Obesity makes Covid-19 worse and may lead to deadly blood clots in the lungs, a new study finds.

The researchers said that obese patients with Covid-19 may have nearly three times the risk of developing what is known as a pulmonary embolism.

“Clinicians can utilise our findings to aid in determining which patients should have evaluation for pulmonary embolism with pulmonary CT angiography, as the symptoms for Covid-19 and pulmonary embolism overlap,” said lead researcher Dr Neo Poyiadi, from the department of diagnostic radiology at Henry Ford Hospital in Detroit.

“Early detection of pulmonary embolism can allow prompt treatment with anticoagulation and minimise clinical problems,” he said.

Statins may offer protection

Hospitalised obese patients with Covid-19 should be evaluated for increases in clotting indicated by a rising D-dimer – a blood test for clotting.

According to the study, 22% of 328 patients suffering from Covid-19 who had a CT scan angiography had a pulmonary embolism.

Researchers also found that patients taking statins to lower cholesterol before coming down with Covid-19 were less likely to have a pulmonary embolism.

“Further studies are needed to determine if statins have a protective effect against pulmonary embolism in Covid-19 patients,” Poyiadi said.

Poyiadi added that a recent study suggests that Covid-19 patients should be placed on blood thinners to prevent clotting.

Obesity may make Covid-19 worse because it’s associated with an increase in inflammation. Inflammation also increases the risk of clotting.

The report was published online on 14 May in the journal Radiology.

Inflammation can lead to blood clots

Dr Marc Siegel is a professor of medicine at NYU Langone Medical Center in New York City. He said, “This study underscores a point that’s becoming more widely known about Covid-19 – that obesity leads to an inflammatory cascade. We know that inflammatory chemicals increase with obesity. That’s the suspected mechanism of why obese patients are more at risk for complications.”

Inflammation can lead to blood clots, although that’s not been proven, he noted.

“The complications of Covid-19 that we’ve been seeing are inflammation and a cytokine storm, which causes inflammation in the arteries and blood clots throughout the body – and obesity is a culprit in high-risk patients,” Siegel said.

“To say that’s why we’re seeing more pulmonary embolism in obese patients is plausible. It’s early small numbers, but it’s a very important finding and it’s not surprising,” he said.

What is surprising is it looks like using statins might be helpful. Statins are anti-inflammatories, Siegel noted.

Preventative anticoagulation

But whether statins are protective is something that would have to be carefully studied, he said. There’s no clear-cut reason to start obese patients on statins if they weren’t already taking them when they were admitted to hospital, he added.

Obese patients with Covid-19 need the same care as other patients, Siegel said. That includes anticoagulation. Many of the complications of Covid-19 seem to be caused by clotting, and starting patients on blood thinners may become a standard treatment.

“We’re already starting to look at preventative anticoagulation,” he said. “It’s already something we’re highly aware of, but this study adds evidence to a direct correlation between obesity and blood clots, that’s what’s new here.”

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Free State Health MEC, Montseng Tsiu, considers having to deal with Covid-19- infected individuals who remain asymptomatic as among the main challenges facing the province in its response to the coronavirus pandemic.

By 19 May the Free State had conducted 19 834 tests and recorded 165 confirmed cases, 118 recoveries and six deaths. “[The issue of] people that don’t show signs and symptoms is challenging,” Tsiu said. “There are others who would not only screen but also test and the results [would] come out negative, and then within 14 days when they test again, the results come out positive. We’re dealing with something that is new. We’re still learning.”

In mid-March the Free State recorded its first Covid-19 case when  a medical technologist who worked at various hospitals in Bloemfontein, tested positive. 

Contact tracing

Tsiu told Spotlight after the province announced its first positive case, the department made sure they traced all contacts. “We screened and tested them. We also went to the school her children attended [and we] screened the teachers, learners as well as their families.”

Many of the province’s first infections were in people who attended a three-day-long church gathering early in March. This outbreak prompted a visit by Health Minister Dr Zweli Mkhize. Since then a large screening initiative and tracing of various individuals who attended the church conference were conducted.

“We immediately went to the church, to make sure we covered [traced] each and every one who was part of the gathering. We screened everyone and tested those who needed testing. That following day, after some who attended [the church gathering] tested positive; we quarantined them. We also went as far as asking cell phone companies to assist us in checking [tracing] the movements of those who attended the church gathering and their contacts,” Tsiu said.

