COVID-19 and Pregnancy: Should Mothers Be Concerned?

Pregnancy is a special phase in a woman’s life, more so because of the various changes which her body undergoes during these 9 months. Perhaps that is why, the concern about the threat of the novel coronavirus is valid- after all pregnancy is a state of slight immunocompromise, and also because there are two lives at stake. WHO declared the COVID-19 outbreak a pandemic on March 11, 2020. Most countries have taken stringent measures to control the spread of this disease, but do pregnant women need to take more measures? So, avid obstetricians out there, let’s find out deeply about the connection between these two:

WHO’s official stand is that there is no higher risk in pregnancy of severe illness BUT because there are trials underway and due to the bodily changes in pregnancy, one can not know the extent of COVID-19 in these patients. [1] Due to the evolving crisis, we are seeing newer studies every day with new results. A study conducted in early February on 38 pregnant women showed that it did not lead to maternal deaths, and neither were there any confirmed cases of intrauterine transmissions, with rt-PCR being negative in all the neonatal specimens tested, hence leading to the belief that there is no intrauterine or transplacental transmission. [2] Even the CT scans done on pregnant women with COVID-19 positive samples, did not show major changes and recovered from pneumonia adequately. [3]

COVID-19: Case fatality rate in Italy

Hello everyone, this post explains the factors behind the higher case fatality rate in Italy compared to the other COVID-19 infected countries.

As of today, there are 937,941 coronavirus cases in the world with 47,273 deaths; that comes down to a mortality rate of around 5%. On the other hand, China, the former epicenter of the disease has a COVID-19 case fatality rate of approximately 4%; while Italy has a much higher rate of 11.897%.

COVID-19: Vaccines under development

COVID-19 pandemic has led researchers around the world to work on developing a safe and effective vaccine. At present, there are 5 agents which are being extensively tested as potential vaccines. Here is some information about them.

1. mRNA- 1273 

Trial: Safety and Immunogenicity Study of 2019-nCoV Vaccine (mRNA-1273) for Prophylaxis SARS CoV-2 Infection

   

- novel lipid nanoparticle encapsulated mRNA based vaccine that encodes for spike protein of SARS-CoV-2

- an open-label phase I dose-ranging clinical trial in the United States

- Study Population: 45 healthy people, males and non-pregnant women aged 18-55

    - enrolled in one of three cohorts - 25mcg, 100mcg, 250mcg

    - IM injection of the vaccine on Day 1 and 29 in deltoid

    - Follow up: 1,2,4 weeks post each vaccination, 3,6,12 months post second vaccine

- Objective

    - To evaluate the safety and reactogenicity of a 2-dose vaccination schedule of mRNA-1273, given 28 days apart, across 3 dosages in healthy adults 

    - To evaluate the immunogenicity as measured by Immunoglobulin G (IgG) enzyme-linked immunosorbent assay ELISA to the SARS-CoV-2 S (spike) protein following a 2-dose vaccination schedule of mRNA-1273 at Day 57

2. BCG Vaccine

BCG vaccine — developed for Tuberculosis. It has favorable in vitro or in vivo effect against RSV, Yellow fever, HSV, HPV. The hypothesis is that it may induce partial protection against the susceptibility to and/or severity of SARS-CoV-2 infection

Trial 1: BCG-CORONA reducing health care workers absenteeism in SARS-CoV-2 pandemic through Bacillus Calmette-Guérin vaccination, a randomized controlled trial (BCG-CORONA)

- RCT in the Netherlands 

- Study population: 1000 Health care workers with direct COVID-infected patient      

  contact

- Study duration: 6 months

- Objective: 

    - To reduce absenteeism among HCW with direct patient contacts during the epidemic phase of COVID19

    - To reduce hospital admission, ICU admission or death in HCW with direct patient contacts during the epidemic phase of COVID19

Trial 2: BRACE - BCG Vaccination to Reduce the Impact of COVID-19 in Australian Healthcare Workers Following Coronavirus Exposure (BRACE) Trial

- Open-label two group phase III RCT in Australia

- Study population: 4170 Healthcare workers

- Study duration: 12 months

- Objective:

    - COVID 19 disease incidence over 6 months, by 12 months

    - severe COVID 19 disease incidence over 6 months, by 12 months

3. Synthetic Minigene Vaccine

Artificial antigen-presenting cell Vaccine - a synthetic minigene that has been engineered based on conserved domains of the viral structural proteins and a polyprotein protease. The vaccine will be produced using a vector system to express viral proteins and immune modulators genes to modify artificial antigen-presenting cells (APC) and to activate T cells

