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Dong TQ, Brown ER. A joint Bayesian hierarchical model for estimating SARS-CoV-2 genomic and subgenomic RNA viral dynamics and seroconversion. Biostatistics 2024; 25:336-353. [PMID: 37490631 DOI: 10.1093/biostatistics/kxad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/26/2023] [Accepted: 07/06/2023] [Indexed: 07/27/2023] Open
Abstract
Understanding the viral dynamics of and natural immunity to the severe acute respiratory syndrome coronavirus 2 is crucial for devising better therapeutic and prevention strategies for coronavirus disease 2019 (COVID-19). Here, we present a Bayesian hierarchical model that jointly estimates the genomic RNA viral load, the subgenomic RNA (sgRNA) viral load (correlated to active viral replication), and the rate and timing of seroconversion (correlated to presence of antibodies). Our proposed method accounts for the dynamical relationship and correlation structure between the two types of viral load, allows for borrowing of information between viral load and antibody data, and identifies potential correlates of viral load characteristics and propensity for seroconversion. We demonstrate the features of the joint model through application to the COVID-19 post-exposure prophylaxis study and conduct a cross-validation exercise to illustrate the model's ability to impute the sgRNA viral trajectories for people who only had genomic RNA viral load data.
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Affiliation(s)
- Tracy Q Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Avenue N, Seattle, WA 98109, USA
| | - Elizabeth R Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Avenue N, Seattle, WA 98109, USA
- Department of Biostatistics, University of Washington, 3980 15th Avenue NE, Seattle, WA 98195, USA
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Stalter RM, Dong TQ, Hendrix CW, Palanee-Phillips T, van der Straten A, Hillier SL, Kiweewa FM, Mgodi NM, Marzinke MA, Bekker LG, Soto-Torres L, Baeten JM, Brown ER. Assessing Per-Sex-Act HIV-1 Risk Reduction Among Women Using the Dapivirine Vaginal Ring. J Infect Dis 2024; 229:1158-1165. [PMID: 38099506 PMCID: PMC11011174 DOI: 10.1093/infdis/jiad550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 11/10/2023] [Accepted: 12/13/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Confounding introduced by individuals' sexual risk behavior is potentially a significant source of bias in HIV-1 prevention intervention studies. To more completely account for sexual behaviors when assessing the efficacy of the monthly dapivirine ring, a new longer-acting HIV-1 prevention option for women, we estimated per-sex-act risk reduction associated with product use. METHODS We conducted a secondary analysis of data from MTN-020/ASPIRE, a phase 3, randomized, placebo-controlled efficacy trial of the dapivirine ring that recruited HIV-uninfected, African women aged 18-45 years. With cumulative sex acts as the time scale, we used multivariable Cox regression with inverse probability of censoring weights to estimate HIV-1 risk reduction associated with a rate of dapivirine release indicative of consistent product use. RESULTS Women in the dapivirine ring group (n = 1187) had an estimated incidence rate of 2.3 (95% confidence interval [CI], 1.8-3.1) HIV-1 acquisition events per 10 000 sex acts versus 3.6 (95% CI, 2.9-4.4) per 10 000 acts in the placebo group (n = 1187). Dapivirine release indicative of consistent ring use was associated with a 63% (95% CI, 33%-80%) per-sex-act HIV-1 risk reduction. CONCLUSIONS These results support the efficacy of the dapivirine vaginal ring for HIV-1 prevention and help to inform decision-making for women, providers, and policymakers regarding product use. CLINICAL TRIALS REGISTRATION NCT01617096.