One death too many

At 141 positive Covid-19 cases, Mangaung Metropolitan Municipality has the most cases in the province. Free State Premier Sisi Ntombela said this week that the city may remain at level 4 when some areas move to level 3 by end of the month. So far, those who have died from Covid-19 in the province are all men from Bloemfontein between the ages of 51 and 86 years.

Among those who died is a 77-year-old man who  was confirmed positive after the virus was detected through a swab of his remains. This prompted the department to swab the remains of all deceased persons across the province, to ensure they know for certain if anyone died of Covid-19. The department will then trace all the contacts of the deceased for testing. “Most of those who have tested positive have recovered,” Tsiu said. “We only have a few that we have lost, which is something that is bothering us as one death is one too many.

“We have lost six people [to date] due to Covid-19 and we know that they had underlying diseases. To us it’s a concern. We would not want any person to lose their life to this illness.” The head of the Free State Health Department, Dr David Motau, told Spotlight of the six deaths that the province recorded, two had multiple morbidities, two had hypertension and the other two had no known co-morbidities. “The dead were swabbed, and some had cardio-respiratory illnesses such as pneumonia. We’re confident that we should be able to deal with this. We have a situation where we have finite resources for infinite healthcare demands. Those are some factors contributing to the challenges we have,” Motau said.

Upscaling screening and testing efforts

According to Tsiu, the provincial department’s “determination to flatten the curve and curb transmissions has been a combination of tracing contacts, screening and testing”.

“We don’t just initially test,” Tsiu said. “We conduct testing after we have received results from the screening. Our soldiers on the ground, who are the community health workers, are dealing with the community transmission. They conduct door-to-door screenings and educate people about the virus. We go to different communities, erect a tent and our nurses stay there during the day, screening, testing and educating people.”

Compared to other provinces such as the Western Cape and Gauteng, however, the latest statistics from the National Institute for Communicable Diseases (NICD) show the Free State by early May had done only 597 tests per 100 000 people whereas Gauteng did 736 tests per 100 000 and the Western Cape 1 023 per 100 000 people.

On Tuesday Motau said the province had done a total of 19 834 tests so far. Spotlight asked him about these testing figures.

“You would know that Western Cape and Gauteng are accounting for more than 70% of the cases in the country, so ordinarily it would make sense that they do a lot of tests,” he said. “However, as the Free State we also need to make sure that we test. [Now] we will be doing targeted testing in our vulnerable areas. While the demand is getting higher, you would know that the country as a whole does not have enough test kits, and the national department is working hard at making sure that we get those test kits. We are also in collaboration with private labs and have agreed that we use private labs to do some of our tests that would have come from some of these targeted areas that we’re talking about,” Motau said.

In March, two mobile Covid-19 screening buses provided by the National Health Laboratory Services for screening and testing were stationed at Pelonomi Hospital and Universitas Academic Hospital, respectively. That same month the department collaborated with private health facilities to increase the number of ICU beds to 320 in the province. Tsiu said the province employed about 500 enrolled nurses to increase screening capacity and deployed 40 tracers from the humanitarian organisation Red Cross in the province. Mangaung Metropolitan Municipality in Bloemfontein has 25 tracer teams of 125 tracers per team. These teams include volunteers, CHWs and nurses.

To quarantine or not to quarantine

Tsiu told Spotlight what “helped” was that the provincial authorities do not allow people to self-quarantine. “We have seen that when people say they have self-quarantined, they still get out of their houses and move around. Sometimes they would move carelessly without the masks, so we make sure that you are where we can monitor you on a daily basis,” she said.

Quarantine is when people may have contracted the disease but are asymptomatic. It is dealing with these asymptomatic people Tsiu describes as the province’s biggest challenge. Isolation refers to separating sick people from others. The guidelines of the NICD provide that where it is safe to do so, people can self-isolate at home. In terms of the Regulations to the Disaster Management Act, however, provinces can force people to isolate in state facilities.

When asked about quarantine and the legal and public health concerns underlying it, Motau clarified that although the MEC has given a “political direction that her wish is for the department to be able to deal with the pandemic, they need to admit everyone and there are still some [people] allowed to self-quarantine”.

Motau said they had some successes with self-quarantine. “But the MEC has said she doesn’t want to take chances, and these people must be quarantined. You now look at how you balance the resources in terms of the available quarantine sites together with the number of patients you have,” Motau said.

Doing exceptionally well

According to Tsiu, there are about 1 078 quarantine beds and 449 isolation beds in the province. This includes 881 quarantine beds in Mangaung, 40 beds in Fezile Dabi District, 36 beds in Thabo Mofutsanyana, 55 beds in Lejweleputswa and 66 beds in Xhariep, she said. Tsiu said there are 14 quarantine sites across the province that include eight sites in Mangaung, two in Xhariep, one in Fezile Dabi, one in Thabo Mofutsanyana and two in Lejweleputswa.

