1
|
Pilkington V, Quinn K, Campbell L, Payne L, Brady M, Post FA. Clinical Presentation of Mpox in People With and Without HIV in the United Kingdom During the 2022 Global Outbreak. AIDS Res Hum Retroviruses 2023; 39:581-586. [PMID: 37071153 DOI: 10.1089/aid.2023.0014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
Early UK surveillance data revealed that people living with HIV were overrepresented among cases of monkeypox (mpox). However, it remains unknown whether mpox infection is more severe in people living with well-controlled HIV. All laboratory-confirmed mpox cases presenting between May and December 2022 to one London hospital service were identified via pathology reporting systems. We extracted demographic and clinical data to allow comparison of clinical presentation and severity of mpox among people with and without HIV. We identified 150 people with mpox (median age 36 years, 99.3% male, 92.7% reporting sex with other men). HIV status was available for 144 individuals, 58 (40.3%) of whom were HIV positive (only 3/58 had CD4 cell counts <200 cells/mm3 and 5/58 had HIV RNA >200 copies/mL). People with HIV had similar clinical presentations to those without HIV, including indicators of more widespread disease, such as extragenital lesions (74.1% vs. 64.0%, p = .20) and nondermatological symptoms (87.9% vs. 82.6%, p = .38). People with HIV also experienced a similar time from onset of symptoms to discharge from all inpatient or outpatient clinical follow-up (p = .63) and total time under follow-up (p = .88) compared with people without HIV. A similar proportion of people with HIV required review in the hospital emergency department (36.2% vs. 25.6%, p = .17) or admission to hospital (19.0% vs. 9.3%, p = .09). There were no recorded deaths. In this cohort of people with mpox, there was a high prevalence of HIV coinfection, the majority of which was well-controlled. We find no evidence that people with well-controlled HIV experienced more severe mpox infection.
Collapse
Affiliation(s)
- Victoria Pilkington
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, United Kingdom
- HIV Research Team, King's College London, London, United Kingdom
| | - Killian Quinn
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Lucy Campbell
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, United Kingdom
- HIV Research Team, King's College London, London, United Kingdom
| | - Lara Payne
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Michael Brady
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Frank A Post
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, United Kingdom
- HIV Research Team, King's College London, London, United Kingdom
| |
Collapse
|
2
|
Charles H, Prochazka M, Murray J, Sexual Health Liaison Group U, Soni S, Haddow L, Beets K, Pilkington V, Low N, Candfield S, Jones R, Bleiker T, Dewsnap C, Phillips M, Phillips D. Surveillance of Mpox Cases Attending Sexual Health Services in England (SOMASS): design, implementation and initial findings from the SOMASS data collection tool, 2022. Sex Transm Infect 2023; 99:461-466. [PMID: 37202181 DOI: 10.1136/sextrans-2023-055755] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/26/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVES We aimed to design and implement a data collection tool to support the 2022 mpox (monkeypox) outbreak, and to describe clinical and epidemiological data from individuals with mpox attending sexual health services (SHSs) in England. METHODS The UK Health Security Agency and the British Association for Sexual Health and HIV established the Surveillance of Mpox Cases Attending Sexual Health Services in England (SOMASS) system.Descriptive data were collected via a secure web-based data collection tool, completed by SHS clinicians following consultation with individuals with suspected mpox. Data were collected on patient demographics, clinical presentation and severity, exposures and behavioural characteristics. RESULTS As of 17 November 2022, 276 SOMASS responses were submitted from 31 SHSs in England.Where recorded, most (245 of 261; 94%) individuals identified as gay, bisexual or men who have sex with men (GBMSM), of whom two-thirds were HIV negative (170 of 257; 66%) and taking HIV pre-exposure prophylaxis (87 of 140; 62%), with a median age of 37 years (IQR: 30-43). Where known, thirty-nine per cent (63 of 161) had a concurrent sexually transmitted infection (STI) at the time of their mpox diagnosis.For 46% of individuals (127 of 276), dermatological lesions were the initial symptom. Lesions were mostly asymmetrical and polymorphic, predominately affecting the genital area and perianal areas.Nine per cent (24 of 276) of individuals were hospitalised. We report an association between receptive anal intercourse among GBMSM and proctitis (27 of 115; 24% vs 7 of 130; 5%; p<0.0001), and the presence of perianal lesions as the primary lesion site (46 of 115; 40% vs 25 of 130; 19%; p=0.0003). CONCLUSIONS We demonstrate multidisciplinary and responsive working to develop a robust data collection tool, which improved surveillance and strengthened the knowledge base. The SOMASS tool will allow data collection if mpox resurges in England. The model for developing the tool can be adapted to facilitate the preparedness and response to future STI outbreaks.