Trial 1: Safety and Immunity of COVID-19 aAPC Vaccine

- Open-label phase I study in China

- Study population: 100 participants aged 6months to 80 years

- Objective: 

    - Injection of COVID-19/aAPC vaccine to volunteers to evaluate the safety

- To evaluate the anti- COVID-19 reactivity of the COVID-19/aAPC vaccine

Trial 2: Phase I/II Multicenter Trial of Lentiviral Minigene Vaccine (LV-SMENP) of COVID-19 Coronavirus

- Open-label Phase I/II study in China

-Study population: 100 participants aged 6months to 80 years

- Objective:

    - Injection and infusion of LV-SMENP DC and antigen-specific cytotoxic T cell vaccines to  

healthy volunteers and COVID-19 infected patients to evaluate the safety

- To evaluate the anti- COVID-19 efficacy of the LV-SMENP DC and antigen-specific  

cytotoxic T cell vaccines

4. ChAdOx1 nCoV-19 Vaccine

Trial: A Phase I/II Study to Determine Efficacy, Safety, and Immunogenicity of the Candidate Coronavirus Disease (COVID-19) Vaccine ChAdOx1 nCoV-19 in UK Healthy Adult Volunteers

- Single-blinded, Randomized Phase I/II study in UK

-Study population: 510 participants aged 18 to 55 years

- Objective: 

    - To assess efficacy of the candidate ChAdOx1 nCoV-19 against COVID-19

    - To assess safety of the candidate ChAdOx1 nCoV

5. Recombinant Novel Coronavirus Vaccine (Adenovirus Type 5 Vector)

Trial: A Single-center,Open-label，Dose-escalating Phase I Clinical Trial to Evaluate Recombinant Novel Coronavirus Vaccine (Adenovirus Type 5 Vector) in Healthy Adults Aged 18-60 Years Old

- Open label, dose-escalating Phase I study in China

-Study population: 108 participants aged 18 to 60 years

- Objective:

    - To evaluate the safety, reactogenicity and immunogenicity of Recombinant Novel Coronavirus Vaccine (Adenovirus Type 5 Vector)

Written by Devi Bavishi

Reference: clincialtrials.gov

COVID-19: App based clinical trials

Let’s see how scientists are using app technology to generate data for research on COVID-19.

COVID-19: Lessons from coronavirus outbreak in China and formulating a strategy

Hello awesomites!

The following information is regarding the situation of COVID19 in China and how did China manage to reduce the incidence of new cases.

Image by  Nakeya. Medicowesome 2020

COVID-19: Was SARS-CoV-2 genetically engineered for biological warfare?

An article published in Nature Medicine noted that it is improbable that SARS-CoV-2 emerged through laboratory manipulation of a related SARS-CoV-like coronavirus. This article disproves most conspiracy theories about the artificial origin of the SARS-CoV-2 virus.

I am going to try to explain what the article says in simplified terms but you need to have some background in biochemistry to understand what it says. Let's begin!

COVID-19: Structure of the novel coronavirus (SARS-CoV-2)

Okay, let's start right away.

Molecular structure of SARS-CoV-2

COVID-19: Summary of drugs that are under investigation for use as potential treatment options

SARS -CoV-2 that causes the famous disease, COVID-19, has no FDA approved treatment yet. Researchers around the world are using drugs that have previously demonstrated efficacy against similar virus types clinically or based on their in-vitro activity. Many clinical trials are also underway to demonstrate the most efficacious drug which can be used against this disease. Let's go through them today.

COVID-19: Summary of drugs that are under investigation for use as potential treatment options

COVID-19: Convalescent plasma as a treatment option

As the pandemic of COVID-19 continues, researchers have been looking at treatment options, most recently the use of convalescent plasma has generated a great deal of interest.

So let's dive in and understand convalescent plasma therapy and its scope:

Convalescent plasma therapy is based on the theory that a patient in the convalescence phase develops antibodies for that disease in their serum, which can be used to treat other patients, after ensuring that safe blood banking practices are being followed.