The MEC said she is satisfied with the work that is being done. “I think that is what we are doing exceptionally good. Once you test positive, we make sure we remove you from the community and quarantine you at places where we have provided beds for isolation. Those [individuals] who are not yet confirmed, we move them to places [stationed] for them alone, until we get the results and until the 14 days of the incubation period pass. After that, if you’re cleared and did not contract the virus, we let you go.”

But what about concerns that removing people to quarantine sites can contribute to rising levels of stigma around Covid-19 and may derail the response by making people less likely to test? Motau acknowledged the issues of stigma are concerning. “This is a worrying factor that has been discussed at the provincial command centre with the DG [Director-General]. We’re in agreement that if we don’t deal with stigma, we will have a serious problem. So, I think we need to invest a lot to educate our communities and making sure that they know this issue around Covid-19,” he said. 

This article was produced by SPOTLIGHT – health journalism in the public interest. SIGN UP for our newsletter.

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Refilwe Mekoa

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A Canadian newborn is a “probable” case of infection with the new coronavirus while still in the womb, doctors report.

Other such cases have been suspected and reported in prior studies. But the mother’s active case of Covid-19, along with the fact that the baby boy was delivered via C-section, add weight to the notion that maternal-foetal transmission of the SARS-CoV-2 virus can occur, the Toronto doctors concluded.

There was good news, however: Although the baby was born preterm (about 36 weeks), he was a healthy 6.5 pounds. And even though testing positive for coronavirus, he did not develop Covid-19.

Still, the case “represents a probable case of congenital SARS-CoV-2 infection in a liveborn neonate,” said researchers led by paediatrician Dr Prakesh Shah, of Toronto’s Mount Sinai Hospital. They published their report on 14 May in the Canadian Medical Association Journal.

‘Semi-urgent’ C-section

As Shah’s group noted, prior studies from China have already confirmed coronavirus infection in newborns born to women infected with the new coronavirus. But it’s been tough to ascertain whether the infant picked up the infection via contact with the vaginal canal during birth, or by being held by the mother, or by breastfeeding.

In the new case, a 40-year-old pregnant woman arrived at the hospital to deliver her baby. She was already suffering from active Covid-19, with body aches, reduced appetite, fatigue, dry cough and a fever of 102 degrees Fahrenheit (38.88 degrees Celsius).

Luckily, she did not require any respiratory support, her doctors said, but it was decided that the woman undergo a “semi-urgent” C-section.

Her baby boy was “vigorous” upon birth and didn’t require any help breathing. However, nasal swab tests conducted at birth, one day after, and then again seven days after, all turned up positive for infection with the new coronavirus.

It’s impossible to confirm that the infant contracted the virus while still in the womb, but Shah’s team wrote that the woman did have reduced immune system function, which would leave her body more vulnerable to the virus.

Infection via the placenta

As well, testing of her placenta revealed inflammation in those tissues that was “consistent with primary viral infection”, the doctors said.

The baby boy had not come in contact with the woman’s vaginal tract during his C-section delivery, and all precautions were taken (masks, gloves etc.) to minimise the spread of coronavirus from mom to newborn in the hours after birth.

So, “we suspect the possibility of a transamniotic route of [coronavirus] infection via the placenta,” the team wrote.

Dr Adi Davidov is associate chair of gynaecology at Staten Island University Hospital in New York City. Reading over the Toronto findings, he said, “This is the first report that clearly shows that there is a small possibility that Covid can be transmitted in utero.”

Davidov added that although people primarily think of SARS-CoV-2 as invading the respiratory tract, “it can occasionally be found in other areas of the body”, and that may include the uterus and placenta.

A rare phenomenon

Still, maternal-foetal transmission of coronavirus probably isn’t common, he believes.

“Given that we have now delivered hundreds of mothers infected with the SARS-CoV-2 and we have not seen this phenomenon, it is pretty safe to assume that this is a rare phenomenon,” Davidov said. “Nonetheless, it is important for clinicians to be aware of this situation and to screen all newborns for Covid-19.”

Shah and his colleagues added that it’s important for health care workers caring for newborns to understand the potential hazard.

“All health care providers attending an infected woman’s delivery and caring for the baby in the NICU should recognise this risk and use appropriate personal protective equipment to prevent droplet, contact and aerosol transmission [of the coronavirus],” they said.

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