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Owens K, Esmaeili S, Schiffer JT. Heterogeneous SARS-CoV-2 kinetics due to variable timing and intensity of immune responses. JCI Insight 2024; 9:e176286. [PMID: 38573774 PMCID: PMC11141931 DOI: 10.1172/jci.insight.176286] [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: 09/29/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
The viral kinetics of documented SARS-CoV-2 infections exhibit a high degree of interindividual variability. We identified 6 distinct viral shedding patterns, which differed according to peak viral load, duration, expansion rate, and clearance rate, by clustering data from 768 infections in the National Basketball Association cohort. Omicron variant infections in previously vaccinated individuals generally led to lower cumulative shedding levels of SARS-CoV-2 than other scenarios. We then developed a mechanistic mathematical model that recapitulated 1,510 observed viral trajectories, including viral rebound and cases of reinfection. Lower peak viral loads were explained by a more rapid and sustained transition of susceptible cells to a refractory state during infection as well as by an earlier and more potent late, cytolytic immune response. Our results suggest that viral elimination occurs more rapidly during Omicron infection, following vaccination, and following reinfection due to enhanced innate and acquired immune responses. Because viral load has been linked with COVID-19 severity and transmission risk, our model provides a framework for understanding the wide range of observed SARS-CoV-2 infection outcomes.
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Affiliation(s)
- Katherine Owens
- Fred Hutchinson Cancer Center, Vaccine and Infectious Diseases Division, Seattle, Washington, USA
| | - Shadisadat Esmaeili
- Fred Hutchinson Cancer Center, Vaccine and Infectious Diseases Division, Seattle, Washington, USA
| | - Joshua T. Schiffer
- Fred Hutchinson Cancer Center, Vaccine and Infectious Diseases Division, Seattle, Washington, USA
- University of Washington, Department of Medicine, Seattle, Washington, USA
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2
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Owens K, Esmaeili-Wellman S, Schiffer JT. Heterogeneous SARS-CoV-2 kinetics due to variable timing and intensity of immune responses. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.08.20.23294350. [PMID: 37662228 PMCID: PMC10473815 DOI: 10.1101/2023.08.20.23294350] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
The viral kinetics of documented SARS-CoV-2 infections exhibit a high degree of inter-individual variability. We identified six distinct viral shedding patterns, which differed according to peak viral load, duration, expansion rate and clearance rate, by clustering data from 768 infections in the National Basketball Association cohort. Omicron variant infections in previously vaccinated individuals generally led to lower cumulative shedding levels of SARS-CoV-2 than other scenarios. We then developed a mechanistic mathematical model that recapitulated 1510 observed viral trajectories, including viral rebound and cases of reinfection. Lower peak viral loads were explained by a more rapid and sustained transition of susceptible cells to a refractory state during infection, as well as an earlier and more potent late, cytolytic immune response. Our results suggest that viral elimination occurs more rapidly during omicron infection, following vaccination, and following re-infection due to enhanced innate and acquired immune responses. Because viral load has been linked with COVID-19 severity and transmission risk, our model provides a framework for understanding the wide range of observed SARS-CoV-2 infection outcomes.