Collapse
Affiliation(s)
| | | | - Judith Murray
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, UK
| | | | - Suneeta Soni
- Claude Nicol Centre, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Lewis Haddow
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, UK
| | | | | | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sophie Candfield
- Warwick Medical School, University of Warwick, Coventry, UK
- West Midlands health protection team, UK Health Security Agency, Birmingham, UK
| | - Rachael Jones
- Genitourinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Claire Dewsnap
- Genitourinary Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Matt Phillips
- North Cumbria Integrated Care NHS Foundation Trust, Penrith, UK
| | | |
Collapse
|
3
|
Harrison S, Pilkington V, Li Y, Quigley MA, Alderdice F. Disparities in who is asked about their perinatal mental health: an analysis of cross-sectional data from consecutive national maternity surveys. BMC Pregnancy Childbirth 2023; 23:263. [PMID: 37101310 PMCID: PMC10132923 DOI: 10.1186/s12884-023-05518-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 03/14/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND The perinatal period is a vulnerable time, with one in five women experiencing mental health problems. Antenatal and postnatal appointments are key contact points for identifying women in need of support. Since 2014, the UK National Institute for Health and Care Excellence (NICE) has recommended that all women be asked about their mental health at their antenatal booking appointment and early in the postnatal period. The aim of this study was to assess the proportions of women who reported being asked about their mental health during the perinatal period across consecutive national maternity surveys (NMS) in England and to evaluate sociodemographic disparities in who was asked. METHODS Secondary analysis was performed on cross-sectional data from the NMS in 2014-2020. In each survey, women reported whether they had been asked about their mental health antenatally (during their booking appointment) and postnatally (up to six months after giving birth). The proportions of women in each survey who reported being asked about their mental health were calculated and compared according to key sociodemographic characteristics and across survey years. Logistic regression was conducted to identify disparities in who was asked. RESULTS The proportion of women who reported being asked about their mental health antenatally increased from 80.3% (95%CI:79.0-81.5) in 2014 to 83.4% (95%CI:82.1-84.7) in 2020, yet the proportion of women who reported being asked postnatally fell from 88.2% (95%CI:87.1-89.3) in 2014 to 73.7% (95%CI:72.2-75.2) in 2020. Ethnic minority women (aOR range:0.20 ~ 0.67) were less likely to report being asked about their mental health antenatally and postnatally across all surveys compared to White women. Women living in less socioeconomically advantaged areas (aOR range:0.65 ~ 0.75) and women living without or separately from a partner (aOR range:0.61 ~ 0.73) were also less likely to report being asked about their mental health, although there was less consistency in these disparities across the antenatal and postnatal periods and across surveys. CONCLUSIONS Despite NICE recommendations, many women are still not asked about their mental health during the perinatal period, particularly after giving birth. Women from ethnic minority backgrounds are less likely to be asked and these disparities have persisted over time.
Collapse
Affiliation(s)
- Sian Harrison
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Victoria Pilkington
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Clinical Academic Graduate School, Oxford, UK
| | - Yangmei Li
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Maria A Quigley
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Fiona Alderdice
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| |
Collapse
|
4
|
Sokhela S, Bosch B, Hill A, Simmons B, Woods J, Johnstone H, Madhi S, Qavi A, Ellis L, Akpomiemie G, Bhaskar E, Levi J, Falconer J, Mirchandani M, Perez Casas C, Moller K, Pilkington V, Pepperrell T, Venter WDF. Comparing Prospective Incident Severe Acute Respiratory Syndrome Coronavirus 2 Infection Rates During Successive Waves of Delta and Omicron in Johannesburg, South Africa. Open Forum Infect Dis 2022; 9:ofac587. [PMID: 36540387 PMCID: PMC9757672 DOI: 10.1093/ofid/ofac587] [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: 08/05/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022] Open
Abstract
In high-risk individuals in Johannesburg, during the Delta coronavirus disease 2019 wave, 22% (125/561) were positive, with 33% symptomatic (2 hospitalizations; 1 death). During Omicron, 56% (232/411) were infected, with 24% symptomatic (no hospitalizations or deaths). The remarkable speed of infection of Omicron over Delta poses challenges to conventional severe acute respiratory syndrome coronavirus 2 control measures.
Collapse
Affiliation(s)
- Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bronwyn Bosch
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, Liverpool University, Liverpool, United Kingdom
| | - Bryony Simmons
- LSE Health, London School of Economics and Political Science, London, United Kingdom
| | - Joana Woods
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Shabir Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,South Africa and African Leadership in Vaccinology Expertise, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ambar Qavi
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Leah Ellis
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Esther Bhaskar
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacob Levi
- Department of Intensive Care Medicine, Royal Free Hospital NHS Trust, London, United Kingdom
| | - Jonathan Falconer
- Respiratory Department, Royal Brompton Hospital NHS Trust, London, United Kingdom
| | - Manya Mirchandani
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Karlien Moller
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Toby Pepperrell
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Willem Daniel Francois Venter
- Correspondence: Willem D. Francois Venter, FCP, Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terr., Johannesburg, 2193, South Africa ()
| |
Collapse
|
5
|
Navarro AP, Pilkington V, Hill A, Pepperrell T. 1946. Efficacy of Approved versus Unapproved Vaccines for SARS-CoV-2 Infection in Randomised Blinded Clinical Trials. Open Forum Infect Dis 2022. [PMCID: PMC9752549 DOI: 10.1093/ofid/ofac492.1573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Five SARS-CoV-2 vaccines are approved in North America and/or Europe: Pfizer/BioNTech, Moderna, Janssen, Oxford-AstraZeneca and Novavax. Other vaccines have been developed, including Sinopharm, SinoVac, QazVac, Covaxin, Soberana, Corbevac, Medicago, Clover and Cansino, but are not approved in high income countries. This meta-analysis compared the efficacy of approved and unapproved vaccines in randomised clinical trials (RCTs). Methods A systematic review of clinical trial registries, PUBMED and EMBASE identified placebo-controlled RCTs of SARS-CoV-2 vaccines prospectively evaluating risks of symptomatic or severe infection with clearly defined endpoints. For each trial, risk of bias was assessed using Cochrane tool 2.0 and the CONSORT checklist. In the pre-defined meta-analysis, relative risks of symptomatic infection and severe disease were compared for each vaccine versus placebo, using Cochrane-Mantel Haenszel Tests (random effects method). Results There were 21 RCTs assessing efficacy of the COVID-19 vaccines identified. One RCT was excluded for high risk of bias. Ten RCTs in 206,667 participants evaluated 5 approved vaccines; 10 RCTs in 158,599 participants evaluated 8 unapproved vaccines. In the meta-analysis, prevention of symptomatic infection was 84% (95% C.I. 68-92%) for approved vaccines versus 72% (95% C.I. 65-77%) for unapproved vaccines, with no significant difference between vaccine types (p=0.13). Prevention of severe SARS-CoV-2 infection was 95% (95% C.I. 78-99%) for approved vaccines versus 84% (95% C.I. 72-91%) for unapproved vaccines (p=0.12). In addition, the risk of serious adverse events was similar between vaccine types (p=0.49). Efficacy of approved and unapproved SARS-CoV-2 vaccines
![]() Percentage efficacy of approved and unapproved SARS-CoV-2 vaccines against symptomatic infection (Panel A) and severe disease (Panel B). Vaccines are arranged by approval-status (approved vaccines to the left and unapproved vaccines to the right of discontinuous line) and colour-coded by vaccine type. Error bars represent 95% confidence intervals. RIBSP, Research Institute for Biological Safety Problems; IFV, Instituto Finlay de Vacunas. Conclusion This meta-analysis of 20 RCTs in 365,266 participants, showed no significant difference in efficacy between the approved and unapproved SARS-CoV-2 vaccines for endpoints of either symptomatic or severe infection. Differences in study design, end-point definitions, variants and prevalence of infection may have influenced the results. Head-to-head RCTs will be required to make definitive conclusions. If efficacy is proved definitively, new patent-free vaccines could lower costs of worldwide SARS-CoV-2 vaccination campaigns significantly. Disclosures All Authors: No reported disclosures.
