Efficacy and safety of baricitinib in hospitalized adults with severe or critical COVID-19 (Bari-SolidAct): a randomised, double-blind, placebo-controlled phase 3 trial

BACKGROUND

Baricitinib has shown efficacy in hospitalized patients with COVID-19, but no placebo-controlled trials have focused specifically on severe/critical COVID, including vaccinated participants.

METHODS

Bari-SolidAct is a phase-3, multicentre, randomised, double-blind, placebo-controlled trial, enrolling participants from June 3, 2021 to March 7, 2022, stopped prematurely for external evidence. Patients with severe/critical COVID-19 were randomised to Baricitinib 4 mg once daily or placebo, added to standard of care. The primary endpoint was all-cause mortality within 60 days. Participants were remotely followed to day 90 for safety and patient related outcome measures.

RESULTS

Two hundred ninety-nine patients were screened, 284 randomised, and 275 received study drug or placebo and were included in the modified intent-to-treat analyses (139 receiving baricitinib and 136 placebo). Median age was 60 (IQR 49-69) years, 77% were male and 35% had received at least one dose of SARS-CoV2 vaccine. There were 21 deaths at day 60 in each group, 15.1% in the baricitinib group and 15.4% in the placebo group (adjusted absolute difference and 95% CI - 0.1% [- 8·3 to 8·0]). In sensitivity analysis censoring observations after drug discontinuation or rescue therapy (tocilizumab/increased steroid dose), proportions of death were 5.8% versus 8.8% (- 3.2% [- 9.0 to 2.7]), respectively. There were 148 serious adverse events in 46 participants (33.1%) receiving baricitinib and 155 in 51 participants (37.5%) receiving placebo. In subgroup analyses, there was a potential interaction between vaccination status and treatment allocation on 60-day mortality. In a subsequent post hoc analysis there was a significant interaction between vaccination status and treatment allocation on the occurrence of serious adverse events, with more respiratory complications and severe infections in vaccinated participants treated with baricitinib. Vaccinated participants were on average 11 years older, with more comorbidities.

CONCLUSION

This clinical trial was prematurely stopped for external evidence and therefore underpowered to conclude on a potential survival benefit of baricitinib in severe/critical COVID-19. We observed a possible safety signal in vaccinated participants, who were older with more comorbidities. Although based on a post-hoc analysis, these findings warrant further investigation in other trials and real-world studies. Trial registration Bari-SolidAct is registered at NCT04891133 (registered May 18, 2021) and EUClinicalTrials.eu ( 2022-500385-99-00 ).

Health system barriers to HPV vaccination in marginalized Roma communities in Slovakia

Background

People from marginalized Roma communities often experience poverty, limited access to education, employment, housing, and health care (HC). The aim of the study was to explore the perceptions of people from marginalized Roma communities and health professionals regarding health system (HS) barriers to HPV vaccination.

Methods

A qualitative study was conducted in the Kosice region as a part of the RIVER-EU project. Semi-structured interviews with marginalized Roma parents (N = 18), children (N = 15), and health professionals (N = 18) were audio-recorded and thematic analysis of the transcripts was performed in MAXQDA.

Findings

Four main themes were identified regarding HS barriers: 1. Lack of information (lack of culturally and linguistically appropriate information, lack of information provision from HC providers, unreliable and conflicting information on the internet), 2. Restricted access to HC providers (lack of capacities, work overload, long wait in the waiting room, distance, traffic connection), 3. Financial and organizational barriers (limited coverage of vaccination expenses from health insurance, picking up prescribed vaccines in a pharmacy by parents, parental consent), 4. Attitudes and behaviours of HC providers (neglect of care, double standard, inappropriate behaviour and communication, prejudices, racism).

Conclusions

The reasoning and perception of several barriers to HPV vaccination differ among groups of respondents. Nevertheless, HPV is not viewed as a priority by both - marginalized Roma and health professionals. HS fails to reach marginalized Roma with appropriate information about HPV and HPV vaccination. Moreover, the lack of capacities and motivation of HC providers to address these topics lead to a lack of awareness. Organization and health insurance coverage of vaccination pose additional barriers to HPV vaccination.

Occurrence of cryptosporidium parvum IIaA17G1R1 in hospitalized hemato-oncological patients in Slovakia

This study aimed to determine the presence of cryptosporidiosis in immunosuppressed patients hospitalized at the Clinic of Haematology and Oncohaematology in a form of routine screening. Samples were collected from November 2019 to February 2020, when the first wave of the Coronavirus pandemic occurred in Slovakia. A total of 36 samples were collected from patients hospitalized at the Clinic of Haematology and Oncohaematology, both from the open ward and the intensive care unit. For the diagnosis of cryptosporidiosis, a nested PCR targeting the gp60 gene and the SSU rRNA locus was used. From the 36 samples, Cryptosporidium parvum subtype IIaA17G1R1 was diagnosed in 9 patients (7 from the open ward and 2 from the intensive care unit), all hospitalized at the clinic at the same time, in February 2020. The occurrence of the same species and subtype, Cryptosporidium parvum IIaA17G1R1, in 9 patients hospitalized at the same time, both at the open ward and the intensive care unit may suggest a possible transmission occurred at the clinic.