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Affiliation(s)
- Katherine Owens
- Fred Hutchinson Cancer Center, Vaccine and Infectious Diseases Division
| | | | - Joshua T Schiffer
- Fred Hutchinson Cancer Center, Vaccine and Infectious Diseases Division
- University of Washington, Department of Medicine
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Yang F, Tran TNA, Howerton E, Boni MF, Servadio JL. Benefits of near-universal vaccination and treatment access to manage COVID-19 burden in the United States. BMC Med 2023; 21:321. [PMID: 37620926 PMCID: PMC10463609 DOI: 10.1186/s12916-023-03025-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND As we continue the fourth year of the COVID-19 epidemic, SARS-CoV-2 infections still cause high morbidity and mortality in the United States. During 2020-2022, COVID-19 was one of the leading causes of death in the United States and by far the leading cause among infectious diseases. Vaccination uptake remains low despite this being an effective burden reducing intervention. The development of COVID-19 therapeutics provides hope for mitigating severe clinical outcomes. This modeling study examines combined strategies of vaccination and treatment to reduce the burden of COVID-19 epidemics over the next decade. METHODS We use a validated mathematical model to evaluate the reduction of incident cases, hospitalized cases, and deaths in the United States through 2033 under various levels of vaccination and treatment coverage. We assume that future seasonal transmission patterns for COVID-19 will be similar to those of influenza virus and account for the waning of infection-induced immunity and vaccine-induced immunity in a future with stable COVID-19 dynamics. Due to uncertainty in the duration of immunity following vaccination or infection, we consider three exponentially distributed waning rates, with means of 365 days (1 year), 548 days (1.5 years), and 730 days (2 years). We also consider treatment failure, including rebound frequency, as a possible treatment outcome. RESULTS As expected, universal vaccination is projected to eliminate transmission and mortality. Under current treatment coverage (13.7%) and vaccination coverage (49%), averages of 81,000-164,600 annual reported deaths, depending on duration of immunity, are expected by the end of this decade. Annual mortality in the United States can be reduced below 50,000 per year with 52-80% annual vaccination coverage and below 10,000 annual deaths with 59-83% annual vaccination coverage, depending on duration of immunity. Universal treatment reduces hospitalizations by 88.6% and deaths by 93.1% under current vaccination coverage. A reduction in vaccination coverage requires a comparatively larger increase in treatment coverage in order for hospitalization and mortality levels to remain unchanged. CONCLUSIONS Adopting universal vaccination and universal treatment goals in the United States will likely lead to a COVID-19 mortality burden below 50,000 deaths per year, a burden comparable to that of influenza virus.
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Affiliation(s)
- Fuhan Yang
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, USA
| | - Thu Nguyen-Anh Tran
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, USA
| | - Emily Howerton
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, USA
| | - Maciej F Boni
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, USA.
| | - Joseph L Servadio
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, 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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Yang F, Tran TNA, Howerton E, Boni MF, Servadio JL. Benefits of near-universal vaccination and treatment access to manage COVID-19 burden in the United States. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.08.23285658. [PMID: 36798204 PMCID: PMC9934803 DOI: 10.1101/2023.02.08.23285658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Background As we enter the fourth year of the COVID-19 pandemic, SARS-CoV-2 infections still cause high morbidity and mortality in the United States. During 2020-2022, COVID-19 was one of the leading causes of death in the United States and by far the leading cause among infectious diseases. Vaccination uptake remains low despite this being an effective burden reducing intervention. The development of COVID-19 therapeutics provides hope for mitigating severe clinical outcomes. This modeling study examines combined strategies of vaccination and treatment to reduce the burden of COVID-19 epidemics over the next decade. Methods We use a validated mathematical model to evaluate the reduction of incident cases, hospitalized cases, and deaths in the United States through 2033 under various levels of vaccination and treatment coverage. We assume that future seasonal transmission patterns for COVID-19 will be similar to those of influenza virus. We account for the waning of infection-induced immunity and vaccine-induced immunity in a future with stable COVID-19 dynamics. Due to uncertainty in the duration of immunity following vaccination or infection, we consider two exponentially-distributed waning rates, with means of 365 days (one year) and 548 days (1.5 years). We also consider treatment failure, including rebound frequency, as a possible treatment outcome. Results As expected, universal vaccination is projected to eliminate transmission and mortality. Under current treatment coverage (13.7%) and vaccination coverage (49%), averages of 89,000 annual deaths (548-day waning) and 120,000 annual deaths (365-day waning) are expected by the end of this decade. Annual mortality in the United States can be reduced below 50,000 per year with >81% annual vaccination coverage, and below 10,000 annual deaths with >84% annual vaccination coverage. Universal treatment reduces hospitalizations by 88% and deaths by 93% under current vaccination coverage. A reduction in vaccination coverage requires a comparatively larger increase in treatment coverage in order for hospitalization and mortality levels to remain unchanged. Conclusions Adopting universal vaccination and universal treatment goals in the United States will likely lead to a COVID-19 mortality burden below 50,000 deaths per year, a burden comparable to that of influenza virus.
