Journal club papers
- Retrospective review over a 15-days in two NYC hospitals (Columbia University Irving and Allen Hospitals).
- Patients were initially screened between March 13-21 based on symptoms and risk factors for Covid-19; universal screening was then commenced from March 22nd.
- 43 patients tested positive for Covid-19 (7 identified by risk factor screening and 36 identified by universal testing).
- Covid-positive patients were young (average 27 years of age), obese (60.5% BMI>30) and more than 41% had an additional comorbidity (asthma, type 2 diabetes, chronic hypertension).
- 37/43 (86%) of women had mild disease, 4 were severe and 2 were critical (requiring ICU).
- Symptomatic disease: 29/43 (67.4%) positive patients had symptoms consistent with Covid-19 infection – dry cough (65.9%), fever (48.3%), shortness of breath (24.1%) and chest pain (17.2%)
- Asymptomatic disease: 14/43 who were positive were asymptomatic at the time they were screened - of these, only 2/14 developed symptoms during obstetric/labour admission (both required ICU admission).
- At the time of the report 18 women had birthed. 8/18 (44.4%) had a caesarean section and 10/18 (55.5%) had a vaginal birth. ALL 18 had epidural and/or spinal.
- There was no evidence of vertical transmission. Reassuringly, none of the 18 infants tested positive for Covid-19 within the first six days.
- It is unclear how many total patients were delivered during this time to calculate the % who were Covid-19 positive.
- The authors conclude that universal testing should be considered for obstetric patients due to high rates of asymptomatic infection.
Before we cause too much alarm can we strongly stress that these findings are unlikely to be generalisable to the current Australian situation as our overall prevalence at the moment (touch wood) seems to be very low. We suggest the data indicates that universal screening might be considered in settings where the baseline prevalence is high.
Between March 22 and April 4 2020, 215 pregnant women presenting to birthsuite were screened for SARS-Cov2 on admission
o Four (1.9%) were symptomatic and they tested positive (See figure 1, from the paper)
o All remaining women were asymptomatic and 29 (13.7%) tested positive.
o Thus, 89.7% (29/33) of patients who were positive for SARS-CoV2 at admission did not have symptoms – only 10% developed them during their admission.
The authors emphasise the risk of Covid-19 amongst asymptomatic obstetric patients, but acknowledge that these observations have limited generalisability in regions with lower rates of infection – such as Australia.
These papers suggest that if we ever reach a situation of a high population prevalence we may need to start universal screening of our pregnant population. Hopefully we do not reach this.
To our Mercy Perinatal followers from overseas who are working in areas of higher Covid-19 prevalence, these data raise the possibility that your hospital might consider universal screening.
With the global COVID-19 death toll approaching 150,000 researchers are accelerating clinical trials at a rate never before seen, with close to 600 newly registered COVID-19 trials.
Therapies that are being evaluated (but are not yet proven) include hydroxychloroquine which we highlighted last week (now 90 registered trials), those aimed at reducing the ‘cytokine storm’ such as anti-TNF and anti-IL-6 therapy (collectively >40 registered trials), and those utilising antiviral therapies, including Remdesivir.
Remdesivir is a viral RNA polymerase inhibitor shown to have activity against SARS-CoV-2 in-vitro. Following pre-clinical success and a small case series (outlined below), 5 additional trials are now underway, with the two largest trials aiming to recruit 3100 patients in France and 2,400 patients across 155 sites worldwide. The anticipated end of recruitment is May 2020 (see https://www.gilead.com/purpose/advancing-global-health/covid-19/remdesivir-clinical-trials)
Compassionate use of Remdesivir for patients with severe Covid-19. Ohmagari et al. NEJM (10/4/20)
- 61 patients (from across the world) with severe COVID-19 infection (on supplemental oxygen or saturation <94%) were treated with intravenous Remdesivir.
- 8 patients were lost to follow up.
- At a median of 18 days follow-up 36/53 (68%) showed an improvement in oxygen support; 17/30 (57%) receiving mechanical ventilation were extubated, ECMO ceased for 3/4; all 12 on room air at baseline improved and 5/7 on non-invasive oxygen support improved.
- At the most recent follow-up 47% had been discharged.
- 7/53 died (13%) – 18% among those received invasive ventilation and 5% in those received non-invasive ventilation (previous reports of mortality among similarly severe cases have ranged between 17-78%).
- Adverse events were common. 32/53 (60%) had adverse events such as increased liver enzymes, renal impairment and hypotension.
Although this case series provides early encouraging signals that Remedesivir may be a useful treatment there are major limitations.
- There was no comparison group, meaning we cannot conclude whether these improvements are due to the drug.
- The sample size is very small.
We will need to await the results of the RCTs that are happening at great pace. And hopefully we get some great news when they are completed (we will get news of some sort as the world is watching with bated breath).
And please note while we may secretly wish we owned it, we declare that we do not have commercial relationships with Gilead, the [possibly soon to be very wealthy] drug company that makes Remdesivir).