Collapse
Affiliation(s)
| | | | - Andrew Hill
- University of Liverpool, London, England, United Kingdom
| | | |
Collapse
|
6
|
Navarro AP, Pilkington V, Pepperrell T, Mirchandani M, Levi J, Hill A. Efficacy of Approved versus Unapproved Vaccines for SARS-CoV-2 Infection in Randomised Blinded Clinical Trials. Open Forum Infect Dis 2022; 9:ofac408. [PMID: 36092832 PMCID: PMC9452066 DOI: 10.1093/ofid/ofac408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Five severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines are approved in North America and/or Europe: Pfizer/BioNTech, Moderna, Janssen, Oxford-AstraZeneca, and Novavax. Other vaccines have been developed, including Sinopharm, SinoVac, QazVac, Covaxin, Soberana, Zifivax, Medicago, Clover, and Cansino, but they are not approved in high-income countries. This meta-analysis compared the efficacy of US Food and Drug Administration (FDA)/European Medicines Agency (EMA)-approved and -unapproved vaccines in randomized clinical trials (RCTs). Methods A systematic review of trial registries identified RCTs of SARS-CoV-2 vaccines. Risk of bias was assessed using the Cochrane tool (RoB 2). In the meta-analysis, relative risks of symptomatic infection and severe disease were compared for each vaccine versus placebo, using Cochrane-Mantel Haenszel Tests (random effects method). Results Twenty-two RCTs were identified and 1 was excluded for high-risk of bias. Ten RCTs evaluated 5 approved vaccines and 11 RCTs evaluated 9 unapproved vaccines. In the meta-analysis, prevention of symptomatic infection was 84% (95% confidence interval [CI], 68%–92%) for approved vaccines versus 72% (95% CI, 66%–77%) for unapproved vaccines, with no significant difference between vaccine types (P = .12). Prevention of severe SARS-CoV-2 infection was 94% (95% CI, 75%–98%) for approved vaccines versus 86% (95% CI, 76%–92%) for unapproved vaccines (P = .33). The risk of serious adverse events was similar between vaccine types (P = .12). Conclusions This meta-analysis of 21 RCTs in 390 459 participants showed no significant difference in efficacy between the FDA/EMA-approved and -unapproved vaccines for symptomatic or severe infection. Differences in study design, endpoint definitions, variants, and infection prevalence may have influenced results. New patent-free vaccines could lower costs of worldwide SARS-CoV-2 vaccination campaigns significantly.
Collapse
Affiliation(s)
| | - Victoria Pilkington
- Oxford University Clinical Academic Graduate School, University of Oxford , United Kingdom
| | - Toby Pepperrell
- University of Edinburgh, School of Medicine and Veterinary Medicine , Edinburgh , UK
| | | | - Jacob Levi
- Royal Free University Hospital NHS Trust , London , UK
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool , Liverpool, L69 3GF , UK
| |
Collapse
|
7
|
Pilkington V, Keestra SM, Hill A. Global COVID-19 Vaccine Inequity: Failures in the First Year of Distribution and Potential Solutions for the Future. Front Public Health 2022; 10:821117. [PMID: 35321196 PMCID: PMC8936388 DOI: 10.3389/fpubh.2022.821117] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/31/2022] [Indexed: 12/14/2022] Open
Abstract
Within the first year of distribution of vaccines against COVID-19, high-income countries (HICs) have achieved vaccination rates of 75-80%, whilst low-income countries (LICs) vaccinated <10%. This disparity in access has been one of the greatest failures of international cooperation during the SARS-CoV-2 pandemic. Global COVID-19 vaccine inequity affects us all, with ongoing risk of new variants emerging until global herd immunity is strengthened. The current model of global vaccine distribution is based on financial competition for limited vaccine supplies, resulting in HICs getting first access to vaccines, with LICs being forced to rely on voluntary donations through schemes like COVAX. Pharmaceutical companies own the intellectual property (IP) rights for COVID-19 vaccines, allowing them to control manufacturing, distribution, and pricing. However, the pharmaceutical industry did not develop these vaccines alone, with billions of dollars of public funding being instrumental in their discovery and development. Solutions to enable global equitable access already exist. The next step in scale up of manufacture and distribution worldwide is equitable knowledge sharing and technology transfer. The World Health Organization centralized technology transfer hub would facilitate international cooperation. Investments made into developing this infrastructure benefit the COVID-19 response whilst promoting future pandemic preparedness. Whilst globally there is majority support for waivers of IP to facilitate this next step, key opponents blocking this move include the UK and other European countries which host large domestic pharmaceutical industries. A nationalistic approach is not effective during a global pandemic. International cooperation is essential to achieve global goals against COVID-19.
