Generic protocol: a prospective cohort study investigating maternal, pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2, 2 December 2020

Generic protocol A prospective cohort study investigating maternal, pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 Version 2.6 Date: 2 December 2020 Contact: hrp_covid19pregnancycohort@who.int Reference: The emergence of a new virus means that understanding transmission patterns, severity, clinical features and risk factors for infection will be limited at the start of an outbreak. To address these unknowns, WHO has provided protocols for special investigations in different settings. Data collected using these investigation protocols will be critical to refine recommendations for case definitions and surveillance; characterize key epidemiological features of COVID-19; help understand the spread, severity and spectrum of disease and impact on the community; and inform guidance for application of countermeasures such as case isolation and contact tracing. These protocols are designed to enable the rapid and systematic collection of data in a format that facilitates comparison across different settings globally. They are available on WHO website here: https://www.who.int/emergencies/diseases/novel- coronavirus-2019/technical-guidance/early-investigations COVID-19 investigations and study protocols available include: 1. The First Few X cases and contacts (FFX) investigation protocol for coronavirus disease 2019 (COVID-19) 2. Household transmission investigation protocol for coronavirus disease 2019 (COVID-19) 3. Protocol for assessment of potential risk factors for coronavirus disease 2019 (COVID-19) among health workers in a health-care setting: cohort or case control designs 4. Population-based age-stratified seroepidemiological investigation protocol for coronavirus 2019 (COVID-19) infection 5. Surface sampling of coronavirus (COVID-19) virus: a practical “how to” protocol for health-care and public health professionals 6. Schools and other educational institutions transmission investigation protocol for coronavirus disease 2019 (COVID-19) 7. Longitudinal cohort study on pregnancy & COVID-19: maternal and neonatal transmission protocol Please contact hrp_covid19pregnancycohort@who.int for questions related to the maternal and neonatal transmission protocol and earlyinvestigations-2019-nCoV@who.int for questions related to other early investigation protocols. All WHO protocols for COVID-19 are available on the WHO website together with the technical guidance documents. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 .................................................................................................................................................................................................................................................................. 3 This protocol may be subject to revisions, pending research governance processes1. Responsible officers: Nathalie Broutet (Coordination of partners and protocol) Anna Thorson (Responsible officer) Coordination of Implementation: Ibukun Abejirinde (Focal point, Implementation) Christine Godwin (Focal point, External partners and working groups) Pregnancy cohort Implementation team Edna Kara (Implementation, Latin America) Soe Soe Thwin (Manager, Data platform and Statistics) Mohamed Ali (Technical support, Statistics) Ndema Habib (Technical support, Statistics) Daniel Giordano (Technical support, Data platform) For questions related to implementation or other aspects of pregnancy related SARS-CoV-2 research, please send an email to hrp_covid19pregnancycohort@who.int 1 Version 2.2 of this protocol and its accompanying appendix dated 14 August 2020 have been approved by the WHO Ethical Review Committee. This updated version (v.2.6 dated 2 December 2020) will undergo an amendment review by the WHO Ethical Review Committee based on revised sample size calculations, including information on the pooled analysis (pp. 10–13, Appendix B), revision of the case report forms (CRFs) (Appendix B), inclusion of draft guidelines on mother-to-child transmission (MTCT) (Apndices I–L) and general revisions to improve coherence and content alignment. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 .................................................................................................................................................................................................................................................................. 4 Contents Protocol summary ........................................................................................................................ 6 List of abbreviations ..................................................................................................................... 7 Preamble ..................................................................................................................................... 8 1 Introduction ........................................................................................................................ 9 2 Research plan ..................................................................................................................... 9 3 Problem statement, aims and objectives ........................................................................... 10 3.1 Definitions .......................................................................................................................................... 11 3.2 Outcomes and objectives .................................................................................................................... 11 4 Required elements of protocol .......................................................................................... 12 5 Methods ........................................................................................................................... 12 5.1 Study design ....................................................................................................................................... 12 5.1.1 Objectives 1, 3, 4 and secondary objectives ................................................................................. 12 5.1.2 Specific study design for Objective 2 ............................................................................................ 16 5.2 Study participants and sampling ......................................................................................................... 16 5.2.1 Study population ........................................................................................................................... 16 5.2.2 Exposure status ............................................................................................................................. 16 5.3 Recruitment ........................................................................................................................................ 17 5.4 Sample size calculation ....................................................................................................................... 17 5.5 Methods of data collection ................................................................................................................. 19 5.5.1 Schedule of the cohort .................................................................................................................. 19 5.6 Data collection and management ....................................................................................................... 19 5.6.1 Questionnaire/CRF and biological specimen ................................................................................ 19 5.6.2 Specimen collection and laboratory investigation ........................................................................ 21 5.6.3 Laboratory procedures ................................................................................................................. 23 5.7 Data analysis ....................................................................................................................................... 23 5.8 Data management and data access ..................................................................................................... 24 5.8.1 Procedures for ensuring confidentiality ....................................................................................... 24 5.8.2 Data management ........................................................................................................................ 25 5.8.3 Dissemination and utilisation of results, including publication plans ........................................... 26 5.8.4 Contributions to gender equality, equity and the human rights agenda ..................................... 26 5.8.5 Research capacity strengthening .................................................................................................. 26 5.8.6 Environmental considerations ...................................................................................................... 27 5.9 Ethical considerations ......................................................................................................................... 27 5.9.1 Informed consent.......................................................................................................................... 27 5.9.2 Incentives to participate and compensation ................................................................................ 30 5.9.3 Policy on incidental findings ......................................................................................................... 30 5.9.4 Benefits and risks for study subjects............................................................................................. 31 5.9.5 Biobank guidance .......................................................................................................................... 32 6 References ........................................................................................................................ 33 7 Acknowledgements ........................................................................................................... 35 Appendix A: Description of investigation and informed consent template ................................... 36 Appendix A1: Consent to the use of biological samples ................................................................................. 44 Appendix B: Sample size estimates for individual sites and standardized questionnaires/CRFs ..... 46 Sample size for site-specific and pooled data ................................................................................................ 46 Standardised questionnaires/CRFs ................................................................................................................ 58 Appendix C: Biological sampling algorithm ................................................................................ 110 Appendix D: Options for variations in study design ................................................................... 112 Appendix E: Standardized questionnaire for non-pregnant women with SARS-CoV-2 ................. 116 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 .................................................................................................................................................................................................................................................................. 5 Appendix F: Specimen storage, preservation and shipment ....................................................... 118 Appendix G: Sample tables for study outcomes ........................................................................ 119 Appendix H: Biobank guidance ................................................................................................. 122 Appendix I: Draft criteria for defining in utero transmission of SARS-CoV-2 ............................... 124 Appendix J: Draft criteria for defining intrapartum and postnatal transmission of SARS-CoV-2 ... 129 Peripartum transmission ............................................................................................................................. 129 Postnatal horizontal transmission ............................................................................................................... 132 Appendix K: Potential testing of live birth for determination of infection timing ........................ 135 Appendix L: Potential samples to test for timing of SARS-COV-2 perinatal infection ................... 136 Appendix references ................................................................................................................ 138 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 .................................................................................................................................................................................................................................................................. 6 Protocol summary To better understand how severe acute respiratory coronavirus-2 (SARS-CoV-2) infection impacts outcomes in women and their neonates during pregnancy and the postpartum period, the World Health Organization (WHO) has developed a standardized research protocol for the investigation of coronavirus disease 2019 (COVID-19) in pregnant women. The protocol addresses key research questions, facilitates systematic and harmonized collection of data and biological specimens, and allows for data comparison and aggregation across different locations while minimizing potential biases. The protocol is designed to be adapted as needed in each study site based on resource availability and local circumstances. This protocol outlines a prospective cohort study investigating the outcomes of pregnant or recently pregnant women infected with SARS-CoV-2 (exposed) compared to pregnant or recently pregnant women not infected with SARS-CoV-2 during pregnancy (unexposed). The purpose of this study is to determine if SARS-CoV-2 infection during pregnancy increases the risk of adverse pregnancy, postpartum or neonatal outcomes. Additionally, the study characterizes the clinical spectrum of COVID-19 in pregnant women, quantify (if any) the rate of in utero/intrapartum/postnatal transmission, determine the incidence of detectable SARS-CoV-2 RNA in pregnancy-related fluids (i.e. amniotic fluid), breast milk and tissues, and follow clinical outcomes of women and their newborns up to 6 weeks after childbirth. It is expected that findings from studies implementing this protocol will be published, widely disseminated and used to develop recommendations on the surveillance, management and counselling of women during and after pregnancy, as well as their babies, in the context of the COVID-19 pandemic. Findings related to the implementation of this study protocol will help to inform public health measures, infectious disease and prevention measures, and future research protocols. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 .................................................................................................................................................................................................................................................................. 7 List of abbreviations ARDS acute respiratory distress syndrome CIOMS Council for International Organizations of Medical Sciences COVID-19 coronavirus disease 2019 CRF case report form FGR fetal growth restriction GCP good clinical practice GDRP general data protection regulation HRP UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction IDMC Independent Data Monitoring Committee IPC infection prevention and control IRB institutional review board IUT intrauterine transmission LFU loss to follow-up LMICs Low- and middle-income countries MERS Middle East respiratory syndrome MTA material transfer agreement MTCT mother-to-child transmission NICU neonatal intensive care unit RDT rapid diagnostic test RT-PCR reverse transcriptase polymerase chain reaction SARS-CoV-2 severe acute respiratory syndrome coronavirus 2 TORCH toxoplasmosis, rubella, cytomegalovirus, herpes simplex WHO World Health Organization WG working group SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 .................................................................................................................................................................................................................................................................. 8 Preamble This protocol is one of the WHO protocols for COVID-19 designed to enable the rapid and systematic collection of data in a format that facilitates comparison across different settings. All WHO investigation protocols for COVID-19 are available on the WHO website. Any partner who wishes to use this protocol can do so freely and without charge or obligations. We ask implementing study sites to kindly inform the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP)/World Health Organization (WHO) about their implementation of this protocol and to provide a contact point. Please share your information with hrp_covid19pregnancycohort@who.int Implementing partners can opt to manage data onsite or through the central HRP repository subject to local circumstances. A pooled analysis bringing together all consenting and contributing sites will be discussed with sites implementing the study. Sites that agree to pool data under the coordination of WHO/HRP will have the option to independently publish their own data. The analysis of the pooled data will be made available and widely disseminated in collaboration with all contributing sites. All partners will retain control of their site data, regardless of whether or not this data is included in pooled or aggregated analyses. All sites wishing to participate are invited to do so; however, WHO/HRP provides no guaranteed support for study implementation. Technical, financial or capacity limitations may be present. However, since this protocol proposes a study design that can be adapted to allow for smaller studies (see Appendix D for proposed methodologies), studies that follow the proposed study design may be pooled/aggregated in order to achieve an overall pooled sample size with sufficient statistical power to answer the primary research questions. It is important to note that this protocol is designed to describe the core data variables in order to answer the key research questions and primary objectives outlined in the protocol. As such, the implementation of this study may include additional objectives or study components, as determined by each implementing site. Comments for the user’s consideration are provided in purple text throughout the document, as the user may need to modify methods slightly because of the local context in which this investigation will be carried out. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 .................................................................................................................................................................................................................................................................. 9 1 Introduction The World Health Organization (WHO) has established an overarching working group for research institutions implementing research on coronavirus disease 2019 (COVID-19) and pregnancy known as the Pregnancy and COVID-19 Research Working Group. The working group is designed to provide a collaborative forum for scientific discussion of research on this topic, with all implementing partners being invited to join the group. In addition, WHO has established a sub-working group (SWG) that is focused on the implementation of the generic protocol. This SWG allows provision of support to sites implementing the generic protocol, and it has also been used to discuss, explain and agree on the core components of the study. We have established core criteria for study design and core variables that should be included in any local adaptation. Local adaptation of the protocol per site are discussed in relation to what is outlined in the protocol. In addition, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP)/WHO holds regular individual meetings with all implementing partners that wish to be part of pooled analyses. Specifically, a small number of selected partner sites in low- and middle-income countries (LMICs) receive tailored support plans in their efforts to implement the protocol. These overarching working groups and SWGs have been in place since April/May 2020 and meet regularly to ensure continuous dialogues with implementing and collaborating partners. Further, WHO monitors any studies adaptations to design or implementation that are planned within sites. This work will be used to guide and ensure quality of implementation as well as to provide an overview of sites and their respective timelines and, additionally, ensure any protocol adaptations are within the scope of what is outlined in the generic protocol. We recognize that sites will be implementing the protocol with varied resource availabilities, and parallel initiatives of research capacity strengthening will be tailored as needed for individual sites. Through close work with WHO colleagues outside HRP, in regional and country offices, we will also ensure regular contact points. 2 Research plan The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been identified as the cause of a febrile respiratory disease officially named COVID-19 (1) that, since its appearance, has spread across the globe. COVID-19 was declared a Public Health Emergency of International Concern by the WHO Director- General on 30 January 2020. At the current rate of transmission, a majority of people worldwide, including pregnant women, will be at risk of infection and acquiring the disease. Given a paucity of knowledge regarding SARS-CoV-2 in the context of pregnancy, there is an urgent need to better understand the disease in pregnancy to improve management and outcomes in this population. The physiological, immunomodulatory and mechanical changes that occur during pregnancy can increase both a woman’s susceptibility to disease and severity for certain infections. At baseline, pregnant women are more vulnerable to respiratory distress from decreased residual lung capacity, increased oxygen consumption and higher circulating blood volume (2). It is currently unknown if pregnant women are more susceptible to infection and severe disease from SARS-CoV-2. Limited data from other coronaviruses, such as severe respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS), suggest mortality rates in pregnant women range between 25-30% (3,4). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 10 It is unknown if SARS-CoV-2 can be transmitted from the mother to the fetus in utero or at childbirth. Although four recent systematic reviews failed to report any evidence for intrauterine infection (5–8), a recent media report and evidence of neonatal IgM antibodies for SARS-CoV-2 suggest otherwise (9–11). Additionally, because nearly all reports are on women who delivered via caesarean, it is unclear if transmission can also occur during vaginal delivery. In other coronavirus outbreaks, such as SARS and MERS, there were no documented reports of in utero transmission from mother to fetus (3). The impact of SARS-CoV-2 infection on pregnancy is unclear. As the virus so recently emerged, data is lacking on outcomes associated with first or second trimester infection and risk of teratogenicity (12). One study of 8000 pregnant women with SARS-CoV-2 in the United States found that infection was associated with hospitalization, increased risk for intensive care unit admission and of receiving mechanical ventilation, but not death (13). Recent estimates indicate a COVID-19 infection fatality rate of 0.68% in the general population (14), while a large study of symptomatic women of reproductive age (15–44 years) in the United States has reported up to a 70% increased risk of death in pregnant women (15). Additionally, although data is not yet peer reviewed, case studies have reported that SARS-CoV-2 infection during pregnancy may increase risk of perinatal complications, including fetal distress, preterm birth and perinatal death (12,16–18). This standardized protocol describes a prospective cohort study investigating the longitudinal course of women with exposure, exposure risk or documented infection with SARS-CoV-2 during their pregnancy. The overarching goal of this study is to gain critical knowledge on how infection with SARS-CoV-2 impacts pregnancy and neonatal outcomes, with the additional aims to understand mother-to-child transmission (MTCT) (if any), viral presence in pregnancy-related body fluids (i.e. amniotic fluid), breast milk and tissues, and the clinical presentation of the disease in pregnant women. Additionally, this protocol includes an option for a case control component to investigate disease severity in pregnancy compared to non-pregnant women with COVID-19. Pooled analyses will be done at global level, and at national or subnational level, subject to priorities of individual partners implementing the protocol. Participation in global analyses is not a prerequisite to implement the protocol. COMMENT: The introduction should be updated with country-specific data on COVID-19 epidemiology and current research findings prior to submission to local/national institutional review boards (IRBs). 3 Problem statement, aims and objectives To better understand how SARS-CoV-2 infection during pregnancy impacts outcomes, the WHO has developed a standardized research protocol for the investigation of COVID-19 in pregnant women. The protocol will address key research questions, facilitate systematic and harmonized collection of data and biological specimens, and allow for data comparison and aggregation across different locations while minimizing potential biases. The protocol is designed to be adapted as needed in each study site, based on resource availability and local circumstances. This protocol is for a prospective cohort study investigating maternal and neonatal outcomes in pregnant women infected with SARS-CoV-2 compared to pregnant women not infected with SARS-CoV-2. The purpose SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 11 of this study is to determine if SARS-CoV-2 infection during pregnancy increases the risk of adverse pregnancy or neonatal outcomes. Additionally, this study will characterize the clinical spectrum of COVID-19 in pregnant women, quantify (if any) the rate of in utero/intrapartum/postnatal transmission, determine the incidence of detectable SARS-CoV-2 RNA in amniotic fluid, breast milk, other bodily fluids and tissues, and follow clinical outcomes of women and their newborns up to 6 weeks after childbirth. It is expected that findings from studies implementing this protocol will be published, widely disseminated and used to develop recommendations on the surveillance, management and counselling of women during and after pregnancy, as well as their babies, in the context of the COVID-19 pandemic. Findings related to the implementation of this study protocol will help to inform public health measures, infection disease and prevention measures, and future research protocols. The overall objective is to assess whether SARS-CoV-2 infection during pregnancy increases the risk of adverse clinical, pregnancy, perinatal or neonatal outcomes. 3.1 Definitions Pregnant women: This protocol uses the term “pregnant women” to describe women who are pregnant or in the immediate postpartum period (up to 48 hours following delivery). Perinatal period denotes the time between 22 weeks gestations and 7 days after birth. Neonatal period denotes the first 4 weeks of a newborn's life. Postpartum period denotes the 42 days following delivery/pregnancy termination. 3.2 Outcomes and objectives Adverse outcomes of interest: 1. Maternal and pregnancy outcomes: (e.g. induced abortion, ectopic pregnancy, miscarriage, delivery mode, preterm birth, fetal growth restriction, haemorrhage, maternal morbidity and mortality); 2. Perinatal outcomes: related to the fetus/neonate that occurs after 22 weeks gestation and within 7 days after birth (e.g. stillbirth, admission to the neonatal Intensive care unit (NICU), neonatal mortality within 7 days of life); 3. Neonatal outcomes: following birth up to 4 weeks of life (e.g. neonatal morbidity, infection, mortality); 4. Postpartum outcomes: maternal outcomes (e.g. infection, bleeding, transmission of SARS-CoV-2) up to 6 weeks after delivery; 5. COVID-19 outcomes: (e.g. hospitalization, acute respiratory distress syndrome (ARDS), severity, mortality, viral persistence). The primary objectives of the study are: 1. to analyse if SARS-CoV-2 infection in pregnant women increases the risk of adverse outcomes (as per outcomes 1–4 above) as compared to pregnant women who are not infected with SARS-CoV-2; 2. to estimate the risk of MTCT of SARS-CoV-2 virus during pregnancy, intrapartum, postpartum (including during breastfeeding) among mother–neonate pairs with confirmed SARS-CoV-2 infection in pregnancy; 3. to describe viral presence and persistence in amniotic fluid, placenta, cord blood, fetus, neonate as well as in breast milk and other bodily fluids (urine, faeces, vaginal fluids); 4. to characterize the clinical course and disease spectrum of COVID-19 during pregnancy. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 12 Secondary objectives include, but are not limited, to: 1. estimate the cumulative incidence of asymptomatic, subclinical and clinically apparent SARS-CoV-2 infection during pregnancy, as assessed by seroconversion or a positive reverse transcriptase polymerase chain reaction (RT-PCR) test during and following pregnancy; 2. measure the frequency of detectable RNA for SARS-CoV-2 by RT-PCR and IgG/IgM antibodies in neonates born to women infected with SARS-CoV-2 during pregnancy; 3. characterize the signs, symptoms and disease course of neonates who have SARS-CoV-2 infection following childbirth from a pregnant woman infected with SARS-CoV-2. Optional secondary objective: To determine if the disease severity and disease characteristics of COVID-19 are different in pregnant women compared with non-pregnant women of reproductive age. Please see Appendix D for details regarding this optional secondary objective. COMMENT: Additional secondary objectives can be included in the protocol and will be informed by the outbreak characteristics and by the local context. 