Utilization POCT inCOVID-19 Pandemic

Umi S. lnt ansari Dept Pat ologi Klinik & Kedokteran Laborat orium

FKKMK-UGM

Curriculum vitae

EDUCATIONPhD Program, Universitas Gadjah Mada, 2016Specializat ion in Clinical Pat hology (main int erest : immunology), July 2007. Vrije Universiteit Amsterdam- Universitas Gadjah Mada, Diploma in

Immunology, April 2004Master in Tropical Medicine, Universitas Gadjah Mada, February 1999, Medical Doctor: Universitas Gadjah Mada February 1995,

EMPLOYMENTAssistant Professor, Clinical Pathology-Faculty of Medicine, Universitas

Gadjah Mada,Teach undergraduate and graduated studentsGuide undergraduate and graduated student on laboratory work and

researchConsultant on clinical pathology laboratory, Sardjito's hospitalConduct studies in immunology field

Introduction: : Covid 19 course of disease

Point of Care Testing

Laboratory test in Covid 19

POCT Biomarker in Covid 19

introductionC O V I D - 1 9 T i m e l i n e

1 2 . 3 1 . 1 9O f f ic i a l s in W u h a n , C h i n a

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Geographic distribution

g(g Workld HealthCovid-19 Response Fund

search by country. Territory or Area

~ o r g a n i z a t i o n D o n a t e

WHO Coronavirus Disease (COVID-19) DashboardData last updated: 2020/85, 3OOpm CEST

O v e r v i e w Data Table E x p l o r e

+

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Map

69HiiTotal

Deaths

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Global ly, as of 3:00pm CEST, 5 August 2020, there have been 18,354,342 conf i rmed c a s e s O - ·COVID-19, including 696,147 deaths, reported to WHO.

COVID-19 DI INDONESIAINFO TERKINI: Uji PCR sebanyak 963.602 orang sudah diperiksa dan hasil negatif sebanyak 840.099orang. Terkonf irm asi Co v I D -19 mencapai 123 .50 3 orang , sembuh 7 9 .306 orang, dan meninggal dunia 5.658 orang , yang tersebar di 34 provinsi dan 480 kabu pa t e n/k ot a. Penguj ian ant igen berbasis real time Polymerase Chain Reaction (PC) dilakukan di seluruh Indonesia. Gunakanmasker untuk lindungi diri dan lindungi sesama, cuci tangan pakai sabun, hindari kerumunan dan#ProduktifAmanCovicdl9 #CuciTangan #MaskerUntukSemua #JagaJarak #AdaptasiKebiasaanBaru

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TERSEBAR DI 34 PROVINSI, 480 KABUPATEN/KOTASurnber. K@renterian Kesehatan

UPDATE TERPAPAR COVID-19 DI DUNIA TE RSEBA R DI 2 6 NEGARA DAN W ILA YA H/ T E IT ORIA L

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iI --IN-F-O--R-M-A-S, I COVID-19

: E E : g ! : ? / 119I i, ww w co@d i9 .s o i ,} CENTER

No: 146/0100/099/0VID-19/BNP8/08082020

of illness & timing of therapiesstagesStage II

(Pulmonary Phase)I

Stage III(Hyperinflammation Phase)

llA 1181II

Viral response phase

Host inflammatory response phase

Time course

Mild constitutional symptomsFever >99.6F

Dry Cough, diarrhea, headache

ARDS SIRS/Shock

Cardiac Failure

Shortness of BreathHypoxia (Pa02/Fi02<300mm#Hg)

CinicalSyrmptons

Lymphopenla, increasedprothrombin time, increased D•

Dimer and LDH (mid)

Elevated inflammatory markers(CRP, LDH, IL-6, D-dimer, ferritin)Troponin, NT-proBNP elevation

Abnormal chest imagingTransaminitis

Low-normal procalcitoninCinicalSigns

Remndesivir, chloroquine, hydroxychloroquine, convalescent plasma transfusionsCorticosteroicls, human immunoglobuhin,

IL-6 inhibitors,L-2 Iinhibitors,JAK inhibitors

Siddiqu HK, Mehra MR, Journal of Heart and Lung Transplantation, 2020

Timeline of coronavirus onsetShortness of breath

Hospitaladmission

Intensive careunit admission

- OOnset of symptoms ARDS

-0-----------------1 3 5 6 8 9 100 2 4 7 11

NUMBER OF DAYS°

ARDS=Acute respiratory disease syndromeMedian time from onset of symptoms, including fever (in 98% of patients), cough (75%), myalgia or fatigue (44%), and others. THE LANCET

80% mild/ asymptomatic, 15% severe infection, 5% critical infection

Mild vs Severe SARS-CoV-2 infection

Isolation/hospitalizationSupportive care...

