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Kelly SP, McEwen LM, Isaksson M, Murphy S, White S, Levy ME, McCrone JT, Levan G, Santhanam S, Baniecki ML, Bramson C, Rubino H, Hendrick V, Soares H, Hammond J, Luo S. Viral SARS-CoV-2 Rebound Rates in Linked Commercial Pharmacy-Based Testing and Health Care Claims. Open Forum Infect Dis 2024; 11:ofae243. [PMID: 38854397 PMCID: PMC11161861 DOI: 10.1093/ofid/ofae243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/29/2024] [Indexed: 06/11/2024] Open
Abstract
Background Viral SARS-CoV-2 rebound (viral RNA rebound) is challenging to characterize in large cohorts due to the logistics of collecting frequent and regular diagnostic test results. Pharmacy-based testing data provide an opportunity to study the phenomenon in a large population, also enabling subgroup analyses. The current real-world evidence approach complements approaches focused on smaller, prospective study designs. Methods We linked real-time reverse transcription quantitative polymerase chain reaction test data from national pharmacy-based testing to health care claims data via tokenization to calculate the cumulative incidence of viral RNA rebound within 28 days following positive test results in nirmatrelvir/ritonavir (NMV-r)-treated and untreated individuals during the Omicron era (December 2021-November 2022) and prior to the Omicron era (October 2020-November 2021). Results Among 30 646 patients, the rate of viral RNA rebound was 3.5% (95% CI, 2.0%-5.7%) in NMV-r-treated infections as compared with 1.5% (95% CI, 1.3%-1.7%) in untreated infections during the Omicron era and 1.9% (95% CI, 1.7%-2.1%) prior to the Omicron era. Viral RNA rebound in patients who were vaccinated (n = 8151), high risk (n = 4411), or older (≥65 years, n = 4411) occurred at comparable rates to the overall cohort (range, 1.1%-4.8%). Viral rebounds to high RNA levels in NMV-r-treated infections occurred in 8% of viral rebounds as compared with 5% to 11% in untreated infections. Rates of hospitalization were comparable between patients with NMV-r-treated infections with viral RNA rebound (0%) and untreated patients with viral RNA rebound (0%-1.2%). Conclusions Our findings suggest viral RNA rebound is rare (< 5%), with rates that were consistent with those from the EPIC-HR trial (Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients). Most occurrences of viral RNA rebound were associated with low viral RNA levels, and viral RNA rebound progression to severe disease was not observed.
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Affiliation(s)
| | | | | | | | | | | | - John T McCrone
- Helix Inc, San Mateo, California, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Sandin R, Veenstra DL, Vankelegom M, Dzingina M, Sullivan SD, Campbell D, Ma C, Harrison C, Draica F, Wiemken TL, Mugwagwa T. Budget impact of oral nirmatrelvir/ritonavir in adults at high risk for progression to severe COVID-19 in the United States. J Manag Care Spec Pharm 2023; 29:1290-1302. [PMID: 38058141 PMCID: PMC10776264 DOI: 10.18553/jmcp.2023.29.12.1290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND Nirmatrelvir/ritonavir (NMV/r) is indicated for the treatment of mild-to-moderate COVID-19 in adults who are at high risk for progression to severe COVID-19. NMV/r has also been authorized for emergency use by the US Food and Drug Administration for the treatment of mild-to-moderate COVID-19 in pediatric patients (aged 226512 years and weighing at least 40 kg) who are at high risk for progression to severe COVID-19. Understanding the budget impact of introducing NMV/r for the treatment of adults with COVID-19 is of key interest to US payers. OBJECTIVE To estimate the annual budget impact of introducing NMV/r in a US commercial health plan setting in the current Omicron COVID-19 era. METHODS A budget impact model was developed to assess the impact of NMV/r on health care costs in a hypothetical 1-million-member commercial health insurance plan over a 1-year period in the US population; clinical and cost inputs were derived from published literature with a focus on studies in the recent COVID-19 era that included vaccinated population and predominance of the Omicron variant. In the base-case analysis, it was assumed the only effect of NMV/r was a reduction in incidence (not severity) of hospitalization or death; its potential effect on post-COVID conditions was assessed in a scenario analysis. Outcomes included the number of hospitalizations, total cost, per patient per year (PPPY) costs, and per member per month (PMPM) costs. Sensitivity and scenario analyses were conducted to assess uncertainty around key model inputs. RESULTS An estimated 29,999 adults were eligible and sought treatment with oral antiviral for COVID-19 over 1 year. The availability of NMV/r was estimated to reduce the number of hospitalizations by 647 with a total budget impact of $2,733,745, $91 PPPY, and $0.23 PMPM. NMV/r was cost saving when including post-COVID conditions with a -$1,510,780 total budget impact, a PPPY cost of -$50, and a PMPM cost of -$0.13. Sensitivity analyses indicated results were most sensitive to the risk of hospitalization under supportive care, risk of hospitalization with NMV/r treatment and cost of NMV/r. CONCLUSIONS Treatment with NMV/r in the current COVID-19 era is estimated to result in substantial cost offsets because of reductions in hospitalization and modest budget impact to potential overall cost savings.