4 Required elements of protocol This generic protocol is designed to be adapted to the local context of the implementing research institutions and sites. The components of this study that should be applied across all study sites include the inclusion/exclusion criteria of study participants and assignment of participants to study groups (see Fig. 1). In addition, it is expected that institutions adopting the generic protocol will utilize the generic case report forms (CRFs) provided in the appendix. These CRFs represent the suggested core of variables that sites should collect data on; however, the CRF is intended to be flexible with online data entry platforms including skip logic to allow sites to omit variables that cannot be collected. In addition, sites are welcome to add additional sections and/or variables to the CRF, if relevant for their context. 5 Methods 5.1 Study design 5.1.1 Objectives 1, 3, 4 and secondary objectives This is a prospective longitudinal open cohort study of pregnant women exposed to SARS-CoV-2 or not exposed that will be recruited consecutively over time until the desired study sample size is achieved. It will compare clinical, pregnancy, perinatal and neonatal outcomes for women with confirmed SARS-CoV-2 infection during pregnancy and the postpartum period of 6 weeks following the end of pregnancy (exposed) with pregnant women not diagnosed with SARS-CoV-2 infection during this period (unexposed). Where possible, assignment of participants into exposed, unexposed and unknown groups will be based on the results of RT-PCR testing. In some settings, analysis of SARS-CoV-2 RT-PCR may not be available due to SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 13 limited laboratory capacity. In these situations, the study design may be adapted to use serology testing for IgG/IgM antibodies for group assignment (as described below and in Fig. 2). Pregnant women will be enrolled into the exposed group of the cohort if they have tested positive for acute SARS-CoV-2 infection by RT-PCR before or until 14 days after pregnancy termination. Diagnostic testing should be available for review to confirm positive RT-PCR testing. Pregnant women will be enrolled into the (SARS-CoV-2 negative) unexposed group after negative RT-PCR and negative antibody testing. Pregnant women with negative RT-PCR (SARS-CoV-2 negative) in settings that do not have access to antibody test will be enrolled in the unknown group. Serology samples may be drawn from this group and saved for future analysis, in case antibody tests become available at a later date. To conserve the limited number of diagnostic tests for SARS-CoV-2 RNA by RT-PCR, the entry point of the cohort is SARS-CoV-2 testing or screening of suspected cases or asymptomatic pregnant women, irrespective of hospitalization due to COVID-19. Crossover between groups will be allowed. Women enrolled into the SARS-CoV-2 negative (unexposed) group who seroconvert during the pregnancy will crossover into the SARS-CoV-2 positive (exposed) group. Infants born to mothers enrolled in the cohort, as well as the mothers themselves, will be followed for 6 weeks after childbirth. Women who are SARS-CoV-2 negative with unknown serology (unknown) may crossover into the SARS-CoV-2 negative and serology negative (unexposed) group if/when antibody testing becomes available and they test antibody negative (see Fig. 1). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 14 Figure 1. Study overview, setting with RT-PCR testing available Outcomes of interest: • Pregnancy outcomes • Fetal outcomes • Perinatal outcomes • Neonatal outcomes (6 weeks postpartum) • COVID-19 clinical spectrum • Disease severity • Viral persistence RT-PCR test IgG/IgM test IgG/IgM unknown Enrolment in Unknown group* IgG/IgM negative Enrolment in Unexposed group RT-PCR positive Enrolment in Exposed group No IgG/IgM test available Save serology samples for future analysis RT-PCR negative IgG/IgM positive Exclusion RT-PCR negative PCR or seroconversion during pregnancy * Crossover to Exposed group if positive RT-PCR Presentation of pregnant woman at COVID-19 testing centre, health facility or antenatal care Monthly follow-up during pregnancy In settings that have limited laboratory capacity for analysing RT-PCR specimens, assignment of pregnant women to study groups may be done using IgG/IgM serology testing (see Fig. 2). With this design, women with a positive IgG/IgM serology test would be enrolled in the exposed group. Women with a negative IgG/IgM serology test would be enrolled in the unexposed group. Crossover from the unexposed to the exposed group may occur when a woman seroconverts during the course of the pregnancy, after her initial enrolment in the study. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 15 Figure 2. Study overview, setting with no capacity for RT-PCR testing Outcomes of interest: • Pregnancy outcomes • Fetal outcomes • Perinatal outcomes • Neonatal outcomes (6 weeks postpartum) • COVID-19 clinical spectrum • Disease severity • Viral persistence No IgG/IgM test available Save serology samples for future analysis IgG/IgM test IgG/IgM negative Enrolment in Unexposed group IgG/IgM unknown Enrolment in Unknown group* IgG/IgM positive Enrolment in Exposed group Seroconversion during pregnancy * Crossover to Exposed group if positive IgG/IgM Presentation of pregnant woman at COVID-19 testing centre, health facility or antenatal care Monthly follow-up during pregnancy COMMENT: The WHO Emergency Use Listing2 dated 2 October 2020 and interim guidance on diagnostic testing for SARS-CoV-2 published 11 September 2020 (19) encourage the use of antigen-based rapid diagnostic tests (RDTs) especially in contexts with limited laboratory capacity. Investigators can opt to assign study participants into groups based on RDT results. While evidence of the performance of these tests is still emerging, kindly refer to the WHO guidance on considerations for the use of RDTs.3 Note that point-of-care immunodiagnostic tests are only recommended for research purposes and not as a basis for clinical decision- making (20). 2 WHO. WHO Emergency Use Listing for in vitro diagnostics (IVDs) detecting SARS-CoV-2 (www.who.int/diagnostics_laboratory/201002_eul_sars_cov2_product_list.pdf). 3 WHO. Antigen-detection in the diagnosis of SARS-CoV-2 infection using rapid immunoassays (https://apps.who.int/iris/handle/10665/334253). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 16 5.1.2 Specific study design for Objective 2 Postpartum and breastfeeding risk of transmission will be assessed in comparison to SARS-CoV-2 non- infected/unexposed mother–neonate pairs. Optional secondary objective Additionally, this study protocol provides the option of a nested case-control design, to be considered if the study sites have limited ability to perform antibody testing for all women (unknown exposure group). Please see Appendix D regarding this optional design. Study setting/s This study is designed to be conducted in areas with an ongoing COVID-19 outbreak. COVID-19 outbreak areas are defined as areas where disease surveillance detects community transmission of SARS-CoV-2 virus based on WHO epidemiologic studies or local surveillance data. The implementation protocol should clearly define the catchment area of included health facilities and describe the study base of the study sample. 5.2 Study participants and sampling 5.2.1 Study population - Inclusion criteria: pregnant women (up to 2 days postpartum at time of enrolment) (Pregnant women with co-morbidities are eligible) - Exclusion criteria: non-pregnant women. Evidence of immunity to SARS-CoV-2 prior to pregnancy start (+ IgG/IgM SARS-CoV-2 serology and no evidence of ongoing infection as in RT-PCR positivity at the time of enrolment). NOTE: serology may need adaptation in relation to resources and availability. In some sites, only clinical history, negative PCR and the end point serology may be used. 5.2.2 Exposure status 1. Exposed status will consist of pregnant women who have tested positive by RT-PCR for SARS-CoV-2 during their current pregnancy or immediate postpartum period. Alternatively, in settings where RT- PCR is not available and/or RT-PCR samples cannot be analysed, women may be enrolled in the exposed group if they have detectable IgG/IgM antibodies during their current pregnancy or immediate postpartum period and no RT-PCR result. Participants enrolled as unexposed will crossover to the exposed group if there is evidence of seroconversion or positive RT-PCR for SARS- CoV-2 after study enrolment. Women who have detectable IgG/IgM antibodies at the onset of the study will be placed in the exposed group only if they have RT-PCR confirmed SARS-CoV-2 infection documented at enrolment. 2. Unexposed status will consist of pregnant women who have had negative testing for SARS-CoV-2 IgG/IgM at time of study entry and at end points: end of pregnancy and/or postpartum period. If women develop acute COVID-19 (as evidenced by positive RT-PCR testing) or demonstrate seroconversion after enrolment, they will crossover to the exposed group. Women with detectable IgG/IgM antibodies at the onset of the study will be excluded if they are RT-PCR negative. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 17 3. Unknown status will consist of women who have tested negative or had no testing by RT-PCR for SARS-CoV-2 at time of study entry and at end points: end of pregnancy and/or postpartum period and who have not had IgG/IgM testing. It is recommended that serology samples for this group be drawn and stored for future analysis, if/when antibody testing becomes available at a later date. 5.3 Recruitment Consecutive prospective recruitment will occur in a health-care setting where either screening and/or symptomatic testing of SARS-CoV-2 among pregnant women is ongoing; typically, this can be a clinic catering for individuals seeking care with COVID-19 suspect symptoms. Pregnancy testing may need to be offered to women of reproductive age seeking COVID-19 care, pending local circumstances. Pregnant minors are suggested to be offered inclusion in the study. If screening for SARS-CoV-2 is applied to pregnant women attending maternal and child health care or antenatal care, this can also be used to recruit consecutive SARS-CoV-2 positive and negative pregnant women. All pregnant women irrespective of SARS-CoV-2 testing or screening results will be offered to participate until sample size of exposed and unexposed groups are fulfilled. Recruitment timing in relation to pregnancy assessment and test/screening results may be implemented differentially depending on the facility and staffing resources at each study site. 1. SARS-CoV-2 positive pregnant women: Confirmed by RT-PCR testing. The areas of recruitment may differ based on local resources and SARS-CoV-2 testing protocols but should be done in a manner that limits exposure to research staff as well pregnant women. Examples of possible recruitment strategies that can be used include: by telephone consent after obtaining status of SARS-CoV-2 testing of pregnant women, at antenatal care appointments/telemedicine visits (routine screening of all pregnant women for COVID-19 can help to facilitate the identification of those who have tested positive), during hospital admission (including labour and childbirth, triage, NICU) or emergency department visit, or in collaboration with COVID-19 testing sites. 2. SARS-CoV-2 negative pregnant women: Recruitment may differ based on local resources and SARS- CoV-2 testing protocols. Examples of possible recruitment strategies for this cohort can include by telephone consent after obtaining a negative SARS-CoV-2 RT-PCR test. 5.4 Sample size calculation The site-specific sample size calculations for this study are informed by estimates of composite adverse pregnancy/neonatal outcome (miscarriage, preterm birth, perinatal death or NICU admission) in women with SARS-CoV-2 infection compared to women without SARS-CoV-2 infection in pregnancy. All sample size estimates provided in this section are based on 80% statistical power and type I error at 5% level. Furthermore, this section provides examples of initial sample size estimates on the basis of the proportion expected to have the outcome of interest among the SARS-CoV-2-unexposed (p0) and also the effect size (ES). Additional information on sample size calculations can be found in Appendix B. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 18 The final number of pregnant women to be enrolled in each group (SARS-CoV-2 exposed versus unexposed) will need to be further inflated to account for one or more of the following factors as relevant: 1. Anticipated crossover of pregnant women from the unexposed to exposed group, assumed to be 10% (based on the current estimated prevalence of 10%); 2. Loss to follow-up (LFU) during pregnancy for the primary outcomes involving adverse pregnancy outcomes, assumed to be at 5%; 3. LFU throughout pregnancy until 6 weeks postpartum, for primary outcomes assessable from post- childbirth and by the end of 6 weeks postpartum, assumed to be at 10%; 4. For the assessment of MTCT of SARS-COV-2 via breast milk, the expected proportion of deliveries resulting in a livebirth AND neonate who is also uninfected with SARS-nCOV-2 at birth, assumed to be at XX%.4 The primary outcome is a composite outcome of any of the following: (i) miscarriage, (ii) preterm birth <37 weeks, (iii) perinatal death and (iv) NICU admission. The assumption, based on preliminary SARS-CoV-2 data in pregnant women, estimates that the exposed group will have between 11% to 22.5% risk for the composite outcome and the unexposed group will have a 10% to 15% risk for the composite outcome. That is, a relative risk of 1.1 to 1.5. Table 1 shows examples of sample size estimations for site-specific considerations. The calculations assume equal allocation of 1:1 ratio in terms of group sizes for SARS-CoV-2 exposed to unexposed. Table 1. Example of sample size estimates for site-specific consideration5 Risk ratio 1.1 1.1 1.5 1.5 Prevalence group 1 unexposed 0.10 0.15 0.10 0.15 group 2 exposed 0.11 0.165 0.15 0.225 Unadjusted sample size N1 14 747 9255 683 423 N2 14 747 9255 683 423 Adjusting for LFU N1 16 385 10 283 758 470 N2 16 385 10 283 758 470 Adjusting for seroconversion N1 18 205 11 425 842 522 N2 14 565 9141 674 418 Sample size calculation for the pooled data will be based on different cohorts and outcomes to allow for outcome-specific and cohort specific analysis, and the single site-specific sample size will vary with national epidemic contexts and national estimates of adverse composite outcomes (see Appendix B for details). 4 This is currently not included in the sample size calculation assumptions and input parameters presented. 5 These numbers are for illustration purposes and could be adjusted as necessary. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 19 5.5 Methods of data collection 5.5.1 Schedule of the cohort Recruitment and enrolment/baseline visit: Recruitment of pregnant women, study participants, should happen consecutively at the suitable facility. Study participation can be offered before SARS-CoV-2 testing results are available. Enrolment visit will be done at the site facility allowing recruitment of exposed and unexposed pregnant women over time. As per the study inclusion criteria, women may be recruited if they are pregnant or up to 2 days postpartum. Informed consent form will be signed at enrolment, following which baseline data will be collected. COMMENT: Individuals who are approached for participation in the study and have not reached the age of majority, as determined by local laws, will be included in the study if they provide assent, supported by consent of parent or legal guardian. Consent of parent or guardian may be waived if allowed by the local ethical review committee (e.g. in case of emancipated minors). Follow-up during pregnancy: Follow-up visits should occur, at a minimum, once per month from enrolment to the time of pregnancy outcome. The local standard of care for antenatal care and ultrasounds should be followed after enrolment. Care should be taken that pregnant women deemed potentially infectious for SARS-CoV-2 are not present for care simply to fulfil research purposes; instead, they should be clinically evaluated as appropriate by their medical provider. Visits via telemedicine or phone, if deemed appropriate by the health-care provider, are acceptable. At birth: Neonatal and pregnancy outcomes, as well as the clinical status and management of pregnant/postpartum women will be studied. Specimens will be collected for testing. Follow up after childbirth: Mother–newborn pairs will be followed for up to 6 weeks following childbirth. In the event of maternal death, prior to study recruitment, the family of the woman may be approached to ask for the possibility of retrieving clinical data from medical records, as well as information from a family member. COMMENT: Guidance on the option of including a comparison with non-pregnant reproductive aged women infected with SARS-CoV-2 to determine disease severity in pregnant compared to non-pregnant individuals can be found in Appendix D. 5.6 Data collection and management 5.6.1 Questionnaire/CRF and biological specimen After informed consent is obtained from study participants, a standardized study questionnaire will be administered to participants by research personnel (see Appendix B). If the woman cannot complete the standardized study questionnaire at the time of enrolment, attempts will be made to complete the questionnaire at the soonest opportunity it is reasonable to do so. However, it may not be feasible for the woman to complete the questionnaire at the time of enrolment if she is seriously ill, has an ongoing obstetric emergency or is in labour. If so, the questionnaire should be deferred until a more appropriate time. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 20 At enrolment: Information from this questionnaire, ideally, to be collected at time of enrolment from the pregnant woman if circumstances allow, will include: • demographic information o socioeconomic history (as indicated by wealth index) • pregnancy characteristics o dating of pregnancy o ultrasound details o gestational age o complications • medical and obstetric history o pregnancy history and outcomes (including adverse outcomes in prior pregnancies) o medical history o medication use o immunization history (in particular, seasonal influenza and bacille Calmette–Guérin (BCG) vaccines) • social history (substance use/abuse) • family history of congenital anomalies • signs and/or symptoms of COVID-19 infection (including details and timing in relation to pregnancy and gestational age, as well as presence or absence of laboratory confirmation) • laboratory evaluation (blood and nasopharyngeal samples) o specifically, confirmation of prior SARS-CoV-2 infection by serology o TORCH infections (toxoplasmosis, rubella virus, cytomegalovirus, HIV) o varicella zoster virus, Zika virus, herpes virus, syphilis, HIV. At subsequent antenatal care visits, changes that have occurred since time of enrolment (for example, health status, pregnancy complications, ultrasound data, laboratory findings) should be updated. COMMENT: Ultrasound surveillance during the pregnancy enables the study group to measure the association between timing (trimester) of SARS-CoV-2 infection in the mother and resulting abnormalities detected in the fetus. Thus far, there is no evidence that would suggest that SARS-CoV-2 infection in pregnancy increases the risk for congenital anomalies. At the end of the pregnancy/study exit, the following information will be collected: • Pregnancy outcome (e.g. live birth, miscarriage, stillbirth, induced abortion, etc.) • Maternal and pregnancy outcomes (e.g. severe maternal morbidity, near miss events, early warning signs, preeclampsia, etc.) • Neonatal outcomes (e.g. preterm birth, small-for-gestational age, SARS-CoV-2 infection, respiratory distress, low 5-minute Apgar score, etc.) • Ultrasound data (in accordance with standard procedures and following national guidelines) • Signs, symptoms and diagnostic evaluation of COVID-19 or other infections such as influenza, other viral infections, TORCH infections • Laboratory evaluation of body fluids including pregnancy related fluids and tissues and breast milk • Laboratory evaluation of the neonate (including testing for SARS-CoV-2 antibodies, influenza or other viral infections as relevant per epidemic context, arboviruses and TORCH infections). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 21 Six weeks after the end of the pregnancy, the following information will be collected about the outcome of the woman and newborn pair: • Laboratory evaluation of SARS-CoV-2 antibodies and/or RT-PCR testing for acute infection as relevant, PCR in breast milk and other testing as needed related to symptoms • Health status and symptomatology of woman and newborn, specifically related to COVID-19, and other postpartum infections. COMMENT: A standardized questionnaire, specific to this protocol, can be found in Appendix B. This questionnaire contains the core data variables that should be collected from study participants to address the objectives of this study. Further questions may be added at the discretion of the research group. The questionnaire is designed to be administered by trained study personnel, without advanced or specialized medical degrees. 5.6.2 Specimen collection and laboratory investigation Table 2 outlines the specimen collection schedule for the study. Table 2. Specimen collection schedule Visits Exposed cohort Unexposed cohort Unknown cohort SARS- CoV- 2 PCR SARS- CoV-2 IgG/IgM TORCH SARS- CoV-2 PCR SARS- CoV-2 IgG/IgM TORCH SARS- CoV-2 PCR SARS- CoV-2 IgG/IgM TORCH At enrolment a Xb Xb X Xb Xb X Xb V1 Xb Xb V2 Xb Xb V3 Xb Xb ….. Delivery/end of pregnancy Xc Xc Xb Xb X Xb Xb X Xb Neonated X X X X Required specimens. a Required to show proof of positive test for SARS-CoV-2 RNA by RT-PCR prior to enrolment. b Optional, based on local resources and testing availability. c Includes umbilical cord blood, placenta, amniotic fluid, products of conception or fetal tissue (if miscarriage, stillbirth or induced abortion), and breast milk (as applicable). d Neonatal specimens will include neonatal throat swab and anal swab. Specimen collection for exposed cohort: - At enrolment: In settings where RT-PCR analysis is available, positive SARS-CoV-2 testing is required to enrol, therefore is not included as a study diagnostic test. TORCH laboratory studies are considered optional. - At delivery/end of pregnancy: 1. RT-PCR testing for umbilical cord blood, placenta, amniotic fluid, products of conception and/or fetal tissue (if miscarriage, stillbirth or induced abortion), breast milk and umbilical cord blood 2. RT-PCR testing of neonate using throat swab and anal swab 3. Antibody testing (SARS-CoV-2 IgM/IgG) of cord blood (optional). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 22 Specimen collection for unexposed and unknown cohorts: - At enrolment: In settings where serology analysis is available, SARS-CoV-2 IgG/IgM is required for enrolment, and SARS-CoV-2 RT-PCR via nasopharyngeal swab and TORCH laboratory studies are considered optional. - During pregnancy (ideally every trimester): SARS-CoV-2 IgG/IgM is optional - At delivery/end of pregnancy: SARS-CoV-2 IgG/IgM is required, and SARS-CoV-2 PCR via nasopharyngeal swab and TORCH laboratory studies are considered optional. All biological sampling for SARS-CoV-2 RNA (umbilical cord blood, placenta, breast milk, amniotic fluid, neonatal throat swab and anal swab) will follow WHO COVID-19 technical guidance documents on the proper handling and processing of potentially infectious specimens (Laboratory biosafety guidance related to coronavirus disease (COVID-19), published 19 March 2020,6 and Laboratory testing for coronavirus disease (COVID-19) in suspected human cases, also published 19 March 20207) as well as WHO general laboratory guidance (updated in 2004).8 COMMENT: Given the rapidly developing guidance related to SARS-CoV-2, it is recommended that investigators check for updates to these documents prior to study initiation to ensure that current recommendations are being followed. Specimen collection: All collection tubes will be labelled with a coded identification number that will also be recorded on the interview questionnaire. Time of collection, location and name of the person collecting the specimen should be noted. COMMENT: In case of a miscarriage, induced abortion or stillbirth, or neonatal death, a post-mortem physical exam is recommended, if consent is obtained from the women to do so. In the event this is preformed, fetal and placental tissue samples should be collected and stored at an appropriate facility for further analysis. Specimen storage, preservation and shipment: Adapted from the interim guidance Laboratory testing for coronavirus disease (COVID-19) in suspected human cases, published 19 March 20209 (see Appendix F). Specimen transportation: Transportation of specimens within national borders should comply with applicable national regulations, international transport should comply with applicable international regulations, and shipping should be performed in accordance with the protocols outlined in WHO’s interim guidance document,10 published 31 March 2020. Where feasible, WHO reference laboratories should be 6 WHO. Laboratory biosafety guidance related to coronavirus disease (COVID-19) (https://apps.who.int/iris/handle/10665/331500). 7 WHO. Laboratory testing for coronavirus disease (COVID-19) in suspected human cases (https://apps.who.int/iris/handle/10665/331501). 8 WHO. Laboratory biosafety manual, 3rd edition (www.who.int/publications/i/item/9241546506). 9 WHO. Laboratory testing for coronavirus disease (COVID-19) in suspected human cases (https://apps.who.int/iris/handle/10665/331501). 10 WHO. Guidance for laboratories shipping specimens to WHO reference laboratories that provide confirmatory testing for COVID- 19 virus (https://apps.who.int/iris/handle/10665/331639). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 23 used.11 The original samples will be packed, labelled and marked (if dry ice is used), and documented as Category B. Where possible, biological specimens will be analysed locally and in the study country. Due to limitations in laboratory capacity, transportation of biological specimens to neighbouring countries may be necessary for the purpose of analysis. In these cases, specimens should be destroyed after they are analysed. If this is the case, this will be clearly indicated in the implementation protocol, and detailed material transfer agreements (MTAs) will be needed. COMMENT 1: Given the rapidly developing guidance related to SARS-CoV-2, it is recommended that investigators check for updates to these documents prior to study initiation to ensure that current recommendations are being followed. COMMENT 2: If local and/or national laboratory capacity is limited, then samples may need to be sent to neighbouring countries for analysis. In these cases, the details of sample storage and transportation will be detailed in the implementation protocol and a detailed MTA will be needed. 5.6.3 Laboratory procedures Specimens will be processed either in the country in which the research institution is based or in collaboration with an external laboratory partner. COMMENT: For sample storage, it is important that a governance structure is in place as per the Council for International Organizations of Medical Sciences (CIOMS) guidelines. 12 An additional section on leftover samples/storage may be added after considering the following matters in accordance with the guidelines. Remaining samples: Samples will be destroyed at the end of the study and analysis period, unless otherwise specified in the site protocol. In these cases, a bio-repository or biobank may be created for possible use in future investigations, and participants need to consent. Storage of remaining samples is NOT a mandatory component to this protocol. The decision is left to the research team to determine if they have the capacity to pursue this endeavour. In some cases, analysis of samples at the clinical site may not be possible and storage of biological specimens may be recommended to ensure timely analysis of the samples, as per the stated aims of the study. In the event that remaining samples can be stored, a proper governance structure has to be put in place. Please see the subsection Ethical considerations, which includes the CIOMS guidelines on storage of biological specimens. 5.7 Data analysis The following primary outcomes correspond to the primary objectives of the study. Sample tables for each study outcome can be found in Appendix B. 11 WHO. WHO reference laboratories providing confirmatory testing for COVID-19 (www.who.int/publications/m/item/who- reference-laboratories-providing-confirmatory-testing-for-covid-19). 12 CIOMS. International ethical guidelines for health-related research involving humans (https://cioms.ch/wp- content/uploads/2017/01/WEB-CIOMS-EthicalGuidelines.pdf). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 24 Primary outcome 1: Determine if COVID-19 infection in pregnancy increases the risk of adverse pregnancy or neonatal outcomes. Primary outcome 2: To estimate the risk of MTCT of SARS-CoV-2 during pregnancy, intrapartum, postpartum or during breastfeeding among mother–neonate pairs with confirmed SARS-CoV-2 infection in pregnancy.13 Primary outcome 3: To describe viral presence and persistence in the placenta as well as breast milk and other bodily fluids (5). Primary outcome 4: To characterize the clinical course and disease spectrum of COVID-19 infection during pregnancy. Secondary outcome 1: To estimate the cumulative incidence of asymptomatic, subclinical and clinically apparent COVID-19 infection during pregnancy, as assessed by seroconversion or an RT-PCR positive test during and following pregnancy. Secondary outcome 2: Measure the frequency of detectable RNA for SARS-CoV-2 by RT-PCR and IgG/IgM antibodies in neonates born to women infected with SARS-CoV-2 during pregnancy. Secondary outcome 3: To characterize the signs, symptoms and disease course of neonates who develop SARS-CoV-2 infection following childbirth from a pregnant woman infected with SARS-CoV-2. COMMENT 1: A study option is available that allows for comparison between pregnant women with COVID- 19 to non-pregnant women with COVID-19 infection to determine differences in disease severity (please see Appendix D for details on this study option). COMMENT 2: Because the benefits outweigh potential risks for transmission, study participants with suspected or confirmed COVID-19 should be encouraged to breastfeed according to WHO guidelines (21). 