Collapse
Affiliation(s)
- Victoria Pilkington
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, United Kingdom
- MetaVirology Ltd., London, United Kingdom
- *Correspondence: Victoria Pilkington
| | - Sarai Mirjam Keestra
- Epidemiology and Data Science, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Andrew Hill
- MetaVirology Ltd., London, United Kingdom
- Department for Translational Medicine, Liverpool University, Liverpool, United Kingdom
| |
Collapse
|
8
|
Hill A, Garratt A, Levi J, Falconer J, Ellis L, McCann K, Pilkington V, Qavi A, Wang J, Wentzel H. Retraction to: Meta-analysis of Randomized Trials of Ivermectin to Treat SARS-CoV-2 Infection. Open Forum Infect Dis 2022; 9:ofac056. [PMID: 35146053 PMCID: PMC8826014 DOI: 10.1093/ofid/ofac056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Andrew Hill
- Correspondence: Andrew Hill, PhD, Department of Pharmacology and
Therapeutics, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK ()
| | - Anna Garratt
- Department of Infectious Diseases, University Hospital of Wales, Cardiff
and Vale University Health Board, Cardiff,
UK
| | - Jacob Levi
- Department of Intensive Care, University College London Hospital, ULCH NHS
Trust, London, UK
| | - Jonathan Falconer
- Department of Infectious Diseases, Chelsea and Westminster Hospital,
Imperial NHS Trust, London, UK
| | - Leah Ellis
- Faculty of Medicine, Imperial College London,
London, UK
| | - Kaitlyn McCann
- Faculty of Medicine, Imperial College London,
London, UK
| | - Victoria Pilkington
- Oxford University Clinical Academic Graduate School, University of
Oxford, Oxford, UK
| | - Ambar Qavi
- Faculty of Medicine, Imperial College London,
London, UK
| | - Junzheng Wang
- Faculty of Medicine, Imperial College London,
London, UK
| | - Hannah Wentzel
- Faculty of Medicine, Imperial College London,
London, UK
| |
Collapse
|
9
|
Hill A, Mirchandani M, Pilkington V. Ivermectin for COVID-19: Addressing Potential Bias and Medical Fraud. Open Forum Infect Dis 2022; 9:ofab645. [PMID: 35071686 PMCID: PMC8774052 DOI: 10.1093/ofid/ofab645] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Ivermectin has become a controversial potential medicine for coronavirus disease 2019. Some early studies suggested clinical benefits in treatment of infection. However, the body of evidence includes studies of varying quality. Furthermore, some trials have now been identified as potentially fraudulent. We present a subgroup meta-analysis to assess the effects of stratifying by trial quality on the overall results. The stratification is based on the Cochrane Risk of Bias measures and raw data analysis where possible. The results suggest that the significant effect of ivermectin on survival was dependent on largely poor-quality studies. According to the potentially fraudulent study (risk ratio [RR], 0.08; 95% CI, 0.02–0.35), ivermectin improved survival ~12 times more in comparison with low-risk studies (RR, 0.96; 95% CI, 0.56–1.66). This highlights the need for rigorous quality assessments, for authors to share patient-level data, and for efforts to avoid publication bias for registered studies. These steps are vital to facilitate accurate conclusions on clinical treatments.
Collapse
Affiliation(s)
- Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | | | - Victoria Pilkington
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Abstract
Background Ivermectin is an antiparasitic drug being investigated in clinical trials for the prevention of COVID-19. However, there are concerns about the quality of some of these trials. Objectives To conduct a meta-analysis with randomized controlled trials of ivermectin for the prevention of COVID-19, while controlling for the quality of data. The primary outcome was RT–PCR-confirmed COVID-19 infection. The secondary outcome was rate of symptomatic COVID-19 infection. Methods We conducted a subgroup analysis based on the quality of randomized controlled trials evaluating ivermectin for the prevention of COVID-19. Quality was assessed using the Cochrane risk of bias measures (RoB 2) and additional checks on raw data, where possible. Results Four studies were included in the meta-analysis. One was rated as being potentially fraudulent, two as having a high risk of bias and one as having some concerns for bias. Ivermectin did not have a significant effect on preventing RT–PCR-confirmed COVID-19 infection. Ivermectin had a significant effect on preventing symptomatic COVID-19 infection in one trial with some concerns of bias, but this result was based on post hoc analysis of a multi-arm study. Conclusions In this meta-analysis, the use of ivermectin was not associated with the prevention of RT–PCR-confirmed or symptomatic COVID-19. The currently available randomized trials evaluating ivermectin for the prevention of COVID-19 are insufficient and of poor quality.
Collapse
Affiliation(s)
- Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool L7 3NY, UK
| | - Manya Mirchandani
- Faculty of Medicine, Imperial College London, London, UK
- Corresponding author. E-mail:
| | - Leah Ellis
- Faculty of Medicine, Imperial College London, London, UK
| | - Victoria Pilkington
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| |
Collapse
|
11
|
Abstract
BACKGROUND Recent clinical trials have shown weight gain associated with newer antiretrovirals. It is unclear how the nucleoside reverse transcriptase inhibitor backbone affects weight. Recent evidence suggests greater weight gain with tenofovir alafenamide (TAF) compared with tenofovir disoproxil fumarate (TDF). However, it is not fully understood whether TDF contributes to weight suppression. METHODS A systematic search of PubMed, Embase and clinicaltrials.gov was conducted to identify all randomized control trials comparing TDF/FTC or TDF to control in HIV-negative individuals. The primary endpoint included the number of events of 5% weight loss. Mantel-Haenszel test with random-effects modelling was used to calculate the odds ratio (OR) and 95% confidence intervals (95% CI). Further analyses of gastrointestinal (GI) adverse events were also undertaken. RESULTS Seven PrEP trials: PARTNERS, VOICE, TDF-2, Bangkok PrEP, iPrEX, FEM-PrEP and HPTN 084 were included in the analysis of weight loss, with a total sample size of 19 359. One study (HPTN 084) compared TDF/FTC to cabotegravir (CAB). HIV-negative individuals taking TDF were more likely to experience weight loss compared with control [odds ratio (OR) 1.44; 95% CI 1.12-1.85; P = 0.005). Exposure to TDF was also linked to greater odds of vomiting (OR 1.81; 95% CI 1.20-2.73; P < 0.005). There were no increased odds of nausea, diarrhoea or loss of appetite. CONCLUSION There is evidence in HIV-negative individuals that TDF may be associated with weight loss. Further research should be carried out in HIV-positive individuals, and clinical trials of TDF/FTC should publish weight data to widen the evidence base.