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Affiliation(s)
- Randy M Stalter
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Tracy Q Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thesla Palanee-Phillips
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Wits Reproductive Health and HIV Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- ASTRA consulting, Kensington, CA, USA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Flavia M Kiweewa
- Research Department, Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Nyaradzo M Mgodi
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Departments of Medicine and Global Health, University of Washington, Seattle, WA, USA
| | - Elizabeth R Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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Deming ME, Dong TQ, Agrawal V, Mills MG, Huang MLW, Greninger AL, Jerome KR, Wener MH, Paasche-Orlow MK, Kissinger P, Luk A, Hoffman RM, Stewart J, Kottkamp AC, Bershteyn A, Chu HY, Stankiewicz Karita HC, Johnston CM, Wald A, Barnabas R, Brown ER, Neuzil KM. Detection and Kinetics of Subgenomic Severe Acute Respiratory Syndrome Coronavirus 2 RNA Viral Load in Longitudinal Diagnostic RNA-Positive Samples. J Infect Dis 2022; 226:788-796. [PMID: 35150571 PMCID: PMC8903395 DOI: 10.1093/infdis/jiac048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/09/2022] [Indexed: 11/14/2022] Open
Abstract
While detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by diagnostic reverse-transcription polymerase chain reaction (RT-PCR) is highly sensitive for viral RNA, the nucleic acid amplification of subgenomic RNAs (sgRNAs) that are the product of viral replication may more accurately identify replication. We characterized the diagnostic RNA and sgRNA detection by RT-PCR from nasal swab samples collected daily by participants in postexposure prophylaxis or treatment studies for SARS-CoV-2. Among 1932 RT-PCR-positive swab samples with sgRNA tests, 40% (767) had detectable sgRNA. Above a diagnostic RNA viral load (VL) threshold of 5.1 log10 copies/mL, 96% of samples had detectable sgRNA with VLs that followed a linear trend. The trajectories of diagnostic RNA and sgRNA VLs differed, with 80% peaking on the same day but duration of sgRNA detection being shorter (8 vs 14 days). With a large sample of daily swab samples we provide comparative sgRNA kinetics and a diagnostic RNA threshold that correlates with replicating virus independent of symptoms or duration of illness.
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Affiliation(s)
- Meagan E Deming
- The Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tracy Q Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson, Cancer Research Center, Seattle, Washington, USA
| | - Vaidehi Agrawal
- The Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Margaret G Mills
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Meei Li W Huang
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Alexander L Greninger
- Vaccine and Infectious Disease Division, Fred Hutchinson, Cancer Research Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson, Cancer Research Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Mark H Wener
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Division of Rheumatology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Patricia Kissinger
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine
| | - Alfred Luk
- Section of Infectious Diseases, John W. Deming, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Risa M Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Jenell Stewart
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Division of Infectious Diseases & Immunology, Department of Medicine, New York University Grossman, School of Medicine, New York, New York, USA
| | - Angelica C Kottkamp
- Department of Population Health; New York University, Grossman School of Medicine, New York, New York, USA
| | - Anna Bershteyn
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Helen Y Chu
- Division of Infectious Diseases & Immunology, Department of Medicine, New York University Grossman, School of Medicine, New York, New York, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Christine M Johnston
- Vaccine and Infectious Disease Division, Fred Hutchinson, Cancer Research Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Division of Infectious Diseases & Immunology, Department of Medicine, New York University Grossman, School of Medicine, New York, New York, USA
| | - Anna Wald
- Vaccine and Infectious Disease Division, Fred Hutchinson, Cancer Research Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Division of Infectious Diseases & Immunology, Department of Medicine, New York University Grossman, School of Medicine, New York, New York, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Ruanne Barnabas
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Division of Infectious Diseases & Immunology, Department of Medicine, New York University Grossman, School of Medicine, New York, New York, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Elizabeth R Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson, Cancer Research Center, Seattle, Washington, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Kathleen M Neuzil
- The Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Bershteyn A, Dahl AM, Dong TQ, Deming ME, Celum CL, Chu HY, Kottkamp AC, Greninger AL, Hoffman RM, Jerome KR, Johnston CM, Kissinger PJ, Landovitz RJ, Laufer MK, Luk A, Neuzil KM, Paasche-Orlow MK, Pitts RA, Schwartz MD, Stankiewicz Karita HC, Thorpe LE, Wald A, Zheng CY, Wener MH, Barnabas RV, Brown ER. Self-Assessed Severity as a Determinant of Coronavirus Disease 2019 Symptom Specificity: A Longitudinal Cohort Study. Clin Infect Dis 2022; 75:e1180-e1183. [PMID: 35152299 PMCID: PMC8903379 DOI: 10.1093/cid/ciac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Indexed: 01/19/2023] Open
Abstract
Coronavirus disease 2019 symptom definitions rarely include symptom severity. We collected daily nasal swab samples and symptom diaries from contacts of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case patients. Requiring ≥1 moderate or severe symptom reduced sensitivity to predict SARS-CoV-2 shedding from 60.0% (95% confidence interval [CI], 52.9%-66.7%) to 31.5% (95% CI, 25.7%- 38.0%) but increased specificity from 77.5% (95% CI, 75.3%-79.5%) to 93.8% (95% CI, 92.7%-94.8%).