5.8 Data management and data access 5.8.1 Procedures for ensuring confidentiality Each participant will be allocated a unique study ID number at enrolment that all documents will subsequently use as identifier. No individual will be identifiable. Security of all study related documents with participant information at the local research site will be ensured by utilizing locked study cabinets for paper study folders and access-controlled with single sign-on features for computer files. The study will remove all identifiers from any data collected for this study at the individual and study site levels. No names or other directly identifying information (such as addresses and dates) will be entered in the regional or global databases including medical data. Subject numbers will be linked to investigator records stored separately and securely making it possible to identify the case in order to correct missing or erroneous data. Identifying information will be maintained by the responsible person in each hospital in accordance with regulatory agencies requirements. Only anonymized data will be transferred via a web-based electronic data capture system that is general data protection regulation (GDPR) compliant and meets good clinical practice (GCP) and 21 CFR Part 11 regulations. WHO study database will be hosted utilizing AWS Frankfurt data centres in Europe using 256-bit encryption for all data in transit, which is the industry standard AES-256 encryption. Access to the data 13 See Appendices I–L for draft guidelines on definition and samples to be collected for testing. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 25 platform will be controlled with logon name, password and user permission levels, and data privacy will be controlled at site level (i.e. users entering data into same site can see data from that site only). 5.8.2 Data management WHO will offer support to data management and access to an online data entry platform. The WHO team, within the capacity of research strengthening, will support the development of local data platforms. Implementing partners can opt to manage data on site or through the central WHO repository subject to local circumstances. Further, the WHO/HRP will identify an external Independent Data Monitoring Committee (IDMC) to advise on study conduct and interim analyses of global pooled data. Each site will be invited to share their data for pooled analysis and will also be able to publish their own data independently. Participation in pooled analysis is not mandatory for any site. Published data from these studies may be used to formulate recommendations on surveillance, diagnostic evaluation and clinical management of pregnant and postpartum women with suspected or confirmed COVID-19 and their newborns. Further, after obtaining agreement from each study site, the use of standardized protocol and harmonized collection of data will allow for pooled analyses, which in turn will contribute to rapid knowledge generation and strengthening the power of the analysis of the data to make recommendations. Data collected in this study will be stored in password-protected databases. Each participant will be linked to an anonymous study ID, and patient-identifiable information (such as name and address) will be stored in password-protected databases. The location of and responsibility for the database will be determined on a case-to-case basis and dependent on national regulations. The designated data manager will be sent a password-protected copy of the database (anonymized and without any patient identifiers) for data analysis. Diagnostic test results from the laboratory will be sent directly to the principle investigators so the results can be communicated to the participants. Results of tests will be shared with the participants or their primary care provider. To protect patient identity, any publications or presentations relating to the study will use only aggregate summary data. The original data collection forms will be stored in a locked storage in accordance with national regulations. An identification log will be used, and this log will be stored in a secure, locked facility within the study country. All essential study documents, including CRFs, will be electronically archived and retained at WHO for 3 years or for the duration required by the national laws and regulations at local research centres. This is to enable completion of the study, to conduct and complete data curation processes, and to finalize the publication and archival process. An editorial and governing board will be set up with consortium members and following CIOMS guidelines, a governance structure for sharing of analytic harmonized data will be implemented. COMMENT: The study group will need to provide details on the procedures used for data management, protection and storage in the adaptation of the protocol. Good practice principles that are suggested for local study sites to follow include developing a manual of operations, monitoring study visits, performing visual inspections of paper forms and having a system of data entry that includes checks to ensure accuracy. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 26 5.8.3 Dissemination and utilisation of results, including publication plans Data sharing agreements will be established with each implementing site. Reporting of pooled results will follow an outlined statistical analysis plan, made available to all participating sites. Any academic publications of pooled results will aim for inclusiveness and equity, and a group author (with alphabetic list of names of participating contributors) as the exclusive author may be considered, following discussion and agreement with participating sites. Reporting forms of site-specific results is up to individual investigators and should follow STROBE guidelines14 for cohort studies and ideally be reported in such a way to allow for comparison of data across different study sites. At the global level, dissemination will be done in the standard ways to inform clinical management and WHO guideline development work. WHO will work with local partners to develop local dissemination plans, which will be included in site-specific study protocols. Findings from the global pooled analysis will be presented in reports and peer-reviewed publications. 5.8.4 Contributions to gender equality, equity and the human rights agenda 1. How does this research support efforts towards gender equality? The research is designed to describe the potential impact of SARS-CoV-2 on pregnant women. 2. How does it promote and protect human rights – which ones? By describing the potential impact of SARS-CoV-2 infection and COVID-19 on pregnant women, this study may be used in advocating for women’s access to reproductive health and maternal health services. 3. How does it ensure no one is left behind and prioritize the most vulnerable? The study includes all women meeting the inclusion criteria regarding pregnancy and SARS-CoV-2 status, regardless of socioeconomic, racial, religious or gender identity attributes. 4. Will it advance/improve (availability, access and/or quality of care) sexual and reproductive health services, goods, facilities or the underlying determinants? The findings from this study will be used to inform appropriate and necessary sexual and reproductive health and obstetric care for women with SARS-CoV-2 infection. 5. Describe how access to any researched products, interventions, technical solutions, etc., will be provided to in-need populations. Findings from this study will be used to inform guidelines on SARS- CoV-2 infection and pregnancy that may be adopted by national and local governments globally. 6. Are there any foreseeable outcomes of the study/product that might negatively impact human rights or gender equality? None. 5.8.5 Research capacity strengthening This protocol will be adopted, adapted and implemented by research institutions across the globe, including members of the HRP Alliance who will receive support from their regional partners or the HRP for their 14 The Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies (www.equator-network.org/reporting-guidelines/strobe/). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 27 conduct of the study. The Pregnancy and COVID-19 Research Working Group will provide technical guidance on the study of the implementation, including pooled analysis of data. 5.8.6 Environmental considerations Environmental impact of this study is low since the data collection follows clinical work. 5.9 Ethical considerations 5.9.1 Informed consent Written or verbal informed consent and/or assent will be obtained from all study participants. Women will not be included in the study without consent, assent or surrogate consent having been obtained. Best practice recommendations for these processes are described in the protocol. An option for verbal consent via telephone will be available in order to limit the risk of exposure to research staff given the nature of the study. Sites obtaining consent via telephone will create a script for research staff to use, which includes reading the full text of the informed consent form to the prospective participant. Informed consent may also be obtained via online means, in which case the text of the informed consent form – including checkboxes at the end of the form – will be presented online to the prospective participant. The participant will give their consent by checking all relevant checkboxes, indicating that they have read and understood the consent form. Before the first interview with the pregnant woman, the study purpose will be explained, and written or verbal informed consent will be obtained upon study enrolment by a trained investigative team member. Individuals who are approached for participation in the study and have not reached the age of majority, as determined by local laws, will be included in the study if they provide assent. As per CIOMS guidelines, assessment of a child’s mental capacity to assent should consider the child’s: 1. ability to understand that there is a choice and that choices have consequences; 2. willingness and ability to make a choice, including the option of choosing that someone else make treatment decisions; 3. understanding of the nature and purpose of the procedure; 4. understanding of the risks and side-effects of the procedure; 5. understanding of the alternatives to the procedure and the risks attached to them, and the consequences of no treatment; 6. freedom from pressure. If allowed by the local ethical review committee, consent of the individual’s parent or guardian may be waived. This can occur because the research involves no more than minimal risk to study participants, as data collection consists of a patient interview and specimen collection. In addition, the waiver of parental/guardian consent will not adversely affect the rights and the welfare of the subjects. In some instances, the research may not be able to be carried out without the waiver of parental consent, for example, if the parent is not present at any of the antenatal care or delivery visits to the facility. In the context of this study, it may be difficult to distinguish between the researcher and the treating physician; however, research personnel should emphasize this distinction in approaching women for enrolment in the study. If the treating physician and researcher are the same person, utmost caution should be used to differentiate between the treatment of the patient and research. Treating physicians’ involvement SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 28 in the enrolment process should emphasize that the woman’s care and treatment is in no way dependent on their participation in the study. COMMENT: If the study group determines that it will be difficult for participants to differentiate between the researcher’s role as physician and as researcher, they may choose to add additional measures to the consent process. This may include inviting the woman to participate in the study only once and allowing her time to reflect on whether or not she would like to participate in the study. All women approached for enrolment will be informed that participation is voluntary and that she has the ability to withdraw from the study, without justification, at any time without consequences and the health care she or her newborn receives will not be affected by this action. Participants may withdraw from the study via in-person conversation, telephone or online means. Data that was collected up to the point of participant withdrawal from the study will remain with the study group, unless consent is retroactively withdrawn by the participant in question. The informed consent form will ask for consent to collect information about the neonate during the birth hospitalization and up to 6 weeks of life. This consent will be collected using the same single consent process of the mother and can be signed by the adult mother. As per local circumstances, sometimes consent from the participant and the father of the neonate may be required for parts of the study concerning the neonate. Only if required by local IRBs, an additional separate consent form will be required and signed by the mother and her partner or a witness of her choice. In the process of informed consent, participants will be asked to approve the sharing of RT-PCR results (collected for purposes of clinical care) with the research team, review of medical records on the current pregnancy and prior pregnancy history, collection of additional biological samples, as well as the collection of data regarding the outcomes of their pregnancies and neonates, for the intended purpose of the study. In some cases, samples may be drawn and analysed for the purposes of clinical care. If consent is obtained, then the samples and/or test results may be repurposed for use in the research study. In the case of a cognitively impaired woman, determination of the cognitive level will be done by the managing physician. The managing physician must be someone who is not involved in the research study. In these instances, the individual responsible for enrolling the woman in the study will provide clear information during the informed consent process, emphasizing that the decision of whether or not to participate in the study will not affect care and that the potential risk of harm from study participation is minimal. Special circumstances: 1. Critically ill patient, unable to consent (family member or responsible party available): If a woman is unable to provide consent due to illness, the family member or other responsible party will be asked to consent on behalf of the patient. If the patient’s responsible party agrees that the patient can participate, the responsible party will sign the consent and be given a copy. If they do not want the patient to participate, they will be thanked for their time and reminded that this decision will not affect their current health care. If the patient who is acutely ill improves and is able to provide consent after their responsible party provides consent, consent will be obtained from the actual study patient once they are able to provide meaningful consent. If the patient does not recover, then the patient’s responsible party will be approached for re-consent. Staff will take into account the sensitivity of the situation, given the death of the patient, in approaching the patient’s surviving family for re-consent. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 29 2. Critically ill patient, unable to consent (no available representative to make decisions on her behalf): Patients will be approached for consent when they have medically improved to the point that they are able to do so. If they decline at that time, no data collection will follow, and no information will be drawn from their clinical records or specimen. All data collection and specimens will be destroyed. 3. Patients who have died where informed consent has not been possible to discuss and without a responsible party available: These patients will not be considered for inclusion in this study. 4. Inability to read or write: If the participant giving consent cannot read or write, information will be shared with a witness of her choice and this information will be read to them by a staff member. The witness will be asked to confirm that the woman received all the information about the study, was given the opportunity to ask questions and her questions were answered, and has verbally and voluntarily consented to taking part in the study. The witness must then sign the document stating that s(he) was present during the consent process with the participant, the form was read to her, all questions were answered including regarding her rights to leave the study at any point, and she agreed to take part in the study. COMMENT: The study group will need to define parameters of data sharing for both partners outside of the country and for future research endeavours that involve study samples. In the process of informed consent, participants will be informed that any suspected or confirmed COVID-19 infection may be notified to national authorities under the International Health Regulations (IHR) requirements. If the study participant agrees, the consent form must be completed legibly, with both the surname and first name, and be dated and signed by the participant (or witness if participant is illiterate) and the member of the investigative team, before any procedure can be performed as part of the current study. The investigative team member is responsible for obtaining the written consent of the participant. There will be a checkbox on the consent form that explains that the participant has to option to withdraw consent at any time. If she chooses to do so, she will be able to consent or not consent to allowing collected specimens to be used. After the informed consent form is signed (optional online agreement can be used), one copy will be made and given to the study participant. The original version of the consent form for each participant will be retained by the investigative team and kept in a secure place for a period of time determined by national and local IRB requirements, but at a minimum for 3 years as per WHO Ethical Review Committee requirements. Information for participant and informed consent form templates for participants (the pregnant woman and her newborn) can be found in Appendix A. In the event of maternal death prior to study recruitment, the family of the woman may be approached to ask for the possibility of retrieving clinical data from medical records, as well as information from a family member. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 30 5.9.2 Incentives to participate and compensation The primary benefit of this study is to gain medical knowledge and advance the care and counselling of women who are pregnant or planning pregnancy in a COVID-19 outbreak area. This study is not anticipated to directly benefit pregnant women enrolled in the study nor their infants. Trained health-care workers will provide study participants with additional information on how to protect against COVID-19 infection, the potential modes of COVID-19 transmission and possible risks during pregnancy. Reimbursement for transportation to the study site will be offered if the visit to the site is for research purposes (as opposed to travel to the site for clinical management of pregnancy or COVID-19 infection). Any additional financial compensation should be determined on a study-by-study basis. This will need to be detailed in the information provided to the participant and during the informed consent process. COMMENT: The clinical management of patients is not a part of this research protocol. It will be at the discretion of the medical consultant, and medical care will be provided per the standard of care at each recruitment site. 5.9.3 Policy on incidental findings Ethical approval will be sought in accordance with local, regional, and national regulations. The sponsor and the investigators will be committed to conducting this research in accordance with the World Medical Association (WMA) Declaration of Helsinki (Ethical Principles for Medical Research Involving Human Subjects) adopted by the 64th WHA General Assembly, Fortaleza, October 2013. Women who test positive for acute COVID-19 infection will be informed on recommended infection prevention and control (IPC) measures in order to limit disease transmission. For women with mild symptoms who are being managed at home, they will be provided with recommendations for home isolation, hand hygiene, respiratory hygiene, movement around the house/utilization of shared spaces and other recommendations as outlined in WHO Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts, published 17 March 2020.15 Pregnant women who do not have COVID-19 infection will be provided with information on recommendations to minimize exposure risk to SARS-CoV-2, including but not limited to proper hand hygiene, recommendations on social distancing (per current local and international guidelines), as well as signs and symptoms of COVID-19 infection, as outlined in WHO COVID-19 risk communication package for health-care facilities published 10 March 2020.16 Investigators should check frequently for updates on recommendations and regulatory guidance, which will be posted on the WHO website. Additionally, investigators should ensure that they are up to date with local regulations and guidelines. WHO will also inform investigators of relevant updates, as they come available. COMMENT: The study group will need to indicate which IRB has approved the adapted protocol, including the protocol version and date of ethical approval. 15 WHO. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts (https://apps.who.int/iris/handle/10665/331473). 16 WHO. COVID-19 risk communication package for healthcare facilities (https://iris.wpro.who.int/bitstream/handle/10665.1/14482/COVID-19-022020.pdf). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 31 5.9.4 Benefits and risks for study subjects The primary benefit of this study is to improve knowledge, counselling and medical management of women who are pregnant or planning a pregnancy in a COVID-19 outbreak area. The anticipated gained knowledge includes, but is not limited to, the presentation and severity of COVID-19 during pregnancy, prevalence of symptomatic and asymptomatic infections, pregnancy outcomes and potential for teratogenicity and for MTCT. This study is not intended to benefit participants directly because standard medical care will be used for all participants. All biological specimens will be collected in accordance with current WHO guidance. WHO guidance on proper handling and processing of potentially infectious specimens should be closely adhered to, as outlined in WHO interim guidance Laboratory biosafety guidance related to coronavirus disease (COVID-19), 17 published 19 March 2020, and Laboratory testing for coronavirus disease (COVID-19) in suspected human cases,18 also published 19 March 2020. WHO reference laboratories19 should be used, and specimens should be shipped in adherence to protocols outlined in WHO interim guidance document Guidance for laboratories shipping specimens to WHO reference laboratories that provide confirmatory testing for COVID-19 virus,20 published 31 March 2020. The 3rd edition of WHO Laboratory biosafety manual,21 updated in 2004, should also be referenced for additional guidance. COMMENT: Given the rapidly developing guidance related to SARS-CoV-2, it is recommended that investigators check for updates to these documents prior to study initiation to ensure that current recommendations are being followed. Individuals in the study will be assigned to study groups based on results of RT-PCR tests for presence of SARS-CoV-2 and/or presence of IgG/IgM via serology testing. This will require a minimum of two blood draws, which are likely to be performed as part of clinical management of the patient. The first blood draw will be obtained at time of study initiation, and the second blood draw will be obtained just prior to childbirth. If a blood draw is unable to be obtained prior to childbirth, it will be obtained as soon as possible after childbirth during the same hospitalization. The collection of a small amount of venous blood poses minimal risk to the women participating in the study. Results of any testing are the property of each participant and should be provided to each participant as soon as possible. COMMENT: Both the protocol and informed consent document must explain all tests that will be performed on collected samples, how the results of the tests will be used, and how results will be shared with the participants. This will likely depend on local IRB requirements. 17 WHO. Laboratory biosafety guidance related to coronavirus disease (COVID-19) (https://apps.who.int/iris/handle/10665/331500). 18 WHO. Laboratory testing for coronavirus disease (COVID-19) in suspected human cases (https://apps.who.int/iris/handle/10665/331501). 19 WHO. WHO reference laboratories providing confirmatory testing for COVID-19 (www.who.int/publications/m/item/who- reference-laboratories-providing-confirmatory-testing-for-covid-19). 20 WHO. Guidance for laboratories shipping specimens to WHO reference laboratories that provide confirmatory testing for COVID- 19 virus (https://apps.who.int/iris/handle/10665/331639). 21 WHO. Laboratory biosafety manual, 3rd edition (www.who.int/publications/i/item/9241546506). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 32 5.9.5 Biobank guidance Biobank guidance can be found in Appendix H and is based on the CIOMS guidelines on storage of biological specimens. Study sites may choose to save biospecimens locally in their country. In this case, the site should follow CIOMS guidelines with regards to how long the specimens can be stored. Implementing sites should also modify the informed consent forms to include this information regarding storage of samples in local biobanks if this is planned. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 33 6 References 1. Naming the coronavirus disease (COVID-19) and the virus that causes it. Geneva: World Health Organization; 2020 (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical- guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it, accessed 25 November 2020). 2. Lapinsky SE. Acute respiratory failure in pregnancy. Obstet Med 2015; 8:126–132. 3. Wong SF, Chow KM, Leung TN, et al. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. Am J Obstet Gynecol. 2004; 191:292–297. 4. Alfari S, Al-Tawfiq J, Memish Z. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature. J Microbiol Immunol Infect. 2019; 52:501–503. 5. Mascio DD, Khalil A, Saccone G, et al. Outcome of coronavirus spectrum infections (SARS, MERS, COVID19) during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM. 2020; 2:100107. 6. Dashraath P, Jeslyn WJL, Karen LMX, et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol. 2020; 222:521–531. 7. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal- fetal transmission of SARS-CoV-2: maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020; 144:799–805. 8. Della Gatta A, Rizzo R, Pilu G. Coronavirus disease 2019 during pregnancy: a systematic review of reported cases. Am J Obstet Gynecol. 2020; 223:36–41. 9. Mckie R. The Covid 19 puzzles that scientists are still trying to answer. The Guardian. 2020 (https://www.theguardian.com/world/2020/mar/14/answering-the-coronavirus-puzzles-baby-covid- 19, accessed 25 November 2020). 10. Dong L, Tian J, He S, et al. Possible vertical transmission of SARS-CoV-2 from an infected mother to her newborn. JAMA. 2020; 323:1846–1848. 11. Zeng H, Xu C, Fan C, et al. Antibodies in infants born to mothers with COVID-19 pneumonia. JAMA. 2020; 323:1848–1849. 12. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020; 395:809–815. 13. Ellington S, Strid P, Tong VT, et al. Characteristics of Women of Reproductive Age with Laboratory- Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69: 769–775. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 34 14. Meyerowitz-Katz G, Merone L. A systematic review and meta-analysis of published research data on COVID-19 infection fatality rates. Int J Infect Dis. 2020; 101:138–148. 15. Zambrano LD. Update: Characteristics of symptomatic women of reproductive age with laboratory- confirmed SARS-CoV-2 infection by pregnancy status — United States, January 22–October 3, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69:1641–1647. 16. Wang X, Zhou Z, Zhang J, et al. A case of 2019 Novel Coronavirus in a pregnant woman with preterm delivery. Infect Dis Soc Am. 2020; 71:844–846. 17. Liu Y, Chen H, Tang K, et al. Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect. 2020; doi:10.1016/j.jinf.2020.02.028. 18. Cochrane Gynaecology and Fertility. COVID-19 (coronavirus disease) — Fertility and pregnancy. Cochrane; 2020 (https://cgf.cochrane.org/news/covid-19-coronavirus-disease-fertility-and-pregnancy, accessed 25 November 2020). 19. Diagnostic testing for SARS-CoV-2: interim guidance, 11 September 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/handle/10665/334254, accessed 7 November 2020). 20. Advice on the use of point-of-care immunodiagnostic tests for COVID-19: scientific brief, 8 April 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/handle/10665/331713, accessed 7 November 2020). 21. Breastfeeding and COVID-19 scientific brief, 23 June 2020. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-Sci_Brief-Breastfeeding-2020.1, accessed 7 November 2020). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 35 7 Acknowledgements The continuous input of members of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP)/Sexual and Reproductive Health (SRH) working group on SARS-CoV-2 and pregnancy research has been invaluable to the development of this generic protocol and is acknowledged. These include: Moazzam Ali Mercedes Bonet Vanessa Brizuela Megan Foeller Caron Kim Loulou Kobeissi Olufemi Oladapo Melanie Taylor SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 36 Appendix A: Description of investigation and informed consent template COMMENT: The language of this document is more technical than information sheets and informed consent forms. The text will therefore need to be adapted based on the local setting and IRB requirements. Part 1: To be completed prior to enrolment INFORMATION FOR THE WOMAN Dear Mrs/Ms/Miss, We are inviting you to participate in the research study entitled: A prospective longitudinal cohort study of women and newborns diagnosed with SARS-CoV-2 during the course of their pregnancy This study is being conducted by __________________________, the International Sponsor, ______________________, the local investigator, and several international collaborators including _________________________. INFORMATION The purpose of this document is to provide you with written information that is needed for you to make a decision regarding your participation in the study. Please read this document carefully, and please feel free to ask any questions you may have to us or your health-care provider. Additionally, if anything is unclear or if you would like further information, please let us know. You may take additional time to consider participating in this research, and you may discuss this with friends or family prior to making a decision. If you agree to participate in the study, your health-care provider will ask you to fill in, sign and date the consent for in the appropriate spaces. CONSENT PROCESS Your participation in the study is completely voluntary. If you chose to participate, you can withdraw your consent at any time, without consequence, ill-feeling or prejudice. GENERAL BACKGROUND AND RESEARCH OBJECTIVES As you may know, coronavirus disease 2019 (COVID-19) has been circulating in [region of study] since [time of first detection of COVID-19 into study region]. You are being asked to participate in a study that aims to understand the role of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – the virus that causes COVID-19 – during pregnancy on you and your baby. SARS-CoV-2 is usually transmitted by respiratory droplets. People who become infected with SARS-CoV-2 may have a range of illness, from asymptomatic disease to mild symptoms to severe illness. Symptoms usually consist of fever, shortness of breath or cough. It is unknown if women who are pregnant experience SARS-CoV-2 infection differently from individuals who are not pregnant. However, one study has shown that SARS-CoV-2 infection during pregnancy is associated with hospitalization, increased risk for intensive care unit admission and receipt of mechanical ventilation, but not with death (1). Additionally, it is not known if pregnant women with SARS-CoV-2 can pass the virus onto their baby, although so far there is no evidence that this occurs. It is unclear if pregnant women who become ill with COVID-19 have higher rates of pregnancy-related complications or health issues in their newborn. The purpose of this study, which we are asking you to consent to participate in, is to answer these questions. