FACT SHEET UPDATE:
On 9/9/21, the fact sheet for healthcare providers was updated. As of 9/9/21, the fact sheet for healthcare providers has been updated. Click to view information on the addition of co-packaged cartons of individual vials of casirivimab and imdevimab and the addition of 5% Dextrose as a diluent when administering REGEN-COV via IV infusion. See the latest fact sheet for healthcare providers for more information.

(Effective September 9, 2021) Changes include but are not limited to:

Dosage and Administration (Box, Section 2.4, Section 3, Section 19): addition of co-packaged carton of individual vials of casirivimab and imdevimab

Dosage and Administration (Section 2.4): addition of 5% Dextrose as diluent

Examining samples Examining samples

REGEN-COV and SARS-CoV-2 Clinical Variants

REGEN-COV has been tested against, and was found to retain neutralization activity against, pseudotyped virus-like particles (VLP) expressing the spike protein substitution(s) identified in the below SARS-CoV-2 clinical variants.

In a plaque reduction assay, REGEN-COV retained activity against authentic SARS-CoV-2 variants of B.1.1.7 (Alpha), B.1.351 (Beta), P.1 (Gamma), B.1.617.2 (Delta), and B.1.617.1 (Kappa) lineages.

It is not known how pseudotyped VLP or authentic SARS-CoV-2 data correlate with clinical outcomes.

There is a potential risk of treatment failure due to the development of viral variants that are resistant to REGEN-COV. Prescribing healthcare providers should consider the prevalence of SARS-CoV-2 variants in their area, where data are available, when considering treatment options.

Pseudotyped Virus-Like Particle Neutralization Data for SARS-CoV-2
Variant Substitutions (Viral Variants) with REGEN-COV

As of September 9, 2021

Lineage with Spike Protein Substitution:
B.1.1.7

Country First Identified

UK

WHO Nomenclature

Alpha

Key Substitutions Tested

N501Ya

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
B.1.351

Country First Identified

South Africa

WHO Nomenclature

Beta

Key Substitutions Tested

K417N+E484K+N501Yb

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
P.1

Country First Identified

Brazil

WHO Nomenclature

Gamma

Key Substitutions Tested

K417T+E484K+N501Yc

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
B.1.617.2/AY.3

Country First Identified

India

WHO Nomenclature

Delta

Key Substitutions Tested

L452R+T478K

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
AY.1/AY.2f

Country First Identified

India

WHO Nomenclature

Delta [+K417N]

Key Substitutions Tested

K417N+L452R+T478Kd

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
B.1.427/B.1.429

Country First Identified

USA (California)

WHO Nomenclature

Epsilon

Key Substitutions Tested

L452R

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
B.1.526g

Country First Identified

USA (New York)

WHO Nomenclature

Iota

Key Substitutions Tested

E484K

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
B.1.617.1/B.1.617.3

Country First Identified

India

WHO Nomenclature

Kappa/no designation

Key Substitutions Tested

L452R+E484Q

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
C.37

Country First Identified

Peru

WHO Nomenclature

Lambda

Key Substitutions Tested

L452Q+F490S

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution:
B.1.621/B.1.621.1h

Country First Identified

Colombia

WHO Nomenclature

Mu

Key Substitutions Tested

R346k+E484k+N501Y

REGEN-COV Retained Neutralization Activity (Y/N)e

Yes

Lineage with Spike Protein Substitution Country First Identified WHO Nomenclature Key Substitutions Tested REGEN-COV Retained Neutralization Activity
(Y/N)e
B.1.1.7 UK Alpha N501Ya Yes
B.1.351 South Africa Beta K417N+E484K+N501Yb Yes
P.1 Brazil Gamma K417T+E484K+N501Yc Yes
B.1.617.2/AY.3 India Delta L452R+T478K Yes
AY.1/AY.2f India Delta
[+K417N]
K417N+L452R+T478Kd Yes
B.1.427/B.1.429 USA
(California)
Epsilon L452R Yes
B.1.526g USA (New York) Iota E484K Yes
B.1.617.1/B.1.617.3 India Kappa/no designation L452R+E484Q Yes
C.37 Peru Lambda L452Q+F490S Yes
B.1.621/B.1.621.1h Colombia Mu R346K+E484K+N501Y Yes

a Pseudotyped VLP expressing the entire variant spike protein was tested. The following changes from wild-type spike protein are found in the variant: del69-70, del145, N501Y, A570D, D614G, P681H, T716I, S982A, D1118H.