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Affiliation(s)
- Anna Bershteyn
- Correspondence: A. Bershteyn, Department of Population Health, New York University Grossman School of Medicine, 227 E 30th St, New York, NY 10016 ()
| | | | - Tracy Q Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Meagan E Deming
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Connie L Celum
- International Clinical Research Center and Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Helen Y Chu
- Department of Medicine and Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Angelica C Kottkamp
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Alexander L Greninger
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Risa M Hoffman
- Department of Medicine and Division of Infectious Diseases, University of California, Los Angeles, California, USA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Christine M Johnston
- Department of Medicine and Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Patricia J Kissinger
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Raphael J Landovitz
- Center for Clinical AIDS Research & Education, University of California, Los Angeles, California, USA
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alfred Luk
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Kathleen M Neuzil
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael K Paasche-Orlow
- Department of Medicine and Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Robert A Pitts
- Department of Medicine and Division of Infectious Diseases, NYC Health & Hospitals/Bellevue, New York, New York, USA
| | - Mark D Schwartz
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | | | - Lorna E Thorpe
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Anna Wald
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA,Department of Medicine, Department of Epidemiology, Seattle, Washington, USA
| | - Crystal Y Zheng
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mark H Wener
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Ruanne V Barnabas
- Department of Global Health and Department of Medicine, University of Washington, Seattle, Washington, USA,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USAand
| | - Elizabeth R Brown
- Department of Biostatistics, University of Washington, Seattle, Washington, USA,Vaccine and Infectious Disease Division and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, USA
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5
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Stankiewicz Karita HC, Dong TQ, Johnston C, Neuzil KM, Paasche-Orlow MK, Kissinger PJ, Bershteyn A, Thorpe LE, Deming M, Kottkamp A, Laufer M, Landovitz RJ, Luk A, Hoffman R, Roychoudhury P, Magaret CA, Greninger AL, Huang ML, Jerome KR, Wener M, Celum C, Chu HY, Baeten JM, Wald A, Barnabas RV, Brown ER. Trajectory of Viral RNA Load Among Persons With Incident SARS-CoV-2 G614 Infection (Wuhan Strain) in Association With COVID-19 Symptom Onset and Severity. JAMA Netw Open 2022; 5:e2142796. [PMID: 35006245 PMCID: PMC8749477 DOI: 10.1001/jamanetworkopen.2021.42796] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The SARS-CoV-2 viral trajectory has not been well characterized in incident infections. These data are needed to inform natural history, prevention practices, and therapeutic development. OBJECTIVE To characterize early SARS-CoV-2 viral RNA load (hereafter referred to as viral load) in individuals with incident infections in association with COVID-19 symptom onset and severity. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was a secondary data analysis of a remotely conducted study that enrolled 829 asymptomatic community-based participants recently exposed (<96 hours) to persons with SARS-CoV-2 from 41 US states from March 31 to August 21, 2020. Two cohorts were studied: (1) participants who were SARS-CoV-2 negative at baseline and tested positive during study follow-up, and (2) participants who had 2 or more positive swabs during follow-up, regardless of the initial (baseline) swab result. Participants collected daily midturbinate swab samples for SARS-CoV-2 RNA detection and maintained symptom diaries for 14 days. EXPOSURE Laboratory-confirmed SARS-CoV-2 infection. MAIN OUTCOMES AND MEASURES The observed SARS-CoV-2 viral load among incident infections was summarized, and piecewise linear mixed-effects models were used to estimate the characteristics of viral trajectories in association with COVID-19 symptom onset and severity. RESULTS A total of 97 participants (55 women [57%]; median age, 37 years [IQR, 27-52 years]) developed incident infections during follow-up. Forty-two participants (43%) had viral shedding for 1 day (median peak viral load cycle threshold [Ct] value, 38.5 [95% CI, 38.3-39.0]), 18 (19%) for 2 to 6 days (median Ct value, 36.7 [95% CI, 30.2-38.1]), and 31 (32%) for 7 days or more (median Ct value, 18.3 [95% CI, 17.4-22.0]). The cycle threshold value has an inverse association with viral load. Six participants (6%) had 1 to 6 days of viral shedding with censored duration. The peak mean (SD) viral load was observed on day 3 of shedding (Ct value, 33.8 [95% CI, 31.9-35.6]). Based on the statistical models fitted to 129 participants (60 men [47%]; median age, 38 years [IQR, 25-54 years]) with 2 or more SARS-CoV-2-positive swab samples, persons reporting moderate or severe symptoms tended to have a higher peak mean viral load than those who were asymptomatic (Ct value, 23.3 [95% CI, 22.6-24.0] vs 30.7 [95% CI, 29.8-31.4]). Mild symptoms generally started within 1 day of peak viral load, and moderate or severe symptoms 2 days after peak viral load. All 535 sequenced samples detected the G614 variant (Wuhan strain). CONCLUSIONS AND RELEVANCE This cohort study suggests that having incident SARS-CoV-2 G614 infection was associated with a rapid viral load peak followed by slower decay. COVID-19 symptom onset generally coincided with peak viral load, which correlated positively with symptom severity. This longitudinal evaluation of the SARS-CoV-2 G614 with frequent molecular testing serves as a reference for comparing emergent viral lineages to inform clinical trial designs and public health strategies to contain the spread of the virus.