Collapse
Affiliation(s)
- Shahini Shah
- Norwich Medical School, University of East Anglia, Norwich
| | | | - Andrew Hill
- Department of Translational Medicine, University of Liverpool, Liverpool, UK
| |
Collapse
|
12
|
Shah S, Pilkington V, Hill A. 882. Use of Tenofovir Disoproxil Fumarate Shows Weight Loss vs Placebo: A Meta-Analysis of 7 Clinical Trials in 19,359 HIV-negative Individuals. Open Forum Infect Dis 2021. [DOI: 10.1093/ofid/ofab466.1077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Recent clinical trials have shown weight gain associated with newer antiretrovirals. It is unclear how the nucleoside reverse transcriptase inhibitor backbone affects weight. Recent evidence suggests greater weight gain with tenofovir alafenamide (TAF) compared to tenofovir disoproxil fumarate (TDF). However, it is not fully understood whether TDF contributes to weight suppression or weight loss.
Methods
A systematic search of PubMed, Embase and clinicaltrials.gov was conducted to identify all randomised control trials comparing TDF/FTC or TDF to control in HIV-negative individuals. The primary endpoint included the number of events of ‘5% weight loss’ or ‘abnormal loss of weight’. The Mantel-Haenszel test with random-effects modelling was used to calculate the odds ratio (OR) and 95% confidence intervals (95% CI). Further analyses of gastrointestinal (GI) adverse events (AEs) were undertaken, including the number of reported adverse events of nausea, vomiting, loss of appetite and diarrhoea.
Results
Seven PrEP trials: PARTNERS, VOICE, TDF-2, Bangkok PrEP, iPrEX, FEM-PrEP and HPTN 084 were included in the analysis of weight loss, with a total sample size of 19,359. One study (HPTN 084) compared TDF/FTC to cabotegravir (CAB). The remaining compared either TDF or TDF/FTC or placebo. HIV-negative individuals taking TDF were more likely to experience weight loss compared to control (OR 1.44 95% CI 1.12 – 1.85 p = 0.005 (table 1)). In a separate analysis of GI AEs, exposure to TDF was also linked to greater odds of vomiting (OR 1.81 95% CI (1.20, 2.73) p < 0.005). There were no increased odds of nausea, diarrhoea, or loss of appetite.
Weight loss events in PrEP trials.
Conclusion
There is evidence in HIV-negative individuals that TDF may be associated weight loss when compared to placebo. Further research should be carried out in HIV positive individuals, and clinical trials of TDF/FTC should publish weight data to widen the evidence base
Disclosures
All Authors: No reported disclosures
Collapse
Affiliation(s)
- Shahini Shah
- University of East Anglia, London, England, United Kingdom
| | - Victoria Pilkington
- Oxford University Clinical Academic Graduate School, London, England, United Kingdom
| | - Andrew Hill
- University of Liverpool, London, England, United Kingdom
| |
Collapse
|
13
|
Wentzel H, Wang J, Dayanamby A, Pilkington V, Levi J, Hill A, Ellis L. 529. Systematic Review and Meta-Analysis of Ivermectin Safety Profile in COVID-19 Trials. Open Forum Infect Dis 2021. [PMCID: PMC8644070 DOI: 10.1093/ofid/ofab466.728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background There is a continued and pressing need for safe and effective treatment of COVID-19. Significant survival benefits have been shown by dexamethasone, tocilizumab and sarilumab, however they are only recommended in hospitalised COVID-19 patients. Ivermectin is a well-established and readily available antiparasitic drug which may be suitable for treatment in mild and moderate disease stages. It recently demonstrated anti-viral properties in vitro and now over 80 clinical trials have been registered worldwide to test its effectiveness in COVID-19 patients. This meta-analysis aims to collect data on adverse events reported in new COVID-19 treatment trials for the use of ivermectin as a repurposed medication. Methods Data was extracted from randomised trials of COVID-19 treatment trials identified through systematic searches of PUBMED, EMBASE, MedRxiv and trial registries. The primary outcome of this meta-analysis is the frequency of adverse events. Key safety events included serious, gastrointestinal, neurological, cardiovascular and dermatological adverse events. Results Overall, 18 trials investigating ivermectin for COVID-19 in a total of 2496 participants reported safety data and were included. There was no significant difference in the proportion of all adverse events between ivermectin and the comparator. There were 371/1261 (29%) adverse events recorded in the ivermectin containing arms and 376/1284 (29%) in the control arms (RR 1.02 [95% CI 0.77 - 1.34]; p = 0.91). There was no significant difference in the rate of serious adverse events across treatment arms (RR 1.95 [95% CI 0.75 - 5.11]; p = 0.18). No significant differences between ivermectin and the control were seen across different subcategories of adverse events. Figure 1 shows a summary of the results for all adverse events. ![]()
Forest plot comparing ivermectin and the control for all adverse events in COVID-19 trials, subdivided into single-day dosing trials and multi-day dosing trials. Conclusion The results of recent COVID-19 trials show that overall, ivermectin is safe and well-tolerated. No significant difference in adverse event reporting was found across all subgroups in single and multi-day treatment regimens for the studies analysed. Safety reporting methodologies often varied across trials. Future and ongoing trials should be encouraged to collect and monitor safety data systematically. Disclosures All Authors: No reported disclosures
Collapse
Affiliation(s)
| | | | | | | | - Jacob Levi
- University College London Hospitals, London, UK
| | | | | |
Collapse
|
14
|
Sbaiti M, Streule MJ, Alhaffar M, Pilkington V, Leis M, Budhathoki SS, Mkhallalati H, Omar M, Liu L, Golestaneh AK, Abbara A. Whose voices should shape global health education? Curriculum codesign and codelivery by people with direct expertise and lived experience. BMJ Glob Health 2021; 6:bmjgh-2021-006262. [PMID: 34475023 PMCID: PMC8413871 DOI: 10.1136/bmjgh-2021-006262] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 05/10/2021] [Accepted: 08/05/2021] [Indexed: 11/05/2022] Open
Abstract
There are contrasting opinions of what global health (GH) curricula should contain and limited discussion on whose voices should shape it. In GH education, those with first-hand expertise of living and working in the contexts discussed in GH classrooms are often absent when designing curricula. To address this, we developed a new model of curriculum codesign called Virtual Roundtable for Collaborative Education Design (ViRCoED). This paper describes the rationale and outputs of the ViRCoED approach in designing a new section of the Global Health Bachelor of Science (BSc) curriculum at Imperial College London, with a focus on healthcare in the Syrian conflict. The team, importantly, involved partners with lived and/or professional experience of the conflict as well as alumni of the course and educators in all stages of design and delivery through to marking and project evaluation. The project experimented with disrupting power dynamics and extending ownership of the curriculum beyond traditional faculty by codesigning and codelivering module contents together with colleagues with direct expertise and experience of the Syrian context. An authentic approach was applied to assessment design using real-time syndromic healthcare data from the Aleppo and Idlib Governorates. We discuss the challenges involved in our collaborative partnership and describe how it may have enhanced the validity of our curriculum with students engaging in a richer representation of key health issues in the conflict. We observed an enhanced self-reflexivity in the students’ approach to quantitative data and its complex interpretation. The dialogic nature of this collaborative design was also a formative process for partners and an opportunity for GH educators to reflect on their own positionality. The project aims to challenge current standards and structures in GH curriculum development and gesture towards a GH education sector eventually led by those with lived experience and expertise to significantly enhance the validity of GH education.