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Affiliation(s)
| | | | | | | | | | | | - Cuiying Ma
- Health Economics & Outcomes Research Ltd, Cardiff, Wales, UK
| | - Cale Harrison
- Health Economics & Outcomes Research Ltd, Cardiff, Wales, UK
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Santos CNO, Caldas GC, de Oliveira FA, da Silva AM, da Silva JS, da Silva RLL, de Jesus AR, Magalhães LS, de Almeida RP. COVID-19 recurrence is related to disease-early profile T cells while detection of anti-S1 IgG is related to multifunctional T cells. Med Microbiol Immunol 2023; 212:339-347. [PMID: 37488347 DOI: 10.1007/s00430-023-00776-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023]
Abstract
COVID-19 is caused by SARS-CoV-2 infection and leads from asymptomatic to severe outcomes. The recurrence of the COVID-19 has been described, however, mechanisms involved remains unclear. Thus, the work aimed to investigate the role of multifunctional T cells in patients with recurrent COVID-19. We evaluated clinical characteristics, presence of anti-S1 and anti-Nucleocapsid IgG in patients' sera, and multifunctional T cells (for IFN-γ, IL-2, and TNF-α) in patients with multiple episodes of COVID-19 and controls. Data demonstrate that patients with recurrent COVID-19 have a T cell pattern predominantly related to IFN-γ production. Also, patients with COVID-19 history and absence of anti-S1 IgG had lower levels of CD4+ IFN + IL-2 + TNF + T cells independently of number of disease episodes. Complementary, vaccination changed the patterns of T cells phenotypes and induced IgG seroconversion, despite not induce higher levels of multifunctional T cells in all patients. In conclusion, the data suggest that recurrent disease is related to early-disease T cell profile and absence of anti-S1 IgG is related to lower multifunctional CD4 T cell response, what suggests possibility of new episodes of COVID-19 in these patients.