b Pseudotyped VLP expressing the entire variant spike protein was tested. The following changes from wild-type spike protein are found in the variant: D80Y, D215Y, del241-243, K417N, E484K, N501Y, D614G, A701V.

c Pseudotyped VLP expressing the entire variant spike protein was tested. The following changes from wild-type spike protein are found in the variant: L18F, T20N, P26S, D138Y, R190S, K417T, E484K, N501Y, D614G, H655Y, T1027I, V1176F.

d For AY.1: Pseudotyped VLP expressing the entire variant spike protein was tested. The following changes from wild-type spike protein are found in the variant: T19R, G142D, E156G, F157-, F158-, K417N, L452R, T478K, D614G, P681R, D950N.

e No change: ≤2-fold reduction in susceptibility.

f Commonly known as “Delta plus”.

g Not all isolates of the New York lineage harbor the E484K substitution (as of February 2021).

h Key substitutions in this variant were tested individually for susceptibility to casirivimab and imdevimab, alone and in combination.

Authentic SARS-CoV-2 Neutralization Data for REGEN-COV Using a
Plaque Reduction Assay

As of September 9, 2021

SARS-CoV-2 Lineage:
B.1.1.7

Country First Identified

UK

WHO Nomenclature

Alpha

Key Substitutionsa

N501Y

REGEN-COV Retained Neutralization Activity (Y/N)b

Yes

SARS-CoV-2 Lineage:
B.1.351

Country First Identified

South Africa

WHO Nomenclature

Beta

Key Substitutionsa

K417N, E484K, N501Y

REGEN-COV Retained Neutralization Activity (Y/N)b

Yes

SARS-CoV-2 Lineage:
P.1

Country First Identified

Brazil

WHO Nomenclature

Gamma

Key Substitutionsa

K417T, E484K, N501Y

REGEN-COV Retained Neutralization Activity (Y/N)b

Yes

SARS-CoV-2 Lineage:
B.1.617.2

Country First Identified

India

WHO Nomenclature

Delta

Key Substitutionsa

L452R, T478K

REGEN-COV Retained Neutralization Activity (Y/N)b

Yes

SARS-CoV-2 Lineage:
B.1.617.1

Country First Identified

India

WHO Nomenclature

Kappa

Key Substitutionsa

L452R, E484Q

REGEN-COV Retained Neutralization Activity (Y/N)b

Yes

SARS-CoV-2 Lineage Country First Identified WHO Nomenclature Key Substitutionsa REGEN-COV Retained Neutralization Activity
(Y/N)​
b
B.1.1.7 UK Alpha N501Y Yes
B.1.351 South Africa Beta K417N, E484K, N501Y Yes
P.1 Brazil Gamma K417T, E484K, N501Y Yes
B.1.617.2 India Delta L452R, T478K Yes
B.1.617.1 India Kappa L452R, E484Q Yes

a Key substitutions occurring in receptor binding domain of spike protein, which are associated with each lineage.

b No Change: ≤2-fold reduction in susceptibility.

Healthcare providers should review the Antiviral Resistance information in Section 15 of the Fact Sheet for Healthcare Providers for details regarding specific variants and resistance, and refer to the CDC website as well as information from state and local health authorities regarding reports of viral variants of importance in their region to guide treatment decisions.

The development and manufacturing of casirivimab and imdevimab has been funded in part with federal funds from the Biomedical Advanced Research and Development Authority (BARDA), part of the Office of the Assistant Secretary for Preparedness and Response at the U.S. Department of Health and Human Services (HHS) under OT number: HHSO100201700020C.