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Affiliation(s)
- Fuhan Yang
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, United States
| | - Thu Nguyen-Anh Tran
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, United States
| | - Emily Howerton
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, United States
| | - Maciej F Boni
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, United States
| | - Joseph L Servadio
- Department of Biology and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, 16802, United States
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Sommer I, Dobrescu A, Ledinger D, Moser I, Thaler K, Persad E, Fangmeyer M, Emprechtinger R, Klerings I, Gartlehner G. Outpatient Treatment of Confirmed COVID-19: A Living, Rapid Review for the American College of Physicians. Ann Intern Med 2023; 176:92-104. [PMID: 36442056 PMCID: PMC9709728 DOI: 10.7326/m22-2202] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Clinicians and patients want to know the benefits and harms of outpatient treatment options for SARS-CoV-2 infection. PURPOSE To assess the benefits and harms of 12 different COVID-19 treatments in the outpatient setting. DATA SOURCES Epistemonikos COVID-19 L·OVE Platform, searched on 4 April 2022. STUDY SELECTION Two reviewers independently screened abstracts and full texts against a priori-defined criteria. Randomized controlled trials (RCTs) that compared COVID-19 treatments in adult outpatients with confirmed SARS-CoV-2 infection were included. DATA EXTRACTION One reviewer extracted data and assessed risk of bias and certainty of evidence (COE). A second reviewer verified data abstraction and assessments. DATA SYNTHESIS The 26 included studies collected data before the emergence of the Omicron variant. Nirmatrelvir-ritonavir and casirivimab-imdevimab probably reduced hospitalizations (1% vs. 6% [1 RCT] and 1% vs. 4% [1 RCT], respectively; moderate COE). Nirmatrelvir-ritonavir probably reduced all-cause mortality (0% vs. 1% [1 RCT]; moderate COE), and regdanvimab probably improved recovery (87% vs. 72% [1 RCT]; moderate COE). Casirivimab-imdevimab reduced time to recovery by a median difference of 4 days (10 vs. 14 median days [1 RCT]; high COE). Molnupiravir may reduce all-cause mortality, sotrovimab may reduce hospitalization, and remdesivir may improve recovery (low COE). Lopinavir-ritonavir and azithromycin may have increased harms, and hydroxychloroquine may result in lower recovery rates (low COE). Other treatments had insufficient evidence or no statistical difference in efficacy and safety versus placebo. LIMITATION Many outcomes had few events and small samples. CONCLUSION Some antiviral medications and monoclonal antibodies may improve outcomes for outpatients with mild to moderate COVID-19. However, the generalizability of the findings to the currently dominant Omicron variant is limited. PRIMARY FUNDING SOURCE American College of Physicians. (PROSPERO: CRD42022323440).
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Affiliation(s)
- Isolde Sommer
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., A.D., D.L., I.M., K.T., E.P., M.F., I.K.)
| | - Andreea Dobrescu
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., A.D., D.L., I.M., K.T., E.P., M.F., I.K.)
| | - Dominic Ledinger
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., A.D., D.L., I.M., K.T., E.P., M.F., I.K.)
| | - Isabel Moser
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., A.D., D.L., I.M., K.T., E.P., M.F., I.K.)
| | - Kylie Thaler
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., A.D., D.L., I.M., K.T., E.P., M.F., I.K.)
| | - Emma Persad
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., A.D., D.L., I.M., K.T., E.P., M.F., I.K.)
| | - Martin Fangmeyer
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., A.D., D.L., I.M., K.T., E.P., M.F., I.K.)
| | - Robert Emprechtinger
- Faculty of Health and Medicine, University for Continuing Education Krems (Danube University Krems), Krems, Austria (R.E.)
| | - Irma Klerings
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., A.D., D.L., I.M., K.T., E.P., M.F., I.K.)
| | - Gerald Gartlehner
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria, and RTI International, Research Triangle Park, North Carolina (G.G.)