Bild n.....;.ra..

Low virus titer

r........ ml>Normal i Recovery

Ammune

response

t•Activation ~----------►

SARS-CoV-2

•• Neutrop•hil

CD4

•Cytokines:IL6/IL 10/TNF/

CD8T cell

Monocyte t tC S F / R A N ~ - - - - - - - -Macrophage

Anti-cytokine storm treatment:Cytokine antagonists/mesenchymal stem cells/convalescent plasma/chloroquine, hydroxychloroquine/corticosteroid/ alternative medicine and others

CytokineStorm

Lung injury/septic shock/organ failure/ coagu loapathy...#

ICUHigh virus titer

FI G U R E 1 Major blood leukocyt e, cyt okine changes, and therapy st rat egies in mild vs. severe SARS-CoV-2 inf ect ion. Conceptual model of the

Iinterplay between immune activation and clinical pathology from patients with mild vs. severe infection, as well as current therapeutic strategieswit h BioRender (ht t ps://a .biorender.com/ )

Cytokine storm induced by COVID-19 infection in some patients results ininfection,

organanddamage followed by immune failure, organ

death.failure, secondary

Pre-Erstnginflammnatory

Candrtic

cytokinestorm 4

Clotting Renal Failure

Shock •CardiacDamage

rune Failure,, Organ FfI ailure, Secondary infection

Diagnostic approach

Clinical suspicion: likelihood of COVID-19 is increased if the patient: resides in or has traveled to a location where there iscommunity transmission of SARS-CoV-2; or Has had close contact with a confirmed or suspected case of COVID-19 in the prior 14 days,

Whom to test Symptomatic worker}

patients (priority to high risk patients, health

Select asymptomatic individuals: important for public health or infection control purposes

• The decision to test should be based on clinical and epidemiological factorsand linked to an assessment of the likelihood of infection. PCR testing of asymptomatic or mildly symptomatic contacts can be considered in the assessment of individuals who have had contact with a COVID-19 case. Screening protocols should be adapted to the local situation.Rapid collection and testing of appropriate specimens from patients meeting the suspect case definition for COVID-19 is a priority for clinical management and outbreak control and should be guided by a laboratory expert. Suspect cases should be screened for the virus with nucleic acidamplification tests {NAAT), such as RT-PCR.

•

Laboratory testing strategy recommendations for COVID-19: interim guidance, 22 March 2020. https://apps.who.int

The Need forDevices

a Rapid Detection Method and Portable Detection

Lab confirmationLab

confirmation First caseT

1/) I 71edFirst case

Potential casesDetecti on/Reporting

(/)0 90 I

S%6 00 50'0 40

Detection /Reporting

II

II

Response 0 90l'& « lO 70

60

ResponseIgo

I

•O 50Opportunity for control is minimal

40n 30 0 30

£E20

z o l ± e . e e e » a2 1 010 Z o l a . s e e

1 4 7 10 13 16 19 22 25 28 31

Number of days37 401 7 10 13 16 19 22 25 28 31 34 37 40

Number of daysImpact of early reporting of infectious diseasesin controlling and preventing an outbreak

Impact of delayed reporting of infectious diseases in controlling and preventing an outbreak

Nguyen T et al. 2020. Micromachines. 11(3):306

POINTDefinition

OF CARE TESTINGCharacteristic

• Point of care testing (POCT) is defined as ••

user friendlynot require any"clinical laboratory testing conducted close

to the site of pat ient care, typically by clinical personnel whose primary training is

extensivetraining to operatecan be used either in

hospit al environment , in the laboratories or at patient bedside without anydifficulty.

•not in the clinical laboratory sciences orpatients {self-testing).

by

• POCT refers to any testing performedoutside of the tradit ional, core or central laboratory".