IMPORTANT SAFETY INFORMATION

REGEN-COV (casirivimab and imdevimab) is an unapproved investigational therapy, and there are limited clinical data available. Serious and unexpected adverse events may occur that have not been previously reported with REGEN-COV use

  • Contraindication:
    REGEN-COV is contraindicated in individuals with previous severe hypersensitivity reactions, including anaphylaxis, to REGEN-COV
  • Warnings and Precautions:
    • Hypersensitivity Including Anaphylaxis and Infusion-Related Reactions: Serious hypersensitivity reactions, including anaphylaxis, have been observed with administration of REGEN-COV. If signs or symptoms of a clinically significant hypersensitivity reaction or anaphylaxis occur, immediately discontinue administration and initiate appropriate medications and/or supportive therapy. Hypersensitivity reactions occurring more than 24 hours after the infusion have also been reported with the use of REGEN-COV under EUA. Infusion-related reactions, occurring during the infusion and up to 24 hours after the infusion, have been observed with administration of REGEN-COV. These reactions may be severe or life threatening
      • Signs and symptoms of infusion-related reactions may include: fever, difficulty breathing, reduced oxygen saturation, chills, nausea, arrhythmia (e.g., atrial fibrillation, tachycardia, bradycardia), chest pain or discomfort, weakness, altered mental status, headache, bronchospasm, hypotension, hypertension, angioedema, throat irritation, rash including urticaria, pruritus, myalgia, vasovagal reactions (e.g., pre-syncope, syncope), dizziness, fatigue and diaphoresis. Consider slowing or stopping the infusion and administer appropriate medications and/or supportive care if an infusion-related reaction occurs
    • Clinical Worsening After REGEN-COV Administration: Clinical worsening of COVID-19 after administration of REGEN-COV has been reported and may include signs or symptoms of fever, hypoxia or increased respiratory difficulty, arrhythmia (e.g., atrial fibrillation, tachycardia, bradycardia), fatigue, and altered mental status. Some of these events required hospitalization. It is not known if these events were related to REGEN-COV use or were due to progression of COVID-19
    • Limitations of Benefit and Potential for Risk in Patients with Severe COVID-19: Monoclonal antibodies, such as REGEN-COV, may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high-flow oxygen or mechanical ventilation. Therefore, REGEN-COV is not authorized for use in patients who are hospitalized due to COVID-19, OR who require oxygen therapy due to COVID-19, OR who require an increase in baseline oxygen flow rate due to COVID-19 in those on chronic oxygen therapy due to underlying non-COVID-19–related comorbidity
    • Post-exposure prophylaxis with REGEN-COV is not a substitute for vaccination against COVID-19
  • Adverse Reactions:
    • COV-2067 (Treatment): Infusion-related reactions (adverse event assessed as causally related by the investigator) of grade 2 or higher severity have been observed in 10/4,206 (0.2%) of those who received REGEN-COV at the authorized dose or a higher dose. Three subjects receiving the 8,000 mg dose of REGEN-COV, and one subject receiving the 1,200 mg casirivimab and 1,200 mg imdevimab, had infusion-related reactions (urticaria, pruritus, flushing, pyrexia, shortness of breath, chest tightness, nausea, vomiting, rash) which resulted in permanent discontinuation of the infusion. All events resolved. Anaphylactic reactions have been reported in the clinical program in subjects receiving REGEN-COV. The events began within 1 hour of completion of the infusion, and in at least one case required treatment including epinephrine. The events resolved
    • COV-2069 (Post-exposure prophylaxis): In subjects who were SARS-CoV-2 negative at baseline (Cohort A), injection site reactions (all grade 1 and 2) occurred in 55 subjects (4%) in the REGEN-COV group and 19 subjects (2%) in the placebo group. The most common signs and symptoms of injection site reactions which occurred in at least 1% of subjects in the REGEN-COV group were erythema and pruritus. Hypersensitivity reactions occurred in 2 subjects (0.2%) in the REGEN-COV group and all hypersensitivity reactions were grade 1 in severity. In subjects who were SARS-CoV-2 positive at baseline (Cohort B), injection site reactions, all of which were grade 1 or 2, occurred in 6 subjects (4%) in the REGEN-COV group and 1 subject (1%) in the placebo group. The most common signs and symptoms of injection site reactions which occurred in at least 1% of subjects in the REGEN-COV group were ecchymosis and erythema
    • COV-2093 (Subcutaneous Dosing): Injection site reactions occurred in 12% and 4% of subjects following single dose administration in the REGEN-COV and placebo groups, respectively. Remaining safety finding following subcutaneous administration in the REGEN-COV group were similar to the safety findings observed with intravenous administration in COV-2067. With repeat dosing, injection site reactions occurred in 252 subjects (35%) in the REGEN-COV group and 38 subjects (16%) in the placebo group; all injection site reactions were grade 1 or 2 in severity. Hypersensitivity reactions occurred in 8 subjects (1%) in the REGEN-COV group; and all hypersensitivity reactions were grade 1 or 2 in severity. There were no cases of anaphylaxis.
  • Patient Monitoring Recommendations: Clinically monitor patients during dose administration and observe patients for at least 1 hour after intravenous infusion or subcutaneous dosing is complete
  • Use in Specific Populations:
    • Pregnancy: There are insufficient data to evaluate a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. REGEN-COV should only be used during pregnancy if the potential benefit outweighs the potential risk for the mother and the fetus
    • Lactation: There are no available data on the presence of casirivimab and/or imdevimab in human milk or animal milk, the effects on the breastfed infant, or the effects of the drug on milk production. The development and health benefits of breastfeeding should be considered along with the mother’s clinical need for REGEN-COV and any potential adverse effects on the breastfed child from REGEN-COV or from the underlying maternal condition
AUTHORIZED USE