Collapse
Affiliation(s)
- Mariam Sbaiti
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Mike J Streule
- Centre for Higher Education Research and Scholarship, Imperial College London, London, UK
| | - Mervat Alhaffar
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Syria Research Group, London School of Hygiene and Tropical Medicine, London and National University of Singapore Saw Swee Hock School of Public Health, UK/ Singapore.,Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Victoria Pilkington
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.,School of Medicine, Imperial College London, London, UK
| | - Melanie Leis
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Shyam Sundar Budhathoki
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Hala Mkhallalati
- Syria Research Group, London School of Hygiene and Tropical Medicine, London and National University of Singapore Saw Swee Hock School of Public Health, UK/ Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Maryam Omar
- Department of Respiratory Medicine, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Lillian Liu
- School of Medicine, Imperial College London, London, UK
| | | | - Aula Abbara
- Department of Infectious Disease, Imperial College London, London, UK
| |
Collapse
|
15
|
Hill A, Garratt A, Levi J, Falconer J, Ellis L, McCann K, Pilkington V, Qavi A, Wang J, Wentzel H. Erratum: Expression of Concern: "Meta-analysis of Randomized Trials of Ivermectin to Treat SARS-CoV-2 Infection". Open Forum Infect Dis 2021; 8:ofab394. [PMID: 34410284 PMCID: PMC8369353 DOI: 10.1093/ofid/ofab394] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Anna Garratt
- Department of Infectious Diseases, University Hospital of Wales, Cardiff and Vale University Health Board, UK
| | - Jacob Levi
- Department of Intensive Care, University College London Hospital, ULCH NHS Trust, London, UK
| | - Jonathan Falconer
- Department of Infectious Diseases, Chelsea and Westminster Hospital, Imperial NHS Trust, London, UK
| | - Leah Ellis
- Faculty of Medicine, Imperial College London, London, UK
| | - Kaitlyn McCann
- Faculty of Medicine, Imperial College London, London, UK
| | - Victoria Pilkington
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Ambar Qavi
- Faculty of Medicine, Imperial College London, London, UK
| | - Junzheng Wang
- Faculty of Medicine, Imperial College London, London, UK
| | - Hannah Wentzel
- Faculty of Medicine, Imperial College London, London, UK
| |
Collapse
|
16
|
Hill A, Garratt A, Levi J, Falconer J, Ellis L, McCann K, Pilkington V, Qavi A, Wang J, Wentzel H. Meta-analysis of randomized trials of ivermectin to treat SARS-CoV-2 infection. Open Forum Infect Dis 2021; 8:ofab358. [PMID: 34796244 PMCID: PMC8420640 DOI: 10.1093/ofid/ofab358] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/05/2021] [Indexed: 12/15/2022] Open
Abstract
Ivermectin is an antiparasitic drug being investigated for repurposing against severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Ivermectin showed in vitro activity
against SARS-COV-2, but only at high concentrations. This meta-analysis investigated
ivermectin in 23 randomized clinical trials (3349 patients) identified through systematic
searches of PUBMED, EMBASE, MedRxiv, and trial registries. The primary meta-analysis was
carried out by excluding studies at a high risk of bias. Ivermectin did not show a
statistically significant effect on survival (risk ratio [RR], 0.90; 95% CI, 0.57 to 1.42;
P = .66) or hospitalizations (RR, 0.63; 95% CI, 0.36 to 1.11;
P = .11). Ivermectin displayed a borderline significant effect on
duration of hospitalization in comparison with standard of care (mean difference, –1.14
days; 95% CI, –2.27 to –0.00; P = .05). There was no significant effect
of ivermectin on time to clinical recovery (mean difference, –0.57 days; 95% CI, –1.31 to
0.17; P = .13) or binary clinical recovery (RR, 1.19; 95% CI, 0.94 to
1.50; P = .15). Currently, the World Health Organization recommends the
use of ivermectin only inside clinical trials. A network of large clinical trials is in
progress to validate the results seen to date.