POINT OF CARE

T R A N S P O R T A B L E

• a[Ya«» To determine the actual cost ofthe

test process, each step of the service chain must be ident if ied and evaluated for it's contribution to the total cost of the test performed.

initiates test

request

TM

• no.osTest Results

review ed by staff

r10:10Phlebotomist dispatched

to draw sample

Results reported

to the

LABORATORY SERVICE CHAIN turnaround time:

1 hour, SO minutes

POCT is an increasingly popular means of delivering laboratory testing.

When usedappropriately

when over-utilizedor incorrectly performed• POCT can improve

patient outcome• faster resu It• a shorter timeframe

to therapeutic intervention.

• POCT presentspatient risk.• False results

a

POCT is not freely interchangeable withpatient care situations

traditional core lab instrumentation in all

in POCTQuality issueless analytically sensitive

more at risk ofinterferences

performed not bylaboratory trained

individual

• Daily QC• Instrument maintenance• Troubleshooting

WHO assured criteria of ideal characteristics for a POCTin resource-limited setting

••••

Affordable by those at risk of infectionSensitive (few false negatives) Specific (few false positives)User friendly (simple to perform and needs minimum training)Rapid (t o enable t reat ment at first visit ) and robust ( does not need refrigerated storage)No equipmentDelivered to those who need it

•

••

The Critical Role of Laboratory Medicine in COVID-19(Modified from: Lippi et al, PMID: 32191623)

rs-CoV-2 Laboratory DiagnosticsRT-PCR, Anti•SARS-CoV-2 antibodies

RT-PCR(See DiagnosticTesting)

EpidemiologicalSurveillance· ~....- - - - - - - - - - ---= =

•

Infection Diagnosis

JOvert Disease

StagingPatient

ManagementVariousTests(See

IVDPrognost icat ion

BiochemicalMonitoring)

Therapeut ic Monitor ingDeath

Anti-SARS-CoVantibodies

EpidemiologicalSurveillance

Etiology diagnosis of covid 19 Infection

Virus particle

The essential role of clinicallaboratories in this pandemic extends be and etiolo icaldiagnosis of COVID-19

M WRNA

Infection

YlgG

Nucleocapsid protein

X lgA

Fig. 1. Schematic illustration of strategies for the detection of COVID-19 patients.

lgM

Value

• Inform individual of infection status so they can anticipate course of illness and take action to prevent transmission

• Individual

Nucleic acidamplification test for viral RNA(nasopharyngeaf swab, oropharyngea/ swab, sputum, bronchoafveofar lavage fluid, others)

Current infection withSARS-Co\V-2

• Inform patient management and actions needed to prevent transmission

• Healthcare or long-term care facility

• Inform actions needed to prevent transmission

• Public health

• Detect susceptible individuals (antibody negative) and those previously infected

• Identify those potentially immune to SARS-CoV-2(if tests can detect protective immunity, individuals could be returned to work)Antibody

detection•Past exposure to

SARS-CoV-2• Identify individuals with

neutralizing antibodies• Healthcare facilities:

Experimental therapy

• Facilitate contact tracing and surveillance

• Public health

http://mbio.asm.org/

covid 19The challenge in pandemic

Current Diagnosis method available for Covid 19' ' i ) [)

' 4 - '

Next generationsequencing(NGS)

Whole genome sequencing Highly sensitive and specific,Provide all related information;

Can identify novel strain

Fast results

Higher sensitivity

1-2 day High expertiseEquipment dependency and high cost

Highly sophisticated Lab required

Higher costs due to the use of expensive consumables

Expensive lab equipment

Detection is also complex and time consuming

RT-PCR Specific primer-probe baseddetection

3-4h

Needs small amount of DNA

Can be performed in a single stepWell established methodology in viral diagnostics

Highly repeatable and accurate

Single working temperatureLAMP More than two sets of

specific primers pair based detection

Antigen/Antibodies IgG/ IgM

1 h Too sensitive, highly prone to falsepositives due to carry-over or cross- contamination

Testing come after 3-4 days of infection

False positive

Testing come after 3-4 days of infectio

False ositive

Indistinguishability from other viral pneumonia and the hysteresis of abnormal CT

Low sensitivity as isolation is not 100%

Serological(traditional)

Sensitive and specific 4-6 h

Rapidserological

Antigen/Antibodies IgG/IgM

POCT 15-30 min

Chest images Enhance sensitivity of detection iffindings combined with RT-PCRresults