Historically, convalescent plasma was used as a prophylactic agent against measles. [1] But with the advent of vaccine development and monoclonal antibodies, the use of convalescent plasma went out of practice. It has also been used for scarlet fever [2] and poliomyelitis [3]. The use of convalescent plasma was recommended as an empirical treatment during outbreaks of the Ebola virus in 2014 [4], and a protocol for the treatment of Middle East respiratory syndrome coronavirus with convalescent plasma was established in 2015 [5].

A case series of 5 critically ill patients with laboratory-confirmed COVID-19 and ARDS was done in Shenzhen, China from January 20, 2020, to March 25, 2020. [6] In this study, 5 patients with severe pneumonia (rapid progression and high viral load requiring mechanical ventilation) received SARS-CoV-2 specific antibody (via convalescent plasma), with a binding titer>1:1000 and neutralization titer>40 along with interferon, lopinavir/ritonavir, and methylprednisolone. On 28th March 2020, the FDA gave approval of IND, i.e. Investigatory new drug application to use of convalescent plasma (after approval) to treat critically ill patients. [7]

COVID-19: Pathophysiology and microbiology

COVID-19: Pathophysiology and microbiology

COVID-19: ACE-inhibitors and SARS-Co-V2

Nowadays, many are aware of the pandemic spreading all around the world and causing victims on a daily basis. This infection which appears for the first time at Wuhan in China represents a great concern. Today, let us explore some questions relating to the disease.

1) ACE-inhibitors and SARS-Co-V2, what is the link existing between them?
The angiotensin-converting-enzyme is secreted by pneumocytes 2 of the lungs and allows the conversion of angiotensin 1 to angiotensin 2, a powerful vasoconstrictor. The receptors for this enzyme are found in various places, including the heart and lungs. Normally, the inhibitor of this enzyme is used in case of high blood pressure, coronary heart disease and also diabetes thanks to its protective effect for the kidneys. However, in the context of COVID19 infection, the virus (SARS-Cov2) uses the converting enzyme receptors to enter the lungs. Given the increase in the number of these receptors in the event of therapy based on ACE inhibitors, the maintenance of this drug in patients infected with SARS-Cov2 is controversial.

COVID-19: Cardiovascular complications

Hi everyone... 

Virus infections are the most common cause of myocarditis. The previous severe acute respiratory syndrome (SARS) beta-coronavirus SARS-CoV-1 was associated with tachyarrhythmias, signs, and symptoms of heart failure.

Let's learn about SARS-CoV-2:

• COVID-19 patients who died had higher levels of troponin, myoglobin, C-reactive protein, serum ferritin, and IL-6.
• This is because of the high inflammatory burden in COVID-19.

Let’s find out and understand about CVS complications by COVID-19:

• Mainly, vascular inflammation, myocarditis, and cardiac arrhythmias
• The possible late phenomenon of the viral respiratory infection
• Commonly observed in severe cases
• Strongly associated with mortality

Cardiovascular complications of COVID-19 

COVID19 and research: What can I do?

With the COVID19 pandemic hitting us, it is imperative to know where to get our trusted info from. Multiple research papers are emerging these days with one main big goal: Understanding this disease and how to stop it!

In addition to reading and following these research papers, you, yes you, can be a researcher yourself. You can help in fighting this disease and aid humanity.

The studies mentioned below are international studies aiming at understanding COVID19 and its implications:

1- Covidsurg:

Covidsurg is an international cohort study, aiming to assess the outcomes of surgery in patients diagnosed in COVID-19.

It is for patients who undergo surgery with either suspected or confirmed COVID-19 infection (either before or after surgery). Cases can be entered either prospectively or retrospectively.

There is no evidence to inform the management of surgical patients with COVID-19 infection. Capturing real-world data and sharing international experience will support the management of this complex group of patients, improving their clinical care.

To start, register at: http://tiny.cc/covidsurg

==================

2- CovidSurg-Cancer: 

CovidSurg-Cancer is an international cohort study assessing the safety of surgery for all types of cancer during the COVID-19 pandemic and the impact of the pandemic in cancer delay and treatment pathways.

For more info : https://globalsurg.org/cancercovidsurg/

=================

-You can start these studies at your hospital anywhere now! Get the required IRB approval and collect data.

-All publications will be Pub-Med indexed. A corporate authorship model will be used under CovidSurg Collaborative group.


Stay safe

Murad

COVID-19: The journey of a viral pandemic

Modes of transmission of SARS-CoV-2

A novel human coronavirus that emerged in Wuhan, China in the later months of 2019 has now dissipated all around the world, causing a pandemic. Let's analyze how this virus manages to spread so virulently breaching our usual barriers.

