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Cheung YYH, Lau EHY, Yin G, Lin Y, Jiang J, Cowling BJ, Lam KF. Joint analysis of vaccination effectiveness and antiviral drug effectiveness for COVID-19: a causal inference approach. Int J Infect Dis 2024; 143:107012. [PMID: 38521448 DOI: 10.1016/j.ijid.2024.107012] [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: 11/30/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVES This study aims to estimate the causal effects of oral antivirals and vaccinations in the prevention of all-cause mortality and progression to severe COVID-19 in an integrative setting with both antivirals and vaccinations considered as interventions. METHODS We identified hospitalized adult patients (i.e. aged 18 or above) in Hong Kong with confirmed SARS-CoV-2 infection between March 16, 2022, and December 31, 2022. An inverse probability-weighted (IPW) Andersen-Gill model with time-dependent predictors was used to address immortal time bias and produce causal estimates for the protection effects of oral antivirals and vaccinations against severe COVID-19. RESULTS Given prescription is made within 5 days of confirmed infection, nirmatrelvir-ritonavir is more effective in providing protection against all-cause mortality and development into severe COVID-19 than molnupiravir. There was no significant difference between CoronaVac and Comirnaty in the effectiveness of reducing all-cause mortality and progression to severe COVID-19. CONCLUSIONS The use of oral antivirals and vaccinations causes lower risks of all-cause mortality and progression to severe COVID-19 for hospitalized SARS-CoV-2 patients.
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Affiliation(s)
- Yue Yat Harrison Cheung
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric Ho Yin Lau
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Guosheng Yin
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Mathematics, Imperial College London, London, The United Kingdom
| | - Yun Lin
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jialiang Jiang
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Benjamin John Cowling
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H) Limited, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China
| | - Kwok Fai Lam
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong Special Administrative Region, China; Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore.
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Wang H, Wei Y, Hung CT, Lin G, Jiang X, Li C, Jia KM, Yam CHK, Chow TY, Ho JYE, Wang Y, Zhao S, Guo Z, Li K, Yang A, Mok CKP, Hui DSC, Yeoh EK, Chong KC. Association of nirmatrelvir-ritonavir with post-acute sequelae and mortality in patients admitted to hospital with COVID-19: a retrospective cohort study. Lancet Infect Dis 2024:S1473-3099(24)00217-2. [PMID: 38710190 DOI: 10.1016/s1473-3099(24)00217-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Studies have established the short-term efficacy of nirmatrelvir-ritonavir in managing COVID-19, yet its effect on post-COVID-19 condition, especially in patients admitted to hospital, remains understudied. This study aimed to examine the effect of nirmatrelvir-ritonavir on post-COVID-19 condition among patients admitted to hospital in Hong Kong. METHODS This retrospective cohort study used real-world, territory-wide inpatient records, vaccination records, and confirmed COVID-19 case data from the Hong Kong Hospital Authority and Department of Health, The Government of the Hong Kong Special Administrative Region. Patients aged 18 years and older who tested positive for SARS-CoV-2 between March 11, 2022, and Oct 10, 2023, and who were admitted to hospital with COVID-19 were included. The treatment group included patients prescribed nirmatrelvir-ritonavir within 5 days of symptom onset, excluding those prescribed molnupiravir within 21 days, and the control group had no exposure to either nirmatrelvir-ritonavir or molnupiravir. The outcomes were post-acute inpatient death and 13 sequelae (congestive heart failure, atrial fibrillation, coronary artery disease, deep vein thrombosis, chronic pulmonary disease, acute respiratory distress syndrome, interstitial lung disease, seizure, anxiety, post-traumatic stress disorder, end-stage renal disease, acute kidney injury, and pancreatitis). These outcomes were evaluated starting at 21 days after the positive RT-PCR date in each respective cohort constructed for the outcome. Standardised mortality ratio weights were applied to balance covariates, and Cox proportional hazards regression was used to investigate the relationship between nirmatrelvir-ritonavir and outcomes. FINDINGS 136 973 patients were screened for inclusion, among whom 50 055 were eligible and included in the analysis (24 873 [49·7%] were female and 25 182 [50·3%] were male). 