Highly (100%) specific

Gold standard

1 h

Virus isolation In vitro live virus isolationand propagation

5-15 days Kumar et al., Virusdis. (April•june 2020) 31(2):97--105

Positivity rate of SARS CoV-2 Detection in DifferentClinical Specimens

Clinical Specimen

Bronchoalveolar lavage fluid

Positive Rate

93% (14/15)72% (72/104)

63% (5/8)

Fibrobronchoscope brush biopsy

Pharyngeal swabs46% (6/13)

32%(126/398)

29% (44/153)1% (3/307)

0% (0/72)

IFCC Information Guide on COVID-19 -IFCC. www.ifcc.org

Estimated Variation Over Time in Diagnostic Tests for Detection of SARS-CoV-2 InfectionRelative to Symptom Onset

l h l d l E E E E

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( D_e_te_c_ti_o_n_u_n_lik_e_ly_a P_C_R_-_L_ik_e_ly_p_o_s_it_iv_e _ , . ) ( P_C_R_-_L_ik_e_ly_n_e_g_at_iv_e_b )

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Symptom onset

- - - N a s o p h a r y n g e a l s w a b P C R

- - - V i r u s i s o l a t i o n f r o m r e s p i r a t o r y t r a c t

- - - B r o n c h o a l v e o l a r l a v a g e / s p u t u m P C R

Stool PCR

lgM antibody

lgG antibody

Kemkes: REV-OS Pedom an P2 COVID-19 13 Juli 2020

• Pemeriksaan dengan Rapid TestPenggunaan Rapid Test tidak digunakan untuk diagnostik. Pada kondisi dengan keterbatasan kapasitas pemeriksaan RT-PCR, Rapid Test dapat digunakan untuk skrining pada populasi spesifik dan situasi khusus, seperti pada pelaku perjalanan

(termasuk kedatangan Pekerja Migran Indonesia, terutama di wilayah Pos Lintas

Batas Darat Negara (PLBDN), serta untuk penguatan pelacakan kontak sepertila pas, panti jompo, panti rehabilitasi, asrama, pondok pesantren, dan pada kelompok-kelompok rentan.

WHO merekomendasikan penggunaan Rapid Test untuk tujuan penelitian epidemiologi atau penelitian lain. Penggunaan Rapid Test selanjutnya dapat

mengikuti perkembangan teknologi terkini dan rekomendasi WHO.

di

•

Types of COVID-19 rapid tests currently in use or in development:

Direct SARS-CoV-2 antigen detection• detect viral components present during the infection

nasopharyngeal secretions.• Viral Particle• Nucleocapsid Protein

Indirect antibody-SARS-CoV-2 detection

in samples like

• detect the antibodies that later appear in serum as response against the virus.

part of the immune

•••

Anti Spike Protein,Anti Nucleocapsid Protein, Antibody to Combination SP/NP

European Centre for Disease Prevention and Control. Stockholm, 2020.

POCT Antigen:the use of point-of-care immunodiagnostic tests for COVID-19 (WHO)Advice on

expressed infection.

only when the virus is actively replicating identify acute or early

Depend to

• the time

several factors:

from onset of illness, -the quality of the specimen-the precise formulation of the reagent• the concentration of virus,

false-positive results: if the ab other than COVID-19 .

on the test strip also recognize antigens of viruses

adequate performance test could potentially be used as triage tests to rapidly identify patients who are very likely to have COVID-19,-reducing or eliminatingthe need for expensive molecular confirmatory testing.

Performances of the COVID-19 Ag Respi-strip.

RT-qPCRLow performance of rapidCOVID-19 diagnosis

antigen detection test as frontline testing forDetected Not detected

COVID-19 Ag Respi-Strip 3274

DetectedNot detected

042

Ensuring accurate diagnosis is essential to limit the spread of the virus

Little use inpandemic setting

Can nott role out SARS CoV inf.