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Wong GLH, Yip TCF, Lai MSM, Wong VWS, Hui DSC, Lui GCY. Incidence of Viral Rebound After Treatment With Nirmatrelvir-Ritonavir and Molnupiravir. JAMA Netw Open 2022; 5:e2245086. [PMID: 36472873 PMCID: PMC9856258 DOI: 10.1001/jamanetworkopen.2022.45086] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/11/2022] [Indexed: 12/12/2022] Open
Abstract
Importance Some patients treated with nirmatrelvir-ritonavir have experienced rebound of COVID-19 infections and symptoms; however, data are scarce on whether viral rebound also occurs in patients with COVID-19 receiving or not receiving molnupiravir. Objective To examine the incidence of viral rebound in patients with COVID-19 who were treated with the oral antiviral agents nirmatrelvir-ritonavir and molnupiravir. Design, Setting, and Participants This cohort study identified 41 255 patients with COVID-19 who were hospitalized from January 1, 2022, to March 31, 2022, in Hong Kong and assessed 12 629 patients with serial cycle threshold (Ct) values measured. Patients were followed up until the occurrence of the clinical end point of interest, death, date of data retrieval (July 31, 2022), or up to 30 days of follow-up, whichever came first. Exposures Molnupiravir or nirmatrelvir-ritonavir treatment. Main Outcomes and Measures Viral rebound, defined as a Ct value greater than 40 that decreased to 40 or less. Results Of 12 629 patients (mean [SD] age, 65.4 [20.9] years; 6624 [52.5%] male), 11 688 (92.5%) were oral antiviral nonusers, 746 (5.9%) were molnupiravir users, and 195 (1.5%) were nirmatrelvir-ritonavir users. Compared with nonusers, oral antiviral users were older, had more comorbidities, and had lower complete vaccination rates. The mean (SD) baseline Ct value was slightly higher in nirmatrelvir-ritonavir users (22.2 [6.0]) than nonusers (21.0 [5.4]) and molnupiravir users (20.9 [5.4]) (P = .04). Viral rebound occurred in 68 nonusers (0.6%), 2 nirmatrelvir-ritonavir users (1.0%), and 6 molnupiravir users (0.8%). Among 76 patients with viral rebound, 12 of 68 nonusers, 1 of 6 molnupiravir users, and neither of the nirmatrelvir-ritonavir users died of COVID-19. Conclusions and Relevance In this cohort study, viral rebound was uncommon in patients taking molnupiravir or nirmatrelvir-ritonavir and was not associated with increased risk of mortality. Given these findings, novel oral antivirals should be considered as a treatment for more patients with COVID-19 in the early phase of the infection.
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Affiliation(s)
- Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Terry Cheuk-Fung Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Mandy Sze-Man Lai
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - David Shu-Cheong Hui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Stanley Ho Centre for Emerging Infectious Diseases, Jockey Club School of Public Health & Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Grace Chung-Yan Lui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- Stanley Ho Centre for Emerging Infectious Diseases, Jockey Club School of Public Health & Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
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9
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Betrosian AP, Christou SM, Kalathaki S. COVID-19 rebound after oral treatment in a nursing home facility: A case series. INFECTIOUS MEDICINE 2022; 1:285-287. [PMID: 38013912 PMCID: PMC9664743 DOI: 10.1016/j.imj.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/12/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022]
Abstract
Paxlovid (nirmatrevir/ritonavir) is a 2 drug regimen taken together twice daily for 5 days was authorized for emergency use for nonhospitalized patients who are at risk for the progression of coronavirus disease (COVID-19). However, recurrence of symptoms 2-8 days after completing the treatment course has been recently recognized. In some cases patients tested negative on a direct SARS-CoV-2 viral test and then tested positive again (rebound COVID-19). The disease is mild and requires no additional antiviral treatment. Data are limited based on anecdotal case reports and few studies. According to the available data it is unclear if rebound symptoms are due to the drug treatment, drug resistance, re-infection or impaired immunity.
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Affiliation(s)
- Alex P Betrosian
- Evgenidion Hospital, Athens University, Papadiamantopoulou 20, 11527 Athens, Greece
- Kallisto Skilled Nursing Facility, Athens, Greece
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