15 242 patients were prescribed nirmatrelvir-ritonavir during acute COVID-19 and 23 756 patients were included in the control group; 11 057 patients did not meet our definition for the exposed and unexposed groups. Patients were followed up for a median of 393 days (IQR 317-489). In the nirmatrelvir-ritonavir group compared with the control group, there was a significantly lower hazard of post-acute inpatient death (hazard ratio 0·62 [95% CI 0·57-0·68]; p<0·0001), congestive heart failure (0·70 [0·58-0·85]; p=0·0002), atrial fibrillation (0·63 [0·52-0·76]; p<0·0001), coronary artery disease (0·71 [0·59-0·85]; p=0·0002), chronic pulmonary disease (0·68 [0·54-0·86]; p=0·0011), acute respiratory distress syndrome (0·71 [0·58-0·86]; p=0·0007), interstitial lung disease (0·17 [0·04-0·75]; p=0·020), and end-stage renal disease (0·37 [0·18-0·74]; p=0·0049). There was no evidence indicating difference between the groups in deep vein thrombosis, seizure, anxiety, post-traumatic stress disorder, acute kidney injury, and pancreatitis. INTERPRETATION This study showed extended benefits of nirmatrelvir-ritonavir for reducing the risk of post-acute inpatient death as well as cardiovascular and respiratory complications among patients admitted to hospital with COVID-19. Further research is essential to uncover the underlying mechanisms responsible for these observed negative associations and to devise effective strategies for preventing the onset of post-acute sequelae. FUNDING Health and Medical Research Fund, Research Grants Council theme-based research schemes, and Research Grants Council Collaborative Research Fund.
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Affiliation(s)
- Huwen Wang
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yuchen Wei
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Chi Tim Hung
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Guozhang Lin
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Xiaoting Jiang
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Conglu Li
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Katherine Min Jia
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Carrie Ho Kwan Yam
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Tsz Yu Chow
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Janice Ying-En Ho
- Division of Landscape Architecture, Department of Architecture, Faculty of Architecture, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yawen Wang
- Division of Landscape Architecture, Department of Architecture, Faculty of Architecture, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Shi Zhao
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; School of Public Health, Tianjin Medical University, Tianjin, China
| | - Zihao Guo
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kehang Li
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Aimin Yang
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Chris Ka Pun Mok
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - David S C Hui
- S H Ho Research Centre for Infectious Diseases, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eng Kiong Yeoh
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - Ka Chun Chong
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
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Zhang Y, Wang X, Huang C, Yang H, Jiang C, Yu X, Hong J, Zhang Y, Wang Y, Zhao R, An Z, Tong Z. Nirmatrelvir-Ritonavir Reduced Mortality in Hospitalized Patients with COVID-19 During the Omicron Outbreak: Real-World Evidence from Beijing. Infect Drug Resist 2024; 17:1367-1377. [PMID: 38618583 PMCID: PMC11012621 DOI: 10.2147/idr.s445826] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/24/2024] [Indexed: 04/16/2024] Open
Abstract
Objective The efficacy of nirmatrelvir-ritonavir for hospitalized patients with COVID-19 has not been fully established. Methods We conducted a retrospective analysis of hospitalized COVID-19 patients with high risk for disease progression at Beijing Chaoyang Hospital from October 15, 2022, to March 31, 2023. Patients ≥18 years old who were hospitalized with COVID-19 within 5 days of symptom onset were included. Baseline data were obtained from the routine electronic health record database of the hospital information system. Outcomes were monitored at 28 days via electronic medical record reviews or telephone interviews. Results We identified 1120 patients hospitalized with COVID-19 during the study period. After exclusions, 167 nirmatrelvir-ritonavir users and 132 controls were included. 28-day all-cause mortality rate was 12.0% (20/167) in the nirmatrelvir-ritonavir group, versus 22.7% (30/132) in the control group (unadjusted log-rank p = 0.010; HR = 0.49, 95% confidence interval [CI] = 0.28-0.86, IPTW-adjusted HR = 0.58, 95% CI = 0.40-0.86). The 28-day disease progression rates did not differ between the two groups (unadjusted HR = 0.59, 95% CI = 0.34-1.02, IPTW-adjusted HR = 0.73, 95% CI = 0.50-1.06). Nirmatrelvir-ritonavir significantly reduced all-cause mortality and disease progression within 28 days among patients aged ≥65 years without ≥2 vaccine doses. Conclusion We found significantly reduced all-cause mortality in the nirmatrelvir-ritonavir group, particularly in elderly patients who were incompletely vaccinated. Future randomized controlled studies are needed to validate our findings.