False negative result

Sensitivity30,2%

A. Scohy, et al. Journal of clinical virolo

- 876543210

l • High sensitivity in nasopharyngealsamples wit h high viral load equivalent at least to 1.7 x 105 copies/mL (Ct <25), but the sensitivity declines substantially when the viral load decreases with Ct values over 30,equivalent to 9.4 x 10 copies/mL

Ec.oJ' = - •• • 0} ¢ • •0--·--5>

0 l

0 0

POSITIVE NEGATIVE

Ag Respi-Strip Results

1. COVID-19 Ag Respi-Strip results according to viral load.

A. Scohy, et al. Journal of clinical virology 129 (2020)

Evaluation of novel antigen-based rapiddetection test for the diagnosis of SARS-CoV-2

•4 0

•in respiratory samples• •• «3 5

• The evaluated RDT showed a highsensitivity and specificity in samples mainly obtained during the first week of symptoms and with high viral loads,Potential to become an important tool for early diagnosis of SARS•CoV-2, particularly in limited accessto molecular methods.

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International Journal of Infectious Diseases DOI: (10.1016/j.ijid.2020.05.098)

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E.Tanpa Gejala

Isolasi Dini di

Rumah

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RumahRujuk ke RS rujukan

Serology: Antibody test

Serological surveys can aid investigation of an ongoing outbreak andretrospective assessment of the attack rate or extent of an outbreak.

In cases where NAAT assays are negative and there is a strong epidemiologicallink to COVID-19 infect ion, paired serum samples (in the acut e and convalescent phase} could support diagnosis once validated serology tests are available.Serum samples can be stored for these purposes.

Paired samples are necessary for confirmation with the initial sample collectedin the first week of illness and the second ideally collected 2-4 weeks later

Cross reactivity to other coronaviruses can be challenging

• lgM ELISA can increase the positive

detection rate when combined with

the PCR method

• positive detection rate was only 51.9%in a single PCR test, but significantly increased (98.6%) when an lgM ELISA assay was applied to PCR-negative

patients

- 98.6C 1 0 08 079 60

c

Q)

4020

Q)

=>,.,,

RoL. Guo et al., Clin. Infect. Dis. (2020), doi:10.1093/cid/ciaa310.

The factors that influence antibody detection performance

FalsePositive

Previously infection by SARS CoV

Anti(SP):

RBD11-14

daysCollecting time samples: Different time seroconversion

Anti NP: 7-12 daysFalse

NegativeHost immune factors: different

immune responses to NP and SPamong people.

Hasil survey performa RDT antibodi SARS COV-2

• Tujuan melihat kondisi performa RDT covid di lapangan• Post marketing surveillance RDT yang beredar

Data sekunder dari komunitas dan rumah sakit

Anonimus dan tidak ada conflict of interestData sekunder sebanyak 130.693 data yang dikumpulkan

••• dari komunitas

dan rumah sakit di seluruh cabang PDS PatKLln {30 cabang mencakup 34provinsi)Didapatkan 63 merk RDT yang digunakan di seluruh IndonesiaBaku emas yang digunakan adalah metode rRT-PCR dan TCM

••

Performa ROTSARS COV-2

antibodi lgG dan lgM

5s1.mPCR

I TOTAL

[ E T . I I . ] Total TotalRapid Test (lgG)Positif300

Negatif3797

Positif314

Negatif39504097 4264

[ E I Z E Z I ' .7/EI'E7[TETTEH7

Rapid Test {lgG)ReaktifNon Reaktif

183131

8523098

23271770

163137

21641633

10353229

95%CI 95% ClETTIE]EIT I E E EH7ZIEL EE7AI7)ETl

43,8454,3343,01

7,0092,26

0,951,06

42,3248,7041,43

4,1291,41-0,150,74

45,3659,9744,587,82

93,112,051,39

76,9558,2878,4317,6895,94

2,700,53

75,6852,8377,1513,4695,33

0,910,31

78,2163,7379,7118,8796,564,500,76

AkurasiSensitivitas Spesifisitas PPVNPV+LR-LR

/_ Perhimpunan Dokter Spesialis Patologi Klinik dan KedoteranLaboratorium Indonesia( )

Masalah teknis yang ditemukan

•• Garis hasil samar / tidak jelas (Biolidies, Boson, Eagteeare, Edan, Genbody,

Wondfo, Vazyme, VivaDiag, Livzon, High Top, SD Biosensor, Star)Hasil TidakJelas • Hasil sangat tebal seperti kotoran ulang = non reaktif (Egens)

• False positive (VivaDiag, Edan, SD Biosensor, Setro, Wondfo)• High Top: pasien geriatri dengan komorbid & gravid

• False negative (High Top, Biozek)• Pasien swab (+), hasil non reaktif, duplo merk lain don Abbott(+)