Collapse
Affiliation(s)
- Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, L7 3NY, UK
| | - Anna Garratt
- Department of Infectious Diseases, University Hospital of Wales, Cardiff and Vale University Health Board, UK
| | - Jacob Levi
- Department of Intensive Care, University College London Hospital, ULCH NHS Trust, London, UK
| | - Jonathan Falconer
- Department of Infectious Diseases, Chelsea and Westminster Hospital, Imperial NHS Trust, London, UK
| | - Leah Ellis
- Faculty of Medicine, Imperial College London, UK
| | | | - Victoria Pilkington
- Oxford University Clinical Academic Graduate School, University of Oxford, UK
| | - Ambar Qavi
- Faculty of Medicine, Imperial College London, UK
| | | | | |
Collapse
|
17
|
Mallia P, Meghji J, Wong B, Kumar K, Pilkington V, Chhabra S, Russell B, Chen J, Srikanthan K, Park M, Owles H, Liew F, Alcada J, Martin L, Coleman M, Elkin S, Ross C, Agrawal S, Gardiner T, Bell A, White A, Hampson D, Vithlani G, Manalan K, Bramer S, Martin Segura A, Kucheria A, Ratnakumar P, Sheeka A, Anandan L, Copley S, Russell G, Bloom CI, Kon OM. Symptomatic, biochemical and radiographic recovery in patients with COVID-19. BMJ Open Respir Res 2021; 8:8/1/e000908. [PMID: 33827856 PMCID: PMC8029037 DOI: 10.1136/bmjresp-2021-000908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/12/2022] Open
Abstract
Background The symptoms, radiography, biochemistry and healthcare utilisation of patients with COVID-19 following discharge from hospital have not been well described. Methods Retrospective analysis of 401 adult patients attending a clinic following an index hospital admission or emergency department attendance with COVID-19. Regression models were used to assess the association between characteristics and persistent abnormal chest radiographs or breathlessness. Results 75.1% of patients were symptomatic at a median of 53 days post discharge and 72 days after symptom onset and chest radiographs were abnormal in 47.4%. Symptoms and radiographic abnormalities were similar in PCR-positive and PCR-negative patients. Severity of COVID-19 was significantly associated with persistent radiographic abnormalities and breathlessness. 18.5% of patients had unscheduled healthcare visits in the 30 days post discharge. Conclusions Patients with COVID-19 experience persistent symptoms and abnormal blood biomarkers with a gradual resolution of radiological abnormalities over time. These findings can inform patients and clinicians about expected recovery times and plan services for follow-up of patients with COVID-19.
Collapse
Affiliation(s)
- Patrick Mallia
- Imperial College Healthcare NHS Trust, London, UK .,National Heart and Lung Institute, Imperial College, London, UK
| | - Jamilah Meghji
- Imperial College Healthcare NHS Trust, London, UK.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Brandon Wong
- Imperial College Healthcare NHS Trust, London, UK
| | - Kartik Kumar
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Ben Russell
- Imperial College Healthcare NHS Trust, London, UK
| | - Jian Chen
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Mirae Park
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Joana Alcada
- Imperial College Healthcare NHS Trust, London, UK
| | - Laura Martin
- Imperial College Healthcare NHS Trust, London, UK
| | - Meg Coleman
- Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Elkin
- Imperial College Healthcare NHS Trust, London, UK
| | - Clare Ross
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Aaron Bell
- Imperial College Healthcare NHS Trust, London, UK
| | - Alice White
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | - Solange Bramer
- Imperial College School of Medicine, Imperial College, London, UK
| | | | | | | | | | | | - Susan Copley
- Radiology Department, Imperial College Healthcare NHS Trust, London, UK
| | | | - Chloe I Bloom
- National Heart and Lung Institute, Imperial College, London, UK
| | - Onn Min Kon
- Imperial College Healthcare NHS Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| |
Collapse
|
18
|
Rodgers F, Pepperrell T, Keestra S, Pilkington V. Missing clinical trial data: the evidence gap in primary data for potential COVID-19 drugs. Trials 2021; 22:59. [PMID: 33451350 PMCID: PMC7809643 DOI: 10.1186/s13063-021-05024-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 09/01/2020] [Accepted: 01/05/2021] [Indexed: 02/07/2023] Open
Abstract
Background Several drugs are being repurposed for the treatment of the coronavirus disease 2019 (COVID-19) pandemic based on in vitro or early clinical findings. As these drugs are being used in varied regimens and dosages, it is important to enable synthesis of existing safety data from clinical trials. However, availability of safety information is limited by a lack of timely reporting of overall clinical trial results on public registries or through academic publication. We aimed to analyse the evidence gap in this data by conducting a rapid review of results posting on ClinicalTrials.gov and in academic publications to quantify the number of trials missing results for drugs potentially being repurposed for COVID-19. Methods ClinicalTrials.gov was searched for 19 drugs that have been identified as potential treatments for COVID-19. Relevant clinical trials for any prior indication were listed by identifier (NCT number) and checked for results and for timely result reporting (within 395 days of the primary completion date). Additionally, PubMed and Google Scholar were searched to identify publications of results not listed on the registry. A second, blinded search of 10% of trials was conducted to assess reviewer concordance. Results Of 3754 completed trials, 1516 (40.4%) did not post results on ClinicalTrials.gov or in the academic literature. Tabular results were available on ClinicalTrials.gov for 1172 (31.2%) completed trials. A further 1066 (28.4%) had published results in the academic literature, but did not report results on ClinicalTrials.gov. Key drugs missing clinical trial results include hydroxychloroquine (37.0% completed trials unreported), favipiravir (77.8%) and lopinavir (40.5%). Conclusions There is an important evidence gap for the safety of drugs being repurposed for COVID-19. This uncertainty could cause unnecessary additional morbidity and mortality during the pandemic. We recommend caution in experimental drug use for non-severe disease and urge clinical trial sponsors to report missing results retrospectively.