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Affiliation(s)
- Camilla Natália O Santos
- Laboratório de Imunologia e Biologia Molecular, Universidade Federal de Sergipe, Aracaju, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Sergipe, Aracaju, Brazil
| | - Gustavo C Caldas
- Laboratório de Imunologia e Biologia Molecular, Universidade Federal de Sergipe, Aracaju, Brazil
- Departamento de Medicina, Hospital Universitário, Universidade Federal de Sergipe, Aracaju, Brazil
| | - Fabricia A de Oliveira
- Laboratório de Imunologia e Biologia Molecular, Universidade Federal de Sergipe, Aracaju, Brazil
| | - Angela Maria da Silva
- Laboratório de Imunologia e Biologia Molecular, Universidade Federal de Sergipe, Aracaju, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Sergipe, Aracaju, Brazil
- Departamento de Medicina, Hospital Universitário, Universidade Federal de Sergipe, Aracaju, Brazil
| | - João S da Silva
- Plataforma de Medicina Translacional da Fundação Oswaldo Cruz e Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Ricardo Luís L da Silva
- Laboratório de Imunologia e Biologia Molecular, Universidade Federal de Sergipe, Aracaju, Brazil
- Departamento de Educação em Saúde, Universidade Federal de Sergipe, Lagarto, Brazil
| | - Amélia R de Jesus
- Laboratório de Imunologia e Biologia Molecular, Universidade Federal de Sergipe, Aracaju, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Sergipe, Aracaju, Brazil
- Departamento de Medicina, Hospital Universitário, Universidade Federal de Sergipe, Aracaju, Brazil
- Instituto de Investigação em Imunologia (iii), Instituto Nacional de Ciência e Tecnologia, São Paulo, Brazil
| | - Lucas S Magalhães
- Laboratório de Imunologia e Biologia Molecular, Universidade Federal de Sergipe, Aracaju, Brazil.
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Sergipe, Aracaju, Brazil.
- Setor de Parasitologia e Patologia, Instituto de Ciência Biológicas e da Saúde, Universidade Federal de Alagoas, Maceió, Brazil.
| | - Roque P de Almeida
- Laboratório de Imunologia e Biologia Molecular, Universidade Federal de Sergipe, Aracaju, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Sergipe, Aracaju, Brazil
- Departamento de Medicina, Hospital Universitário, Universidade Federal de Sergipe, Aracaju, Brazil
- Instituto de Investigação em Imunologia (iii), Instituto Nacional de Ciência e Tecnologia, São Paulo, Brazil
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Currier JS, Moser C, Eron JJ, Chew KW, Smith DM, Javan AC, Wohl DA, Daar ES, Hughes MD. ACTIV-2: A Platform Trial for the Evaluation of Novel Therapeutics for the Treatment of Early COVID-19 in Outpatients. J Infect Dis 2023; 228:S77-S82. [PMID: 37650231 PMCID: PMC10469341 DOI: 10.1093/infdis/jiad246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Clinical Trials Registration ClinicalTrials.gov Identifier: NCT04518410.
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Affiliation(s)
- Judith S Currier
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Carlee Moser
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joseph J Eron
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Kara W Chew
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Davey M Smith
- Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | | | - David Alain Wohl
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Eric S Daar
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Michael D Hughes
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Pandit JA, Radin JM, Chiang DC, Spencer EG, Pawelek JB, Diwan M, Roumani L, Mina MJ. The Coronavirus Disease 2019 Rebound Study: A Prospective Cohort Study to Evaluate Viral and Symptom Rebound Differences in Participants Treated With Nirmatrelvir Plus Ritonavir Versus Untreated Controls. Clin Infect Dis 2023; 77:25-31. [PMID: 36810665 PMCID: PMC10320179 DOI: 10.1093/cid/ciad102] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND The uptake of nirmatrelvir plus ritonavir (NPR) in patients with coronavirus disease 2019 (COVID-19) has been limited by concerns around the rebound phenomenon despite the scarcity of evidence around its epidemiology. The purpose of this study was to prospectively compare the epidemiology of rebound in NPR-treated and untreated participants with acute COVID-19 infection. METHODS We designed a prospective, observational study in which participants who tested positive for COVID-19 and were clinically eligible for NPR were recruited to be evaluated for either viral or symptom clearance and rebound. Participants were assigned to the treatment or control group based on their decision to take NPR. Following initial diagnosis, both groups were provided 12 rapid antigen tests and asked to test on a regular schedule for 16 days and answer symptom surveys. Viral rebound based on test results and COVID-19 symptom rebound based on patient-reported symptoms were evaluated. RESULTS Viral rebound incidence was 14.2% in the NPR treatment group (n = 127) and 9.3% in the control group (n = 43). Symptom rebound incidence was higher in the treatment group (18.9%) compared to controls (7.0%). There were no notable differences in viral rebound by age, gender, preexisting conditions, or major symptom groups during the acute phase or at the 1-month interval. CONCLUSIONS This preliminary report suggests that rebound after clearance of test positivity or symptom resolution is higher than previously reported. However, notably we observed a similar rate of rebound in both the NPR treatment and control groups. Large studies with diverse participants and extended follow-up are needed to better understand the rebound phenomena.