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Affiliation(s)
| | - Tracy Q. Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Christine Johnston
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
| | - Kathleen M. Neuzil
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Michael K. Paasche-Orlow
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | | | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Lorna E. Thorpe
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Meagan Deming
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Angelica Kottkamp
- Department of Medicine, New York University Grossman School of Medicine, New York
| | - Miriam Laufer
- Department of Medicine, University of Maryland School of Medicine, Baltimore
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | | | - Alfred Luk
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Risa Hoffman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Pavitra Roychoudhury
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
| | - Craig A. Magaret
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
| | - Alexander L. Greninger
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
| | - Meei-Li Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Keith R. Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
| | - Mark Wener
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
- Division of Rheumatology, University of Washington, Seattle
| | - Connie Celum
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Helen Y. Chu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Jared M. Baeten
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Anna Wald
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Ruanne V. Barnabas
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Elizabeth R. Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Johnston C, Brown ER, Stewart J, Karita HC, Kissinger PJ, Dwyer J, Hosek S, Oyedele T, Paasche-Orlow MK, Paolino K, Heller KB, Leingang H, Haugen HS, Dong TQ, Bershteyn A, Sridhar AR, Poole J, Noseworthy PA, Ackerman MJ, Morrison S, Greninger AL, Huang ML, Jerome KR, Wener MH, Wald A, Schiffer JT, Celum C, Chu HY, Barnabas RV, Baeten JM. Hydroxychloroquine with or without azithromycin for treatment of early SARS-CoV-2 infection among high-risk outpatient adults: A randomized clinical trial. EClinicalMedicine 2021; 33:100773. [PMID: 33681731 PMCID: PMC7912360 DOI: 10.1016/j.eclinm.2021.100773] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Treatment options for outpatients with COVID-19 could reduce morbidity and prevent SARS-CoV-2 transmission. METHODS In this randomized, double-blind, three-arm (1:1:1) placebo-equivalent controlled trial conducted remotely throughout the United States, adult outpatients with laboratory-confirmed SARS-CoV-2 infection were recruited. Participants were randomly assigned to receive hydroxychloroquine (HCQ) (400 mg BID x1day, followed by 200 mg BID x9days) with or without azithromycin (AZ) (500 mg, then 250 mg daily x4days) or placebo-equivalent (ascorbic acid (HCQ) and folic acid (AZ)), stratified by risk for progression to severe COVID-19 (high-risk vs. low-risk). Self-collected nasal swabs for SARS-CoV-2 PCR, FLUPro symptom surveys, EKGs and vital signs were collected daily. Primary endpoints were: (a) 14-day progression to lower respiratory tract infection (LRTI), 28-day COVID-19 related hospitalization, or death; (b) 14-day time to viral clearance; secondary endpoints included time to symptom resolution (ClinicalTrials.gov: NCT04354428). Due to the low rate of clinical outcomes, the study was terminated for operational futility. FINDINGS Between 15th April and 27th July 2020, 231 participants were enrolled and 219 initiated medication a median of 5.9 days after symptom onset. Among 129 high-risk participants, incident LRTI occurred in six (4.7%) participants (two control, four HCQ/AZ) and COVID-19 related hospitalization in seven (5.4%) (four control, one HCQ, two HCQ/AZ); no LRTI and two (2%) hospitalizations occurred in the 102 low-risk participants (one HCQ, one HCQ/AZ). There were no deaths. Among 152 participants with viral shedding at enrollment, median time to clearance was 5 days (95% CI=4-6) in HCQ, 6 days (95% CI=4-8) in HCQ/AZ, and 8 days (95% CI=6-10) in control. Viral clearance was faster in HCQ (HR=1.62, 95% CI=1.01-2.60, p = 0.047) but not HCQ/AZ (HR=1.25, p = 0.39) compared to control. Among 197 participants who met the COVID-19 definition at enrollment, time to symptom resolution did not differ by group (HCQ: HR=1.02, 95% CI-0.63-1.64, p = 0.95, HCQ/AZ: HR=0.91, 95% CI=0.57-1.45, p = 0.70). INTERPRETATION Neither HCQ nor HCQ/AZ shortened the clinical course of outpatients with COVID-19, and HCQ, but not HCQ/AZ, had only a modest effect on SARS-CoV-2 viral shedding. HCQ and HCQ/AZ are not effective therapies for outpatient treatment of SARV-CoV-2 infection. FUNDING The COVID-19 Early Treatment Study was funded by the Bill & Melinda Gates Foundation (INV-017062) through the COVID-19 Therapeutics Accelerator. University of Washington Institute of Translational Health Science (ITHS) grant support (UL1 TR002319), KL2 TR002317, and TL1 TR002318 from NCATS/NIH funded REDCap. The content is solely the responsibility of the authors and does not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. PAN and MJA were supported by the Mayo Clinic Windland Smith Rice Comprehensive Sudden Cardiac Death Program.Trial registration ClinicalTrials.gov number NCT04354428.