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Affiliation(s)
- Yi Zhang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xinrui Wang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chong Huang
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, People’s Republic of China
| | - Hui Yang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chunguo Jiang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xiaojia Yu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jun Hong
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, People’s Republic of China
| | - Yi Zhang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yushu Wang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Rui Zhao
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhuoling An
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
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McNeil T, Zhang F, Moffatt S, Emeto TI, Tucker E. Nosocomial COVID-19 infection in the era of vaccination and antiviral therapy. Intern Med J 2024; 54:374-381. [PMID: 38010619 DOI: 10.1111/imj.16298] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIMS Coronavirus disease 2019 (COVID-19) vaccination and antiviral therapies have altered the course of the COVID-19 pandemic through mitigating severe illness and death. However, immunocompromised, elderly and multimorbid patients remain at risk of poor outcomes and are overrepresented in hospital populations. The aim of this study was to describe the characteristics and outcomes of patients with nosocomial COVID-19 infection. METHODS This was a retrospective, observational study of patients who acquired COVID-19 after 7 days of hospital admission within the Southern Adelaide Local Health Network (SALHN) in South Australia between 1 June 2022 and 30 November 2022. Data were ascertained from the electronic medical record and the South Australian registry of births, deaths and marriages. RESULTS Of 1084 COVID-19 inpatient cases managed in SALHN, 295 (27%) were nosocomial, with 215 included in the study. The median age of patients was 80 years (interquartile range [IQR], 68-88 years), the median Charlson Comorbidity Index score was 5 (IQR, 4-7) and 6% were immunocompromised. Most nosocomial COVID-19 infections were of mild severity (81%). The 30-day all-cause mortality rate following COVID-19 infection was 6%, and, in most cases, a cause of death other than COVID-19 was recorded on the death certificate. CONCLUSION The majority of cases of nosocomial COVID-19 infection were mild, with a lower mortality rate than in earlier studies. This finding is likely attributable to immunity through vaccination and prior infection, early antiviral therapy and attenuated severity of the Omicron variant. The high proportion of nosocomial infections supports ongoing infection control measures.
