et al. Effectiveness of two-dose vaccination with mRNA COVID-19 vaccines against COVID-19-associated hospitalizations among immunocompromised adults-Nine States, January-September 2021. Am J Transplant. Jan 2022;22(1):306-314. doi:10.1111/ajt.16641
  27. Tenforde MW, Patel MM, Gaglani M, et al. Effectiveness of a Third Dose of Pfizer-BioNTech and Moderna Vaccines in Preventing COVID-19 Hospitalization Among Immunocompetent and Immunocompromised Adults – United States, August-December 2021. MMWR Morb Mortal Wkly Rep. Jan 28 2022;71(4):118-124. doi:10.15585/mmwr.mm7104a2
  28. Kwon JH, Tenforde MW, Gaglani M, et al. mRNA Vaccine Effectiveness Against Coronavirus Disease 2019 Hospitalization Among Solid Organ Transplant Recipients. J Infect Dis. Sep 13 2022;226(5):797-807. doi:10.1093/infdis/jiac118