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Affiliation(s)
- Jay A Pandit
- Scripps Research Translational Institute, La Jolla, California, USA
| | - Jennifer M Radin
- Scripps Research Translational Institute, La Jolla, California, USA
| | | | - Emily G Spencer
- Scripps Research Translational Institute, La Jolla, California, USA
| | - Jeff B Pawelek
- Scripps Research Translational Institute, La Jolla, California, USA
| | - Mira Diwan
- Scripps Research Translational Institute, La Jolla, California, USA
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Hiremath S, Blake PG, Yeung A, McGuinty M, Thomas D, Ip J, Brown PA, Pandes M, Burke A, Sohail QZ, To K, Blackwell L, Oliver M, Jain AK, Chagla Z, Cooper R. Early Experience with Modified Dose Nirmatrelvir/Ritonavir in Dialysis Patients with Coronavirus Disease 2019. Clin J Am Soc Nephrol 2023; 18:485-490. [PMID: 36723285 PMCID: PMC10103226 DOI: 10.2215/cjn.0000000000000107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Nirmatrelvir/ritonavir was approved for use in high-risk outpatients with coronavirus disease 2019 (COVID-19). However, patients with severe CKD were excluded from the phase 3 trial, and the drug is not recommended for those with GFR <30 ml/min per 1.73 m 2 . On the basis of available pharmacological data, we developed a modified low-dose regimen of nirmatrelvir/ritonavir 300/100 mg on day 1, followed by 150/100 mg daily from day 2 to 5. In this study, we report our experience with this modified dose regimen in dialysis patients in the Canadian province of Ontario. METHODS We included dialysis patients who developed COVID-19 and were treated with the modified dose nirmatrelvir/ritonavir regimen during a 60-day period between April 1 and May 31, 2022. Details of nirmatrelvir/ritonavir use and outcomes were captured manually, and demographic data were obtained from a provincial database. Data are presented with descriptive statistics. The principal outcomes we describe are 30-day hospitalization, 30-day mortality, and required medication changes with the modified dose regimen. RESULTS A total of 134 dialysis patients with COVID-19 received nirmatrelvir/ritonavir during the period of study. Fifty-six percent were men, and the mean age was 64 years. Most common symptoms were cough and/or sore throat (60%). Medication interactions were common with calcium channel blockers, statins being the most frequent. Most patients (128, 96%) were able to complete the course of nirmatrelvir/ritonavir, and none of the patients who received nirmatrelvir/ritonavir died of COVID-19 in the 30 days of follow-up. CONCLUSIONS A modified dose of nirmatrelvir/ritonavir use was found to be safe and well tolerated, with no serious adverse events being observed in a small sample of maintenance dialysis patients.