Collapse
Affiliation(s)
| | | | - Sarai Keestra
- Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
| | | |
Collapse
|
19
|
Abstract
Background Many treatments are being assessed for repurposing to treat coronavirus disease 2019 (COVID-19). One drug that has shown promising results in vitro is nitazoxanide. Unlike other postulated drugs, nitazoxanide shows a high ratio of maximum plasma concentration (Cmax), after 1 day of 500 mg twice daily (BD), to the concentration required to inhibit 50% replication (EC50) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Cmax : EC50 roughly equal to 14:1). As such, it is important to investigate the safety of nitazoxanide for further trials. Furthermore, treatments for COVID-19 should be cheap to promote global access, but prices of many drugs are far higher than the costs of production. We aimed to conduct a review of the safety of nitazoxanide for any prior indication and calculate its minimum costs of production. Methods A review of nitazoxanide clinical research was conducted using EMBASE and MEDLINE databases, supplemented by
ClinicalTrials.gov. We searched for phase 2 or 3 randomised controlled trials (RCTs) comparing nitazoxanide with placebo or active control for 5–14 days in participants experiencing acute infections of any kind. Data extracted were grade 1–4 and serious adverse events (AEs). Data were also extracted on gastrointestinal (GI) AEs, as well as hepatorenal and cardiovascular effects. Active pharmaceutical ingredient cost data from 2016 to 2019 were extracted from the Panjiva database and adjusted for 5% loss during production, costs of excipients, formulation, a 10% profit margin and tax. Two dosages, at 500 mg BD and a higher dose of 1100 mg three times daily (TDS), were considered. Our estimated costs were compared with publicly available list prices from a selection of countries. Results Nine RCTs of nitazoxanide were identified for inclusion. These RCTs accounted for 1514 participants and an estimated 95.3 person-years-of-follow-up. No significant differences were found in any of the AE endpoints assessed, across all trials or on subgroup analyses of active- or placebo-controlled trials. Mild GI AEs increased with dose. No hepatorenal or cardiovascular concerns were raised, but few appropriate metrics were reported. There were no teratogenic concerns, but the evidence base was very limited. Based on a weighted-mean cost of US $61/kg, a 14-day course of treatment with nitazoxanide 500 mg BD would cost $1.41. The daily cost would therefore be $0.10. The same 14-day course could cost $3944 in US commercial pharmacies, and $3 per course in Pakistan, India and Bangladesh. At a higher dose of 1100 mg TDS, our estimated cost was $4.08 per 14-day course, equivalent to $0.29 per day. Conclusion Nitazoxanide demonstrates a good safety profile at approved doses. However, further evidence is required regarding hepatorenal and cardiovascular effects, as well as teratogenicity. We estimate that it would be possible to manufacture nitazoxanide as generic for $1.41 for a 14-day treatment course at 500 mg BD, up to $4.08 at 1100 mg TDS. Further trials in COVID-19 patients should be initiated. If efficacy against SARS-CoV-2 is demonstrated in clinical studies, nitazoxanide may represent a safe and affordable treatment in the ongoing pandemic.
Collapse
Affiliation(s)
| | | | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, UK.,MRC Centre for Drug Safety Science, University of Liverpool, UK
| | | | - Andrew M Hill
- Department of Molecular and Clinical Pharmacology, University of Liverpool, UK
| |
Collapse
|
20
|
Pilkington V, Hill A, Hughes S, Nwokolo N, Pozniak A. How safe is TDF/FTC as PrEP? A systematic review and meta-analysis of the risk of adverse events in 13 randomised trials of PrEP. J Virus Erad 2018; 4:215-224. [PMID: 30515300 PMCID: PMC6248833] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Tenofovir/emtricitabine (TDF/FTC) used as pre-exposure prophylaxis (PrEP) has proven benefits in preventing HIV infection. Widespread use of TDF/FTC can only be justified if the preventative benefits outweigh potential risks of adverse events. A previous meta-analysis of TDF/FTC compared to alternative tenofovir alafenamide (TAF)/FTC for treatment found no significant difference in safety endpoints when used without ritonavir or cobicistat, but more evidence around the safety of TDF/FTC is needed to address concerns and inform widespread use. METHODS A systematic review identified 13 randomised trials of PrEP, using either TDF/FTC or TDF, versus placebo or no treatment: VOICE, PROUD, IPERGAY, FEM-PrEP, TDF-2, iPrEX, IAVI Kenya, IAVI Uganda, PrEPare, PARTNERS, US Safety study, Bangkok TDF study, W African TDF study. The number of participants with grade 3/4 adverse events or serious adverse events (SAEs) was compared between treatment and control in the meta-analysis. Further analyses of specific renal and bone markers were also undertaken, with fractures as a marker of bone effects and creatinine elevations as a surrogate marker for renal impairment. Analyses were stratified by study duration (</>1 year of follow up). RESULTS The 13 randomised trials included 15,678 participants in relevant treatment and control arms. Three studies assessed TDF use only. The number of participants with grade 3/4 adverse events was 1306/7504 (17.4%) on treatment versus 1259/7502 (16.8%) on control (difference=0%, 95% confidence interval [CI] -1% to +2%). The number of participants with SAEs was 740/7843 (9.4%) on treatment versus 795/7835 (10.1%) on no treatment (difference=0%, 95% CI -1% to +1%). The number of participants with creatinine elevations was 8/7843 on treatment versus 4/7835 on control (difference=0%, 95% CI 0%-0%). The number of participants with bone fractures was 217/5789 on treatment versus 189/5795 on control (difference=0%, 95% CI 0% to 1%). There was no difference in outcome between studies with <1 versus >1 year of randomised treatment. CONCLUSIONS In this meta-analysis of 13 randomised clinical trials of PrEP in 15,678 participants, there was no significant difference in risk of grade 3/4 clinical adverse events or SAEs between TDF/FTC (or TDF) and control. Furthermore, there was no significant difference in risk of specific renal or bone adverse outcomes. The favourable safety profile of TDF/FTC would support more widespread use PrEP in populations with a lower risk of HIV infection.
Collapse
Affiliation(s)
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool,
UK,Corresponding author: Andrew M Hill,
Department of
Translational Medicine,
University of Liverpool,
70 Pembroke Place,
LiverpoolL69 3GF,
UK.
| | | | - Nneka Nwokolo
- Chelsea and Westminster Hospital, 56 Dean Street,
LondonUK
| | | |
Collapse
|
21
|
Pilkington V, Hill A, Hughes S, Nwokolo N, Pozniak A. How safe is TDF/FTC as PrEP? A systematic review and meta-analysis of the risk of adverse events in 13 randomised trials of PrEP. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30312-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
|