Preventing COVID-19 Transmission on Labor and Delivery: A Decision AnalysisFunding None.
27 May 2020
01 June 2020
16 June 2020 (online)
Objective The health care system has been struggling to find the optimal way to protect patients and staff from coronavirus disease 2019 (COVID-19). Our objective was to evaluate the impact of two strategies on transmission of COVID-19 to health care workers (HCW) on labor and delivery (L&D).
Study Design We developed a decision analytic model comparing universal COVID-19 screening and universal PPE on L&D. Probabilities and costs were derived from the literature. We used individual models to evaluate different scenarios including spontaneous labor, induced labor, and planned cesarean delivery (CD). The primary outcome was the cost to prevent COVID-19 infection in one HCW. A cost-effectiveness threshold was set at $25,000 to prevent a single infection in an HCW.
Results In the base case using a COVID-19 prevalence of 0.36% (the rate in the United States at the time), universal screening is the preferred strategy because while universal PPE is more effective at preventing COVID-19 transmission, it is also more costly, costing $4,175,229 and $3,413,251 to prevent one infection in the setting of spontaneous and induced labor, respectively. For planned CD, universal PPE is cost saving. The model is sensitive to variations in the prevalence of COVID-19 and the cost of PPE. Universal PPE becomes cost-effective at a COVID-19 prevalence of 34.3 and 29.5% and at a PPE cost of $512.62 and $463.20 for spontaneous and induced labor, respectively. At a higher cost-effectiveness threshold, the prevalence of COVID-19 can be lower for universal PPE to become cost-effective.
Conclusion Universal COVID-19 screening is generally the preferred option. However, in locations with high COVID-19 prevalence or where the local societal cost of one HCW being unavailable is the highest such as in rural areas, universal PPE may be cost-effective and preferred. This model may help to provide guidance regarding allocation of resources on L&D during these current and future pandemics.
Universal screening is the preferred strategy for labor.
With high prevalence, universal PPE is cost-effective.
For planned cesarean, universal PPE is cost saving.
- 1 WHO. Novel coronavirus – China. WHO. Available at: http://www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/ . April 15, 2020
- 2 CDC. Coronavirus disease 2019 (COVID-19) in the U.S. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html . Accessed May 4, 2020
- 3 Guan W-J, Ni Z-Y, Hu Y. , et al; China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; 382 (18) 1708-1720
- 4 Sutton D, Fuchs K, D'Alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med 2020; 382 (22) 2163-2164
- 5 Zou L, Ruan F, Huang M. , et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med 2020; 382 (12) 1177-1179
- 6 COVID-19 Map. Johns hopkins coronavirus resource center. Available at: https://coronavirus.jhu.edu/map.html . Accessed May 4, 2020
- 7 Breslin N, Baptiste C, Gyamfi-Bannerman C. , et al. COVID-19 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM DOI: 10.1016/j.ajogmf.2020.100118.
- 8 Grobman WA, Rice MM, Reddy UM. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med 2018; 379 (06) 513-523
- 9 Liu Y, Gayle AA, Wilder-Smith A, Rocklöv J. The reproductive number of COVID-19 is higher compared to SARS coronavirus. J Travel Med 2020; 27 (02) taaa021
- 10 Zhang S, Diao M, Yu W, Pei L, Lin Z, Chen D. Estimation of the reproductive number of novel coronavirus (COVID-19) and the probable outbreak size on the Diamond Princess cruise ship: a data-driven analysis. Int J Infect Dis 2020; 93: 201-204
- 11 Biggerstaff M, Cauchemez S, Reed C, Gambhir M, Finelli L. Estimates of the reproduction number for seasonal, pandemic, and zoonotic influenza: a systematic review of the literature. BMC Infect Dis 2014; 14: 480
- 12 Haber MJ, Shay DK, Davis XM. , et al. Effectiveness of interventions to reduce contact rates during a simulated influenza pandemic. Emerg Infect Dis 2007; 13 (04) 581-589
- 13 Zhang J, Landy HJ, Branch DW. , et al; Consortium on Safe Labor. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010; 116 (06) 1281-1287
- 14 Teleman MD, Boudville IC, Heng BH, Zhu D, Leo YS. Factors associated with transmission of severe acute respiratory syndrome among health-care workers in Singapore. Epidemiol Infect 2004; 132 (05) 797-803
- 15 Fay EE, Hitti JE, Delgado CM. , et al. An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost. Am J Obstet Gynecol 2019; 221 (04) 349.e1-349.e9
- 16 American Health Insurance Plans Recent Trends in Hospital Prices in California and Oregon. Available at: http://www.ahipresearch.org/pdfs/PricesCaliforniaOregon2010.pd . Accessed December 2010
- 17 Khazeni N, Hutton DW, Garber AM, Hupert N, Owens DK. Effectiveness and cost-effectiveness of vaccination against pandemic influenza (H1N1) 2009. Ann Intern Med 2009; 151 (12) 829-839
- 18 US Department of Labor. Bureau of Labor Statistics. Occupational Outlook Handbook, Healthcare Occupations. Available at: https://www.bls.gov/ooh/healthcare/mobile/home.htm . Accessed April 16, 2020
- 19 CDCMMWR. Severe outcomes among patients with coronavirus disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69 . Doi: 10.15585/mmwr.mm6912e2
- 20 U.S. Census Bureau QuickFacts. United States. Available at: https://www.census.gov/quickfacts/fact/table/US/PST045219 . Accessed May 4, 2020.
- 21 Administrator J website. Global Progress on COVID-19 Serology-Based Testing. Johns Hopkins Center for Health Security. Available at: https://www.centerforhealthsecurity.org/resources/COVID-19/serology/Serology-based-tests-for-COVID-19.html . Accessed April 15, 2020
- 22 Sheridan C. Fast, portable tests come online to curb coronavirus pandemic. Nat Biotechnol 2020; 38 (05) 515-518