Study Rationale

Over 100 patients were hospitalized at Hadassah in the recent 2 months with the diagnosis of
COVID-19.

We would like to summarize the clinical outcomes and their correlation to a cytokine storm at
Hadassah and additional hospitals and additional hospitals in Israel.

COVID-19, the name given to the clinical syndrome associated with the newly recognized virus
SARS-CoV-2 has become pandemic with a mortality estimated based on reports from China between
1-3% and complications among hospitalized patients leading to up to 15-25% admissions to the
ICU.

The clinical presentation includes both upper and lower respiratory tract infection, but
patients may also be asymptomatic.

A diagnostic PCR assay was rapidly developed in Hong Kong and Berlin that accurately detects
SARS-CoV-2 in samples from nose and throat swabs or sputum of hospitalized patients and is
used by public-health authorities around the world.

To avoid cross-reactivity with SARS-CoV or other coronaviruses, the test detects a region of
the gene encoding RNA-dependent RNA polymerase that is unique to SARS-CoV-2.

Not all patients need hospitalization but due to the high index of infection spread, all
detected patients are put in isolation to prevent transmission of the infection to others.

The development of vaccines is undoubtedly an important step and several MERS vaccines were
already in clinical trials when word of the new outbreak spread. However, developing and
testing the correct viral protein that will be effective (and probably not 100% protective)
will take some time.

In the meantime, anti-viral agents are tested including a combination of two human
immunodeficiency virus (HIV) antivirals. Lopinavir and ritonavir have been taking center
stage as potential therapies for COVID-19 and there are at least three registered randomized
clinical trial testing the lopinavir-ritonavir combination in Chinese patients infected with
SARS-CoV-2 (NCT04255017, NCT04252885 and NCT04251871) with the results of one being negative,
as published in the New England Journal of Medicine in March 2020. A handful of other HIV
antivirals are currently in clinical testing against SARS-CoV-2, including
darunavir-cobicistat. , donated by the US pharmaceutical company Johnson & Johnson to the
Shanghai Public Health Clinical Center. Nucleoside analogs are being considered too and
Remdesivir was used to treat the first US patient infected with SARS-CoV-2, who recovered. It
is also in phase 3 trials in Wuhan patients infected with SARS-CoV-2, overseen by the
China-Japan Friendship Hospital in Beijing (NCT04252664 and NCT04257656). However, SARS-CoV-2
have its own proteases, including its main protease, Mpro, and HIV antivirals design are
tailored specifically to block the activity of HIV proteases to avoid off-target effects on
human cells, which makes them less likely to bind SARS-CoV-2 proteases as well. Chloroquine
was recently suggested as an additional anti-viral medication. In addition, even if
anti-viral therapy will be found to be efficacious against SARS-CoV-2, will this be the
treatment of choice in patients admitted to the ICU? Not necessarily.

The term "cytokine storm" calls up vivid images of an immune system gone awry and an
inflammatory response flaring out of control. The term has captured the attention of the
public and the scientific community alike and is increasingly being used in both the popular
media and the scientific literature. Indeed, a few publications have indicated an important
part of the complications in COVID-19 are related to a cytokine storm (Huang et al. Lancet
2020, Mehta et al. Lancet 2020).

Taken together, in patients with moderate to severe COVID-19, there may be an underlying
immunological mechanism of action that is a hyper-inflammatory pathway associated with
increased death.

Study Design

A multi-center study comparing clinical outcomes in patients with COVID-19 in subjects
hospitalized at Hadassah and other hospitals for PCR or serology confirmed COVID-19 and
compare the outcomes to the presence of different degrees of a cytokine storm.

The patients will be subdivided into five severities of COVID-19 illness according to the new
NIH Patient Classification
(www.covid19treatmentguidelines.nih.gov/overview/management-of-covid-19/):

- Asymptomatic or Pre-symptomatic Infection: Individuals who test positive for SARS-CoV-2
by virologic testing using a molecular diagnostic (e.g., polymerase chain reaction) or
antigen test, but have no symptoms.

- Mild Illness: Individuals who have any of the various signs and symptoms of COVID-19
(e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of
breath, dyspnea, or abnormal chest imaging.

- Moderate Illness: Individuals who have evidence of lower respiratory disease by clinical
assessment or imaging and a saturation of oxygen (SpO2) ≥94% on room air at sea level.

- Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2
<94% on room air at sea level, ratio of arterial partial pressure of oxygen to fraction
of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%

- Critical Illness: Individuals who have respiratory failure, septic shock, and/or
multiple organ dysfunction.

The cytokine storm will be compared to cytokine storm in sepsis and in chimeric antigen
receptor (CAR)-T therapy, associated with Cytokine release Syndrome (CRS).

Handling of blood samples

Blood results will be taken from the Hospital clinical evaluation system (MAHAR). Blood
leftover samples obtained from Hadassah biological blood bank, or for serological
confirmation or IL6 level tests (as a rationale for injecting tocilizumab, or from any
routine blood examination, will be used for cytokines/chemokines/hematopoietic growth
factors/ Complement/ DNA methylation measurements.

In the case of hospitalized patients, a total amount of up to 10 ml of blood will be drawn.
Blood samples will be obtained and handled according to the institutional guidelines and
approvals.

Statistical Analysis

The data will be summarized by different clinical outcomes listing the mean, standard
deviation, minimum, median, maximum, and number of subjects for continuous data, or in tables
listing count and percentage for categorical and event data, as appropriate. Descriptive
analyses and, where appropriate, statistical testing will compare between each of the
subgroups.

All statistical analyses will be performed, and data appendixes will be created using the
SAS® system (SAS Institute, Cary, NC), Version 9.4, or higher.