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Affiliation(s)
- Thomas McNeil
- Microbiology and Infectious Diseases, Flinders Medical Centre, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Frank Zhang
- Microbiology and Infectious Diseases, Flinders Medical Centre, Adelaide, South Australia, Australia
- Microbiology and Infectious Diseases, SA Pathology, Adelaide, South Australia, Australia
| | - Samuel Moffatt
- Microbiology and Infectious Diseases, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Theophilus I Emeto
- Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Science, James Cook University, Townsville, Queensland, Australia
- World Health Organisation Collaborating Centre for Vector-Borne and Neglected Tropical Diseases, James Cook University, Townsville, Queensland, Australia
| | - Emily Tucker
- Microbiology and Infectious Diseases, Flinders Medical Centre, Adelaide, South Australia, Australia
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Wang S, Sun J, Zhang X, Li M, Qin B, Liu M, Zhang N, Wang S, Zhou T, Zhang W, Ma C, Deng X, Bai Y, Qu G, Liu L, Shi H, Zhou B, Li K, Yang B, Li S, Wang F, Ma J, Zhang L, Wang Y, An L, Liu W, Chang Q, Zhang R, Yin X, Yang Y, Ao Q, Ma Q, Yan S, Huang H, Song P, Gao L, Lu W, Xu L, Lei L, Wang K, Zhang Q, Song Q, Zhang Z, Fang X, He Y, Li T, Zhu P. Antiviral effectiveness and survival correlation of azvudine and nirmatrelvir/ritonavir in elderly severe patients with COVID-19: a retrospective real-world study. EClinicalMedicine 2024; 69:102468. [PMID: 38361990 PMCID: PMC10867603 DOI: 10.1016/j.eclinm.2024.102468] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 02/17/2024] Open
Abstract
Background Azvudine and nirmatrelvir/ritonavir are approved to treat mild-to-moderate coronavirus disease 2019 (COVID-19) in adults with a high risk for progression to severe infection. We sought to compare the antiviral effectiveness and clinical outcomes of elderly severe patients with COVID-19 receiving these two antiviral agents. Methods In this observational study, we identified 249 elderly patients with severe COVID-19 infection who were admitted to the Second Medical Center of the People's Liberation Army General Hospital from December 2022 to January 2023, including 128 azvudine recipients, 66 nirmatrelvir/ritonavir recipients and 55 patients not received antiviral treatments. We compared the cycle threshold (Ct) value dynamic change of all three groups. The primary outcome was a composite outcome of disease progression, including all-cause death, intensive care unit admission, and initiation of invasive mechanical ventilation. The outcomes of all enrolled patients were followed up from the electronic medical record system. Kaplan-Meier and Cox risk proportional regression analyses were used to compare the clinical outcomes of all three groups. To more directly compare the effectiveness of the two antiviral drugs, we performed propensity-score matching between the two antiviral groups and compared antiviral efficacy and clinical outcomes in the matched population. Findings Among 249 patients (mean age, 91.41 years), 77 patients died during the follow-up period. When compared to patients who did not receive any antivirals, neither nirmatrelvir/ritonavir nor azvudine demonstrated a survival benefit. The Cox analysis of the all-cause death of the three groups showed that the risk of death was 0.730 (0.423-1.262) in the azvudine group 0.802 (0.435-1.480) and in the nirmatrelvir/ritonavir group compared with the non-antiviral group. After propensity score matching, we included 58 azvudine recipients and 58 nirmatrelvir/ritonavir recipients. The fitted curve of the Ct value after matching illustrated that the rate of viral decline in the early stage of nirmatrelvir/ritonavir treatment seems to surpass that of azvudine, but there was no statistical significance. Azvudine was seemly associated with a lower risk of composite outcomes (HR:1.676, 95% CI:0.805-3.488) and short-term all-cause death (HR: 1.291, 95%CI: 0.546-3.051). Interpretation Patients who received azvudine have a similar antiviral effectiveness and survival curve trend compared to nirmatrelvir/ritonavir. In this limited series, antiviral treatment was not associated with a significant clinical benefit. This lack of clinical benefit might be attributed to potential bias. Funding This study was supported by the "National Key R&D Program of China" (Funding No. 2020YFC2008900) and the National Defense Science and Technology Innovation Special Zone Project (223-CXCY-N101-07-18-01).
