3.5.5. Risks for Health Care Workers in General

In Italy, health care workers with COVID-19 were reported to be 8.9% of all COVID-19 patients (2026 of 22512 people, respectively). In comparison, the 2002–2003 SARS epidemic led to 8422 probable cases, with 916 deaths in 29 countries, affecting health care workers in approximately 30% of all SARS infections. As has been demonstrated for SARS, peak viral loads were reached at 12–14 days of illness, when patients were probably hospitalized, explaining the relatively high number (n = 174, 17%) of health care workers testing positive for the SARS virus. Another aspect that merits more attention is the huge amount of psychological stress among medical and paramedical team members, associated with risks of burnout, insomnia, anxiety, distress, depression or post-traumatic stress disorder (PTSD) [29,30]. This aspect, however, is not the focus of this review, also due to the currently limited data relating to this issue.

#### 3.5.6. Health Care Workers with Pregnancy

The elevated risk of COVID-19 in health care workers may also involve pregnant transplant team members. Data on pregnant COVID-19 patients are very limited. The clinical presentation in pregnant women was similar to those reported for non-pregnant adult patients who developed COVID-19 pneumonia [25]. Currently, there is no evidence for intrauterine infection caused by vertical transmission in women who develop COVID-19 pneumonia in late pregnancy [31]. Another study with 15 pregnant patients with COVID-19 pneumonia showed no worse clinical outcome in terms of CT imaging features of COVID-19 pneumonia. Nevertheless, these patients had only a mild type of COVID-19 pneumonia. There was no neonatal asphyxia, neonatal death, stillbirth or abortion, but 4/15 patients still were pregnant at the end of the study, and the final outcome of this population

has not been reported yet [32]. However, it is noteworthy that the maternal immune system in early pregnancy is very sensitive, and for the fetus this is an important stage of organ development [33].

In the H1N1 2009 influenza viral infections, the SARS outbreak in 2003, and the MERS outbreak in 2012, there were high incidences of maternal and infant complications, such as spontaneous abortion, premature delivery, intrauterine growth retardation, tracheal intubation, admission to intensive care unit, renal failure and disseminated intravascular coagulation (DIC) [33–36]. In the SARS outbreak, 57% of the women during the first trimester had spontaneous abortions, likely a result of the hypoxia during SARS-related acute respiratory distress [36].

In a case-control study to determine the effects of SARS on pregnancy, comparing ten hospitalized pregnant and 40 hospitalized non-pregnant women with the SARS infection in Hong Kong, the maternal mortality rate with SARS was 30%, compared to 0% in the non-pregnant group [37]. In pregnant women with SARS-CoV during the 2002–2003 epidemic, there were no cases of vertical transmission of the virus documented [11].