Modes of transmission of SARS-CoV-2

COVID-19: Coping with GRIEF in midst of coronavirus pandemic

The known death toll from the coronavirus has surpassed 25,000 globally. The pandemic has ended communal prayer and congregational funeral gatherings at many major churches, synagogues, mosques, and temples. With these restrictions and isolation measures, dying people can’t see their families at the endpoint of their life. The internet, however, offered some solace to others ( Facebook live streaming, Video calling, etc.) 

Tragic losses of life…Let’s understand grief in the midst of coronavirus.

Normal grief reaction :

Precipitated by the loss of a loved one (bereavement).

Sadness revolves around feelings of loss and typically occurs in "waves" intermixed with positive memories of the deceased.  

Simple hallucinations ( Visual / Auditory ) of the deceased one. 

Thoughts of dying involve wish to join the deceased but active suicidality uncommon 
For most, the natural mourning process lasts 6-12 months 

f/b the integration of grief, in which the individual continues to feel transient but less pronounced sadness, and life plans/routines have adapted to living without the deceased.

There are 5 stages of grief according to the Kübler-Ross model are denial, anger, bargaining, depression, and acceptance (may occur in any order).

“Mnemonic” = ABCD 

COVID-19: Remdesivir (GS-5734)

Here is a short post about Remdesivir (GS-5734).

Compound:
A '-cyano-substituted adenosine nucleotide analog prodrug.

COVID-19: From authors' diary for health care workers

I want to write this post and acknowledge that the pandemic is a very stressful time for healthcare workers. 

We are looking at the epidemiology that shows the increase in mortality related to the COVID-19 disease. Even though we see death everyday, addition of deaths due to SARS-CoV-2 is heartbreaking. Thoughts about not having enough ventilators, not having proven medical therapies, or a vaccine in the near future are distressing. It is in our inherent nature as healthcare professionals to try and help, it's saddening when we can't. 

Hearing the news is also very depressing. Some don't believe it. Some aren't serious enough... Yet. But when you hear the stories instead of looking at the numbers, it becomes real. How strange must it be, to be in quarantine and see your old grandparent go to the hospital alone? How sad must it be to think that it may be the last time that you see them? 

There are concerns about our safety as healthcare workers. We are being exposed on a daily basis and there are concerns about having not enough personal protective equipment such as masks in the future. Even worse, there are concerns about our families safety. We expose them every time we come home. 

I just want to tell you that all your anxieties and concerns are valid. You're not the only one thinking about these things. As we fight this pandemic together, our mental health is important. I'm proud of you for being concerned. I'm proud of you for continuing to fight everyday. 

If you are a health care provider and are distressed by this like I was and want to talk about it, email me at medicowesome@gmail.com. We also have a well being group on Whatsapp to help each other stay strong! 

I was recently talking to a colleague about how we have chosen this profession because this is what we always wanted to do - treat patients. We spoke about the retired physician in Italy who came back to work for his patients. It's noble. It's humbling. If we don't take care of the sick, who will?

-IkaN

COVID-19: Water transmission and the effects of heat on the SARS-CoV-2 virus

Hi!

I am going to be writing a series of COVID-19 posts and answering frequently asked questions by patients. Today's post is about water transmission and the effects of heat on the SARS-CoV-2 virus.

Recent updates about treatment of COVID19

All things you need to know about COVID19 

https://www.youtube.com/watch?v=A6WpCkjqJSM

Recent Updates: 

At present Best Option = HydroxyCQ +/- Azithromycin 

HydroxyCQ for 10 day ( 200 mg TDS ) 

As ACE 2 enzyme is receptor for SARS-Cov-2 & these RAS inhibitors ⬆️ ACE2 enzyme. So hypothetically, there's an ⬆️ Risk of Covid19. But the guidelines recommend that ACEI / ARBs should not be discontinued. 

Drugs under Clinical Trials:

Remdesivir (USA) 

Ritonavir-Lopinavir 

Tocilizumab (IL6) 

Sarilumab (IL6) 

Favipiravir+ Tocilizumab 

Meplazumab (CD147) 

Fingolimod 

Darunavir + Cobicistat 

Which Rx is used in your country now?  Please comment below ⬇️

Thank you.. 

- Drashtant 

Everything you need to know about coronavirus COVID-19

Resources: CDC, UpToDate, WHO website.
Video by Drashtant Prajapati, MBBS.