• Garis kontrol tidak muncul (Aero, High Top, Lungene, Vazyme, Wondfo)• Muncul 5 garis da lam 1 alat uji (Viva Diag)

HasilInvalid

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• Strip sangat kecil (Aero)• Pipet sulit digunakan (High Top, Livzon)• Jumlah lgM don lgG tidak sama (Livzon)• Tidak ado buffer don pipet (Edan, New Test)

Kit KurangLengkap

Prosedurunclear

• SOP rumit (Aero, Edan)• buffer ditetes 20-30 detik sesudah sampel, strip sangat kecil (Aero)

Perhimpunan Dokter Spesialis Patologi Klinik dan KedoteranLaboratorium Indonesia

KesimpulanBanyak ROT beredar yang tidak memiliki rekomendasi/tugas/ FDA/ CE

sertifikasi gugus

Validitas ROT antibodi SARS COV-2 yang bervariasilgG sensitivitas 33-96% dan spesifistas 19-100% -

lgM sensitivitas 16-100% dan spesifisitas 7-97%

••

Performa lgG secara umum lebih baik dibanding lgM anti SARS COV-2Ditemukan hasil PCR positif disertai hasil lgG reaktif , yang mengindikasikan lgG dapat timbul pada fase akutDijumpai banyak masalah teknis terkait pemakaian ROT COVID-19•

RekomendasiPemilihan RDT per lu dipert imbangkan dengan memperhat ikan performa dan masalah teknis yang timbul

Perlunya diadakan post marketing surveillance dari user untuk setiap masalah yang ditemukan di lapangan

Perlunya pelatihan untuk petugas (SDM) yang akan melakukan pemeriksaan RDTterutama dalam hal pengerjaan dan interpretasi

Berkaitan dengan rendahnya validitas RDT, tidak direkomendasikan penggunaan RDT secara tunggal, namun dikombinasikan dengan parameter lain yaitu klinis (formulir sesuai buku pedoman Kememkes) serta pemeriksaan lab lain (PCR, CBC)

Tidak merekomendasikan penggunaan RDT antibody tunggal untuk skrining dan diagnosis COVID-19 namun untuk surveilans (seroprevalence) dengan

mempertimbangkan performa RDT yang akan digunakan

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•

•

•

•

Main laboratory abnormalities observed in adult patients withunfavorable COVID-19 progression (Modified 1-30)aboratory Test bnormali t ies otential cl inical signif icance

Bacterial (super)infection

Bacterial (superinfection

Decreased immunological response to

Increased white bloodcell

Increase neutrophil countomplete bloodount Decreased lymphocyte count the virus

Decreased platelet count Consumption (disseminated)coagulopa thyImportant in critical care managment Impairment of liver function Pulmonary injury and/or widespread organ damageLiver injury and/or organ damageLiver injury and/or organ damageLiver injury Kidney injury Kidney Injury Cardiac injuryActivation of blood coagulation and/ordisseminated coagulopathyActivation of blood coagulation and/or disseminated coag ulopathyBacterial (super)infectionSevere viral infection/viremia/viralsepsis

Estimated modificationsDecreasedIncreased

Increased Increased IncreasedIncreasedEstimated IncreaseIncreased

Increased

lo o d aseslbumln

otal bilirubinreatininreaardiac tror nin

Increased

Increased

Increased

IncreasedIncreased

rothrombin Time

rocalcitonin

reactive protein

erritinokines IL-6

Severe inflammationCytokine storm syndrome

IFCC Information Guide on COVID-19- IFCC. www.ifcc.org

C-REACTIVE PROTEIN

Synthesized within 6-8 hours of exposure to an infective process or tissue damageHalf life 19hrs and may reach to 1000 fold during an acute phase responsePeaks at 36-50 hours. It decreased when there was no stimuli

•

•

•

• It has higher sensitivity and specificity than total neutrophils and I/Tratio (immature granulocyte to total).