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 37 The main objectives of this research study are to: • describe the symptoms, clinical course and outcomes for pregnant women with COVID-19; • describe any pregnancy complications or health problems the baby may experience after childbirth, if any, for pregnant women with SARS-CoV-2 infection; • determine if SARS-CoV-2 infection can be passed from the mother to her baby during pregnancy and, if so, how often this occurs and what it means for the baby; • estimate the number of pregnant women who may experience SARS-CoV-2 infection with no symptoms or just minimal symptoms. COMMENT: Briefly describe the location of the study and the anticipated study size. If the option to assess the disease severity of pregnant verses non-pregnant women with SARS-CoV-2 infection is conducted, this should be added to the study objectives. RESEARCH PROCESS If you agree to participate in the study, you will be asked questions about your health, pregnancy and medical history, and your life. We will ask for permission to access your past and present medical records. We will ask to take a sample of amniotic fluid by either amniocentesis prior to delivery (if performed for a separate reason) or during caesarean section. We will also ask to take a small portion of the placenta, a swab of the placenta and a small amount (less than 2 teaspoons) of blood from the umbilical cord after the baby is born and the umbilical cord is cut. Additionally, we will ask to swab the baby’s throat after birth. Tests will be performed to see if the SARS-CoV-2 virus can be identified in these items. COMMENT: If additional specimens are collected (see Appendix C, Tier 2 and 3 specimens), they should be added and described here. [Add the following for individuals enrolling into the non-exposed group]: We would like to draw a small amount (less than 2 teaspoons) of your blood using a needle in your arm. If possible, we will draw these samples with your routine prenatal testing, so you do not have to have any additional blood draws performed. This will be tested for antibodies to SARS-CoV-2 to see if you have already experienced infection (which may be asymptomatic). At the end of pregnancy when you come to maternity unit for childbirth, we will ask to draw approximately 7.5 mL of blood (less than 2 teaspoons) of your blood to, once again, test for antibodies to SARS-CoV-2 to see if you have experienced infection. If possible, we will draw these samples at the same time as the routine testing done during labour, so you do not experience additional blood draws. At the birth, up to 3 ml (approximately ½ teaspoon) will also be collected from your baby. This will be done with a needle and if we are having difficulty in obtaining the blood sample, we will attempt the blood draw no more than two times. The samples collected from you and your baby will be tested for the coronavirus and may be tested for other viral infections as part of your clinical care. Exam findings from the newborn exam will also be collected. Samples will be analysed locally. However, if this is not possible due to lack of local laboratory capacity, then samples may be sent to a neighbouring country for analysis and will be destroyed after analysis is complete. We will also ask for a follow up visit after childbirth to examine the newborn within 6 weeks following birth. This visit will entail another newborn examination and blood tests for coronavirus and other infections. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 38 COMMENT: The tables below may be adapted to facilitate comprehension of the study visits. As the local team will determine the total number of follow up visits during pregnancy, they will fill in the appropriate number of “follow-up visit” rows. The minimum amount of follow-up visits as stated in the protocol is at least once per trimester until the end of pregnancy. Therefore, the number of follow-up visits is not set as it is dependent on the time point that the woman entered prenatal care and enrolled, as well as the outcome of childbirth (e.g. fewer follow- up visits if the woman was enrolled in the 2nd trimester or if the pregnancy ended earlier than expected). Table A1. Visits and lab tests for unexposed group only Visit Questionnaire Lab tests (control group) Enrolment Study questionnaire part I Blood test for SARS-CoV-2 IgG/IgM antibodies (7.5 mL of blood) Follow-up visits 1–3 (at ---- weeks) Study questionnaire part II Blood test for SARS-CoV-2 IgG/IgM antibodies (7.5 mL of blood) Comment: include if planning to test for antibodies multiple times during the pregnancy Childbirth hospitalization Yes, pregnancy outcome and delivery mode Blood test for SARS-CoV-2 IgG/IgM antibodies (7.5 mL of blood) Post-birth follow-up visit (within 6 weeks following delivery) Study questionnaire part III No lab tests Comment: only include Table A1 for the control group. Table A2. Visits and lab tests for exposed group only Visit Questionnaire Lab tests (control group) Enrolment Study questionnaire part I No lab tests Follow-up visits 1–3 (at ---- weeks) Study questionnaire part II No lab tests Childbirth hospitalization Yes, pregnancy outcome and delivery mode Placental sample Umbilical cord blood Amniotic fluid at delivery Baby throat swab Baby anal swab Post-birth follow-up visit (within 6 weeks following birth) Study questionnaire part III No lab tests Comment: only include Table A2 for the study group. There is a risk that you may experience some discomfort with the blood draw. Sometimes, a small bruise may appear. Some individuals may feel lightheaded with the blood draw. If this occurs, it is temporary and does not require medical treatment or consultation. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 39 COMMENT: Blood sample/childbirth specimens may require a second informed consent form for collection and, if so, they will need to be signed prior to childbirth. These requirements often depend on local IRB rules and regulations. RISKS AND BENEFITS OF YOUR PARTICIPATION This research does not pose any foreseeable risk to you, and no procedures will be performed that are not designed for the purpose of this study. There is no anticipated direct benefit to you or your child by participating in this study. However, this study will help to answer important research questions for other women who experience a pregnancy in a COVID-19 outbreak area. RESEARCH RESULTS The results of this research will be shared with national and international organizations, such as the World Health Organization. Data from this research may be presented in scientific conferences or in publications. Your personal data will not be identifiable in any way. Additionally, all study data will remain confidential and coding will be used to remove your first and last name, as well as any other identifying information. Only a small number of key study personnel will be able to access the study data. COMMENT: If the results of the study will be made available online and there is information on how participants can access this information, this should be added. In addition, there should be additional information inserted by the country team in how the results can be made easily accessible and understood by the lay person (i.e. community meetings, creation of a poster that provides the main results from the study, which is placed in the reception area of the health centres where the research has taken place). CONFIDENTIALITY AND TREATMENT OF COMPUTERIZED DATA We will need to enter your data into an electronic data to be able to analyse it and answer the research questions in the study. Your medical data and lifestyle data will be transmitted confidentially and under strict protection only to your doctor or to individuals from the research group or key study personnel in [country of study] or overseas in other countries [name these individuals here]. If, during the study, you decide that you no longer want to participate, the study group will ask for your permission to keep the data you have contributed up to the point you withdraw the study or to destroy all data. INFORMATION ON YOUR SAMPLES DURING AND AFTER THIS STUDY COMMENT: This section should only be included if the research team has the capacity for a biobank and has set up a governance structure as detailed in the protocol. The following is a sample section that can be elaborated and adapted to the parameters set up by the research team. We will also ask you if you would be willing to allow researchers to use any “left over” samples for other research studies. What we mean is, if your samples are not completely used upon completion of this study, they could be stored in a biobank (a storage facility in the study laboratory) and used for other research studies that are looking at SARS-CoV-2 infection. In any future studies, your identity would remain confidential. This future research may be conducted in your country or outside of your country but researchers of the team who collected your samples in the first place will receive priority in the case that multiple researchers are requesting use of the sample. The remaining samples will be stored at [name of national/designated laboratory]. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 40 At any time, and without consequence to your participation in the present study or to your medical care, you may choose not to answer certain questions. You may also choose to withdraw your consent for the use of your samples for these other research objectives. This can be done simply by contacting the health-care professional who is supervising your participation in this study. COMMENT: Ensure to insert the details of how confidentiality will be maintained. Samples stored in the biobank are usually anonymized, de-identified or coded. Please provide the pertinent description based on your team’s decision of how samples will be stored. Examples are given below. Anonymous data: All personal information that identifies you will be removed, and there will be no link between you and your sample. This would be the process of anonymizing your data. De-identified data: Your sample will be de-identified, which means that any personal information that identifies you will be removed permanently. There will be nothing that exists which will link you to the sample. Coded data: All personal identifying information will be replaced with a code which is usually made up of letters, numbers, symbols or a combination of figures. However, a link between this code and you will be kept in a confidential manner. This will be done by having the codes remain with a custodian of the biobank and there will be limited access to the materials by anyone outside of the research team. The research team needs to decide on the above when setting up their governance structure. Further description of how the samples will be stored should be explained in this information sheet for the patient to make an informed decision. Measures to protect confidentiality (per CIOMS guidelines): • how confidentiality of the link between the specimen and personal identifiers is maintained; • who may have access to the materials for future research and under what circumstances; • to which other sources of personal information the results of analyses on biological materials may be linked. Please feel free to ask any questions about the information you have just read/been given or about the study itself. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 41 INFORMED CONSENT OF THE WOMAN I, undersigned, _________________________________________ confirm that I have read and understood all the information presented to me, relative to my participation in the study entitled A prospective longitudinal cohort study of women and newborns diagnosed with coronavirus disease 2019 (COVID-19) during the course of their pregnancy This study has been described to me, the document “Information for the participant” has been read to me by ____________________________________, and I have received answers for all the questions that I asked. ☐ I have read or orally received all the necessary information to understand the topic and enrolment process of the study. ☐ I was able to ask questions and received clear and adequate responses. ☐ I confirm my participation in this study, which includes responding to a questionnaire and allowing the taking of biological samples from me and my newborn baby. ☐ I understand that there are no predicted risks to me or my fetus or newborn in participation in the study. ☐ I have been advised that there is no financial incentive foreseen in this study. ☐ I am aware reimbursement for transportation to the study site will be offered if the visit to the site is for research purposes (as opposed to travel to the site for clinical management of pregnancy or SARS-CoV-2 infection). ☐ I understand that I can withdraw, at any time, my consent to participate in this study, for any reason and without having to justify myself, and without incurring any consequence or prejudice to me or my fetus/baby. I must simply inform the health-care professional in charge of this study through in-person, telephone or online means. If I choose to withdraw from the study, I will be given the option to consent or not consent to allowing samples that have already been collected to be used. ☐ I agree to give access to the study investigators to my past and present clinical data. This clinical data may include biological samples, clinical observations related to the current pregnancy or suspect SARS-CoV-2 infection, and/or prior pregnancy history. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 42 CONSENT TO USE OF PERSONAL DATA I accept that my personal data will be recorded and computerized by a data manager for the purpose of this study. I accept that my baby’s personal data will be recorded and computerized by a data manager for the purpose of this study. I accept that my medical files and the medical files for my baby may be looked at by the appropriate persons implicated in this research study, all of whom will keep my confidential. CONSENT TO THE USE OF BIOLOGICAL SAMPLES I accept the use and storage of my biological samples as it has been described by the study group. I have been informed that my biological samples may be stored even after the end of the study period in order to conduct further research on SARS-CoV-2 infection. Other research teams, national or international, may carry out this research. This authorization will no longer be valid if I withdraw my consent during the study. SIGNATURES Study participant I freely and voluntarily accept to participate in the study that has been described to me. LAST NAME, First name: Date: Signature: Researcher I have accurately read or witness the accurate reading of the assent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given assent freely. LAST NAME, First name: Contact number: Date: Signature: SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 43 If the person giving consent cannot read or write, a witness must be present and sign here: Witness I was present during the consent process with the participant. This form was read to him/her, all questions were answered s(he) agreed to take part in the study. LAST NAME, First name: Date: Signature: Researcher I have accurately read or witness the accurate reading of the assent form to the witness, and the individual has had the opportunity to ask questions. I confirm that the individual has given assent freely. LAST NAME, First name: Contact number: Date: Signature: COMMENT: The last page of this document must have the signatures of the researcher and of the person being solicited and must be dated by the hand of the person who has consented in the spaces where indicated. This information and consent document must be made in two original copies: one copy is to be given to the participant, and one is to be kept for the required legal duration for research documented by the health-care professional in charge of the research, in the research locations at each regional site of the study. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 44 Appendix A1: Consent to the use of biological samples COMMENT: As noted in the protocol, the decision is left to the research team to determine if they have the capacity to store leftover samples (biobank). In the event that leftover samples can be stored, a proper governance structure has to be put in place. Components of that governance structure have been listed in the protocol. A separate consent can be obtained with regards to the biobanking of study samples. The following can be used as a potential sample that will require further details based on the governance structure the research team has set up. From the samples you provide during this study, a large amount will be used for the analysis planned in this protocol, but there may be some leftover volume of each sample. This consent form is to discuss the storage of these leftover samples in a biobank, which is a storage facility in the study laboratory. The samples can be used to conduct further research on SARS-CoV-2. This future research may be conducted in your country or outside of your country but researchers of the team who collected your samples in the first place will receive priority in the case that multiple researchers are requesting use of the sample. Your sample will not be sold for profit, and any research that uses your sample will have been approved by the proper research governing bodies. This consent for use of samples in future studies will no longer be valid if you withdraw your consent during this current study. If you agree to have your leftover samples stored and used in future studies, you can decide if you also agree to have your samples included in studies about the impact of human genes on disease. COMMENT: Ensure to check Appendix H for further details on biobanking of specimen. Ensure to insert the details of how confidentiality will be maintained; where and how long the respective specimen would be stored, per CIOMS international guidelines.22 Note that the transfer of biological materials must be covered by an MTA. Measures to protect confidentiality (per CIOMS guidelines): • how confidentiality of the link between the specimen and personal identifiers is maintained; • who may have access to the materials for future research, and under what circumstances; • to which other sources of personal information the results of analyses on biological materials may be linked. If you do not agree to have your leftover samples stored and used in future studies, we will destroy the leftover samples after this study is completed. You have the right to refuse the storage of your samples and also have the right to put restrictions on the use of these samples. This will not impact your care or the current research study. 22 CIOMS. International ethical guidelines for health-related research involving humans (https://cioms.ch/wp- content/uploads/2017/01/WEB-CIOMS-EthicalGuidelines.pdf). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 45 Please indicate below: 1) Do you agree to have your leftover samples stored and used in future studies? YES NO 2) If you agree to have your leftover samples stored and used in future studies, do you understand your sample will be anonymized at the start of the storage time? YES NO If yes, please note that you will be unable to request destruction of the samples at a later date. Study participant LAST NAME, First name: Date: Signature: Researcher I have accurately read or witnessed the accurate reading of the assent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given assent freely. LAST NAME, First name: Contact number: Date: Signature: SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 46 Appendix B: Sample size estimates for individual sites and standardized questionnaires/CRFs Sample size for site-specific and pooled data Two approaches were used to determine the required sample sizes for the study: 1. Site-specific sample size calculation is based on a composite adverse pregnancy/neonatal outcome that includes outcomes at each stage of pregnancy, delivery and postpartum (e.g. miscarriage, preterm birth, perinatal death or NICU admission). 2. Pooled data sample size calculation is based on outcome and cohort specific prevalence. The main components of the sample size determinations are: the study design, which is a prospective cohort study with two groups and predefined outcomes, the statistical analytical methods used to test the study hypothesis, includes likelihood ratio test, generalized linear model (GLM) and possible multilevel modelling. In addition, the significance level α (type I error) is set at 0.05 to protect the null hypothesis or a state in which an incorrect decision is more costly, P(reject H0|H0 is true) = α. The power of the test (or type II error) is the probability of correctly rejecting the null hypothesis when the null hypothesis is false P(reject H0|H0 is false) = 1-β, it was set to be 80%. The baseline rate, which is the anticipated outcome(s) rate for the unexposed group, and finally the clinically meaningful relative difference or relative risk. Once the sample size calculation is determined, several considerations for LFU and seroconversion need to be taken into consideration when determining the required sample size. Also, due to limited human and maternal resources, it may not be feasible to conduct the study under the original ideal specifications; therefore, varying the input parameters to find an appropriate balance between the desired detectable effect, sample size available resources, time and the primary objective of the study, would help in reaching a decision on the “final achievable” sample size. Thus, several scenarios for sample size calculations are presented below for both site-specific and pooled data required sample sizes. Site-specific sample size estimate 1- Outcome (composite adverse outcomes) in the unexposed group ranges between 4% to 50% 2- Relative risk ranges between 1.1 to 1.5 (i.e. an increase between 10% to 50% in the exposed group) 3- Equal group allocation 4- LFU of 10% in both groups 5- Seroconversion of 10% (i.e. 10% of the recruited non-COVID-19 pregnant women will become infected during the study). Table B1 presents different sample sizes for different parameters. The duration of the recruitment depends on the level of infection (seroprevalence) among pregnant women. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 47 Table B1. Site-specific sample size estimates Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.1 0.04 0.044 39 462 39 462 43 846 43 846 48 717 38 975 1.1 0.05 0.055 31 224 31 224 34 693 34 693 38 547 30 839 1.1 0.06 0.066 25 732 25 732 28 591 28 591 31 767 25 415 1.1 0.07 0.077 21 809 21 809 24 232 24 232 26 924 21 540 1.1 0.08 0.088 18 867 18 867 20 963 20 963 23,292 18 634 1.1 0.09 0.099 16 578 16 578 18 420 18 420 20 466 16 374 1.1 0.10 0.110 14 747 14 747 16 385 16 385 18 205 14 565 1.1 0.15 0.165 9255 9255 10 283 10 283 11 425 9141 1.1 0.20 0.220 6509 6509 7232 7232 8035 6429 1.1 0.25 0.275 4861 4861 5401 5401 6001 4801 1.1 0.30 0.330 3763 3763 4181 4181 4645 3717 1.1 0.35 0.385 2978 2978 3308 3308 3675 2941 1.1 0.40 0.440 2390 2390 2655 2655 2950 2360 1.1 0.45 0.495 1932 1932 2146 2146 2384 1908 1.1 0.50 0.550 1566 1566 1740 1740 1933 1547 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 48 Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.15 0.04 0.046 17 930 17 930 19 922 19 922 22,135 17,709 1.15 0.05 0.058 14 183 14 183 15 758 15 758 17,508 14,008 1.15 0.06 0.069 11 685 11 685 12 983 12 983 14 425 11 541 1.15 0.07 0.081 9,901 9,901 11 001 11 001 12 223 9779 1.15 0.08 0.092 8563 8563 9514 9514 10 571 8457 1.15 0.09 0.104 7522 7522 8357 8357 9285 7429 1.15 0.10 0.115 6689 6689 7432 7432 8257 6607 1.15 0.15 0.173 4191 4191 4656 4656 5173 4139 1.15 0.20 0.230 2942 2942 3268 3268 3631 2905 1.15 0.25 0.288 2193 2193 2436 2436 2706 2166 1.15 0.30 0.345 1693 1693 1881 1881 2090 1672 1.15 0.35 0.403 1336 1336 1484 1484 1648 1320 1.15 0.40 0.460 1069 1069 1187 1187 1318 1056 1.15 0.45 0.518 860 860 955 955 1,061 849 1.15 0.50 0.575 694 694 771 771 856 686 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 49 Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.2 0.04 0.048 10 304 10 304 11 448 11 448 12 720 10 176 1.2 0.05 0.060 8149 8149 9054 9054 10 060 8048 1.2 0.06 0.072 6712 6712 ,457 7457 8285 6629 1.2 0.07 0.084 5685 5685 6316 6316 7017 5615 1.2 0.08 0.096 4916 4916 5462 5462 6068 4856 1.2 0.09 0.108 4317 4317 4796 4796 5328 4264 1.2 0.10 0.120 3838 3838 4264 4264 4737 3791 1.2 0.15 0.180 2401 2401 2667 2667 2963 2371 1.2 0.20 0.240 1682 1682 1868 1868 2075 1661 1.2 0.25 0.300 1251 1251 1390 1390 1544 1236 1.2 0.30 0.360 964 964 1071 1071 1190 952 1.2 0.35 0.420 758 758 842 842 935 749 1.2 0.40 0.480 604 604 671 671 745 597 1.2 0.45 0.540 484 484 537 537 596 478 1.2 0.50 0.600 388 388 431 431 478 384 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 50 Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.25 0.04 0.050 6733 6733 7481 7481 8312 6650 1.25 0.05 0.063 5323 5323 5914 5914 6571 5257 1.25 0.06 0.075 4383 4383 4870 4870 5411 4329 1.25 0.07 0.088 3712 3712 4124 4124 4582 3666 1.25 0.08 0.100 3209 3209 3565 3565 3961 3169 1.25 0.09 0.113 2817 2817 3130 3130 3477 2783 1.25 0.10 0.125 2504 2504 2782 2782 3091 2473 1.25 0.15 0.188 1564 1564 1737 1737 1930 1544 1.25 0.20 0.250 1094 1094 1215 1215 1350 1080 1.25 0.25 0.313 812 812 902 902 1002 802 1.25 0.30 0.375 624 624 693 693 770 616 1.25 0.35 0.438 489 489 543 543 603 483 1.25 0.40 0.500 388 388 431 431 478 384 1.25 0.45 0.563 310 310 344 344 382 306 1.25 0.50 0.625 247 247 274 274 304 244 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 51 Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.3 0.04 0.052 4771 4771 5301 5301 5890 4712 1.3 0.05 0.065 3771 3771 4190 4190 4655 3725 1.3 0.06 0.078 3105 3105 ,450 3450 3833 3067 1.3 0.07 0.091 2628 2628 2920 2920 3244 2596 1.3 0.08 0.104 2271 2271 2523 2523 2803 2243 1.3 0.09 0.117 1993 1993 2214 2214 2460 1968 1.3 0.10 0.130 1771 1771 1967 1967 2185 1749 1.3 0.15 0.195 1104 1104 1226 1226 1362 1090 1.3 0.20 0.260 771 771 856 856 951 761 1.3 0.25 0.325 571 571 634 634 704 564 1.3 0.30 0.390 438 438 486 486 540 432 1.3 0.35 0.455 342 342 380 380 422 338 1.3 0.40 0.520 271 271 301 301 334 268 1.3 0.45 0.585 215 215 238 238 264 212 1.3 0.50 0.650 170 170 188 188 208 168 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 52 Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.35 0.04 0.054 3575 3575 3972 3972 4413 3531 1.35 0.05 0.068 2825 2825 3138 3138 3486 2790 1.35 0.06 0.081 2325 2325 2583 2583 2870 2296 1.35 0.07 0.095 1968 1968 2186 2186 2428 1944 1.35 0.08 0.108 1700 1700 1888 1888 2097 1679 1.35 0.09 0.122 1492 1492 1657 1657 1841 1473 1.35 0.10 0.135 1325 1325 1472 1472 1635 1309 1.35 0.15 0.203 825 825 916 916 1017 815 1.35 0.20 0.270 575 575 638 638 708 568 1.35 0.25 0.338 425 425 472 472 524 420 1.35 0.30 0.405 325 325 361 361 401 321 1.35 0.35 0.473 253 253 281 281 312 250 1.35 0.40 0.540 199 199 221 221 245 197 1.35 0.45 0.608 158 158 175 175 194 156 1.35 0.50 0.675 124 124 137 137 152 122 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 53 Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.4 0.04 0.056 2790 2790 3100 3100 3444 2756 1.4 0.05 0.070 2204 2204 2448 2448 2720 2176 1.4 0.06 0.084 1814 1814 2015 2015 2238 1792 1.4 0.07 0.098 1535 1535 1705 1705 1894 1516 1.4 0.08 0.112 1325 1325 1472 1472 1635 1309 1.4 0.09 0.126 1163 1163 1292 1292 1435 1149 1.4 0.10 0.140 1032 1032 ,146 1146 1273 1019 1.4 0.15 0.210 642 642 713 713 792 634 1.4 0.20 0.280 446 446 495 495 550 440 1.4 0.25 0.350 329 329 365 365 405 325 1.4 0.30 0.420 251 251 278 278 308 248 1.4 0.35 0.490 195 195 216 216 240 192 1.4 0.40 0.560 153 153 170 170 188 152 1.4 0.45 0.630 120 120 133 133 147 119 1.4 0.50 0.700 94 94 104 104 115 93 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 54 Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.45 0.04 0.058 2246 2246 2495 2495 2772 2218 1.45 0.05 0.073 1774 1774 1971 1971 2190 1752 1.45 0.06 0.087 1459 1459 1621 1621 1801 1441 1.45 0.07 0.102 1234 1234 1371 1371 1523 1219 1.45 0.08 0.116 1066 1066 1184 1184 1315 1053 1.45 0.09 0.131 935 935 1038 1038 1153 923 1.45 0.10 0.145 830 830 922 922 1024 820 1.45 0.15 0.218 515 515 572 572 635 509 1.45 0.20 0.290 357 357 396 396 440 352 1.45 0.25 0.363 263 263 292 292 324 260 1.45 0.30 0.435 200 200 222 222 246 198 1.45 0.35 0.508 155 155 172 172 191 153 1.45 0.40 0.580 121 121 134 134 148 120 1.45 0.45 0.653 95 95 105 105 116 94 1.45 0.50 0.725 73 73 81 81 90 72 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 55 Unadjusted Adjusted for LFU Adjusted for seroconversion RR P1 P2 N1 N2 N1 N2 N1 N2 1.5 0.04 0.060 1853 1853 2058 2058 2286 1830 1.5 0.05 0.075 1463 1463 1625 1625 1805 1445 1.5 0.06 0.090 1203 1203 1336 1336 1484 1188 1.5 0.07 0.105 1017 1017 1130 1130 1255 1005 1.5 0.08 0.120 878 878 975 975 1083 867 1.5 0.09 0.135 770 770 855 855 950 760 1.5 0.10 0.150 683 683 758 758 842 674 1.5 0.15 0.225 423 423 470 470 522 418 1.5 0.20 0.300 293 293 325 325 361 289 1.5 0.25 0.375 215 215 238 238 264 212 1.5 0.30 0.450 163 163 181 181 201 161 1.5 0.35 0.525 126 126 140 140 155 125 1.5 0.40 0.600 98 98 108 108 120 96 1.5 0.45 0.675 76 76 84 84 93 75 1.5 0.50 0.750 59 59 65 65 72 58 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 56 Figure B1. COVID-19 negative (by the time of pregnancy outcome) (n = XXX) COVID-19 positive (by the time of pregnancy outcome) (n = XX) Livebirth (n = XXX) No livebirth Livebirth (n = XXX) No livebirth (n = XXX) Newborns with COVID-19 negative status at birth (n = XXX) Neonatal outcomes: 1. Perinatal death (n = XX) 2. NICU admission (n = XX) 3. MTCT of SARS-CoV-2 Newborns with COVID-19 negative status at birth (n = XXX) Neonatal outcomes: 1. Perinatal death (n = XX) 2. NICU admission (n = XX) 3. MTCT of SARS-CoV-2 Newborns with COVID-19 positive status at birth (n = XX) Neonatal outcomes: 1. Perinatal death (n = XX) 2. NICU admission (n = XX) Composite outcome: 6. Either of: (1) Preterm birth <37 weeks or (2) perinatal death or (3) fetal growth restriction or (4) NICU admission (n=XX) Composite outcome: 6. Either of: (1) Preterm birth <37 weeks or (2) perinatal death or (3) fetal growth restriction or (4) NICU admission (n = XX) Composite outcome: 6. Either of: (1) Preterm birth <37 weeks or (2) perinatal death or (3) fetal growth restriction or (4) NICU admission (n = XX) Composite outcome: 6. Either of: (1) Preterm birth <37 weeks or (2) perinatal death or (3) fetal growth restriction or (4) NICU admission (n = XX) Composite outcome: 6. Either of: (1) Preterm birth <37 weeks or (2) perinatal death or (3) fetal growth restriction or (4) NICU admission (n = XX) Assuming 15% seroconversion Screening phase Screened pregnant women (of any gestational age) attending COVID-19 clinic for testing (n = XXXXX) Pregnancy outcomes 1. Preterm birth <37 weeks (n = XX) 2. Fetal growth restriction (n = XX) 3. Miscarriage (n = XX) – Livebirths (for assessment of MTCT through breastmilk)* (n = XXX) Pregnancy outcomes 1. Preterm birth <37 weeks (n = XX) 2. Fetal growth restriction (n = XX) 3. Miscarriage (n = XX) – Livebirths (for assessment of MTCT through breastmilk)* (n = XX) Pregnancy outcomes 1. Preterm birth <37 weeks (n = XX) 2. Fetal growth restriction (n = XX) 3. Miscarriage (n = XX) – Livebirths (for assessment of MTCT through breastmilk)* (n = XXX) Confirmed COVID-19 (positive) (n = XXX) Confirmed COVID-19 (negative) (n = XXX) Maternal outcomes: 4. Positive SARS-CoV-2 in breastmilk (persistence) (n = XXX) Maternal outcomes: 4. Positive SARS-CoV-2 in breastmilk (persistence) (n = XX) Maternal outcomes: 4. Positive SARS-CoV-2 in breastmilk (persistence) (n = XXX) Maternal outcomes: 4. Positive SARS-CoV-2 in breastmilk (persistence) (n = XX) Maternal outcomes: 4. Positive SARS-CoV-2 in breastmilk (persistence) (n = XX) Maternal outcomes: 4. Positive SARS-CoV-2 in breastmilk (persistence) (n = XXX) Maternal outcomes: Maternal outcomes: Enrolment phase Eligible and consented pregnant women (n = XXXX) Po st -d el iv er y fo llo w -u p ph as e fo r w om en a nd /o r b ab ie s Pr e- de liv er y fo llo w -u p ph as e fo r w om en Livebirth Newborns with COVID-19 positive status at birth (n = X) Neonatal outcomes: 1. Perinatal death (n = X) 2. NICU admission (n = X) Newborns with COVID-19 negative status at birth (n = XXX) Neonatal outcomes: 1. Perinatal death (n = XX) 2. NICU admission (n = XX) 3. MTCT of SARS-CoV-2 No livebirth (n = XXX) SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 57 Pooled data sample size estimates All pregnant women and women admitted for delivery or delivered outside the study site in the last 48 hours are eligible for inclusion, therefore, time of enrolment can be divided into THREE periods in relation to the study outcomes: 1. before 22 weeks of gestation (cohort C1) 2. 