Epidemiology and clinical course of primary biliary cholangitis in Eastern Slovakia

OBJECTIVE

To determine both the incidence and the prevalence of primary biliary cholangitis (PBC) in Eastern Slovakia and to describe its clinical course and the response to ursodeoxycholic acid (UDCA).

METHODS

We recorded data of patients with PBC, who were followed up in gastroenterology and hepatology centers in Eastern Slovakia during the period from June 30, 1999, through June 30, 2019.

RESULTS

The annual incidence of PBC varied from 0.7 to 1.5 cases per 100,000 inhabitants between 2014 and 2018. PBC prevalence steadily increased from initial 10.2 cases per 100,000 inhabitants in 2014 to 14.9 cases per 100,000 inhabitants in June 2019. The mean age at the time of diagnosis was 56.3 ± 10.9 years. 95.7% of patients were females, and female/male gender ratio was 22.3:1. In June 2019, prevalence in the female population was 28 cases per 100,000 women. At the time of diagnosis, three-quarters of patients were symptomatic and 10% of patients had liver cirrhosis. The mean follow-up was 7.3 ± 5.2 years. Response to UDCA was observed in 72.1% of patients. Patients with higher baseline alkaline phosphatase (ALP) levels, liver cirrhosis at entry or at the end of follow-up and women younger than 45 years responded worse to UDCA. One-quarter of patients had liver cirrhosis at the end of follow-up. During follow-up, 1.6% of patients underwent liver transplantation and 5.5% of patients died. Five-year and 10-year liver-related mortalities were 2.7% and 4.3%, respectively.

CONCLUSION

PBC prevalence in Eastern Slovakia is increasing, and most of the patients respond to therapy with UDCA.

What is the Role of the Horizontal Transmission of Hepatitis B Virus Infection in Young Adult and Middle-Aged Roma Population Living in the Settlements in East Slovakia?

Background: The aim of our work is to objectify the manner of transmission of HBV infection in young adult and middle-aged Roma people who live in the settlements. Methods: We used data from the cross-sectional study HepaMeta. We analyzed Roma people living in the settlements in East Slovakia, who have had HBsAg and anti HBc IgG antibodies examined. Results: We analyzed a cohort of 452 Roma participants with a mean of age 34.67 ± 9.14 years—159 (35.2%) were males. HBsAg positivity was diagnosed in 12.4% and the presence of anti HBc IgG antibodies was confirmed in 52% of participants. Prevalence of HBsAg positivity increases significantly with higher age, (p = 0.026), as well as the presence of anti HBc IgG antibodies (p < 0.0001). The prevalence of HBsAg positivity has doubled and anti HBc IgG positivity has tripled within two decades (<25 years vs. 35–45 years) in Roma settlements in East Slovakia. Conclusions: These findings allow us to express an opinion that horizontal transmission in adulthood may play an important role in the spreading of HBV infection.

The Roma Population Living in Segregated Settlements in Eastern Slovakia Has a Higher Prevalence of Metabolic Syndrome, Kidney Disease, Viral Hepatitis B and E, and Some Parasitic Diseases Compared to the Majority Population

Background: The Roma population is one of the largest marginalized population groups in Europe. The aim of our work was to summarize the morbidity of lifestyle-related diseases and infectious diseases in the Roma population living in segregated settlements. Methods: We used data from the cross-sectional study HepaMeta, in which we examined 452 Roma subjects with an average age of 34.7 ± 9.1 years, 35.2% of which were men, and 403 non-Roma subjects with an average age of 33.5 ± 7.4 years, 45.9% of which were men. We collected data by means of a questionnaire, anthropometric measures, and we analyzed blood and urine samples. Results: Roma subjects had a higher incidence of metabolic syndrome (RR: 1.478 (1.159-1.885), p < 0.0001), obesity or waist circumference >94 cm in men/80 cm in women (RR: 1.287 (1.127-1.470), p < 0.0001), and HDL-C < 1.03 mmol/L in men or <1.29 in women (RR: 2.004 (1.730-2.321), p < 0.0001) than their non-Roma counterparts. Subjects of the Roma population were more frequently diagnosed with kidney disease (RR: 1.216 (1.096-1.349), p < 0.0001), HBsAg positivity (RR: 4.468 (2.373-8.415), p < 0.0001), anti HBc IgG positivity (RR: 3.13 (2.598-4.224), p < 0.0001), and anti HEV positivity (RR: 2.972 (1.226-7.287), p < 0.0001). Serological markers of Toxoplasma gondii infection and Toxocara spp. were observed much more frequently among Roma than non-Roma subjects (RR: 1.868 (1.520-2.296), p < 0.0001, for Toxoplasma gondii; and RR: 21.812 (8.097-58.761), p < 0.0001, for Toxocara spp.). Conclusions: Poor socio-economic conditions, an unhealthy lifestyle, and barriers precluding access to healthcare are factors that affect the Roma population in settlements and lead to an increased prevalence of metabolic syndrome and its components, kidney disease, viral hepatitis B and E, and some parasitic diseases.