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Affiliation(s)
- Shuxia Wang
- Department of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Jin Sun
- Department of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
- Medical School of Chinese PLA, Beijing 100853, China
| | - Xin Zhang
- The Second Medical Center, PLA General Hospital, Beijing 100853, China
| | - Man Li
- Department of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Bangguo Qin
- Medical School of Chinese PLA, Beijing 100853, China
| | - Miao Liu
- Department of Anti-NBC Medicine, Graduate School of Chinese PLA General Hospital, Beijing 100853, China
| | - Nan Zhang
- Medical School of Chinese PLA, Beijing 100853, China
| | - Shengshu Wang
- Institute of Geriatrics, The Second Medical Center, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatrics Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Tingyu Zhou
- National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Wei Zhang
- Department of Integrative Therapy, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Cong Ma
- Department of Health Medicine, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xinli Deng
- Department of Clinical Laboratory, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yongyi Bai
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Geping Qu
- Department of Respiratory and Critical Care Medicine, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Lin Liu
- Department of Respiratory and Critical Care Medicine, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Hui Shi
- Department of Gastroenterology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Bo Zhou
- Department of Neurology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ke Li
- Department of Neurology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Bo Yang
- Department of Hematology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Suxia Li
- Department of Hematology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Fan Wang
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Jinling Ma
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Lu Zhang
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Yajuan Wang
- Department of Respiratory and Critical Care Medicine, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Li An
- Department of Respiratory and Critical Care Medicine, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Wenhui Liu
- Department of Gastroenterology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qing Chang
- Department of Gastroenterology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ru Zhang
- Department of Gastroenterology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xi Yin
- Department of Neurology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yang Yang
- Department of Neurology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qiangguo Ao
- Department of Nephrology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qiang Ma
- Department of Nephrology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Shuangtong Yan
- Department of Endocrinology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Haili Huang
- Department of Medical Oncology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Peng Song
- Department of Medical Oncology, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Linggen Gao
- Department of General Surgery, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Wenning Lu
- Department of General Surgery, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Lining Xu
- Department of General Surgery, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Li Lei
- Department of Health Medicine, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Keyu Wang
- Department of Clinical Laboratory, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qi Zhang
- The Second Medical Center, PLA General Hospital, Beijing 100853, China
| | - Qing Song
- Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhijian Zhang
- Department of Respiratory and Critical Care Medicine, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiangqun Fang
- Department of Respiratory and Critical Care Medicine, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yao He
- Institute of Geriatrics, The Second Medical Center, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatrics Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Tianzhi Li
- The Second Medical Center, PLA General Hospital, Beijing 100853, China
| | - Ping Zhu
- Department of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
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Jang YR, Oh Y, Kim JY. Determining and Comparing the Real-World Effectiveness of Molnupiravir and Nirmatrelvir-Ritonavir in Patients Hospitalized With COVID-19. J Korean Med Sci 2024; 39:e52. [PMID: 38374626 PMCID: PMC10876432 DOI: 10.3346/jkms.2024.39.e52] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/06/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Current guidelines recommend using nirmatrelvir-ritonavir for coronavirus disease 2019 (COVID-19) treatment, but its potential drug interactions and contraindications limit its applicability in certain categories of patients. The aim of the study was to evaluate the real-world effectiveness of molnupiravir and nirmatrelvir-ritonavir in managing COVID-19 among hospitalized patients. METHODS We conducted a retrospective cohort study among hospitalized COVID-19 patients who received molnupiravir or nirmatrelvir-ritonavir and did not require baseline supplemental oxygen from February 2022 to January 2023. We compared the effectiveness of molnupiravir and nirmatrelvir-ritonavir with a focus on disease progression. RESULTS The study included 401 high-risk, hospitalized adult COVID-19 patients who received molnupiravir or nirmatrelvir-ritonavir. No significant difference was found in disease progression, the composite outcome of disease progression (4.0% vs. 1.4%, P = 0.782), and O2 supplementation via nasal prong (21.8% vs. 14.8%, P = 0.115) between the patients treated with molnupiravir and those treated with nirmatrelvir-ritonavir. This finding was similar after 1:1 propensity-score matching. In the multivariate analysis, molnupiravir treatment was not significantly associated with progression to severe disease. CONCLUSION In conclusion, our findings suggest that similar to nirmatrelvir-ritonavir, molnupiravir has a distinct potential role in COVID-19 treatment, transcending its current perceived status as only a secondary option.