3#Respiratorytract infection

0

·0·0·w

L r

Figure 1]Functional CRP patways. In response to cytolines such as IL6 and IL 1$. hepatic expression of CRP increases dramatically. Circulating CRP opsonies bacteria and apoptotic cells, facilitating their clearance via the complement system and Foy/mediated phagocytosis. CRP ligation might controute to the release by phagocytic cells of immunomodulatory cytolioe s such as IL10. Evidence is mounting tat plasma CRP deposited onto inflamed tssue breaks into biologcaly active monomeric subunits, to which have been attributed a range of proinflammatory effects . Abbreviations. CRPf o e t i n w n t a l e p l n h a e n h a i h r i t r l r e

Original article

C-reactive protein levelsL Wang

in the early stage of COVID-19

IN F O A R T I C L E A B S T R A C T

Hitorigue de tarncie Baoiground c0OVID 19 is a new infect ious disease , for which there th erefo re necessary to explore biomarkers to determine the ext ent of lu Objective. We aim ed toa ssess the use fulnessc& CP leve ls in the ear ly s t , th em with tung lesions and severe presentat ion

ru le 26 mar a0UAccept& e 30 mars 20.20Dispouble sur Interre t le 11 Mr« h 20t

At the early stage of COVID-19, CRP levels werepositively correlated with lung lesions. CRP levels could reflect disease severity and should be used as a key indicator for disease monitoring.

Mild group Moderate group Severe group Critical group

- C R P l e v e l s - Diameter of the largest lung lesion

, T i i W IL EC-reactive protein correlates with computed tomographicfindings and

I(E)

%z·%5 «c:i.

predicts severe COVID-19 early

(F)C reactive protein

, CT scores15- S e v e n t y group-« Mild group

compared with severitygroup.P<0.05

- Seventy group-« Mild groupcompared with severity

group.P<0 0510

·. s: Initial stageStage lz0 •• •£ Stage 2 : Progression stagse e sf.e dA v , r a g e d

4 Stage 4 : Recovery stage3

Stage of illness

2 3Stage of illness

"CRP increased significantly at the initial stage insevere COVID-1 9 patients; while still no significant diffe rence in the CT scores were found between the severe and mild groups"

Tan et al, 2020. DOI 10.1002/mv.25871•

Procalcitonin,,Hormokines''

Hormones expressed like CytokinesHealthy Se

ThyroidLeukocytesPerit. MacrophagesSpleenLung Liver Kidney Adrenals BrainSpine Stomach PancreasSmall intestineColon Heart MSkinAdipose TissueTestes

InflammationBacterial InterferonToxins tat.ai-1»TNFa

Procalcitonin

Thyrocytes c-Cells

! uscle~Thyroxine Calcitonin

e $

Muller B. et al. J CIin Endocrinol Metab 200

Co-infection with respiratory pathogens among COVID-2019 casesXiaojuan Zhu, Yiyue Ge', Tao Wu, Kangchen Zhao, Yin Chen, Bin Wu, FengcaiBaoli Zhu"", Lunbiao Cui

Zhu,

- - - - · - - - - - -C h a r a c t e r i s t i c s o f r e s p i r a t o r y p a t h o g e n s w i t h t h e S A R S - C o V - 2 c o - i n f e c t i o n .

No. (%)

Charac t e r i s t i cTotal(n =257)

242 (94.2)

81 (31.5)

A s y mp t o ma t i c( n = 2 2 )

21 (95.5)

l\Iild(n = 78)

75 (96.2)

26(33.3)

75 (96.2)

18 (23.8)

26(33.3)

20 (25.6)

11

(14.1)

Moderate(n= 140)

129 (92.1)

(n= 17)

17 (100)Co-infections

any virus isolated 4 ( 8 . 2 ) 45 (32.1 6(35.3)

any bacteriai so la ted '

any fungi isolated°

236(91.8)

60 (23.3)

21(95.5) 124(88.6) 16 (94.1)

6 (27.3) 31 (22.1) 5(29 .9 )

Bacteria-virus 77 (30.0) 4 (18.2) 42 (30) 5(29 .5 )

Bacteria-fungi 61 (23.7) 5 (29.5)6027.3) 30 (21.9

Virus-fungi 24 (9.3) 1(4.5) 11 (7.9) 1(5.9)

Bacteria- virus-fungi 23 (8.9) 1(4.5) 10 (7.1) 1(5.9)

Procalcitonin

Contents lists available at ScienceDirect

serial procalcitonin measurement may playa role for predicting evolution towards a more severe form of diseasereflect bacterial coinfection in those