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Affiliation(s)
- Christine Johnston
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Department of Laboratory Medicine and Pathology, University of Washington, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Elizabeth R. Brown
- Department of Biostatistics, University of Washington, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Jenell Stewart
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Department of Global Health, University of Washington, United States
| | | | - Patricia J. Kissinger
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States
| | - John Dwyer
- School of Medicine, Tulane University, New Orleans, LA, United States
| | - Sybil Hosek
- John H. Stroger, Jr., Hospital of Cook County, Chicago, IL, United States
- Rush University Medical Center, Chicago, IL, United States
| | - Temitope Oyedele
- John H. Stroger, Jr., Hospital of Cook County, Chicago, IL, United States
- Rush University Medical Center, Chicago, IL, United States
| | - Michael K. Paasche-Orlow
- Boston University School of Medicine, Boston, MA, United States
- Boston Medical Center, Boston, MA, United States
| | - Kristopher Paolino
- State University of New York Upstate Medical University, Syracuse, NY, United States
| | - Kate B. Heller
- Department of Global Health, University of Washington, United States
| | - Hannah Leingang
- Department of Global Health, University of Washington, United States
| | - Harald S. Haugen
- Department of Global Health, University of Washington, United States
| | - Tracy Q. Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Anna Bershteyn
- New York University Grossman School of Medicine, NY, NY, United States
| | - Arun R. Sridhar
- Division of Cardiology, University of Washington, United States
| | - Jeanne Poole
- Division of Cardiology, University of Washington, United States
| | | | | | - Susan Morrison
- Department of Global Health, University of Washington, United States
| | - Alexander L. Greninger
- Department of Laboratory Medicine and Pathology, University of Washington, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Meei-Li Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Keith R. Jerome
- Department of Laboratory Medicine and Pathology, University of Washington, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mark H. Wener
- Department of Laboratory Medicine and Pathology, University of Washington, United States
- Division of Rheumatology, University of Washington, Seattle, WA, United States
| | - Anna Wald
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Department of Laboratory Medicine and Pathology, University of Washington, United States
- Department of Epidemiology, University of Washington, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Joshua T. Schiffer
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Connie Celum
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Department of Epidemiology, University of Washington, United States
- Department of Global Health, University of Washington, United States
| | - Helen Y. Chu
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Department of Epidemiology, University of Washington, United States
- Department of Global Health, University of Washington, United States
| | - Ruanne V. Barnabas
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Department of Laboratory Medicine and Pathology, University of Washington, United States
- Department of Epidemiology, University of Washington, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jared M. Baeten
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Department of Epidemiology, University of Washington, United States
- Department of Global Health, University of Washington, United States
| | - for the COVID-19 Early Treatment Study Team
- Division of Allergy and Infectious Diseases, University of Washington, United States
- Department of Laboratory Medicine and Pathology, University of Washington, United States
- Department of Biostatistics, University of Washington, United States
- Department of Epidemiology, University of Washington, United States
- Department of Global Health, University of Washington, United States
- Division of Cardiology, University of Washington, United States
- Division of Rheumatology, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States
- School of Medicine, Tulane University, New Orleans, LA, United States
- John H. Stroger, Jr., Hospital of Cook County, Chicago, IL, United States
- Rush University Medical Center, Chicago, IL, United States
- Boston University School of Medicine, Boston, MA, United States
- Boston Medical Center, Boston, MA, United States
- State University of New York Upstate Medical University, Syracuse, NY, United States
- New York University Grossman School of Medicine, NY, NY, United States
- Mayo Clinic, Rochester, MN, United States
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