22+ weeks of gestation (cohort C2) 3. at delivery and 2 days after delivery (cohort C3). The pooled data sample size will be an outcome and cohort specific and, for each stage, sample size will be determined. As with the size-specific estimates, type I and II errors and allocation values will be the same. However, the LFU and seroconversion will be cohort specific, in addition to the outcome of interest. Attrition due to other outcomes will be used to determine the number of women in each group who are likely to progress to the second stage or to the end of the study to help in estimating the number of additional women to be recruited. Table B2 below gives an example of outcome and cohort specific input parameters and Table B3 provides detailed sample size needed for relative risks of 1.1 to 1.5. Table B2. Outcome and cohort specific sample size calculation parameters for the pooled data23 Cohort 1 Cohort 2 Cohort 3 Type I error 0.05 0.05 0.05 Power 0.8 0.8 0.8 Allocation 1 1 1 Primary outcome (unexposed group) 0.058 0.040 0.050 Attritions LFU 0.04 0.04 0.02 Seroconversion 0.04 0.04 0.02 Other possible outcomes 0.10 0.10 0.05 Table B3. Sample size calculation for the pooled data with varying relative risks24 Maternal and Pregnancy outcomes (Cohort 1): Relative risk 1.2 1.3 1.4 1.5 Proportion in the unexposed group 1 0.058 0.058 0.058 0.058 Proportion in the exposed group 2 0.0696 0.0754 0.0812 0.0870 Adjusted sample for group 1 7552 3493 2040 1354 23 These numbers are for illustration purposes and could be adjusted as necessary. 24 These numbers are for illustration purposes and could be adjusted as necessary. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 58 Adjusted sample for group 2 6948 3215 1878 1246 Continued to Cohort 2-group 1 5754 2661 1554 1031 Continued to Cohort 2-group 2 5252 2413 1399 921 Perinatal outcomes (Cohort 2): Relative risk 1.2 1.3 1.4 1.5 Proportion in the unexposed group 1 0.040 0.040 0.040 0.040 Proportion in the exposed group 2 0.048 0.052 0.056 0.060 Adjusted sample for group 1 11 180 5176 3027 2010 Adjusted sample for group 2 10 286 4762 2785 1850 Additional recruitment group 1 5426 2515 1473 979 Additional recruitment group 2 5034 2349 1386 929 Continued to Cohort 3-group 1 8720 4037 2361 1567 Continued to Cohort 3-group 2 7989 3680 2141 1415 Neonatal outcomes (Cohort 3): Relative risk 1.2 1.3 1.4 1.5 Proportion in the unexposed group 1 0.050 0.050 0.050 0.050 Proportion in the exposed group 2 0.060 0.065 0.070 0.075 Adjusted sample for group 1 8720 4037 2361 1567 Adjusted sample for group 2 8146 3769 2203 1462 Additional recruitment group 1 0 0 0 0 Additional recruitment group 2 157 89 62 47 Continued to end of the study group 1 7499 3471 2030 1347 Continued to end of the study group 2 6734 3095 1797 1185 Standardised questionnaires/CRFs Development of the Draft Questionnaires These questionnaires (also known as CRFs) have been designed by WHO and HRP with contributions from members of the established working groups on COVID-19 and pregnancy research. Purpose of the generic questionnaire and instructions for use These questionnaires have been designed to collect the minimum amount of data to address the primary objectives of the generic cohort study of pregnant women. Additional questions may be added to the questionnaire, as determined by the financial and technical capacity of the study group and by the outbreak characteristics. Each questionnaire is designed to be implemented by trained study personnel, without advanced degrees or specialized medical degrees. COMMENT: By using a standardized protocol, researchers can address many research objectives and will have the opportunity to collaborate with other research sites/countries conducting the same study and potentially will be able to pool data to address the primary research questions of this protocol. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 59 Instructions for completing the questionnaire When completing the sections of the questionnaire, please ensure that: • the participant has been given information about the study and the informed consent form has been completed and signed; • the study ID codes have been assigned for both the pregnant woman and neonate as per study protocol; • all information should be kept confidential at all times, and no identifiable information is to be recorded on the questionnaires; • patients’ hospital ID and contact details are recorded on a separate contact list to allow later follow- up by a limited number of key/approved study personnel. The contact forms must be kept separate from the questionnaires at all times and kept in a secure location. General guidance • The questionnaire is designed to collected data obtained through patient examinations, through parent/guardian/representative interview (for neonates), and the review of hospital charts. Each questionnaire will state where information should be obtained (i.e. from medical records or patient interview). • Patient ID codes should be filled in on all pages of the questionnaire (neonate and mother). • Complete every line of every section, except for where the instructions say to skip a section based on certain responses. • It is important to indicate when the answer to a particular question is not known. Please mark the “Unknown” box if this is the case. Do not leave the question blank. • Some sections have open text areas where you can write additional information. To permit standardized data entry, please avoid writing additional information outside of these areas. • Place an (X) when you choose the corresponding answer. To make corrections, strike through (---) the data you wish to delete and write the correct data above it. Please initial and date all corrections. • Please keep all sheets for each study participant together, e.g. with a staple or in a folder that is unique to the participant. • We recommended writing clearly in black or blue ink, using BLOCK CAPITAL LETTERS or completing electronically. • Do not use abbreviations, write out each letter. • Complete the heading on each page. • Use standard medical language. • Write only one character per box (I_I) • Numerical values: o Align numerical values to the right; o Do not add commas or full stops, they will already be present in the form field if appropriate; o Do not leave any space empty, enter a zero if necessary:  Incorrect: l_2_l_1_l_l  Correct: I_0_l_2_l_1_l • If the response must be entered into closed tick-boxes, mark the box as follows: o Yes ☐ No ☒ • Dates: enter dates in the format Day/Month/Year (DD/MM/YYYY). • In the case that the data is missing or unknown, leave tick boxes or other spaces empty and enter the codes that follow, as appropriate: o NA: Not applicable o ND: Not done o NK: Not known SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 60 For the primary investigators of this study, please contact us if we can help with any questionnaire completion questions, if you have comments and to let us know that you are using the forms. Please contact hrp_covid19pregnancycohort@who.int Disclaimer: These questionnaires are intended for use as a standardized document for the collection of clinical data in studies investigating COVID-19. Responsibility for use of these questionnaires rests with the study investigators. The authors of the questionnaire accept no responsibility for its use in an amended format nor for the use of the questionnaire outside its intended purpose. Overview of the CRFs The nine CRFs linked to this study (see Fig. B2) are designed to collect data obtained through participant interview, examination and review of hospital notes and other medical records. The data collection period is defined as the period from study enrolment to transfer from study site, death, study exit (i.e. 6 weeks postpartum) or continued hospitalization without possibility to continue data collection. Data may be collected retrospectively if the patient is enrolled into the study after hospitalization or death (with family consent). If CRFs cannot be completed at particular time points (e.g. respondent may be seriously ill, being managed for an obstetric emergency or in labour), attempts should be made to complete them at the soonest opportunity it is reasonable to do so. Note that the schematic below is a simplified general overview that may not reflect the dynamics of participant presentation and data collection in each site. Evidence on MTCT of SARS-CoV-2 is emerging. It is helpful to review Appendices I–L for draft definitions, criteria and scenarios regarding in utero, intrapartum and postnatal transmission of SARS-CoV-2. Appendices K and L contain guides for determining timing of infection and samples for assay. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 61 Figure B2. Simplified schedule of study progression and administration of CRFs Unknown group Exposed group CRF2: Participant characteristics CRF7: Neonatal outcomes between birth and 7 days At enrolment Monthly** prenatal/ follow-up At delivery or pregnancy termination Postpartum follow-up/ study CRF9: Maternal outcomes at 6 weeks post-partum/study exit CRF1: Screening and eligibility assessment* CRF8: Neonatal outcomes at 4 weeks of life CRF6: Maternal outcomes at delivery or pregnancy termination CRF5: Prenatal/follow-up visit CRF3: Clinical characteristics CRF4: COVID-19 * Investigators can opt to assign study participants into groups based on RDT results. Kindly refer to the WHO guidance on the use of RDTs (www.who.int/publications/i/item/antigen-detection-in-the-diagnosis-of-sars-cov-2infection-using-rapid-immunoassays). Note that point-of-care immunodiagnostic tests are only recommended for research purposes and not as a basis for clinical decision- making. ** Depending on contextual realities, the frequency of follow-up visits may coincide with the regular schedule of prenatal visits or an alternative schedule. Follow-up visits may be conducted online or via phone to allow for reporting of symptoms or events, as needed. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 62 Table B4. CRF Descriptive Name Indications for use and notes CRF1 Screening and eligibility assessment To be completed at first contact with prospective participants CRF2 Participant characteristics at enrolment To be completed at time of enrolment for all participants regardless of test result. This questionnaire is designed to be conducted as an interview with questions directed to the participant. Depending on situation at time of enrolment, it may be conducted at a later date or information retrieved through review of medical records. CRF3 Clinical characteristics at enrolment To be completed at time of enrolment for all participants regardless of test result. If diagnosis of SARS-CoV-2 occurred prior to enrolment, research staff to fill form per review of medical records. Depending on situation at time of enrolment, this form may also be filled at a later date and based on review of medical records. CRF4 COVID-19 To be completed for exposed group only at enrolment or verification of seroconversion (i.e. crossover into exposed group), or where needed, for hospitalization due to COVID-19. CRF5 Prenatal visit / follow-up information To be completed for all participants regardless of group (exposed, unexposed, unknown) at every follow-up prenatal visit. These visits should ideally occur once a month. This questionnaire should be filled out by the research staff upon review of the medical record. CRF6 Maternal outcomes at delivery or pregnancy termination To be completed for all participants regardless of group (exposed, unexposed, unknown) at delivery or pregnancy termination. This questionnaire should be filled out by the research staff upon review of the medical record. CRF7 Neonatal outcomes between birth and 7 days To be completed for all participants regardless of group (exposed, unexposed, unknown) at any point between birth and the first 7 days of life (i.e. the perinatal period). This questionnaire should be filled out by the research staff upon review of the medical record. Complete one form per neonate CRF8 Neonatal outcomes assessed at 4 weeks of life To be completed for all participants regardless of group (exposed, unexposed, unknown) at four weeks of life. This questionnaire should be filled out by the research staff upon review of the medical record. CRF9 Maternal outcomes at 6 weeks postpartum/study exit To be completed for all participants regardless of group (exposed, unexposed, unknown) at 6 weeks postpartum or study exit (including death of participant). This questionnaire should be filled out by the research staff upon review of the medical record. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 63 A66012 - A prospective cohort study investigating maternal 2. Date of RT-PCR test result Day Month Year 9. Date of serology test result Day Month Year pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 SCREENING AND ELIGIBILITY ASSESSMENT FORM CR1 page 1/2 V1.0 (16 Nov 2020) Project ID: Center ID: Screening ID: Country: Date of Assessment VERIFICATION OF ELIGIBILITY A. Assessment of Exposure (Assignment based on RT-PCR) B. Assessment of Exposure (Assignment based on IgG/IgM 1. Confirmed test of SARS-CoV-2 by RT-PCR serology tests) before or until 2 days after delivery/pregnancy 8. Confirmed test of SARS-CoV-2 by serology termination (Note: check medical records. before or until 2 days after delivery/pregnancy Review of diagnostic result is required for study termination(Note:check medical records.Review of enrollment) diagnostic result is required for study enrollment) 1 = Yes 1 = Yes 2 = No 2 = No if RT-PCR positive skip to C 4. If RT-PCR negative or unknown, conduct antibody (IgG/IgM) testing, or take specimen sample for storing and analysis at a later date Date of serology test result 5. Test Result 1 = Positive 2 = Negative 9= Unknown 6. Commercial name of serology test used 10. Commercial name of serology test used 11. Is serology test positive? 1 = Yes 2 = No 9= Unknown If serology positive, conduct individual assessment and decide enrollment into exposed group based on level of antibody,gestational age and case history/presenting symptoms If serology negative, candidate for unexposed group. Skip to C Note: If serology test not available, you may enroll participant into unknown group and consider collecting and storing specimen sample for future analysis. Skip to C C. Other criteria (in addition to assessment of exposure, participants must answer yes to this question) 12. Planning to live in the region and attend follow up visits at study site (or catchment health facility) or be followed up by telephone 1 = Yes 2 = No Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 3. Test Result 1 = Positive 2 = Negative 9= Unknown 7. Is serology test positive? 1 = Yes 2 = No If serology positive, conduct individual assessment and decide enrollment into exposed group based on level of antibody,gestational age and case history/presenting symptoms If serology negative, candidate for unexposed group. Skip to C Note: If RT-PCR negative or unknown and antibody test not available, you may enroll participant into unknown group and consider collecting and storing specimen sample for future analysis. Skip to C SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 64 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 SCREENING AND ELIGIBILITY ASSESSMENT FORM CR1 page 2/2 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Screening ID: EXCLUSION CRITERIA (participant ineligible if ‘yes’ to any of these questions) 13. Woman is unable or unwilling to give informed consent or assent, or (where applicable) surrogate consent has not been secured 1 = Yes 2 = No 14. Woman is planning to move outside of study area during study period 1 = Yes 2 = No 15. Woman is/was not pregnant at the time of SARS-CoV-2 infection 1 = Yes 2 = No 16. Woman has not reached the age of majority, as determined by local laws 1 = Yes 2 = No ELIGIBILITY DECISION 17. Does participant meet eligibility criteria for enrollment? 1 = Yes 2 = No If eligibility is confirmed, the pregnant woman can be enrolled in the study 18. Informed consent obtained 1 = Yes 2 = No 19. Date of enrollment 20. Gestational age at time of enrollment 20a) weeks 20b) days 21. Group Allocation 1 = Exposed 2 = Unexposed 9= Unknown 22. Participant ID COMMENTS: Interviewer's name: Signature: Date: Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 65 6. Ethnicity 1 = Ethnicity #1 2 = Ethnicity #2 3= Ethnicity #3 4 = Ethnicity #4 5 = Ethnicity #5 11= Other 6s) If "Other", specify 6 = Ethnicity #6 7 = Ethnicity #7 8= Ethnicity #8 9 = Ethnicity #9 10 = Ethnicity #10 99 = Unknown 11. Professional category/Occupation Comment:Include occupational / professional categories that are appropriate for study context. Select all that apply 7. Refugee status? 1 = Yes 2 = No 3 = Unkown A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PARTICIPANT CHARACTERISTICS AT ENROLLMENT FORM CR2 page 1/5 V1.0 (16 Nov 2020) Project ID GENERAL 1. Date of Assessment/Extraction DEMOGRAPHIC INFORMATION 2. Date of birth (DOB) Center ID Participant ID: Day Month Year 3. If DOB unknown, Age and Birth Year 3a) Age 3b) Birth Year 8. Gender identity 1 = Woman 2 = Man 3= Transgender 4 = Non-binary 5 = Do not wish to respond 6 = Other 6s) If "Other", specify Day Month Year World Health Organization A 6 6 0 1 2 9. What is your marital status? 1 = Single 2 = Currently married 3= Separated 4 = Divorced 5 = Widowed 6 = Cohabitating 7 = Do not wish to respond 4. Area of residence during pregnancy (Or, enter GPS coordinates) 10. What is the highest level of schooling attained? 1 = No formal schooling 2 = Less than primary school 3= Primary school completed 4 = Secondary/High school completed 5 = College/University completed 6 = Post-graduate degree 7 = Do not wish to respond 5. Born in country of current residence? 1 = Yes 2 = No 5s) If "No", specify country of birth 1 = Yes 2 = No 11a) Government employee 11b) Non-government employee 11c) Self-employed 11d) Student 11e) Homemaker/Housewife 11f) Retired 11g) Daily wage/informal laborer 11h) Unemployed (able to work) 11i) Unemployed (unable to work) 11j) Do not wish to respond 11k) Other 11s) If "Other", specify SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 66 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PARTICIPANT CHARACTERISTICS AT ENROLLMENT FORM CR2 page 2/5 V1.0 (16 Nov 2020) Project ID A 6 6 0 1 2 Center ID Participant ID: INFORMATION ON LIFESTYLE DURING PREGNANCY The following questions aim to collect information on the pregnancy participants’ lifestyle during.Comment:This is sensitive information and the study group may wish to collect this information at the end of the Part I section 12. Have you consumed any alcohol within the past 30 days? 1 = Yes if "Yes", go to Q13 2 = No if "No", go to Q15 3= Do not wish to answer if "No", go to Q15 9 = Unknown if "No", go to Q15 17. On average, how many tobacco products (the equivalent of a cigarette) do you smoke each day/week? 17a) Daily 17b) Weekly 18. Have you ever used any recreational drugs? 1 = Yes 2 = No go to Q21 3 = Do not wish to answer 9 = Unknown 13. During the past 30 days, on how many occasions did you have at least one standard alcoholic drink? 13a) Number 13b) Do not wish to answer skip to Q15 13c)Unknown skip to Q15 14. During the past 30 days, when you drank alcohol, how many standard drinks on average did you have during one drinking occasion? Standard measures of alcoholic drinks include: 1 can of ordinary beer; a single shot of spirits (e.g., whiskey, gin, vodka, etc.); a glass of wine or a small glass of sherry; a small glass of liqueur or aperitif 14a) Number 14b) Do not wish to answer 14c) Unknown 19. Do you currently use any recreational drugs? 1 = Yes 2 = No 3 = Do not wish to answer 9 = Unknown 19a) Cannabis 19b) Crack 19c) Cocaine 19d) Heroine 19e) Methamphetamine 19f) Opiates / opioids 19g) Other 19s) If "Other", specify 15. Have you ever smoked any tobacco products, such as cigarettes, cigars, pipes, or vaping? 1 = Yes 2 = No 3 = Do not wish to answer 9 = Unknown 20. During the past 30 days, on how many occasions did you use recreational drugs? 16. Do you currently smoke any tobacco products, such as cigarettes,cigars, pipes, or vaping? 1 = Yes 2 = No 3 = Do not wish to answer 9 = Unknown 16s) If "Yes" to above, do you currently smoke tobacco products (such as cigarettes, cigars, pipes, or vaping) daily? 1 = Yes 2 = No 3 = Do not wish to answer 9 = Unknown SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 67 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 68 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PARTICIPANT CHARACTERISTICS AT ENROLLMENT FORM CR2 page 4/5 V1.0 (16 Nov 2020) Project ID Center ID Participant ID: MEDICATIONS DURING THIS PREGNANCY 22. Medications that have been or are in use during the current pregnancy and taken 22s) If "Yes", specify generic name (s) 22si) specify regularly or as prescribed 1 = Yes 2 = No 9 = Unknown a) Fever or pain treatment b) Aspirin c) Anticonvulsants d) Antihypertensives e) Anti-nausea f) Antivirals g) Antibiotics h) Intermittent preventive treatment i) Medications for diabetes mellitus j) Prenatal vitamins/micronutrients k) Iron Supplement l) Folic acid supplement m) Other prescribed or routine medications 1=Acetaminophen/paracetamol 2=NSAIDS 3=Other (specify) If yes, trimestre IMMUNIZATION HISTORY Provide information on immunizations ever received, including during current pregnancy. The list of options should be revised based on contextual norms and depending on availability of records. Where multiple (booster) doses have been received, indicate dates for each dose 23. Immunized? 23s) If "Yes", date of last dose 23si) specify 1 = Yes 2 = No 9 = Unknown Day Month Year Unknown a) Pneumococcal vaccine? b) Meningococcal vaccine? c) MMR vaccine? d) Varicella(chicken pox)vaccine? e) DPT vaccine? f) Poliomyelitis vaccine? g) Seasonal influenza vaccine? h) Hepatitis B vaccine? i) Hepatitis A vaccine? j) BCG vaccine? k) Inactivated typhoid vaccine? l) Rabies vaccine? m) Yellow fever vaccine? n) Other vaccinations vaccine? If yes, specify Note: list should be revised per context e.g. tick-borne encephalitis; Japanese encephalitis) If no, history of chickenpox? 1 = Yes 2 = No 9 = Unknown World Health Organization A 6 6 0 1 2 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 69 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PARTICIPANT CHARACTERISTICS AT ENROLLMENT FORM CR2 page 5/5 V1.0 (16 Nov 2020) Project ID A 6 6 0 1 2 Center ID Participant ID: OBSTETRIC HISTORY Excluding the current pregnancy and regardless of whether the pregnancy resulted in a live birth, please indicate 24. Number of past pregnancies Please complete CRF C2a for each previous pregancy 25. Number of previous pregnancies beyond 22 weeks gestation 26. Number of previous vaginal deliveries 27. Number of previous cesarean deliveries COMMENTS: Interviewer's name: Signature: Date: Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 70 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PARTICIPANT CHARACTERISTICS AT ENROLLMENT FORM C2a page 1/1 V1.0 (16 Nov 2020) Project ID Center ID Participant ID: Date of the end of the pregnancy Day Month Year 1. Number of fetuses (1 -9) 2. What was the outcome of the pregnancy? 1 = Livebirth 2 = Spontaneous abortion 3 = Induced abortion 4 = Missed abortion 5 = Stillbirth 6 = Ectopic pregnancy 3. Gestational age at birth/termination of pregnancy 3a) Weeks 3b) Days 4. Mode of delivery 1 = Vaginal delivery 2 = Spontaneous 3 =Instrumental (vacuum/forceps) 4 = Planned cesarean delivery 5 = Emergency cesarean delivery Following section should be repeated separately for each fetus/baby indicated in question 1. 5. Fetus/Baby 6. Gender of Baby 7. Weight of baby 8. If weight unknown, 9. If live birth, current 10. If born alive and now dead, Number (1-9) 1 = Male 2 = Female at delivery estimate size of baby status how old was the baby when 3 = Non-binary from card from recall 1 = Very large 2 = Larger than average 1 = Alive he/she died? 4 = Do not wish to respond Kg Kg 3 = Average 4 = Smaller than average 9 = Unknown 5 = Very small 9 = Don’t know Years Months Days World Health Organization A 6 6 0 1 2 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 71 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 CLINICAL CHARACTERISTICS AT ENROLLMENT FORM CR3 page 1/4 V1.0 (16 Nov 2020) Project ID: Center ID: Participant ID: Country: GENERAL 1. Date of Assessment/Extraction CURRENT PREGNANCY 2. Number of fetuses (1 -9) 3. Dating of pregnancy 1 = Yes 2 = No 3a) LMP 3b) LMP consistent with ultrasound during pregnancy 3c) First trimester ultrasound 3d) Second trimester ultrasound 3e)Third trimester ultrasound 3f) ART (artificial reproductive technology) 3fs) If "yes", date Day Month Year Pregnancy complications, diagnoses or symptoms in relation to the current pregnancy and prior to COVID-19 diagnosis if this has occurred Note: ask of all women, regardless of test result status Note that this form needs to be repeated at all (bi)monthly follow up visits until termination/delivery irrespective of COVID-19 11. Placental abruption 1 = Yes 2 = No 9 = Unknown 4. Gestational diabetes 1 = Yes 2 = No 9 = Unknown 8. Fetal growth restriction 1 = Yes 2 = No 9 = Unknown 3g) Unknown 3h) Other 3hs) If "Other", specify Day Month Year World Health Organization A 6 6 0 1 2 5. Gestational hypertension 1 = Yes 2 = No 9 = Unknown 5s) If "Yes", specify 5si) Non-proteinuric hypertension 5sii) Pre-eclampsia / eclampsia 5siii) Unspecified / don’t know 6. Anemia (Hb < 11 g/dL) 1 = Yes 2 = No 9 = Unknown 7. Hyperemesis 1 = Yes 2 = No 9 = Unknown 9. Placental previa/accreta/percreta 1 = Yes 2 = No 9 = Unknown 10. Embolic disease 1 = Yes 2 = No 9 = Unknown SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 72 A66012 - A prospective cohort study investigating maternal 18. Right upper quadrant (abdominal) pain 1 = Yes 2 = No 9 = Unknown 23. Was ultrasound performed ? 