Clinica Chimica Acta

journal homepage: www.elsevier.com/locate/cca

7 4_2 a T $ } "£ %

Study

Guan et al, 2020

2Zang et al, 2020

Hang et al, 2020

Wang et al, 2020

0R(95%.0 % Weight

contributing to complicate the clinicalpicture

4,14( 206, 8,33) 38.0

3,25 (1,48, 7,15) 29.8

350 (0,82,14,93) 8.8

10,91 ( 4,48,26.56) 234

Overal

0=456,p-0.21, 02-34%

4,76 (274, 8.29) 100.0

10 12 14 16 18 20 22OR

24 26

l i K ] [t,l e t + ; i [ i

Clotting Optimal time forAbnormal Bf o gFibrin(ogen)D-Dimer

tt

Normal toslightly increased but increasing

Bleeding and Thrvomb-oc»ytopeniat Fibrin(ogen)

4

D.-di.mer

tD-dimer

P-selectin

COVID-19 Personalized TreatmentCOVID-19 Point-Of-Care Options

TEG*Platelet function tests

F ibrinogen, P-selectin and vWF concentrations Other circulat ing inflammatory marker

concentrationst cytokine stormInt. J. Mol. Sci. 2020, 21, 5168

Why are D-dimer levels elevated in severe courses of COVID-19 patients?

activatedImmune

cells and a potential

influence of cytokines

Inflammatoryprocesses

and infections

(COVID-19)

This highnumber of

blood clots is degraded by fibrinolysis.

D-dimera marker for increased coagulation processes in the body.

D-dimer levels correlate with D-dimer is commonly elevated in patients

with COVID-19 and reliable prognostic marker for in-hospital mortality .

disease severity

Table 4 Test characteristics of D-dimer for predicting in-hospitalmortality with the optimal sensitivity andCutoff point for D-dimer (mg/L)

Area under curve

95% Cl

Subjects with D-dimer > 2.14 mg/L (6)

Sensitivity (%)

Specificity (%)

Likelihood ratio

specificity scores2.14

0.85

0.77-0.92

77 (31.2%)

88.2

71.3

3.08

Correlations of D-dimer levels with clinical stagingYao et al. Journal of Intensive Care (2020) 8:49

Possible approach to empiric anticoagulation in COVID-19No 'fpvr prophylactic anticoagulation (consider

higher dose than normal, if D-dimer ismoderately elevated).

Is D-dimer above 1,000-2,000 ng/ml?

]rsContraindication to anticoagulation?

Follow serial D-dimer (If D-dimer rises above1,000-2,000 ng/mu, then re-consider

anticoagulation).Yes

]Check fibrinogen level and/or thromboelastography (TEG)

Normal or hyper-coagulable pattern (nearly always)- R-time low or normal on thromboelastogrophy- Fibrinogen level is normal or elevated

Hypo-coagulable pattern (rare, late-stage)- R-time prolonged on thromboelastography• Fibrinogen level low

][Therapeutic anticoagulation, e.g.:- Normal renal function: therapeut ic dose low molecular weight heparin- Renal failure heparin infusion

No anticoagulation

f ..

"Follow fibrinogen level and/ or thromboelastography occasionally. Discontinue anticoagulation if evidence of hypo• coagulable pat tern.For severe hypercoagulability, consider addition of aspirin

, )'-

The role of anticoagulation remains unknown and highly controversial. This is one general approach which couldbe reasonable, but treatment decisions should always be individualized.

f l t r n t Seel el Critical Care, ty r ut Crit

15TH interim guidance on recognition and management of coagulopathy in COVID-19

I I I I I

1.2.3.4.

D-dimer* Prothrombin time Platelet count Fibrinogen** v

1.2.3.4.

D-dimer markedly raised Prothrombin time prolonged Platelet count 100 x 109/L Fibrinogen <2.0 g/L

1.2.3.4.

D-dimer not markedly raised Prothrombin time normal Platelet count normal Fibrinogen elevated

IV

Admit (even if no other concerns) Monitor once or twice daily

If admitted for other clinical reasons, Monitor daily

If discharged, use as baseline for if re-presenting with symptoms

l •In all patients

Start prophylactic doseWorseninglow molecular weight heparin In non-bleeding patients, keep

► platelet count above 20 x 10/L► fibrinogen above 2.0 g/L

In bleeding patients, keep► platelet count above 50 10/L• Blood products as per protocol (see box on the

right)• Consider experimental therapies

► fibrinogen above 2.0 g/L» PT ratio <1.5 (not the same as INR)

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