Urogenital chlamydiosis among Slovak women

OBJECTIVE

To investigate the prevalence of urogenital chlamydial infections in women from Eastern Slovakia and to compare the occurrence in women with and without clinical signs of disease.

MATERIAL AND METHODS

We examined a total of 1978 women from Eastern Slovakia for the presence of C. trachomatis over a three year period. Antichlamydial antibodies of classes IgG and IgA were detected by ELISA while PCR was applied to detect pathogen.

RESULTS

3.6 % of the population had presence of antibodies while 10.1 % of the women showed presence of bacteria by PCR.

CONCLUSIONS

Obtained results when compared with clinical examination revealed clear distinction, which was age dependent. Lower age categories were more likely affected by acute infection with positivity for IgA and IgG antibodies as well as PCR. Middle age categories showed significantly higher level of IgG antibodies in comparison to IgA, while pathogen was readily detected by PCR. In women older than 51 years the results reflected more likely a past infection that is presence of only IgG and negative PCR (Tab. 4, Ref. 18).

Immune response to Encephalitozoon infection review

The microsporidia are emerging agents of infectious disease in both immunocompromised and immunocompetent mammals. Recently, there has been an increased interest in studying the immunobiology of microsporidiosis. This paper discusses the humoral and cell-mediated immune responses to Encephalitozoon spp. The T-cell-mediated responses appear to be most important in conferring resistance. This has become evident by the lethal effects of microsporidiosis in T-cell-deficient hosts. However, much still needs to be learned about the immunobiology of microsporidiosis regarding the specific T-cell responses and the cytokines that provide protective immunity and facilitate the macrophage-mediated killing of microsporidia. Such information will become important in developing immunotherapeutic strategies to control microsporidiosis in the future.

Occurrence of IgG antibodies to Anaplasma phagocytophilum in humans suspected of Lyme borreliosis in eastern Slovakia

Human granulocytic anaplasmosis (HGA) and Lyme borreliosis (LB) are tick-borne and emerging infectious diseases caused by the Anaplasma phagocytophilum and Borrelia burgdorferi species. In Europe, including Slovakia, the principal vector of both pathogens is the common tick - Ixodes ricinus, in which double infections with these pathogens have been reported. The aim of our study was evidence of IgG antibodies against A. phagocytophilum in blood sera of humans with suspects LB from several Clinics of University Hospitals, and the evaluation of the possibility of B. burgdorferi and A. phagocytophilum co-infection in examined patients. The serological method ELISA was used to detect IgM and IgG antibodies against B. burgdorferi. Anti-A. phagocytophilum IgG antibodies were analyzed by the A. phagocytophilum Indirect Immunofluorescence Antibody (IFA) IgG test. A total of 214 human samples (91 men, 123 women) were obtained from patients living in Kosice town and in villages around Kosice (Eastern Slovakia). IgG antibodies against A. phagocytophilum were detected in 15 cases (6 men, 9 women), which represented 7.0 % positivity. Two cases of the co-infection B. burgdorferi with A. phagocytophilum, which equals 0.93 % of the total number, were found.

Molecular evidence for Anaplasma phagocytophilum and Borrelia burgdorferi sensu lato in Ixodes ricinus ticks from eastern Slovakia

Ixodes ricinus ticks (20 males, 20 females and 20 nymphs) collected in Kosice, Slovakia were examined for the presence of Anaplasma phagocytophilum and Borrelia burgdorferi sensu lato (s.l.) by PCR. 38.3 % of the tested ticks carried single infection of B. burgdorferi s.l. and 8.3 % were infected with A. phagocytophilum. Double infection of both pathogens was detected in 5 % of tested ticks. These results indicate that both B. burgdorferi s.l. and A. phagocytophilum co-circulate in the enzootic sites of Eastern Slovakia and may cause co-infection in humans.