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Affiliation(s)
- Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Angie Yeung
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Michaeline McGuinty
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Doneal Thomas
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Jane Ip
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Pierre Antoine Brown
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Pandes
- Division of Nephrology, Department of Medicine, Mackenzie Health, Richmond Hill, Ontario, Canada
| | - Andrew Burke
- Grand River Hospital, Kitchener-Waterloo, Ontario, Canada
| | - Qazi Zain Sohail
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Karen To
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lindsay Blackwell
- Department of Pharmacy, London Health Sciences Centre, London, Ontario, Canada
| | - Matthew Oliver
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Arsh K. Jain
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Zain Chagla
- Division of Infectious Disease, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
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Chen PY, Wang JT, Chang SY, Hung CC, Fang CT, Cheng A, Liu WD, Huang YS, Lin KY, Sun HY, Pan SC, Cheng YC, Wang HY, Sheng WH, Chen YC, Ho YL, Wu MS, Chang SC. Factors associated with viral rebound among COVID-19 patients receiving oral antivirals. J Formos Med Assoc 2023:S0929-6646(23)00062-1. [PMID: 36934018 PMCID: PMC9992060 DOI: 10.1016/j.jfma.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/16/2023] [Accepted: 02/20/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND COVID-19 rebound is usually reported among patients experiencing concurrent symptomatic and viral rebound. But longitudinal viral RT-PCR results from early stage to rebound of COVID-19 was less characterized. Further, identifying the factors associated with viral rebound after nirmatrelvir-ritonavir (NMV/r) and molnupiravir may expand understanding of COVID-19 rebound. METHODS We retrospectively analyzed clinical data and sequential viral RT-PCR results from COVID-19 patients receiving oral antivirals between April and May, 2022. Viral rebound was defined by the degree of viral load increase (ΔCt ≥ 5 units). RESULTS A total of 58 and 27 COVID-19 patients taking NMV/r and molnupiravir, respectively, were enrolled. Patients receiving NMV/r were younger, had fewer risk factors for disease progression and faster viral clearance rate compared to those receiving molnupiravr (All P < 0.05). The overall proportion of viral rebound (n = 11) was 12.9%, which was more common among patients receiving NMV/r (10 [17.2%] vs. 1 [3.7%], P = 0.16). Of them, 5 patients experienced symptomatic rebound, suggesting the proportion of COVID-19 rebound was 5.9%. The median interval to viral rebound was 5.0 (interquartile range, 2.0-8.0) days after completion of antivirals. Initial lymphopenia (<0.8 × 109/L) was associated with viral rebound among overall population (adjusted odds ratio [aOR], 5.34; 95% confidence interval [CI], 1.33-21.71), and remained significant (aOR, 4.50; 95% CI, 1.05-19.25) even when patients receiving NMV/r were considered. CONCLUSION Our data suggest viral rebound after oral antivirals may be more commonly observed among lymphopenic individuals in the context of SARS-CoV-2 Omicron BA.2 variant.
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Affiliation(s)
- Pao-Yu Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; National Institutes of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli, Taiwan.
| | - Sui-Yuan Chang
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Tropical Medicine and Parasitology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chi-Tai Fang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Aristine Cheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Da Liu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Shan Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuan-Yin Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Ching Pan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Cheng Cheng
- Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hurng-Yi Wang
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; National Institutes of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Lwun Ho
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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Deo R, Choudhary MC, Moser C, Ritz J, Daar ES, Wohl DA, Greninger AL, Eron JJ, Currier JS, Hughes MD, Smith DM, Chew KW, Li JZ. Symptom and Viral Rebound in Untreated SARS-CoV-2 Infection. Ann Intern Med 2023; 176:348-354. [PMID: 36802755 PMCID: PMC10052317 DOI: 10.7326/m22-2381] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Although symptom and viral rebound have been reported after nirmatrelvir-ritonavir treatment, the trajectories of symptoms and viral load during the natural course of COVID-19 have not been well described. OBJECTIVE To characterize symptom and viral rebound in untreated outpatients with mild to moderate COVID-19. DESIGN Retrospective analysis of participants in a randomized, placebo-controlled trial. (ClinicalTrials.gov: NCT04518410). SETTING Multicenter trial. PATIENTS 563 participants receiving placebo in the ACTIV-2/A5401 (Adaptive Platform Treatment Trial for Outpatients With COVID-19) platform trial. MEASUREMENTS Participants recorded the severity of 13 symptoms daily between days 0 and 28. Nasal swabs were collected for SARS-CoV-2 RNA testing on days 0 to 14, 21, and 28. Symptom rebound was defined as a 4-point increase in total symptom score after improvement any time after study entry. Viral rebound was defined as an increase of at least 0.5 log10 RNA copies/mL from the immediately preceding time point to a viral load of 3.0 log10 copies/mL or higher. High-level viral rebound was defined as an increase of at least 0.5 log10 RNA copies/mL to a viral load of 5.0 log10 copies/mL or higher. RESULTS Symptom rebound was identified in 26% of participants at a median of 11 days after initial symptom onset. Viral rebound was detected in 31% and high-level viral rebound in 13% of participants. Most symptom and viral rebound events were transient, because 89% of symptom rebound and 95% of viral rebound events occurred at only a single time point before improving. The combination of symptom and high-level viral rebound was observed in 3% of participants. LIMITATION A largely unvaccinated population infected with pre-Omicron variants was evaluated. CONCLUSION Symptom or viral relapse in the absence of antiviral treatment is common, but the combination of symptom and viral rebound is rare. PRIMARY FUNDING SOURCE National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Rinki Deo
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (R.D., M.C.C., J.Z.L.)