Treatment:

REGEN-COV is authorized for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death.

Limitations of Authorized Use (Treatment)

  • REGEN-COV is not authorized for use in patients:
    • who are hospitalized due to COVID-19, OR
    • who require oxygen therapy due to COVID-19, OR
    • who require an increase in baseline oxygen flow rate due to COVID-19 in those on chronic oxygen therapy due to underlying non-COVID-19 related comorbidity
  • Monoclonal antibodies, such as REGEN-COV, may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high-flow oxygen or mechanical ventilation

Post-Exposure Prophylaxis:

REGEN-COV is authorized in adult and pediatric individuals (12 years of age and older weighing at least 40 kg) for post-exposure prophylaxis of COVID-19 in individuals who are at high risk for progression to severe COVID-19, including hospitalization or death, and are:

  • not fully vaccinated or who are not expected to mount an adequate immune response to complete SARS-CoV-2 vaccination (for example, individuals with immunocompromising conditions including those taking immunosuppressive medications) and
    • have been exposed to an individual infected with SARS-CoV-2 consistent with close contact criteria per Centers for Disease Control and Prevention (CDC), or
    • who are at high risk of exposure to an individual infected with SARS-CoV-2 because of occurrence of SARS-CoV-2 infection in other individuals in the same institutional setting (for example, nursing homes, prisons)

Limitations of Authorized Use (Post-Exposure Prophylaxis)

  • Post-exposure prophylaxis with REGEN-COV is not a substitute for vaccination against COVID-19.
  • REGEN-COV is not authorized for pre-exposure prophylaxis for prevention of COVID-19

REGEN-COV has not been approved, but has been authorized for emergency use by FDA

These uses are authorized only for the duration of the declaration that circumstances exist justifying the authorization of the emergency use under section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner

Healthcare providers should review the Fact Sheet for Healthcare Providers for information on the authorized uses of REGEN-COV and mandatory requirements of the EUA and must comply with the requirements of the EUA. The FDA Letter of Authorization is available for reference, as well as the Dear Healthcare Provider Letter and Patient Fact Sheet

Criteria for Identifying High Risk Individuals

Please refer to the Fact Sheet for Healthcare Providers for criteria for identifying high risk individuals.