1 = Yes 2 = No go to question 34 pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 CLINICAL CHARACTERISTICS AT ENROLLMENT FORM CR3 page 2/4 V1.0 (16 Nov 2020) Project ID: Center ID: Participant ID: Country: Ultrasound abnormalities (if performed) 25. Oligohydramnios (SDP <2cm) 1 = Yes 2 = No 9 = Unknown 24s) If "Yes", specify gestational age World Health Organization A 6 6 0 1 2 12. Preterm labor 1 = Yes 2 = No 9 = Unknown 20. Hemorrhage (>500ml of blood loss) 1 = Yes 2 = No 9 = Unknown 20s) If "Yes", specify 20si) Antepartum/intrapartum 20sii) Postpartum haemorrhage 20siii) Abortion-related 13. Preterm premature rupture of membranes (< 37weeks) (PPROM) 1 = Yes 2 = No 9 = Unknown 21. Liver disease 1 = Yes 2 = No 9 = Unknown 21s) If "Yes", specify 21si) Obstetric cholestasis 21sii) Other 21siii) If "Other", specify 14. Bleeding during pregnancy 1 = Yes 2 = No 9 = Unknown 15. Vaginal watery discharge 1 = Yes 2 = No 9 = Unknown 22. Other complications/diagnoses/symptoms 1 = Yes 2 = No 9 = Unknown 22s) If "Yes", specify 16. Headaches 1 = Yes 2 = No 9 = Unknown 17. Vision changes 1 = Yes 2 = No 9 = Unknown 24. Fetal growth restriction <10th centile 1 = Yes 2 = No 9 = Unknown 23s) If "Yes", specify gestational age 19. Decreased or no fetal movement 1 = Yes 2 = No 9 = Unknown SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 73 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 CLINICAL CHARACTERISTICS AT ENROLLMENT FORM CR3 page 3/4 V1.0 (16 Nov 2020) Project ID: Center ID: Participant ID: Country: 26. Polyhydramnios (SDP >8cm) 1 = Yes 2 = No 9 = Unknown 25s) If "Yes", specify gestational age 27. Echogenic bowel 1 = Yes 2 = No 9 = Unknown 26s) If "Yes", specify gestational age 28. Ventriculomegaly (≥ 10 mm) 1 = Yes 2 = No 9 = Unknown 27s) If "Yes", specify gestational age 29. Effusion 1 = Yes 2 = No 9 = Unknown 28s) If "Yes", specify gestational age 30. Cardiomegaly 1 = Yes 2 = No 9 = Unknown 29s) If "Yes", specify gestational age 31. Ascites 1 = Yes 2 = No 9 = Unknown 30s) If "Yes", specify gestational age 32. Hydrops fetalis 1 = Yes 2 = No 9 = Unknown 31s) If "Yes", specify gestational age CLINICAL INFORMATION AT ENROLLMENT (Note: complete all boxes with 9s in case of unknown value) 34. Current body weight kg 35. Height m 36. Body temperature 37. Respiratory rate breaths/minute 38. Heart rate beats/minute 39. Urinary Glucose 1 = (+) 2 = (++) 3 = (+++) 4 = Negative 40. Urinary Protein 1 = (+) 2 = (++) 3 = (+++) 4 = Negative mmHg mmHg 42. Pulse beats/minute 33. Other/Suspected anomaly 1 = Yes 2 = No 9 = Unknown 32s) If "Yes", specify gestational age World Health Organization A 6 6 0 1 2 °C °F 41. Arterial blood pressure (Systolic / Diastolic) SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 74 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 CLINICAL CHARACTERISTICS AT ENROLLMENT FORM CR3 page 4/4 V1.0 (16 Nov 2020) Project ID: Center ID: Participant ID: Country: 42. Pulse oximetry % 43. Fetal heart rate beats/minute LABORATORY RESULTS AT ENROLLMENT Note: Specify unit of measurement for each parameter. Modify list as relevant for the contex. complete all boxes with 9s in case of unknown value 44. Haemoglobin 45. Creatinine 46. WBC Count 47. Sodium 48. Haematocrit % 49. Potassium mEq/L = mmol/L 50. Platelets 51. Procalcitonin 52. APTT/APTR 53. CRP mg/L 54. PT seconds 55. LDH IU/L 56. INR 57. Creatinine Kinase 58. ALT/SGPT 62. ESR mm/hr 63. Total bilirubin 64. D-dimer 65. Urea (BUN) 66. Ferritin 67. Lactate 68. IL-6 pg/mL COMMENTS: Interviewer's name: Signature: 60. Troponin 61. AST/SGOT ng/mL μg/L IU/L Date: Day Month Year World Health Organization A 6 6 0 1 2 mg/L μmol/L ng/mL μg/L g/L mg/dL mmol/L ng/mL μg/L g/L g/dL mg/L μmol/L mm3 G/L (= x 10 9 /L) mEq/L = mmol/L mg/dL mmol/L mm3 G/L (= x 10 9 /L) ng/mL μg/L seconds IU/L UKAT/L IU/L SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 75 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 1/10 V1.0 (16 Nov 2020) Project ID: Country: GENERAL Center ID: Participant ID: 1. Date of Assessment/Extraction PREGNANCY STATUS AT TIME OF SARS-CoV-2 INFECTION These questions pertain to the time that the participant was symptomatic and diagnosed with COVID-19 2. Gestational age at time of COVID-19 diagnosis 2a) Weeks 2b) Days 6. Was diagnosis made at point of miscarriage? 1 = Yes 2 = No 9 = Unknown 7. Number of fetuses (1 -9) Day Month Year 9. Type of test conducted 1 = Yes 2 = No 9a) RT-PCR 9b) Serology 9bs) If "Serology", commercial name of test used COVID-19 SYMPTOMS Please answer the following questions about being infected with COVID-19. (Note: These questions pertain to the time that the participant was diagnosed with SARS-CoV-2.) 10. Date of symptom onset type 1 = Known 2 = Asymptomatic 9 = Unknown 10s)If "Known",date (i.e. first/earliest symptom) Day Month Year 11. Which of the following symptoms did you experience? 1 = Yes 2 = No 11a)None 11b) Fever 11c) Confusion 11d) Shortness of breath 11e) Diarrhea 11f) Muscle pains 11g) Nausea or vomiting 11h) Chills 11i) Headache 11j) Chest pain 11k) Loss of smell 11l) Loss of taste 11m) Sore throat 11n) Runny/stuffy nose Day Month Year 8. Date of diagnostic test result 5. Was diagnosis made post-abortion? 1 = Yes 2 = No 5s) If "Yes", specify number of days post-abortion 4.Was diagnosis made at time of labor/delivery? 1 = Yes 2 = No 9 = Unknown 3. Post-partum at time of diagnosis? 1 = Yes 2 = No 3s) If "Yes", specify number of days post-partum at time of diagnosis World Health Organization A 6 6 0 1 2 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 76 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 2/10 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: 11o) Abdominal pain 11p) Tingling sensation 11q) Dizziness 11r) Inability to walk 11s) Contractions 11t) Decreased fetal movement 11u) Wheezing 11v) Sore throat 11w) Skin rash 11x) Seizures 11y) Joint pain 11z) Fatigue/malaise 11aa) Lower chest indrawing 11ab) Conjunctivitis 11ac) Skin ulcers 11ad) Lymphadenopathy 11ae) Cough 11aes) If "Yes", specify 11aesi) Cough with sputum production 11aesii) Cough with haemoptysis 11af) Bleeding 11afs) If "Yes", specify site 11ag) Other symptoms 11ags) If "Yes", specify 12. For how many days did you have (or have you had) symptoms of COVID-19? 1 = Yes 2 = No 12a) No day of symptoms 12b) Days 13. Which of the following symptoms were still present 2 weeks (or more) after you had a positive Covid-19 test? 1 = Yes 2 = No 13a) Not applicable- Diagnosed less than 2 weeks ago 13b) None 13c) Fever 13d) Confusion 13e) Shortness of breath 13f) Diarrhea 13g) Muscle pains 13h) Nausea or vomiting 13i) Chills 13j) Headache 13k) Chest pain 13l) Loss of smell 13m) Loss of taste 13n) Sore throat 13o) Runny/stuffy nose 13p) Abdominal pain 13q) Tingling sensation 13r) Dizziness 13s) Inability to walk 13t) Contractions 13u) Decreased fetal movement 13v) Wheezing 13w) Sore throat 13x) Skin rash 13y) Seizures 13z) Joint pain 13aa) Fatigue/malaise 13ab) Lower chest indrawing 13ac) Conjunctivitis 13ad) Skin ulcers 13ae) Lymphadenopathy 13af) Cough 13afs) If "Yes", specify 13afsi) Cough with sputum production 13afsii) Cough with haemoptysis 13ag) Bleeding 13ags) If "Yes", specify site 13ah) Other symptoms 13ahs) If "Yes", specify SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 77 39si) If "Yes", date discharged Day Month Year A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 3/10 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: 28. Creatinine Kinase 29. ALT/SGPT 14a) If "Yes" all symptoms , date Day Month Year 14b) If "No", specify persisting symptoms LABORATORY FINDINGS DURING SARS-CoV-2 INFECTION Note: Specify unit of measurement for each parameter. Modify list as relevant for the context. Complete all boxes with 9s in case of unknown value 15. Haemoglobin g/L g/dL 16. Creatinine mg/L μmol/L 17. WBC Count mm3 G/L (= x 10 9 /L) 18. Sodium mEq/L = mmol/L 19. Haematocrit % 20. Potassium mEq/L = mmol/L 21. Platelets 22. Procalcitonin 23. APTT/APTR 24. CRP mg/L 25. PT seconds 26. LDH IU/L 27. INR 30. Troponin 31. AST/SGOT 32. ESR mm/hr 33. Total bilirubin 34. D-dimer 35. Urea (BUN) 36. Ferritin 37. Lactate 38. IL-6 HOSPITALIZATION 39. Were you admitted to the hospital at anytime after being diagnosed with COVID-19? In cases of multiple hospital admissions,repeat this section for each admission episode 1 = Yes 2 = No 39s) If "Yes", date admitted 39sii) If dates unknown, specify number of days 40. What was the reason for admission? 1 = Yes 2 = No 40a) Pregnancy-related? 40as) If "Yes", specify reason Day Month Year World Health Organization A 6 6 0 1 2 14. Have symptoms resolved 1 = Yes 3 = Not applicable - Diagnosed less than 2 = No two weeks ago 9= Unknown IU/L UKAT/L IU/L ng/mL μg/L IU/L mg/L μmol/L ng/mL μg/L g/L mg/dL mmol/L ng/mL μg/L mg/dL mmol/L pg/mL mm3 G/L (= x 10 9 /L) ng/mL μg/L seconds SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 78 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 4/10 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: 40c) Other reason? 40cs) If "Yes", specify reason 40d) Do not know VITAL SIGNS ON ADMISSION (Note: complete all boxes with 9s in case of unknown value) 51. Oxygen Saturation % 41. Temperature °C . 42. Maternal Heart rate beats per min 43. Respiratory rate breaths/min 44. Arterial BP systolic mmHg diastolic mmHg 45. Severe dehydration 1 = Yes 2 = No 9 = Unknown 46. Sternal capillary refill time > 2 seconds 1 = Yes 2 = No 9 = Unknown 47. Alert 1 = Yes 2 = No 48. Voice 1 = Yes 2 = No 49. Pain 1 = Yes 2 = No 52. GCS/15 53. Fetal heart rate beats per min DIAGNOSTIC/PATHOGEN TESTING 54. Chest X-ray/CT performed? 1 = Yes 2 = No skip to Q64 9 = Unknown 54a) If "Yes", infiltrates present? 1 = Yes 2 = No 9 = Unknown 55. Was pathogen testing done during this illness episode? 1 = Yes 2 = No 9 = Unknown 56. Influenza virus 1 = Positive 2 = Negative 3 = Not done 50. Unresponsive 1 = Yes 2 = No 40b) COVID-19 related? 40bs) If "Yes", specify reason World Health Organization A 6 6 0 1 2 51a) on Room air 1 = Yes 2 = No 51b) Oxygen therapy 1 = Yes 2 = No 51c) Unknown 1 = Yes 2 = No SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 79 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 5/10 V1.0 (16 Nov 2020) Project ID: Country: A 6 6 0 1 2 Center ID: Participant ID: PRESENTING SYMPTOMS ON ADMISSION 57. Coronavirus 1 = Positive 2 = Negative 3 = Not done 57s) If "Positive", type 1 = Yes 2 = No 57si) MERS-CoV 57sii) SARS-CoV-2 57siii) Other 64. Symptoms on admission 1 = Yes 2 = No 64a) Fever 64b) Confusion 64c) Shortness of breath 64d) Runny/stuffy nose 64e) Abdominal pain 64f) Diarrhea 64g) Muscle pains 64h) Nausea or vomiting 64i) Joint pain 64j) Fatigue/malaise 64k) Chills 64l) Headache 64m) Chest pain 64n) Contractions 64o) Vaginal bleeding 64p) Wheezing 64q) Loss of smell 64r) Loss of taste 64s) Sore throat 64t) Skin rash 64u) Seizures 64v) Skin ulcers 64w) Lymphadenopathy 64x) Lower chest indrawing 64y) Conjunctivitis 64z) Tingling sensation 64aa) Dizziness 64ab) Inability to walk 64ac) Decreased fetal movement 64ad) Cough 64ads) If "Cough", specify 64adsi) Cough with sputum production 64adsii) Cough with haemoptysis 64ae) Other symptoms 64aes) If "Yes", specify 58. Other respiratory pathogen 1 = Positive 2 = Negative 3 = Not done 58s) If "Positive", specify 59. Viral haemorrhagic fever 1 = Positive 2 = Negative 3 = Not done 59s) If "Positive", specify virus 60. Other pathogen of public health interest detected 1 = Yes 2 = No 60s) If "Yes", specify 61. Falciparum malaria 1 = Positive 2 = Negative 3 = Not done 62. Non-falciparum malaria 1 = Positive 2 = Negative 3 = Not done 63. HIV 1 = Positive 2 = Negative 3 = Not done SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 80 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 6/10 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: MEDICATION AND SUPPORTIVE CARE DURING HOSPITALIZATION 65i) Immunotherapy 65is) If "Yes", specify 65isi) Convalescent plasma 65isii) Monoclonal antibodies 65isiii) Interferons 65isiv) duration of treatment (days) 65j) Non-steroidal anti-inflammatory (NSAID) 65js) If "Yes", specify 65k) Angiotensin converting enzyme inhibitors (ACE inhibitors) 65ks) If "Yes", specify 65l) Angiotensin II receptor blockers (ARBs) 65ls) If "Yes", specify 65m) Systemic anticoagulants 65ms) If "Yes", specify 65n) Other medications received 65ns) If "Yes", please list all others 65. At any time during hospitalization or at discharge, did the patient receive 1 = Yes 2 = No 9 = Unknown 65a) Oral/orogastric fluids? 65b) Intravenous fluids? 65c) Antiviral? 65cs) If "Yes", specify 65csi) Ribavirin 65csii) Lopinavir/Ritonavir 65csiii) Neuraminidase inhibitor 65csiv) Interferon alpha 65csv) Interferon beta 65csvi) Remdesivir 65csvii) Favipiravir 65d) Corticosteroids 65ds) If "Yes", route 65dsi) Oral 65dsii) Intravenous 65dsiii) Inhaled 65dsiv) specify agent and maximum dose 65e) Antibiotic 65es) If "Yes", specify 65f) Antifungal agent 65fs) If "Yes", specify 65g) Antimalarial agent 65gs) If "Yes", specify 65h) Experimental agent 65hs) If "Yes", specify SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 81 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 7/10 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: 66. At any time during hospitalization, did the patient receive or undergo 1 = Yes 2 = No 9 = Unknown 66a) ICU or high dependency unit (HDU) admission 66as) If "Yes", Date of ICU/HDU admission Unknown 66asi) If "Yes", Date of ICU/HDU discharge Not yet discharged Unknown 66b) Oxygen therapy 66bs) if "Yes", total duration in days 66bsi) If "Yes", 02 flow 1-5 L/min 66bsii) If "Yes", 02 flow 6-10 L/min 66bsiii) If "Yes", 02 flow 11-15 L/min 66bsiv) If "Yes", 02 flow >15 L/min 66bsv) Unknown 66bsvi) Source oxygen Piped 66bsvii) Source oxygen Cylinder 66bsviii) Source oxygen Concentrator 66bsix) Source oxygen Unknown 66bsx) Interface Nasal prongs 66bsxi) Interface HF nasal cannula 66bsxii) Interface Mask 66bsxiii) Interface Mask with reservoir 66bsxiv) Interface CPAP/NIV mask 66bsxv) Interface Unknown 66c) Non-invasive ventilation (e.g. BIPAP, CPAP) 66s) If "Yes", total duration in days 66d) Any type of invasive ventilation 66ds) If "Yes", total duration in days 66dsi)If "Yes",specify PEEP(cm H20) . 66dsii)If "Yes",specify FI02 (%) 66dsiii) Plateau pressure (cm H20) . 66dsiv) Plateau PaC02 66dsv) Plateau Pa02 66e) Extracorporeal (ECMO) support 66es) If "Yes", total duration in days 66f)Prone position 66fs) If "Yes", total duration in days 66g)Inotropes/vasopressors 66gs) If "Yes", specify 66gsi) If "Yes", total duration in days 66h)Renal replacement therapy (RRT) or dialysis 66i)Tocolysis 66fis) If "Yes", specify Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 82 70. Outcome/ Discharge date Day Month Year A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 8/10 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: 66m) Other forms or treatment or interventions received 66ms) If "Yes", please list all others COMPLICATIONS 67. At any time during hospitalization, did the patient experience 1= Yes 2 = No 9 = Unknown 67a)Shock 67b) Seizure 67c) Meningitis/Encephalitis 67d) Anaemia 67e) Cardia arrhythmia 67f) Cardia arrest 67g) Pneumonia 67h) Bronchiolitis 67i) Stroke: ischaemic stroke 67j) Stroke: intracerebral haemorrhage 67k) Bacteraemia/Septicaemia 67l)Vaginal bleeding 67m) Hemorrhage (>500ml blood loss) 67n)Endocarditis 67o)Myocarditis/Pericarditis 67p) Acute renal injury 67q) Pancreatitis 67r)Liver dysfunction OUTCOME OF HOSPITALIZATION 68. Outome 1 = Discharged alive 2 = Transfer/Referral to another facility 3 = Death 4 = Palliative Discharge 9 = Unknown 69. If discharged alive, ability to self-care at discharge versus before illness 1 = Same as before illness 2 = Worse than before illness 3 = Better than before illness 9 = Unknown PREGNANCY STATUS AT DISCHARGE 71. Pregnancy outcome/status at discharge 1 = Yes 2 = No 71a) Not yet delivered 71b) Livebirth 71c) Spontaneous abortion 71d) Induced abortion 71e) Missed abortion 71f) Stillbirth 71g) Ectopic pregnancy 71h) Post-abortion or postpartum on admission (Note:If postpartum on admission and discharge at 6 weeks post-partum, fill CRF 9: Maternal outcomes at 6 weeks post-partum/study exit) 67s) Cardiomyopathy 67t) Acute respiratory distress syndrome (ARDS) 67u) Other 67us) If "Other", specify 66j)Induction of labour 66k)Casearean section 66l) Blood transfusion 66ls) If "Yes", specify blood product transfused World Health Organization A 6 6 0 1 2 66lsi) If "Yes" specify units of each component transfused SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 83 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 9/10 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: 72. Delivery or Pregnancy termination during admission? 1 = Yes 2 = No 72s) If "Yes",date of delivery or pregnancy termination Day Month Year (Note, If yes, fill CRF 6: Maternal outcomes at delivery or pregnancy Termination and, where applicable, CRF 7: Neonatal outcomes between birth and 7 days) MATERNAL STATUS AT DISCHARGE 73. Maternal death at discharge 1 = Yes 2 = No if "No", go to Q75 74e) Obstetric related infection 74f) Unsafe abortion 74g) Ectopic pregnancy 74h) Unanticipated complications of management(e.g.anaesthesia-related complications) 74i) Other direct cause 74j)Other indirect cause(e.g.severe anaemia) 74k)Coincidental cause (e.g.motor vehicle accident) 74l) Other 74ls) If "Other", specify 74m) Unknown BIOSPECIMEN COLLECTION AND RESULTS 75. Umbilical cord blood. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 75s) If "Positive" or "Negative" or "Unknown", date specimen obtained 76. Placenta. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 76s) If "Positive" or "Negative" or "Unknown", date specimen obtained 77. Amniotic fluid. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 77s) If "Positive" or "Negative" or "Unknown", date specimen obtained 78. Breast milk. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 78s) If "Positive" or "Negative" or "Unknown", date specimen obtained (Note: If maternal death at discharge, fill CRF 9: Maternal outcomes at 6 weeks post-partum/study exit) 74. What was the underlying cause of death 1 = Yes 2 = No 74a) Obstetric hemorrhage 74b) Hypertensive disorder 74c) Acute respiratory infection 74d) Complications related to COVID-19 74ds) If "Yes",specify Day Month Year Day Month Year Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 84 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 COVID-19 FORM CR4 page 10/10 V1.0 (16 Nov 2020) Project ID: Country: A 6 6 0 1 2 Center ID: Participant ID: COMMENTS: 79. Vaginal swab. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 79s) If "Positive" or "Negative" or "Unknown", date specimen obtained 80. Feceas/Anal swab. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 80s) If "Positive" or "Negative" or "Unknown", date specimen obtained 81. Fetal tissue (in the case of fetal death/ induced abortion). Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 81s) If "Positive" or "Negative" or "Unknown", date specimen obtained Interviewer's name: Signature: Date: Day Month Year Day Month Year Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 85 4q) Hemorrhage (>500ml of blood loss) 4qs) If "Yes", specify 4qsi) Antepartum/intrapartum 4qsii) Postpartum haemorrhage 4qsiii) Abortion-related 4r) Liver disease 4rs) If "Yes", specify 4rsi) Obstetric cholestasis 4rsii) Other 4rsiii) If "Other", specify A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PRENATAL VISIT / FOLLOW UP INFORMATION FORM CR5 page 1/4 V1.0 (16 Nov 2020) Project ID: Country: GENERAL Center ID: Participant ID: 1. Date of Assessment/Extraction CURRENT PREGNANCY (Note: in the case of recent pregnancy loss, collect data based on latest pregnancy) 2b) Days 3.If post-partum, number of weeks/days since delivery 3a) Weeks 3b) Days Day Month Year 4s) Other complications/diagnoses/symptoms 4ss) If "Yes", specify CURRENT CONDITIONS 5. Any changes to medical conditions / infections/chronic conditions since enrollment into study? 1 = Yes if "Yes", specify 2 = No if "No", go to Q6 9 = Unknown 2. Current gestational age 2a) Weeks World Health Organization A 6 6 0 1 2 4. Pregnancy complications, diagnoses or symptoms in relation to the current pregnancy (Note: ask of all women, regardless of test result status) 1 = Yes 2 = No 9 = Unknown 4a) Gestational diabetes 4b) Gestational hypertension 4bs) If "Yes", specify 4bsi) Non-proteinuric hypertension 4bsii) Pre-eclampsia / eclampsia 4bsiii) Unspecified / don’t know 4c) Anemia (Hb < 11 g/dL) 4d) Hyperemesis 4e) Fetal growth restriction 4f) Placental previa/accreta/percreta 4g) Embolic disease 4h) Placental abruption 4i) Preterm labor 4j) Preterm premature rupture of membranes (< 37weeks) (PPROM) 4k) Bleeding during pregnancy 4l) Vaginal watery discharge 4m) Headaches 4n) Vision changes 4o) Right upper quadrant (abdominal) pain 4p) Decreased or no fetal movement SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 86 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PRENATAL VISIT / FOLLOW UP INFORMATION FORM CR5 page 2/4 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: CURRENT CONDITIONS 5) Medical conditions / infections/chronic 5s) If "Yes", specify 5si) If "Yes",date conditions since enrollment into study? of diagnosis or symptom 1 = Yes 2 = No 9 = Unknown onset Day Month Year a) Heart disease b) Lung disease c) Blood disease d) Kidney disease e) Liver disease f) Neurological disease g) Thyroid disease h) Endocrine disease i) Immunosuppression j) Hypertension k) Type 1 or Type 2 diabetes l) Malaria m) Dengue n) Chikungunya o) Zika p) Influenza q) HIV r) Syphilis s) Hepatitis A t) Hepatitis B u) Hepatitis C v) Hepatitis D w) Hepatitis E x) Toxoplasmosis y) Rubella z) Cytomegalovirus aa) Herpes Simplex ab) Other medical condition/infection CLINICAL INFORMATION AT FOLLOW-UP VISIT (Note: complete all boxes with 9s in case of unknown value) 6. Current body weight kg 9. Respiratory rate breaths/min 10. Heart rate beats/min 7. Height m . 8. Body temperature °C °F World Health Organization A 6 6 0 1 2 11. Urinary Glucose 1 = (+) 3 = (+++) 2 = (++) 4 = Negative 9= Unknown/ not done SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 87 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PRENATAL VISIT / FOLLOW UP INFORMATION FORM CR5 page 3/4 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: +++) 9= Unknown/not done egative 13. Arterial blood pressure systolic mmHg diastolic mmHg 14. Pulse beats/min 15. Pulse oximetry % LABORATORY RESULTS AT FOLLOW-UP VISIT Note: Specify unit of measurement for each parameter. Modify list as relevant for the context. complete all boxes with 9s in case of unknown value. 16. Haemoglobin 17. Creatinine 18. WBC Count 19. Sodium 20. Haematocrit % 21. Potassium mEq/L = mmol/L 22. Platelets 23. Procalcitonin 24. APTT/APTR 25. CRP mg/L 26. PT seconds 27. LDH IU/L 28. INR 30. ALT/SGPT IU/L 31. Troponin 32. AST/SGOT 33. ESR mm/hr 34. Total bilirubin 35. D-dimer 36. Urea (BUN) 37. Ferritin 38. Lactate 39. IL-6 COVID-19 SYMPTOMS Please answer the following questions about experiencing any of the following symptoms. (Note: These questions pertain to the period since the last follow-up visit of the participant) 40. Which of the following symptoms have you experienced since your last prenatal/follow-up visit? 1 = Yes 2 = No 29. Creatinine Kinase IU/L UKAT/L World Health Organization A 6 6 0 1 2 12. Urinary Protein 1 = (+) 3 = ( 2 = (++) 4 = N ng/mL μg/L IU/L mg/L μmol/L ng/mL μg/L g/L mg/dL mmol/L ng/mL μg/L mg/dL mmol/L pg/mL g/L g/dL mg/L μmol/L mm3 G/L (= x 10 9 /L) mEq/L = mmol/L mm3 G/L (= x 10 9 /L) 40a)None 40b) Fever 40c) Confusion 40d) Shortness of breath 40e) Diarrhea 40f) Muscle pains 40g) Nausea or vomiting 40h) Chills 40i) Headache 40j) Chest pain 40k) Loss of smell 40l) Loss of taste 40m) Sore throat 40n) Runny/stuffy nose 40o) Abdominal pain ng/mL μg/L seconds SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 88 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 PRENATAL VISIT / FOLLOW UP INFORMATION FORM CR5 page 4/4 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: 40ag) Other symptoms 40ags) If "Yes", specify 41. For how many days did you have (or have you had) these symptoms? 1 = Yes 2 = No 41a) No day of symptoms 41b) Days SARS-CoV-2 TEST RESULT d) Date of result e) Test Result 1=Positive 2=Negative 9=Unknown f) If positive, is participant already assigned to exposed group? 1 = Yes 2 = No Note: If No, assess participants' clinical history, presenting complaints and consider repeating test to determine sero-conversion. g) Is sero-conversion reasonably established? 1 = Yes Re-assign to exposed group and complete CR4 form 2 = No Note: A participant who was previously SARS-CoV-2 positive and assigned to the exposed group and has a negative test result in a follow-up visit should not be re-assigned to the unexposed group COMMENTS: b) Commercial name of Test: go to End Interviewer's name: Signature: Date: Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 40p) Tingling sensation 40q) Dizziness 40r) Inability to walk 40s) Contractions 40t) Decreased fetal movement 40u) Wheezing 40v) Sore throat 40w) Skin rash 40x) Seizures 40y) Joint pain 40z) Fatigue/malaise 40aa) Lower chest indrawing 40ab) Conjunctivitis 40ac) Skin ulcers 40ad) Lymphadenopathy 40ae) Cough 40aes) If "Yes", specify 40aesi) Cough with sputum production 40aesii) Cough with haemoptysis 40af) Bleeding 40afs) If "Yes", specify site 42.SARS-CoV-2 test result at follow up visit a) Type of Test 1=RT-PCR 3=Ag-RDT 2=Serology 4=Not performed SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 89 2. Date of Delivery or Pregnancy termination Day Month Year 4q) Hemorrhage during pregnancy (>500ml of blood loss) If "Yes", specify 4rsi) Antepartum hemorrhage 4rsii) Intrapartum hemorrhage 4rsiii) Abortion-related hemorrhage 4r) Embolic disease 4s) Anaesthetic complication 4t) Bacterial infection 4u) Other complications/ diagnoses/symptoms 4us) If "Yes", specify 6. Indication for admission 1 = Yes 2 = No go to Q7 if yes, complete 6a) Scheduled induction of labor 6b) Scheduled cesarean delivery 6c) Indication for emergency cesarean delivery 6cs) If "Yes", specify indication A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 MATERNAL OUTCOMES AT DELIVERY OR PREGNANCY TERMINATION FORM CR6 page 1/5 V1.0 (16 Nov 2020) Project ID: Country: GENERAL Center ID: Participant ID: 1. Date of Assessment/Extraction CURRENT PREGNANCY 3. Gestational age at delivery/pregnancy termination 3a) Weeks 3b) Days Day Month Year PRESENTATION AND DELIVERY 5. Status on presentation 1 = Pregnant not in labor 2 = Pregnant in labor 3 = Recent pregnancy termination (post abortion/miscarriage) 6d) Hemorrhage (>500ml of blood loss) 6e) Vaginal bleeding 6f) Obstruction of labour 6g) Fever 6gs) If "Yes", specify C° F° 6h) Other 6hs) If "Other", specify World Health Organization A 6 6 0 1 2 4. Pregnancy complications/diagnosis/symptoms at time of delivery/pregnancy termination 1 = Yes 2 = No 9 = Unknown 4a) Gestational diabetes 4b) Gestational hypertension 4bs) If "Yes", specify 4bsi) Non-proteinuric hypertension 4bsii) Pre-eclampsia / eclampsia 4bsiii) Unspecified / don’t know 4c) Anemia (Hb < 11 g/dL) 4d) Hyperemesis 4e) Fetal growth restriction 4f) Placental previa/accreta/percreta 4g)Placental abruption 4h) Preterm labor 4i)Preterm premature rupture of membranes (< 37weeks) (PPROM) 4j) Decreased or no fetal movement 4k) Bleeding during pregnancy 4l) Vaginal watery discharge 4m) Headaches 4n) Vision changes 4o) Right upper quadrant (abdominal) pain 4p) Liver disease 4ps) If "Yes", specify 4psi) Obstetric cholestasis 4psii) Other 4psiii) If "Other", specify SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 90 7i) Uterine contractions 7j) Fetal distress 7js) If "Yes", specify fetal heart rate beats/min A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 MATERNAL OUTCOMES AT DELIVERY OR PREGNANCY TERMINATION FORM CR6 page 2/5 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: 7. Signs and symptoms 1 = Yes 2 = No 9 = Unknown 7a) Vaginal watery discharge 7b) Vaginal bleeding 7c) Headaches 7d) Vision changes 7e) Right upper quadrant (abdominal) pain 7f) Decreased or no fetal movement 7g) High blood pressure 7gs) If "Yes", specify blood pressure systolic mmHg diastolic mmHg 7h) Low blood pressure 7hs) If "Yes", specify blood pressure systolic mmHg diastolic mmHg 1 = Yes 2 = No 9 = Unknown 8a) Suspected or verified SARS-CoV-2 infection 8b) Elective/scheduled induction of labor 8c) Elective/scheduled cesarean delivery 8d) Spontaneous labor 8e) Premature rupture of membranes 8f) Fetal distress 8g) Preeclampsia/gestational hypertension 8h)Vaginal bleeding 8i) Post-dates 8j) Fetal growth restriction 8k) Maternal request 8l) Other 8ls) If "Other, specify 9. Mode of Delivery 1 = Vaginal delivery 2 = Spontaneous 3 = Instrumental (vacuum/forceps) 4 = Planned Cesarean delivery 5 = Emergency Cesarean delivery h wn 11. Amniotic fluid at delivery 1 = Clear 2 = Meconium-stained 9 = Unknown (check all apply in case of multiple fetuses) MATERNAL NEAR-MISS MARKERS 13. Occurred during hospitalization for delivery 1 = Yes 2 = No 13a) Acute cyanosis 13b) Oxygen saturation <90% for > 60 minutes 13c) Use of continuous vasoactive drugs 13d) Gasping a 13e)PaO2/FiO2 <200 mmHg 13f) Hysterectomy following infection or haemmorhage 13g) Respiratory rate >40/min or <6/min 13h) Creatinine ≥ 300 micromol/l or ≥ 2.5 mg/dl 13i) Transfusion ≥ 5 units red cells 13j) Shock b 13k) Bilirubin > 100 micromol/l or > 6.0 mg/dl 13l) Intubation and ventilation for ≥ 60 minutes not related to anesthesia 13m)Oliguria non-responsive to fluids diuretics c 13n) pH <7.1 World Health Organization A 6 6 0 1 2 10. Fetal presentation at delivery 1 = Cephalic 3 = Bree 2 = Transverse 9 = Unkn 12. Pregnancy Outcome 1 = Yes 2 = No a) Livebirth b) Spontaneous abortion c) Induced abortion d) Missed abortion e)Stillbirth f) Ectopic pregnancy 7k) Fever 7ks) If "Yes", specify temperature °C °F 8. Indication for Childbirth SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 91 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 MATERNAL OUTCOMES AT DELIVERY OR PREGNANCY TERMINATION FORM CR6 page 3/5 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: 13o) Dialysis 13p) Clotting failure d 13q) Lactate >5 13r) Cardiopulmonary resuscitation (CPR) 13s) Loss of consciousness lasting ≥ 12 hours e 13t) Acute thrombocytopenia (<50,000 platelets) 13u) Loss of consciousness and absence of pulse/heartbeat 13v) Loss of consciousness and the presence of glucose and ketoacids in urine 13w) Stroke f 13x) Uncontrollable fit/total paralysis 13y)Jaundice in the presence of preeclampsia h 17. Sodium 18. Haematocrit 19. Potassium 20. Platelets 21. Procalcitonin 22. APTT/APTR mm3 G/L (= x 10 9 /L) mEq/L = mmol/L % mEq/L = mmol/L mm3 G/L (= x 10 9 /L) seconds a Gasping is a terminal respiratory pattern and the breath is convulsively and audibly caught b Shock is persistent severe hypotension, defined as a systolic blood pressure < 90 mmHg for > 60 minutes with a pulse rate of at least 120 despite aggressive fluid replacement (>2 liters) c Oliguria is defined as urinary output <30 ml/hr for 4 hours or <400 ml/24 hours d Clotting failure can be assessed by the bedside clotting test or absence of clotting from the IV site after 7-10 minutes e Loss of consciousness is a profound alteration of mental state that involves complete or near-complete lack of responsiveness to external stimuli. It is defined as a Coma Glasgow Scale <10 (moderate to severe coma). f Stroke is a neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours g Condition in which the brain is in h Preeclampsia is defined as hypertension plus proteinuria i For instance, continuous use of any dose of dopamine, epinephrine or norepinephrine LABORATORY DATA ON ADMISSION Note: Specify unit of measurement for each parameter. Modify list as relevant for the context. Complete all boxes with 9s in case of unknown value. 