| | - Manish C Choudhary
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (R.D., M.C.C., J.Z.L.)
| | - Carlee Moser
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts (C.M., J.R., M.D.H.)
| | - Justin Ritz
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts (C.M., J.R., M.D.H.)
| | - Eric S Daar
- Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, California (E.S.D.)
| | - David A Wohl
- University of North Carolina, Chapel Hill, North Carolina (D.A.W., J.J.E.)
| | | | - Joseph J Eron
- University of North Carolina, Chapel Hill, North Carolina (D.A.W., J.J.E.)
| | - Judith S Currier
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California (J.S.C., K.W.C.)
| | - Michael D Hughes
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts (C.M., J.R., M.D.H.)
| | - Davey M Smith
- University of California, San Diego, San Diego, California (D.M.S.)
| | - Kara W Chew
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California (J.S.C., K.W.C.)
| | - Jonathan Z Li
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (R.D., M.C.C., J.Z.L.)
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10
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Savinkina A, Paltiel AD, Ross JS, Gonsalves G. Population-Level Strategies for Nirmatrelvir/Ritonavir Prescribing-A Cost-effectiveness Analysis. Open Forum Infect Dis 2022; 9:ofac637. [PMID: 36589482 PMCID: PMC9792084 DOI: 10.1093/ofid/ofac637] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022] Open
Abstract
Background New coronavirus disease 2019 (COVID-19) medications force decision-makers to weigh limited evidence of efficacy and cost in determining which patient populations to target for treatment. A case in point is nirmatrelvir/ritonavir, a drug that has been recommended for elderly, high-risk individuals, regardless of vaccination status, even though clinical trials have only evaluated it in unvaccinated patients. A simple optimization framework might inform a more reasoned approach to the trade-offs implicit in the treatment allocation decision. Methods We conducted a cost-effectiveness analysis using a decision-analytic model comparing 5 nirmatrelvir/ritonavir prescription policy strategies, stratified by vaccination status and risk for severe disease. We considered treatment effectiveness at preventing hospitalization ranging from 21% to 89%. Sensitivity analyses were performed on major parameters of interest. A web-based tool was developed to permit decision-makers to tailor the analysis to their settings and priorities. Results Providing nirmatrelvir/ritonavir to unvaccinated patients at high risk for severe disease was cost-saving when effectiveness against hospitalization exceeded 33% and cost-effective under all other data scenarios we considered. The cost-effectiveness of other allocation strategies, including those for vaccinated adults and those at lower risk for severe disease, depended on willingness-to-pay thresholds, treatment cost and effectiveness, and the likelihood of severe disease. Conclusions Priority for nirmatrelvir/ritonavir treatment should be given to unvaccinated persons at high risk of severe disease from COVID-19. Further priority may be assigned by weighing treatment effectiveness, disease severity, drug cost, and willingness to pay for deaths averted.
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Affiliation(s)
- Alexandra Savinkina
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
- Public Health Modeling Unit, Yale School of Public Health, New Haven, Connecticut, USA
| | - A David Paltiel
- Public Health Modeling Unit, Yale School of Public Health, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Joseph S Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
- Section of General Internal Medicine and the National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Gregg Gonsalves
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
- Public Health Modeling Unit, Yale School of Public Health, New Haven, Connecticut, USA
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