SARS-CoV-2 Viral Variants

Circulating SARS-CoV-2 viral variants may be associated with resistance to monoclonal antibodies. Healthcare providers should review the Antiviral Resistance information in Section 15 of the Fact Sheet for details regarding specific variants and resistance, and refer to the CDC website as well as information from state and local health authorities regarding reports of viral variants of importance in their region to guide treatment decisions.

Reporting Adverse Events

  • The prescribing healthcare provider and/or the provider's designee are responsible for mandatory reporting of all medication errors and ALL SERIOUS ADVERSE EVENTS potentially related to REGEN-COV. These adverse events must be reported within 7 calendar days from the onset of the event
  • Healthcare facilities and providers must report therapeutics information and demonstrate adequate utilization via data reported through HHS Protect, Teletracking or National Healthcare Safety Network (NHSN) as directed by the U.S. Department of Health and Human Services
  • MedWatch adverse event reports can be submitted to the FDA here, by submitting a postage-paid Form FDA 3500 and returning by mail/fax, or by calling 1-800-FDA-1088 to request a reporting form. In addition, please provide a copy of all FDA MedWatch forms to Regeneron Pharmaceuticals, Inc via fax (1-888-876-2736) or email ([email protected])

*Individuals are considered to be fully vaccinated 2 weeks after their second vaccine dose in a 2-dose series (such as the Pfizer or Moderna vaccines), or 2 weeks after a single-dose vaccine (such as Johnson & Johnson’s Janssen vaccine). See this website for more details: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html#vaccinated

See this website for more details: https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully-vaccinated-people.html

Close contact with an infected individual is defined as: being within 6 feet for a total of 15 minutes or more, providing care at home to someone who is sick, having direct physical contact with the person (hugging or kissing, for example), sharing eating or drinking utensils, or being exposed to respiratory droplets from an infected person (sneezing or coughing, for example). See this website for additional details: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html

IMPORTANT SAFETY INFORMATION

REGEN-COV (casirivimab and imdevimab) is an unapproved investigational therapy, and there are limited clinical data available. Serious and unexpected adverse events may occur that have not been previously reported with REGEN-COV use