14. Haemoglobin g/L g/dL 23. CRP mg/L 24. PT seconds 25. LDH IU/L 26. INR 27. Creatinine Kinase 28. ALT/SGPT 29. Troponin 30. AST/SGOT 31. ESR mm/hr 32. Total bilirubin 33. D-dimer 34. Urea (BUN) 35. Ferritin 15. Creatinine 36. Lactate mg/dL OR mmol/L 16. WBC Count mg/L μmol/L 37. IL-6 pg/mL World Health Organization A 6 6 0 1 2 IU/L UKAT/L IU/L ng/mL μg/L IU/L mg/L μmol/L ng/mL μg/L g/L mg/dL mmol/L ng/mL OR μg/L g/L g/dL SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 92 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 MATERNAL OUTCOMES AT DELIVERY OR PREGNANCY TERMINATION FORM CR6 page 4/5 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: BIOSPECIMEN COLLECTION AND RESULTS 38. Umbilical cord blood. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 38s) If "Positive" or "Negative" or "Unknown", date specimen obtained 39. Placenta. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 39s) If "Positive" or "Negative" or "Unknown", date specimen obtained 40. Amniotic fluid. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 40s) If "Positive" or "Negative" or "Unknown", date specimen obtained 41. Breast milk. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 41s) If "Positive" or "Negative" or "Unknown", date specimen obtained 42. Vaginal swab. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 42s) If "Positive" or "Negative" or "Unknown", date specimen obtained 43. Feceas/Anal swab. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 43s) If "Positive" or "Negative" or "Unknown", date specimen obtained 44. Fetal tissue (in the case of fetal death/ induced abortion). Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = No 2 = Positive 3 = Negative 9 = Unknown 44s) If "Positive" or "Negative" or "Unknown", date specimen obtained MATERNAL STATUS/OUTCOMES 45. Status/Outcome 1 = Discharge 2 = Referral If discharge or referral Day Month Year 46. Date of discharge or referral Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 3 = Death skip to Q48 9 = Unknown SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 93 49) Specify cause of death 1 = Yes 2 = No a) Obstetric hemorrhage b) Hypertensive disorder c) Acute respiratory infection d Complications related to COVID-19 49ds) If "Yes", specify A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 MATERNAL OUTCOMES AT DELIVERY OR PREGNANCY TERMINATION FORM CR6 page 5/5 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: b) Commercial name of Test: nknown If Maternal death 48) date of death m) Unknown Note: Also fill CRF 9- Maternal outcomes at 6 weeks post-partum/study exit SARS-CoV-2 TEST RESULT go to End d) Date of result e) Test Result 1=Positive 2=Negative 9=Unknown f) If positive, is participant already assigned to exposed group? 1 = Yes 2 = No Note: If No, assess participants' clinical history, presenting complaints and consider repeating test to determine sero-conversion. g) Is sero-conversion reasonably established? 1 = Yes Re-assign to exposed group and complete CR4 form 2 = No Note: A participant who was previously SARS-CoV-2 positive and assigned to the exposed group and has a negative test result in a follow-up visit should not be re-assigned to the unexposed group COMMENTS: Interviewer's name: Signature: Date: Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 47. Discharge with newborn(s)? 1 = Yes 2 = No 9 = U 47s) If "No", specify reason Day Month Year e) Obstetric related infection f) Unsafe abortion g) Ectopic pregnancy h) Unanticipated complications of management (e.g. anaesthesia-related complications) i) Other direct cause j)Other indirect cause (e.g.severe anaemia) k) Coincidental cause (e.g. motor vehicle accident) l) Other ls) If "Other", specify 50.SARS-CoV-2 test result at follow up visit a) Type of Test 1=RT-PCR 3=Ag-RDT 2=Serology 4=Not performed SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 94 5. Place of birth 1 = Health facility 2 = Home 3 = Other 5s) If "Other", specify 11. Result 1 = Positive 2 = Negative 9 = Unknown A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES BETWEEN BIRTH AND 7 DAYS FORM CR7 page 1/8 V1.0 (16 Nov 2020) Project ID: Country: GENERAL Center ID: Participant ID: Birth order 1. Date of Assessment/Extraction CHILDBIRTH INFORMATION 2. Date of birth 3.Time of birth 24hs clock : 4.Gestational age at delivery/termination 4a) Weeks = Ag-RDT = Unknown skip to 13 4b) Days 10. Commercial name of test: 12. Date of the test Day Month Year Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 8. If "Performed", specify 1 = Yes 2 = No 8a) Standard 8b) MTCT screening 9. SARS-CoV-2 Test 1 = RT-PCR 4 2 = Serology 9 3 = Not performed 6. Source of information on birth outcomes 1 = Medical record 2 = Interview with mother 3 = Interview with family 4 = Other 6s) If "Other", specify 13. Apgar scores a) 1 min b) 5 min c) 10 min 14. Respiratory distress 1 = Yes 2 = No 9 = Don't know 7. Laboratory analyses of the foetus or neonate 1 = Performed go to Q8 2 = Not performed go to Q9 15. NICU admission 1 = Yes 2 = No 15s) If "Yes", number of days SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 95 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES BETWEEN BIRTH AND 7 DAYS FORM CR7 page 2/8 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: Birth order 17 18 skip to Q20a 19bs) If "With complications/sequelae ", specify xii) Unknown NEONATAL PHYSICAL EXAM AT BIRTH Note: complete all boxes with 9s in case of unknown value. 22. Temperature Day Month Year If death 21a) Date of death Day Month Year If referral, 20a) Date of referral 20s) specify 19b) Neontal status 1 = Healthy 2 = With complications/sequelae viii) Complications from COVID-19 viiis) If "Yes", specify Day Month Year If discharged 19a) Date of discharge World Health Organization A 6 6 0 1 2 16. Neonatal complications 1 = Yes if "Yes", go to Q 2 = No if "Yes", go to Q 21b. If neonate died, what was the primary cause of death? 1 = Yes 2 = No i) Preterm ii) Low birth weight iii) Birth asphyxia iv) Infection COVID-19 v) Infection Bacteraemia/Septicemia vi) Infection HIV vii) Other infection viis) If"Other", specify 17. If "Yes", check all that apply 17a) Ventilator support 17b) Seizures 17c) Hypoxic ischemic encephalopathy 17d) Sepsis 17e) Other 17es) If "Other", specify 18. Neonatal outcome 1 = Discharged 2 = Referral to specialist /other hospital 3 = Death skip to Q21a ix) Birth trauma x) Congenital/birth defects xi) Other xis) If "Other", specify °C °F 22a. Temperature taken 1 = Oral 2 = Tympanic 3 = Rectal 4 = Axillary 5= Other 22as) If "Other", specify SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 96 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES BETWEEN BIRTH AND 7 DAYS FORM CR7 page 3/8 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: Birth order 23. Respiratory rate breaths/min 24. Heart rate beats/min 25. Blood pressure systolic mmHg diastolic mmHg 26. Peripheral O2 saturation (SpO2) % 27. Birth weight grams 28. Length cm 29. Head circumference cm 30. Cord blood arterial pH cm 31. Cord blood arterial base excess cm 32. Cardiovascular system 1 = Normal 4 = Other 2 = Abnormal 9 = Unknown 3 = Murmur 32s) If "Other" specify 33. Respiratory system 1 = Normal 2 = Abnormal If "Abnormal" describe 9 = Unknown 33s) If "Abnormal", describe 34. Gastrointestinal system 1 = Normal 2 = Abnormal 9 = Unknown 34a) Jaundice 34b) Hepatomegaly 34c) Hernia 34d) Gastroschisis 34e) Omphalocele 34f) Splenomegaly 34g) Abdominal tenderness 34h) Other 35hs) If Other, specify 35. Seizure 1 = Yes If "Yes", describe 2 = No 4 = Focal 3 = General 9 = Unknown 35s) If "Yes", describe 36. Paralysis 1 = Yes If "Yes", describe 2 = No 4 = Ascending 3 = General 9 = Unknown 36s) If "Yes", describe 37. Hypotonia (floppiness) 1 = Yes 2 = No 9 = Unknown SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 97 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES BETWEEN BIRTH AND 7 DAYS FORM CR7 page 4/8 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: Birth order 38. Stiffness or spasticity or increased tone of limbs 1 = Yes 2 = No 9 = Unknown 39. Arthrogryposis 1 = Yes 2 = No 9 = Unknown 40. Other neurological signs 1 = Yes 2 = No 41. Other abnormal movements (e.g. writhing movements) 1 = Yes 2 = No 42. Tonic neck reflex 1 = Present 2 = Absent 3 = Not done 43. Moro reflex 1 = Present 2 = Absent 3 = Not done 44. Rooting reflex 1 = Present 2 = Absent 3 = Not done 45. Sucking reflex 1 = Present 2 = Absent 3 = Not done 46. Grasp reflex 1 = Present 2 = Absent 3 = Not done 47. Babinski reflex 1 = Present 2 = Absent 3 = Not done 48. Rash 1 = Yes 2 = No 9 = Unknown 48s) If "Yes", date of onset 49. Oedema 1 = Yes 2 = No 9 = Unknown 49s) If "Yes", date of onset 50. Fever 1 = Yes 2 = No 9 = Unknown 50s) If "Yes", date of onset 51. Eye redness/conjunctivitis 1 = Yes 2 = No 9 = Unknown 51s) If "Yes", date of onset 52. Other condition 1 = Yes 2 = No 9 = Unknown 52s) If "Yes", date of onset 52ss)If "Yes", describe Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 98 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES BETWEEN BIRTH AND 7 DAYS FORM CR7 page 5/8 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: Birth order NEONATAL LABORATORY EXAMINATION specify 54. Red reflex or chorioretinitis 1 = Present 2 = Absent 3 = Not done 9 = Unknown specify specify 58a) Neonatal throat swab at birth 58as)Date specimen obtained If Positive or Negative or Unknown 58b) Neonatal anal swab at birth 58bs)Date specimen obtained If Positive or Negative or Unknown NEONATAL FEEDING, SEPARATION, CONTACT, MORBIDITY 59. Please indicate time point for which questions are being asked or data is being extracted 1 = Between birth and day 2 post-delivery 2 = Between day 2 and day 7 post-delivery 62. Has the baby been given breastmilk from a cup, bottle, spoon, tube or other method? 1 = Yes If "Yes", skip to Q65 2 = No 9 = Unknown If "Unknown", skip to Q65 Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 53. Fundoscopy 1 = Normal 2 = Abnormal If "Abnormal" 3 = Not done 9 = Unknown 53s) If "Abnormal", specify 58. Specimen obtained and SARS-2-CoV RNA RT-PCR Result 1 = Positive 3 = Not done 2 = Negative 9 = Unknown 55. Cataract 1 = Normal 2 = Abnormal If "Abnormal" 3 = Not done 9 = Unknown 55s) If "Abnormal", specify 56. Hearing test 1 = Normal 2 = Abnormal If "Abnormal" 3 = Not done 9 = Unknown 56s) If "Abnormal", specify 60. Has the baby been put to the breast? 1 = Yes If "Yes", skip to Q62 2 = No 9 = Unknown If "Unknown", skip to Q62 61.If "No",why was the baby not put to the breast? 1 = Baby unwell 2 = Mother unwell 3 = Problems with breastmilk supply or with breasts 4 = Hospital policy for COVID-19 5 = Usual hospital policy 6 = Other 61s) If "Other", specify 57. Newborn blood screening 1 = Positive 2 = Negative 3 = Not done 57a) Hypothyroidism 57b) Phenylketonuria SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ............................................................................................................................................................................................................................................................. 99 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES BETWEEN BIRTH AND 7 DAYS FORM CR7 page 6/8 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Country: Participant ID: Birth order 63.If "Yes",was the breastmilk your own milk or someone else’s milk? 1 = Own milk 2 = Someone else's milk 9 = Unknown 69. Where did the baby sleep? 1 = In a cot near the mother’s bed skip to Q71 2 = In a cot outside the mother’s room 3 = In the mother’s bed skip to Q71 4 = Other 69s) If "Other", specify 70. If outside of mother’s room, why was this? 1 = Baby unwell 2 = Mother unwell 3 = Problems with breastmilk supply or with breasts 4 = Hospital policy for COVID-19 5 = Usual hospital policy 71. Did the child have any of the following problems? 1 = Yes 2 = No 71a) Poor feeding 71b) Convulsions or fits 71c) Fast breathing 71d) Severe chest indrawing 71e) Not moving spontaneously/by self 71f) Temperature >37.5C 71g) Temperature <35.5C 71h)Jaundice or yellow colour in skin or eyes 71i) Nasal congestion/runny nose 71j) Vomiting 71k) Diarrhea 71l) Skin rash 71m) Skin peeling from hands, feet, or lips 71n) Enlarged lymph nodes 71o) Red eyes 71p) Discharge or fluid coming from eyes 71q) Any other symptom 71qs) If "Yes", specify 71qsi) If "Yes",and the child was not in a health facility, did the mother seek care for the illness or problem? 1 = Yes 2 = No 9 = Unknown 64.If "Yes",why was the baby given breastmilk from a cup, bottle, spoon, tube, or other method? 1 = Baby unwell 2 = Mother unwell 3 = Problems with breastmilk supply or with breasts 4 = Hospital policy for COVID-19 5 = Usual hospital policy 6 = Other 64s) If "Other", specify 65. Did the mother (or caregiver) give the baby any other foods or fluids? 1 = Yes 2 = No 9 = Unknown 66. Was the baby ever been put on the mother’s chest? 1 = Yes 2 = No If "No", skip to Q68 9 = Unknown If "Unknown", skip to Q68 67. If yes, was the baby’s bare skin touching the mother’s bare skin? 1 = Yes 2 = No 9 = Unknown 68. How long is/was the baby on the bare skin of the mother’s chest? 1 = All the time 2 = Occasionally 3 = No 4 = Other 68s) If "Other", specify SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 100 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES BETWEEN BIRTH AND 7 DAYS FORM CR7 page 7/8 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: Birth order 71qsii) If "Yes",did the baby receive any of the following 1 = Yes 2 = No 71qsiia) Antibiotics 71qsiib) Medicine but name unknown 71qsiic) Help with breathing 71qsiid) Admission to intensive care unit 71qsiie) Oxygen 71qsiie) Medicine for COVID-19 71qsiies) If "Yes" specify 71qsiif) Other 71qsiifs) If "Other", specify 72. Any congenital anomalies? 1 = Yes 2 = No 72a) None 72b) Neural tube defects 72bs) If "Yes", date assesed Unknown 72c) Microcephaly 72cs) If "Yes", date assesed Unknown 72d) Congenital malformations of ear 72ds) If "Yes", date assesed Unknown 72e) Congenital heart defects 72es) If "Yes", date assesed Unknown 72f) Orofacial clefts 72fs) If "Yes", date assesed Unknown 72g) Congenital malformations of digestive system 72gs) If "Yes", date assesed Unknown 72h) Congenital malformations of genital organs 73hs) If "Yes", date assesed Unknown 73i) Abdominal wall defects 72is) If "Yes", date assesed Unknown 72j) Chromosomal abnormalities 72js) If "Yes", date assesed Unknown Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 101 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES BETWEEN BIRTH AND 7 DAYS FORM CR7 page 8/8 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: Birth order 72k) Genetic abnormalities 72ks) If "Yes", date assesed Unknown 72l) Reduction defects of upper and lower limbs 72ls) If "Yes", date assesed Unknown 72m) Talipes equinovarus/clubfoot 72ms) If "Yes", date assesed Unknown 72n) Others 72ns) If "Other", specify 72nsi) date assesed Unknown COMMENTS: Interviewer's name: Signature: Date: Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 102 11. Neonatal complications 1 = Yes 2 = No 11a) ventilator support 11b) Seizures 11c) Hypoxic ischemic encephalopathy 11d) Sepsis 11e) Other 11es) If "Other", specify A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES ASSESSED AT 4 WEEKS OF LIFE FORM CR8 page 1/7 V1.0 (16 Nov 2020) Project ID: Country: GENERAL Center ID: Participant ID: Birth order 1. Date of Assessment/Extraction NEONATAL PHYSICAL EXAM Note: complete all boxes with 9s in case of unknown value. 2. Temperature 4. Respiratory rate breaths/min 5. Heart rate beats/min 6. Blood pressure systolic mmHg diastolic mmHg 7. Peripheral O2 saturation (SpO2) % 8. Weight grams 9. Length cm 10. Head circumference cm = Other = Unknown 12s) If "Other" or "Abnormal", specify scribe Day Month Year World Health Organization A 6 6 0 1 2 °C °F 3. Temperature taken 1 = Oral 2 = Tympanic 3 = Rectal 4 = Axillary 5= Other 3s) If "Other", specify 12. Cardiovascular system 1 = Normal 4 2 = Abnormal 9 3 = Murmur 13. Respiratory system 1 = Normal 2 = Abnormal If "Abnormal" de 9 = Unknown 13s) If "Abnormal", describe SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 103 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES ASSESSED AT 4 WEEKS OF LIFE FORM CR8 page 2/7 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Country: Participant ID: Birth order 14. Gastrointestinal system 1 = Normal 2 = Abnormal 9 = Unknown 14a) Jaundice 14b) Hepatomegaly 14c) Hernia 14d) Gastroschisis 14e) Omphalocele 14f) Splenomegaly 14g) Abdominal tenderness 14h) Other 14hs) If "Other" or "Abnormal", specify 19. Arthrogryposis 1 = Yes 2 = No 9 = Unknown 20. Other neurological signs 1 = Yes 2 = No 21. Other abnormal movements (e.g. writhing movements) 1 = Yes 2 = No 15. Seizure 1 = Yes If "Yes", describe 2 = No 4 = Focal 3 = General 9 = Unknown 22. Tonic neck reflex 1 = Present 2 = Absent 3 = Not done 15s) If "Yes", describe 23. Moro reflex 1 = Present 2 = Absent 3 = Not done 16. Paralysis 1 = Yes If "Yes", describe 2 = No 4 = Ascending 3 = General 9 = Unknown 24. Rooting reflex 1 = Present 2 = Absent 3 = Not done 16s) If "Yes", describe 25. Sucking reflex 1 = Present 2 = Absent 3 = Not done 17. Hypotonia (floppiness) 1 = Yes 2 = No 9 = Unknown 26. Grasp reflex 1 = Present 2 = Absent 3 = Not done 18. Stiffness or spasticity or increased tone of limbs 1 = Yes 2 = No 9 = Unknown 27. Babinski reflex 1 = Present 2 = Absent 3 = Not done SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 104 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES ASSESSED AT 4 WEEKS OF LIFE FORM CR8 page 3/7 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: Birth order 28. Rash 1 = Yes 2 = No 9 = Unknown 28s) If "Yes", date of onset 29. Oedema 1 = Yes 2 = No 9 = Unknown 29s) If "Yes", date of onset 30. Fever 1 = Yes 2 = No 9 = Unknown 30s) If "Yes", date of onset 31. Eye redness/conjunctivitis 1 = Yes 2 = No 9 = Unknown 31s) If "Yes", date of onset 32. Other condition 1 = Yes 2 = No 9 = Unknown 32s) If "Yes", date of onset 32ss)If "Yes", describe 33. Fundoscopy 1 = Normal 2 = Abnormal If "Abnormal" specify 9 = Unknown 4 = Not done 33s) If "Abnormal", specify 34. Red reflex or chorioretinitis 1 = Present 2 = Absent 9 = Unknown 4 = Not done 35. Cataract 1 = Normal 2 = Abnormal If "Abnormal" specify 9 = Unknown 4 = Not done 35s) If "Abnormal", specify 36. Hearing test 1 = Normal 2 = Abnormal If "Abnormal" specify 9 = Unknown 4 = Not done 36s) If "Abnormal", specify 37. Newborn blood screening 1 = Positive 2 = Negative 3 = Not done 37a) Hypothyroidism 37b) Phenylketonuria Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 105 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES ASSESSED AT 4 WEEKS OF LIFE FORM CR8 page 4/7 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Country: Participant ID: Birth order NEONATAL FEEDING, SEPARATION, CONTACT, MORBIDITY 38. Please indicate time point for which questions are being asked or data is being extracted 1 = In the last 24hours 2 = Between 1 and 4 weeks post-delivery 44. Did the mother (or caregiver) give the baby any other foods or fluids? 1 = Yes 2 = No 9 = Unknown 39. Has the baby been ever put to the breast? 1 = Yes If "Yes", skip to Q41 2 = No 9 = Unknown If "Unknown", skip to Q41 45. Was the baby ever been put on the mother’s chest? 1 = Yes 2 = No If "No", skip to Q48 9 = Unknown If "Unknown", skip to Q48 40. If "No", why was the baby never put to the breast? 1 = Baby unwell 2 = Mother unwell 3 = Problems with breastmilk supply or with breasts 4 = Hospital policy for COVID-19 5 = Usual hospital policy 6 = Other 40s) If "Other", specify 41. Has the baby been given breastmilk from a cup, bottle, spoon, tube or other method? 1 = Yes 2 = No If "No", skip to Q44 9 = Unknown If "Unknown", skip to Q44 46. If "Yes", was the baby’s bare skin touching the mother’s bare skin? 1 = Yes 2 = No skip to Q48 9 = Unknown skip to Q48 47. How long is/was the baby on the bare skin of the mother’s chest? 1 = All the time 2 = Occasionally 3 = Other 9 = Unknown 47s) If "Other", specify 42. If "Yes", was the breastmilk mother’s milk or someone else’s milk? 1 = Mother’s milk 2 = Someone else's milk 9 = Unknown 48. Where does the baby sleep? 1 = In a cot near the mother’s bed skip to Q50 2 = In a cot outside the mother’s room 3 = In the mother’s bed skip to Q50 4 = Other 48s) If "Other", specify 43.If "Yes",why was the baby given breastmilk from a cup, bottle, spoon, tube, or other method? 1 = Baby unwell 2 = Mother unwell 3 = Problems with breastmilk supply or with breasts 4 = Hospital policy for COVID-19 5 = Usual hospital policy 6 = Other 43s) If "Other", specify 49. If outside of mother’s room, why? 1 = Baby unwell 2 = Mother unwell 3 = Problems with breastmilk supply or with breasts 4 = Hospital policy for COVID-19 5 = Usual hospital policy SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 106 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES ASSESSED AT 4 WEEKS OF LIFE FORM CR8 page 5/7 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: Birth order 50. Does the child have any of the following problems? 1 = Yes 2 = No 50a) Convulsions or fits 50b) Fast breathing 50c) Severe chest indrawing 50d) Not moving spontaneously/by self 50e) Temperature >37.5C 50f) Temperature <35.5C 50g)Jaundice or yellow colour in skin or eyes 50h) Nasal congestion/runny nose 50i) Vomiting 50j) Diarrhea 50k) Skin rash 50l) Skin peeling from hands, feet, or lips 50m) Enlarged lymph nodes 50n) Red eyes 50o) Discharge or fluid coming from eyes 50p) Any other symptom 50ps) If "Yes", specify 51) If "Yes",and the child was not in a health facility, did you seek care for the illness or problem? 1 = Yes 9 = Unknown 2 = No 52) If "Yes", did your baby receive any of the following 1 = Yes 2 = No 52a) Antibiotics 52b) Medicine but name unknown 52c) Help with breathing 52d) Admission to intensive care unit 52e) Oxygen 52f) Medicine for COVID-19 52fs) If "Yes" specify 52g) Other 52gs) If "Other", specify 53. Did neonate die? 1 = Yes 2 = No skip to Q53 9 = Unknown skip to Q53 53s) If "Yes", date of death 54. If neonate died, what was the primary cause of death? 1 = Yes 2 = No 54a) Preterm 54b) Low birth weight 54c) Birth asphyxia 54d) Infection 54e) COVID-19 54f) Bacteraemia/Septicemia 54g) HIV 54h) Other 54hs) If "Other", specify 54i) Complications from COVID-19 54is) If "Yes", specify 54j) Birth trauma 54k) Congenital/birth defects 54l) Other 54ls) If "Yes", specify 55. Any congenital anomalies? 1 = Yes 2 = No 55a) None 55b) Neural tube defects 55bs) If "Yes", date assesed Unknown Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 107 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES ASSESSED AT 4 WEEKS OF LIFE FORM CR8 page 6/7 V1.0 (16 Nov 2020) Project ID: A 6 6 0 1 2 Center ID: Participant ID: Country: Birth order 55c) Microcephaly 53cs) If "Yes", date assesed Unknown 55d) Congenital malformations of ear 55ds) If "Yes", date assesed Unknown 55e) Congenital heart defects 55es) If "Yes", date assesed Unknown 55f) Orofacial clefts 55fs) If "Yes", date assesed Unknown 55g) Congenital malformations of digestive system 55gs) If "Yes", date assesed Unknown 55h) Congenital malformations of genital organs 55hs) If "Yes", date assesed Unknown 55i) Abdominal wall defects 55is) If "Yes", date assesed Unknown 55j) Chromosomal abnormalities 55js) If "Yes", date assesed Unknown 55k) Genetic abnormalities 55ks) If "Yes", date assesed Unknown 55l) Reduction defects of upper and lower limbs 55ls) If "Yes", date assesed Unknown 55m) Talipes equinovarus/clubfoot 55ms) If "Yes", date assesed Unknown 55n) Others 53ns) If "Other", specify 55nsi) date assesed Unknown Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 108 World Health Organization A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 NEONATAL OUTCOMES ASSESSED AT 4 WEEKS OF LIFE FORM CR8 page 7/7 V1.0 (16 Nov 2020) Project ID: A 6 6 Country: 0 1 2 Center ID: Participant ID: Birth order SARS-CoV-2 Test Result COMMENTS: 56. Laboratory analyses of the neonate 1 = Performed go to Q57 2 = Not performed go to Q58 57. If "Performed", specify 1 = Yes 2 = No a) Standard b) MTCT screening 58. SARS-CoV-2 Test 1 = RT-PCR 2 = Serology 3 = Not performed 4= Ag-RDT 9 = Unknown go to End 59. Commercial name of test: 60. Result 1 = Positive 2 = Negative 9 = Unknown 61. Date of the test Interviewer's name: Signature: Date: Day Month Year Day Month Year SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 109 A66012 - A prospective cohort study investigating maternal pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2 MATERNAL OUTCOMES AT 6 WEEKS POST-PARTUM / STUDY EXIT FORM CR9 page 1/1 V1.0 (16 Nov 2020) Project ID: Country: Center ID: Participant ID: Unknown 5. Any maternal medical visit since discharge? 1 = Yes 2 = No 9 = Unknown 5s) If "Yes", specify MEDICAL HISTORY AND INFECTIONS 6. Any updates to medical history or infections? 6s.If "yes" please specify 1 = Yes 2 = No 9 = Unknown a) Heart didease b) Lung disease c) Blood disease d) Kidney disease e) Livery disease f) Neurological disease g) Thyroid disease h) Endocrine disease i) Immunosuppression j) Hypertension k) Type 1 or Type 2 diabetes l) Malaria m) Dengue n) Chikungunya o) Zika p) Influenza q) HIV r) Syphillis s) Hepatitis A t) Hepatitis B u) Hepatitis C v) Hepatitis D w) Hepatitis E x) Toxoplasmosis y) Rubella z) Cytomegalovirus aa) Herpes Simplex ab) Other medical condition/infection Interviewer's name: Signature: Date: Day Month Year Day Month Year World Health Organization A 6 6 0 1 2 1. Date of Assessment/ Extraction 3e) Other cardiovascular complications 3f) Maternal blood transfusion 3g) Perineal pain 3h) Mastitis 3i) Other 3is) If "Other", specify 2. Status of the mother 1 = Alive 9 = Unknown 2 = Dead 2s) If "Dead", explain cause of death 4. Was the woman readmitted to the hospital since discharge? 1 = Yes 2 = No 9 = 4s) If "Yes", specify 3. Has the woman had any of the following postpartum complications 1 = Yes 2 = No 9 = Unknown 3a) Infection or endometritis 3b) Fever 3c) Postpartum haemorrhage 3d) Postpartum preeclampsia/hypertension SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 110 Appendix C: Biological sampling algorithm For the exposed group of pregnant women, the following specimens will be collected as shown in Table C1. Table C1. Tier sampling approach Tier 1: minimum sample set Tier 2: comprehensive sampling set Tier 3: samples to be taken dependent on resources Pregnant women with RT-PCR confirmed SARS-CoV-2 infection or evidence of seroconversion during pregnancya Timing of collection Specimen Method Minimum volume Test Storage Childbirth specimens Amniotic fluid samples 1. Collected at time of cesarean section after amniotomy 2. Amniocentesis prior to deliveryb 0.5 mL or 1 swab PCR 1. 2–8◦ C for up to 72 hours prior to nucleic acid extraction 2. −70◦ C if extraction after 72 hours (per CDC recommendations) Cord blood Directly obtain from segment of cord at time of childbirth 0.5 mL PCR Placenta (2) Placental sampling (umbilical cord, chorionic villi, amniotic membrane) 1 cm sections PCR Placenta (2) Placental sampling (umbilical cord, chorionic villi, amniotic membrane) 1 cm sections Histopathology Maternal blood As described by Wang et al. (3) 0.5 mL (need to confirm) PCR Vaginal/cervical swab Directly obtain swab of vaginal mucosa/cervix prior to rupture of membranes 1 swab PCR Specimens following birthc Maternal breast milk From dedicated breast pump or directly from breast after delivery 0.5 mL (need to confirm) PCR Neonatal throat swab Neonatal throat swab immediately following delivery 1 swab PCR Neonatal anal swab Neonatal anal swab immediately following delivery 1 swab PCR a Participants must have confirmed SARS-CoV-2 by RT-PCR prior to enrolment. b If collected for other purposes. c If any RT-PCR tests result positive from specimens collected following birth, it is recommended to continue testing specimens every 24–72 hours, if feasible, until specimens test negative by 2 consecutive swabs separated by at least 24 hours. To perform real time RT-PCR on specimens, country-specific protocols should be followed, if available: • US CDC protocol for SARS-2-CoV RT-PCR25 25 CDC. 2020. CDC 2019-novel coronavirus (2019-nCoV) real-time RT-PCR diagnostic panel (https://www.fda.gov/media/134922/download). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 111 • Other country-specific protocols are available on the WHO website. Standard safety procedures for handling and processing specimens will be followed, in addition to WHO specific guidance for SARS-2-CoV.26 To perform ELISA antibody testing for SARS-2-CoV IgG/IgM, the following protocol is available in: • A serological assay to detect SARS-CoV-2 seroconversion in humans (4). It is helpful to review Appendices I–L for draft definitions, criteria and scenarios regarding in-utero, intrapartum and postnatal transmission of SARS-CoV-2. Appendices K and L contain guides for determining timing of infection and samples for assay. 26 WHO. Laboratory biosafety guidance related to coronavirus disease (COVID-19) (https://apps.who.int/iris/handle/10665/331500). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 112 Appendix D: Options for variations in study design Option 1: Disease severity in pregnant versus non-pregnant women (see Fig. D1) Figure D1: Disease severity Non-pregnant women of productive age End points • Hospitalization • Intensive care unit admission • Invasive ventilation • Complications • Death End points • Hospitalization • Intensive care unit admission • Invasive ventilation • Complications • Death women Pregnant Positive SARS-CoV-2 testing Enrolment sites: COVID-19 testing centres, healthcare centres (including hospitals), antenatal care centres Matching: Recommended to match 1:3 (pregnant to non-pregnant) based on age, body mass index and comorbidities - Objective: To determine if COVID-19 is more severe in pregnant women compared with non-pregnant women of reproductive age. Study population - Inclusion criteria: RT-PCR for SARS-CoV-2, ability to review clinical records/hospitalization course and diagnostic evaluation for COVID-19 infection. - Exclusion criteria: inability to review clinical records/hospitalization course or diagnostic evaluation for COVID-19 to confirm infection. Pregnancy status - Pregnancy status will be confirmed if there is recent sonographic evidence of pregnancy, confirmation of fetal heart rate (e.g. fetal doppler) or recent urine pregnancy test/blood pregnancy test. For non-pregnant SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 113 group, it is preferred to confirm non-pregnant status through recent urine/blood pregnancy test and/or verbal confirmation from the study participant Recruitment - Consecutive prospective recruitment is recommended in a health-care setting where the screening or symptomatic testing of SARS-CoV-2 is ongoing. Study enrolment should not occur until after a positive SARS- CoV-2 test has resulted. - Matching is recommended between the study groups on the following characteristics as they are known to impact disease severity of SARS-CoV-2 infection: 1. age (<18, 18–24, 25–29, 30–34, 35–39, 40–45) 2. gestational age 3. body mass index (<18.5, 18.6–24.9, 25–29.9, 30–34.9, 35–39.9, 40+) 4. comorbidities (specifically, type 1 or type 2 diabetes mellitus, chronic hypertension, chronic kidney disease, asthma/chronic obstructive pulmonary disease/obstructive sleep apnoea).27 Data collection Data to be collected at enrolment: - Pregnant women: Please see protocol. - Non-pregnant women: • demographic information • socioeconomic history (as indicated by wealth index) • medical and obstetric history • medical history • medication use • immunization history (in particular, seasonal influenza and bacille Calmette–Guérin (BCG) vaccines) • social history (substance use/abuse) • signs and/or symptoms of COVID-19 (hospitalization, laboratory studies, clinical characteristics and disease course) • laboratory evaluation (blood and nasopharyngeal samples) • specifically, confirmation of prior SARS-CoV-2 infection by RT-PCR and serology. Table D1. Sample data collection Clinical variables for data collection (during acute COVID-19 illness) Pregnant women Non-pregnant women Hospitalized patients: Duration of hospitalization Presenting signs/symptoms (if available) Intensive care unit admission (Y/N) Intubation (Y/N) Supplemental oxygen Vasopressor support (Y/N) Childbirth during acute COVID-19 illness (Y/N) 27 This list is suggestive and subject to revisions. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 114 Cardiac manifestation: Myocardial infarction (Y/N) Cardiomyopathy (Y/N) Arrhythmia (Y/N) Other (Y/N) Neurological manifestation: Seizures (Y/N) Haemorrhagic or ischaemic stroke (Y/N) Coma (Y/N) Other (Y/N) Thrombotic manifestation: Deep vein thrombosis (Y/N) Pulmonary embolism (Y/N) Arterial thrombosis (Y/N) Other (Y/N) Coagulopathy (Y/N) Laboratory data (white blood cells including differential to analyse individual cell lines, Hgb/Hct, platelets, lactate, procalcitonin, fibrinogen, pH) *if collected (obtained as deemed necessary by health- care provider) Treatment (antibiotics, antivirals, investigational therapeutics) Death (Y/N) If yes, please specify cause of death as listed on the death certificate Non-hospitalized patients: Presenting signs/symptoms (if available) Duration of signs/symptoms (if available) Treatment (if available) * Note: see Appendix E for questionnaires for non-pregnant individuals with SARS-CoV-2 infection. Option 2: Nested case control (for sites with limited antibody testing ability) Purpose: This study design is for study sites who have limited ability to perform antibody testing for all individuals enrolled into the cohort and who are not assessed as exposed upon cohort entry. It allows for antibody testing to be conducted on only a proportion of individuals from the unexposed cohort (this proportion should be determined based on the testing capability of the study site). Cases: All or a random sample of women in the cohort experiencing selected outcomes, these women would be SARS-CoV-2 tested to assess exposure status unless they have a confirmed positive exposure status. Controls: A randomly drawn matching number of controls from the cohort (controls as in women without any outcome of interest (i.e. a pregnancy/delivery without registered events deviating from a “normal” course). These women would be tested to assess exposure status, unless they are already tested positive. The odds ratios (instead of relative risk) for adverse outcomes would be analysed between cases (adverse outcome) and controls (non-adverse outcome) in relation to their exposure status. This would generate odds ratios for e.g. pre-term birth when exposed/infected with SARS-CoV-2 versus non-exposed/non-infected. This design option can be considered in areas where antibody testing may be limited. Data collection: - The general protocol should be followed for the full cohort, random sample. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 115 - The following lab tests can be collected on a randomly selected proportion for the selected unexposed cases and controls (see Table D2): Table D2. Pregnant women without RT-PCR confirmed SARS-CoV-2 infection (UNEXPOSED GROUP) Timing of collection Specimen Method Minimum volume Test Storage At time of enrolment Maternal blood Standard blood draw (preferred: with routine prenatal lab tests) To be determined ELISA (4) To be determined If deemed medically necessary by health-care provider Nasopharyngeal swab Per standard testing procedures 10 mL 5 mL for RT- PCR, 5 mL for biobank PCR On admission to maternity unit for childbirth Maternal blood Standard blood draw (preferred: with routine lab tests on admission to maternity unit To be determined ELISA (4) To be determined SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 116 Appendix E: Standardized questionnaire for non-pregnant women with SARS-CoV-2 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 117 SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 118 Appendix F: Specimen storage, preservation and shipment Specimen type Collection materials Storage temperature until testing Recommended temperature for shipment according to expected shipment time Nasopharyngeal (NP) swab Dacron or polyester flocked swabs 2–8 °C 2–8 °C < 5 days or −70 °C (dry ice) if > 5 days Tissue (placental) Sterile container with saline or viral transport medium 2–8 °C 2–8 °C < 24 hours or −70 °C (dry ice) if 24 hours 5 days Serum Serum separator tubes (collect 3–5 mL of whole blood) 2–8 °C 2–8 °C < 5 days or −70 °C (dry ice) if > 5 days Whole blood Collection tube 2–8 °C 2–8 °C < 5 days or −70 °C (dry ice) if > 5 days Stool or anal swab Stool container or Dacron or polyester flocked swabs 2–8 °C 2–8 °C < 5 days or -70 °C (dry ice) if > 5 days Breastmilk Sterile container 2–8 °C 2–8 °C < 5 days or −70 °C (dry ice) if > 5 days Amniotic fluid Sterile container or Dacron or polyester flocked swabs 2–8 °C 2–8 °C < 5 days or −70 °C (dry ice) if > 5 days SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 119 Appendix G: Sample tables for study outcomes Primary outcome 1: Determine if COVID-19 infection in pregnancy increases the risk of adverse pregnancy or neonatal outcomes. Table G1. Sample table for primary pregnancy outcome 1 Pregnancy outcomes Entire cohort COVID-19 positive COVID-19 negative Preterm birth < 37 weeks Preterm birth < 32 weeks Premature preterm rupture of membranes Placental abruption Antepartum haemorrhage Postpartum haemorrhage Caesarean section Operative delivery Fetal distress (defined by healthcare provider) Fetal growth restriction Stillbirth Miscarriage Preeclampsia/eclampsia/gestational hypertension/HELLP (i.e. hemolysis, elevated liver enzymes, and a low platelet count) Gestational diabetes Chorioamnionitis/endometritis Sepsis Blood transfusion Maternal death Near miss criteria (one or more) SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 120 Table G2. Sample table for primary neonatal outcome 1 Neonatal outcomes Entire cohort COVID-19 positive COVID-19 negative Small for gestational age Very small for gestational age Extremely small for gestational age Large for gestational age Apgar <7 at 5 minutes NICU admission Length of stay >4 days Respiratory distress Ventilator support Anaemia Sepsis COVID-19 infection Congenital anomaly Hypoxic ischaemic encephalopathy Neonatal death Primary outcome 2: To estimate the risk of mother-to-child-transmission of SARS-CoV-2 virus during pregnancy, intrapartum, postpartum or during breastfeeding among mother-neonate pairs with confirmed SARS-CoV-2 infection in pregnancy. Primary outcome 3: To describe viral presence and persistence in the placenta as well as breast milk and other bodily fluids Primary outcome 4: To characterize the clinical course and disease spectrum of COVID-19 infection during pregnancy SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 121 Table G3. Sample table for primary outcome 4 Maternal clinical variables for data collection (during acute COVID-19 infection) Hospitalized patients: Duration of hospitalization Presenting signs/symptoms (if available) Intensive care unit admission (Y/N) Intubation (Y/N) Supplemental oxygen Vasopressor support (Y/N) Childbirth during acute COVID-19 infection (Y/N) Cardiac manifestation: Myocardial infarction, cardiomyopathy, arrhythmia (Y/N) Neurologic manifestation: seizures, haemorrhagic or ischaemic stroke, coma, other (Y/N) Thrombotic manifestation: deep vein thrombosis, pulmonary embolism, arterial thrombosis, other (Y/N) Coagulopathy (Y/N) Laboratory data (white blood cells including differential to analyse individual cell lines, Hgb/Hct, platelets, lactate, procalcitonin, fibrinogen, pH) if collected (obtained as deemed necessary by health-care provider) Treatment (antibiotics, antivirals, investigational therapeutics) Maternal death (Y/N) Non-hospitalized patients Presenting signs/symptoms (if available) Duration of signs/symptoms (if available) Treatment (if available) SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 122 Appendix H: Biobank guidance According to the CIOMS guidelines28 on storage of biological specimens, the following are key components to the governance structure that the research team should take into account and adhere to: Responsible body: - name of the legal entity the samples will be entrusted - name of the body that will review research proposals for future use of the material Setting the parameters for storage: - types of research that will be pursued (in broad terms) - types of research that will be excluded or included only after recontacting the donor for consent - how the quality of the material is controlled - length of time: samples cannot be stored for an indefinite amount of time; term of validity for the biobank should align with the national guidelines Protection of the donor: - how authorization from the donor was obtained and how the donor can retract this authorization - how the rights and welfare of individuals from whom the materials were collected are not adversely affected Measures to protect confidentiality: - how confidentiality of the link between the specimen and personal identifiers is maintained* - who may have access to the materials for future research, and under what circumstances - to which other sources of personal information the results of analyses on biological materials may be linked *In relation to this, consideration has to be taken into how the samples will be stored. Samples can be anonymized, de-identified or coded. Anonymous data: All personal identifying information have not been retained and cannot be retrieved. Therefore, there is no link between the sample and the participant which will be a matter of consideration for the participant and research team when discussing the point in time when the participant can withdraw their samples. De-identified data: This is permanent removal of any personal identifying information and no code exists to link the sample to the participant. Therefore, as in the case above, this is a matter of consideration for the the participant and research team when discussing the point in time when the participant can withdraw their samples. Coded data: Personal identifying information has been replaced with letters, numbers, symbols or a combination of figures. However, a link between this code and the participant is retained. If coded, then the participant needs to understand that the key to the code will remain with the custodian of the biobank 28 CIOMS. International ethical guidelines for health-related research involving humans (https://cioms.ch/wp- content/uploads/2017/01/WEB-CIOMS-EthicalGuidelines.pdf). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 123 and there is limited access of the materials of third parties. Unlike the other two situations, this scenario allows a broader period of time that the participant can request withdrawal of their samples. Taking the above into account, the research team needs to decide on the above when setting up their governance structure. Further description of how the samples will be stored should be explained in the information sheet for the patient to make an informed decision. Considerations for re-contacting and/or disseminating future findings: - circumstances in which donors need to be recontacted - procedure for determining whether unsolicited findings should be disclosed, and if so, how they should be managed - appropriate mechanisms for keeping donors informed of research outcomes - how participatory engagement with patient groups or the wider community is organized SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 124 Appendix I: Draft criteria for defining in utero transmission of SARS-CoV- 229 NOTE: These draft criteria have been informed by an ongoing expert consultation process convened by HRP on MTCT of SARS-CoV-2. The information in this section are early extracts of this consultation process and are subject to revision and finalization. Certain assumptions have been made in order to develop these criteria for defining MTCT of SARS-CoV-2. These include: 1. possibility of transmission at different stages of pregnancy 2. in utero/peripartum/postnatal (breast milk) 3. maternal infection: timing of infection, confirmed infection 4. laboratory results of the women: timing and type of samples, type of laboratory test 5. clinical status of the infant at/close to birth: presence of symptoms 6. laboratory results of the infant: timing and type of samples (sterile versus non-sterile tissues/fluid), type of test, confirmatory test 7. contamination/transient colonization: persistence on multiple tests Intrauterine transmission (IUT) is presumed to have occurred if there is evidence of both early presumably in utero SARS-CoV-2 exposure AND persistence of SARS-CoV-2 in the infant. The definitions and specimen guidelines cover the assessment of IUT for two major pregnancy outcomes (born alive and stillbirth), and four time periods: at birth; from birth to 24 hours; between 24 hours and 7 days; and from 7 to 14 days. Using the definitions presented below, IUT may be classified as either confirmed, possible or unlikely. Figure I1. Schematic of possibilities: IUT of SARS CoV-2 in live births IUT unlikely See details below IUT possible See details below IUT confirmed (Mother positive and viral exposure and viral persistence) AND Evidence of early presumably in utero infant viral exposure (any of 3 possibilities) See details below AND Evidence viral persistence or immune response in infant (any of 3 possibilities) See details below IUT of SARS-CoV-2 (born alive) Mother positive (nasopharyngeal RT-PCR or IgM) 14 days before delivery to 2 days after birth 29 Final definitions and guide will be made available on the WHO website. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 125 Figure I2. Confirmed IUT of SARS CoV-2 in live births If only evidence of early infection and persistence is positive NP, then infant must also have symptoms to be considered confirmed Newborn (age >24 hr) NP positive Newborn (age <7 days) IgM positive Newborn (age >24 hr) blood positive 3. Evidence viral persistence or immune response in infant (any one of below) INTRAUTERINE TRANSMISSION BORN ALIVE Newborn (age <24 hr) NP positive Amniotic fluid (C/S, before ROM) positive Placenta fetal side swab or placental tissue positive Newborn (age <24 hr) blood positive 2. Evidence of early presumably in utero infant viral exposure (any one of below) 1. Mother positive NP RT-PCR sample or IgM (14 days before delivery to 2 days after birth) AND AND CONFIRMED intrauterine transmission Mother positive + in utero viral exposure + late infection and viral persistence Note: C/S, caesarean section; NP, Nasopharyngeal; ROM, rupture of membranes. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 126 Figure I3. Possible IUT of SARS CoV-2 in live births Newborn (age <7 days) IgM positive Newborn (age >24 hr) NP positive IgM positive at age <7 days and other tests negative or not done and confirmed by 2nd IgM positive at age >7 days Newborn (age >24 hr) blood positive 3. Evidence viral persistence or immune response in infant (any one of below) NP positive age >24 hr and other tests not done and infant does not have symptoms Blood, placenta or amniotic fluid positive and persistence tests (item 3) not done and infant has symptoms Newborn (age <24 hr) NP positive Amniotic fluid (C/S, before ROM) positive Placenta fetal side swab or placental tissue positive Newborn (age <24 hr) blood positive INTRAUTERINE TRANSMISSION BORN ALIVE 2. Evidence of early presumably in utero infant viral exposure (any one of below) 1. Mother positive NP RT-PCR sample or IgM (14 days before delivery to 2 days after birth) AND AND Po ss ib le in tr au te ri ne tr an sm iss io n SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 127 Figure I4. Unlikely IUT of SARS-CoV-2 in live births Newborn (age <24 hr) NP positive Only positive NP at <24 hrs and persistence tests (item 3) not done Amniotic fluid (C/S, before ROM) positive Placenta fetal side swab or placental tissue positive Newborn (age <24 hr) blood positive Newborn (age >24 hr) blood positive Newborn (age <7 days) IgM positive IgM positive at age <7 days and other tests negative or not done Newborn (age >24 hr) NP positive INTRAUTERINE TRANSMISSION BORN ALIVE 2. Evidence of early presumably in utero infant viral exposure (any one of below) 1. Mother positive NP RT-PCR sample or IgM (14 days before delivery to 2 days after birth) AND AND 3. Evidence viral persistence or immune response in infant (any one of below) One or more positive early and persistence (item 3) tests negative Placenta or amniotic fluid or blood positive and persistence tests (item 3) not done and infant does not have symptoms U nl ik el y in tr au te ri ne tr an sm iss io n SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 128 Figure I5. Possibilities for IUT of SARS-CoV-2 in stillbirths Evidence of early presumably in utero infant viral infection IUT of SARS-CoV-2 (stillbirth) Mother positive (NP RT-PCR or IgM) 14 days before delivery to 2 days after birth AND IUT confirmed (mother positive and fetal tissue positive) IUT possible (placenta positive without fetal tissue testing) IUT unlikely (placenta positive and fetal tissue negative on testing) Note: Confirmed infection requires detection of SARS-CoV-2 in fetal tissue SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 129 Appendix J: Draft criteria for defining intrapartum and postnatal transmission of SARS-CoV-230 NOTE: These draft criteria have been informed by an ongoing expert consultation process convened by HRP on MTCT of SARS-CoV-2. The information in this section are early extracts of this consultation process and are subject to revision and finalization. Certain assumptions have been made in order to develop these criteria for defining MTCT of SARS-CoV-2. These include: 1. Possibility of transmission at different stages of pregnancy 2. in utero/peripartum/postnatal (breast milk) 3. maternal infection: timing of infection, confirmed infection 4. laboratory results of the women: timing and type of samples, type of laboratory test 5. clinical status of the infant at/close to birth: presence of symptoms 6. laboratory results of the infant: timing and type of samples (sterile vs non-sterile tissues/fluid), type of test, confirmatory test 7. contamination/transient colonization: persistence on multiple test The following pages include draft guidelines and definitions for peripartum (i.e. intrapartum/early <24 hours postpartum) and postnatal horizontal transmission including through breast milk. Peripartum transmission Peripartum (intrapartum/early ≤24 hours) transmission is presumed to have occurred if there is evidence of both lack of early exposure AND infection with persistence of SARS-CoV-2 in the infant after early period. 30 Final definitions and guide will be made available on the WHO website. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 130 Figure J1. Newborn (age >24 hr) NP positive and confirmed by 2nd NP positive at age 1–7 days Newborn (age 7–14 days) IgM positive and confirmed by 2nd IgM positive test POSSIBLE peripartum transmission No early tests done (item 2 not done) and positive confirmed late testing (item 3) 3. Evidence LATER infection and viral persistence or immune response in infant (any one of below) Newborn (age <7 days) IgM negative CONFIRMED peripartum transmission Mother positive + in utero viral exposure + late infection and viral persistence PERIPARTUM (INTRAPARTUM/ EARLY <24HRS) TRANSMISSION Newborn (age <24 hr) NP negative RT-PCR Amniotic fluid (C/S, before ROM) negative Placenta fetal side swab or placental tissue negative Newborn (age <24 hr) blood negative 2. LACK of evidence of early presumably in utero infant viral exposure (≥1 test done, and all tests done are negative) 1. Mother positive NP RT-PCR sample or IgM (14 days before delivery to 2 days after birth) SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 131 Figure J2. Single NP positive at age >24 hr with negative 2nd confirmatory NP test or no other testing done Single IgM positive at age 7–14 days with negative 2nd confirmatory IgM test or no other testing done UNLIKELY peripartum transmission Newborn (age >24 hr) NP positive and confirmed by 2nd NP positive at age 1–7 days Newborn (age 7–14 days) IgM positive and confirmed by 2nd IgM positive test 3. Evidence LATER infection and viral persistence or immune response in infant (any one of below) Newborn (age <7 days) IgM negative CONFIRMED peripartum transmission Mother positive + in utero viral exposure + late infection and viral persistence PERIPARTUM (INTRAPARTUM/ EARLY <24HRS) TRANSMISSION Newborn (age <24 hr) NP negative RT-PCR Amniotic fluid (C/S, before ROM) negative Placenta fetal side swab or placental tissue negative Newborn (age <24 hr) blood negative 2. LACK of evidence of early presumably in utero infant viral exposure (≥1 test done, and all tests done are negative) 1. Mother positive NP RT-PCR sample or IgM (14 days before delivery to 2 days after birth) SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 132 Postnatal horizontal transmission Postnatal horizontal transmission is presumed to have occurred if there is evidence of both lack of early exposure AND infection and persistence of SARS-CoV-2 in the infant after the peripartum period. Figure J3. Infant NP positive at age >7 days and confirmed by 2nd NP positive test Infant IgM positive at age >14 days and confirmed by 2nd IgM positive test POSSIBLE postnatal transmission No early tests done (item 2 not done) and positive confirmed late testing (item 3) CONFIRMED postnatal transmission Mother positive + no peripartum exposure + subsequent infection and viral persistence POSTNATAL HORIZONTAL TRANSMISSION 3. Evidence SUBSEQUENT infection with viral persistence or immune response in infant (any one of below) Infant IgM in any samples at age <14 days negative if done Newborn blood, placenta and amniotic fluid (C/S, before ROM) negative if done Infant NP negative in any samples obtained at age <7 days 2. LACK of evidence of peripartum infant viral exposure (≥1 test done, and all tests done are negative) 1. Mother positive NP RT-PCR sample or IgM (14 days before delivery to 2 days after birth) SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 133 Figure J4. Infant NP positive at age >7 days and confirmed by 2nd NP positive test Infant IgM positive at age >14 days and confirmed by 2nd IgM positive test POSSIBLE postnatal transmission No early tests done (item 2 not done) and positive confirmed late testing (item 3) CONFIRMED postnatal transmission Mother positive + no peripartum exposure + subsequent infection and viral persistence Single NP positive at age >7 days with negative 2nd confirmatory NP test or no other testing done Single IgM positive at age >14 d ys with negative 2nd confirmatory IgM test or no other testing done UNLIKELY peripartum transmission Infant IgM positive at age >14 days and confirmed by 2nd IgM positive test POSTNATAL HORIZONTAL TRANSMISSION 3. Evidence SUBSEQUENT infection with viral persistence or immune response in infant (any one of below) Infant IgM in any samples at age < 14 days negative if done Newborn blood, placenta and amniotic fluid (C/S, before ROM) negative if done Infant NP negative in any samples obtained at age <7 days 2. LACK of evidence of peripartum infant viral exposure (≥1 test done, and all tests done are negative) 1. Mother positive NP RT-PCR sample or IgM (14 days before delivery to 2 days after birth) SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 134 Breast milk transmission: Breast milk transmission will be difficult to document as breastfeeding infant will likely be exposed to an environment with SARS-CoV-2 (mother, household) so ruling out horizontal acquisition will be difficult. Figure J5. Negative IgM converts to positive IgM following breast milk ingestion Negative infant NP or faecal specimen become positive, confirmed by second specimen following breast milk ingestion 5. Initially uninfected infant has confirmed infection 1 + 2 + 3 = CONFIRMED breast milk transmission BREAST MILK TRANSMISSION 4. Positive breast milk ingested in environment where horizontal transmission unlikely/minimized ≥2 breast milk samples positive 3. Breastmilk confirmed positive for SARS-CoV-2 ALL infant sample negative in any samples obtained prior to ingestion + breast milk 2. LACK of evidence of infection prior to breastfeeding (must have at least 1 negative test before breastfeeding) 1. Mother positive NP RT-PCR sample or IgM (14 days before delivery to 2 days after birth) Note: This category is so difficult. Scenarios for possible or unlikely breast milk transmission could not be developed. If mother first becomes infected with SARS-CoV-2 after childbirth while breastfeeding, it will be extremely difficult to distinguish infant exposure/ acquisition horizontally from mother/environment versus breast milk acquisition. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 135 Appendix K: Potential testing of live birth for determination of infection timing31 NOTE: These draft criteria have been informed by an ongoing expert consultation process convened by HRP on MTCT of SARS-CoV-2. The information in this section are early extracts of this consultation process and are subject to revision and finalization. Figure K1. Mother has documented SARS-CoV-2 positive NP RT-PCR or IgM or other sample If possible, additional maternal specimens: • Vaginal • Rectal Optional: • Breastmilk • Blood If possible, birth specimens: • Placental swab (fetal side)/ biopsy for PCR/ histology • Amniotic fluid (CS prior to ROM) • Umbilical cord sample • Cord blood for PCR, IgM Birth–24 hours • Neonatal NP swab • Neonatal blood PCR • Neonatal blood IgM Optional: • Neonatal rectal 24 hours–7 days: • Infant NP swab • Infant blood IgM Optional: • Infant blood PCR • Infant rectal 7–14 days: • Neonatal NP swab • Neonatal blood IgM To confirm in utero infection if testing positive from birth to 24 hours (or positive birth specimen) To confirm peripartum infection when birth test is negative and 24 hours–7 days test positive 31 Final definitions and guide will be made available on the WHO website. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 136 Appendix L: Potential samples to test for timing of SARS-COV-2 perinatal infection32 NOTE: These draft criteria have been informed by an ongoing expert consultation process convened by HRP on MTCT of SARS-CoV-2. The information in this section are early extracts of this consultation process and are subject to revision and finalization. Table L1. Maternal SARS-CoV-2 (in addition to positive nasopharyngeal) Fetal/neonatal SARS-CoV-2 testing Antenatal • Optional - Amniotic fluid RT-PCR (if done for other purpose) 1st trimester miscarriage • Vaginal swab RT-PCR • Optional - Blood RT-PCR • Products of conception RT-PCR or other viral identification (EM, culture) 2nd trimester miscarriage/ stillbirth • Vaginal swab RT-PCR • Optional - Blood RT-PCR • Placenta swab (fetal side preferred) or biopsy RT-PCR or other viral identification (EM, culture) • Umbilical cord for RT-PCR or other viral identification (EM, culture) • Umbilical cord blood RT-PCR • Fetal tissues RT-PCR or other viral identification (EM, culture) • Placenta histology when possible Live birth Intrapartum/immediately postpartum: • Vaginal swab RT-PCR • Rectal swab RT-PCR • Optional - Blood RT-PCR Postpartum: • Optional - Breast milk (if positive, must confirm with at least one more sample) RT-PCR or cytotoxicity/ infectivity assay • When possible: - Amniotic fluid (prior to rupture membrane with caesarean section aspirate through intact membrane after uterine incision) - Placenta swab (fetal side preferred) or biopsy RT-PCR or other viral identification (EM, culture) - Umbilical cord for RT-PCR or other viral identification (EM, culture) - Umbilical cord blood RT-PCR and/or SARS-CoV-2 IgM (must be confirmed with peripheral blood) • Placenta histology when possible 32 Final definitions and guide will be made available on the WHO website. SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 137 Birth to 24 hours for SARS-CoV-2 testing: • Respiratory sample for RT-PCR • Peripheral blood for RT-PCR • Peripheral blood for SARS-CoV-2 IgM • Optional: - Neonatal rectal swab for RT-PCR 24 hours–7 days for SARS-CoV-2 testinga: • Respiratory sample for RT-PCR • Blood for SARS-CoV-2 IgM • Optional - Blood for RT-PCR - Rectal swab for RT-PCR 14 days for SARS-COV-2 RT-PCR (if test at birth negative or not done and test at age 24 hours–7-days positive)b: • Respiratory sample for RT-PCR • SARS-CoV-2 IgM Note: EM, electron microscopy. a To confirm in uteroinfection if birth specimen positive; to determine peripartum (intrapartum/early postnatal transmission) if birth specimen is negative. b To confirm intrapartum/early postnatal transmission when birth testing negative and 24 hour-7 days test positive. Note: Table L1 has been modified from (4). SARS-CoV-2 and pregnancy prospective cohort study Generic protocol: Last updated 2 December 2020, version 2.6 ........................................................................................................................................................................................................................................................ 138 Appendix references 1. Ellington S, Strid P, Tong VT, et al. Characteristics of Women of Reproductive Age with Laboratory- Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69:770–775. 2. Costa ML, Venceslau EM, Paulo J, et al. Adequate placental sampling for the diagnosis and characterization of placental infection by Zika virus. Front Microbiol. 2020; 11:1–11. 3. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA. 2020. 323:1843–1844. 4. Amanat F, Nguyen THO, Chromikova V, et al. A serological assay to detect SARS-CoV-2 seroconversion in humans. Nat Med. 2020; 26:1033–1036. 5. Mahyuddin AP, Kanneganti A, Wong JJL, et al. Mechanisms and evidence of vertical transmission of infections in pregnancy including SARS-CoV-2s. Prenat Diagn. 2020; doi:10.1002/pd.5765. © World Health Organization 2020. Some rights reserved. This work is available under the CC BY- NC-SA 3.0 IGO licence. WHO reference number: WHO/2019-nCoV/pregnancy_and_neonates/2020.1