  • Contraindication:
    REGEN-COV is contraindicated in individuals with previous severe hypersensitivity reactions, including anaphylaxis, to REGEN-COV
  • Warnings and Precautions:
    • Hypersensitivity Including Anaphylaxis and Infusion-Related Reactions: Serious hypersensitivity reactions, including anaphylaxis, have been observed with administration of REGEN-COV. If signs or symptoms of a clinically significant hypersensitivity reaction or anaphylaxis occur, immediately discontinue administration and initiate appropriate medications and/or supportive therapy. Hypersensitivity reactions occurring more than 24 hours after the infusion have also been reported with the use of REGEN-COV under EUA. Infusion-related reactions, occurring during the infusion and up to 24 hours after the infusion, have been observed with administration of REGEN-COV. These reactions may be severe or life threatening
      • Signs and symptoms of infusion-related reactions may include: fever, difficulty breathing, reduced oxygen saturation, chills, nausea, arrhythmia (e.g., atrial fibrillation, tachycardia, bradycardia), chest pain or discomfort, weakness, altered mental status, headache, bronchospasm, hypotension, hypertension, angioedema, throat irritation, rash including urticaria, pruritus, myalgia, vasovagal reactions (e.g., pre-syncope, syncope), dizziness, fatigue and diaphoresis. Consider slowing or stopping the infusion and administer appropriate medications and/or supportive care if an infusion-related reaction occurs
    • Clinical Worsening After REGEN-COV Administration: Clinical worsening of COVID-19 after administration of REGEN-COV has been reported and may include signs or symptoms of fever, hypoxia or increased respiratory difficulty, arrhythmia (e.g., atrial fibrillation, tachycardia, bradycardia), fatigue, and altered mental status. Some of these events required hospitalization. It is not known if these events were related to REGEN-COV use or were due to progression of COVID-19
    • Limitations of Benefit and Potential for Risk in Patients with Severe COVID-19: Monoclonal antibodies, such as REGEN-COV, may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high-flow oxygen or mechanical ventilation. Therefore, REGEN-COV is not authorized for use in patients who are hospitalized due to COVID-19, OR who require oxygen therapy due to COVID-19, OR who require an increase in baseline oxygen flow rate due to COVID-19 in those on chronic oxygen therapy due to underlying non-COVID-19–related comorbidity
    • Post-exposure prophylaxis with REGEN-COV is not a substitute for vaccination against COVID-19
  • Adverse Reactions:
    • COV-2067 (Treatment): Infusion-related reactions (adverse event assessed as causally related by the investigator) of grade 2 or higher severity have been observed in 10/4,206 (0.2%) of those who received REGEN-COV at the authorized dose or a higher dose. Three subjects receiving the 8,000 mg dose of REGEN-COV, and one subject receiving the 1,200 mg casirivimab and 1,200 mg imdevimab, had infusion-related reactions (urticaria, pruritus, flushing, pyrexia, shortness of breath, chest tightness, nausea, vomiting, rash) which resulted in permanent discontinuation of the infusion. All events resolved. Anaphylactic reactions have been reported in the clinical program in subjects receiving REGEN-COV. The events began within 1 hour of completion of the infusion, and in at least one case required treatment including epinephrine. The events resolved
    • COV-2069 (Post-exposure prophylaxis): In subjects who were SARS-CoV-2 negative at baseline (Cohort A), injection site reactions (all grade 1 and 2) occurred in 55 subjects (4%) in the REGEN-COV group and 19 subjects (2%) in the placebo group. The most common signs and symptoms of injection site reactions which occurred in at least 1% of subjects in the REGEN-COV group were erythema and pruritus. Hypersensitivity reactions occurred in 2 subjects (0.2%) in the REGEN-COV group and all hypersensitivity reactions were grade 1 in severity. In subjects who were SARS-CoV-2 positive at baseline (Cohort B), injection site reactions, all of which were grade 1 or 2, occurred in 6 subjects (4%) in the REGEN-COV group and 1 subject (1%) in the placebo group. The most common signs and symptoms of injection site reactions which occurred in at least 1% of subjects in the REGEN-COV group were ecchymosis and erythema
    • COV-2093 (Subcutaneous Dosing): Injection site reactions occurred in 12% and 4% of subjects following single dose administration in the REGEN-COV and placebo groups, respectively. Remaining safety finding following subcutaneous administration in the REGEN-COV group were similar to the safety findings observed with intravenous administration in COV-2067. With repeat dosing, injection site reactions occurred in 252 subjects (35%) in the REGEN-COV group and 38 subjects (16%) in the placebo group; all injection site reactions were grade 1 or 2 in severity. Hypersensitivity reactions occurred in 8 subjects (1%) in the REGEN-COV group; and all hypersensitivity reactions were grade 1 or 2 in severity. There were no cases of anaphylaxis.
  • Patient Monitoring Recommendations: Clinically monitor patients during dose administration and observe patients for at least 1 hour after intravenous infusion or subcutaneous dosing is complete
  • Use in Specific Populations:
    • Pregnancy: There are insufficient data to evaluate a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. REGEN-COV should only be used during pregnancy if the potential benefit outweighs the potential risk for the mother and the fetus
    • Lactation: There are no available data on the presence of casirivimab and/or imdevimab in human milk or animal milk, the effects on the breastfed infant, or the effects of the drug on milk production. The development and health benefits of breastfeeding should be considered along with the mother’s clinical need for REGEN-COV and any potential adverse effects on the breastfed child from REGEN-COV or from the underlying maternal condition

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