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Affiliation(s)
- Young Rock Jang
- Division of Infectious Diseases, Department of Internal Medicine, Incheon Medical Center, Incheon, Korea
| | - Yoonju Oh
- Division of Metabolism and Endocrinology, Department of Internal Medicine, Incheon Medical Center, Incheon, Korea
| | - Jin Yong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Incheon Medical Center, Incheon, Korea.
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Lee JY. Could Molnupiravir Be the First-Line Alternative Oral Antiviral Agent for COVID-19 Patients at High Risk? J Korean Med Sci 2024; 39:e74. [PMID: 38374633 PMCID: PMC10876427 DOI: 10.3346/jkms.2024.39.e74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/21/2024] Open
Affiliation(s)
- Ji Yong Lee
- Division of Infectious Disease, Department of Internal Medicine, Gumdan Top Hospital, Incheon, Korea.
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Ombelet S, Castanares-Zapatero D, Desimpel F, Hulstaert F, Stordeur S, Roberfroid D. Effectiveness of nirmatrelvir-ritonavir on severe outcomes of COVID-19 in the era of vaccination and Omicron: An updated meta-analysis. J Med Virol 2024; 96:e29434. [PMID: 38376947 DOI: 10.1002/jmv.29434] [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: 09/20/2023] [Revised: 12/18/2023] [Accepted: 01/16/2024] [Indexed: 02/22/2024]
Abstract
Nirmatrelvir-ritonavir (NR) was approved to treat SARS-CoV-2 positive outpatients at high risk of progression to severe disease, based on a randomized trial in unvaccinated patients. Effectiveness in vaccinated patients and against Omicron has not yet been confirmed by clinical trial data, but a recent meta-analysis suggested good real-world effectiveness based on 12 studies. We updated this meta-analysis by searching Medline and Embase databases for studies assessing effectiveness of NR on mortality, hospitalization, composite outcome of hospitalization and/or death, and progression to severe disease, published between October 1, 2022 and May 22, 2023. Random effects meta-analysis and subgroup analysis for vaccinated patients was performed. A total of 32 studies were included in the meta-analysis. Pooled RR for the effect of NR on mortality, hospitalization, hospitalization and/or mortality, and progression to severe disease were 0.36 (95% confidence interval [CI]: 0.25-0.52), 0.43 (CI: 0.37-0.51), 0.52 (CI: 0.45-0.61) and 0.54 (CI: 0.41-0.73), respectively. A subgroup analysis on vaccinated patients indicated lower effectiveness of NR on mortality (RR: 0.55, CI: 0.45-0.68), but similar effectiveness for hospitalization, hospitalization and/or mortality, or progression to severe disease (RR: 0.52, 0.58, and 0.66, respectively). This updated meta-analysis robustly confirms the protective effects of NR on severe COVID-19 outcomes.
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Affiliation(s)
- Sien Ombelet
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | | | - Fabian Desimpel
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | - Frank Hulstaert
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | - Sabine Stordeur
- Directorate-General Public Health, Federal Public Service of Health, Food Chain Safety and Environment, Brussels, Belgium
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Kwok WC, Tam TCC, Ho JCM, Lam DCL, Ip MSM, Ho PL. Real-World Effectiveness Study of Nirmatrelvir-Ritonavir or Molnupiravir in Hospitalized Unvaccinated Patients with Chronic Respiratory Diseases and Moderate COVID-19 at Presentation. Int J Chron Obstruct Pulmon Dis 2024; 19:77-86. [PMID: 38222320 PMCID: PMC10787548 DOI: 10.2147/copd.s440895] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/26/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Nirmatrelvir-ritonavir (NMV-r) and molnupiravir (MOL) were developed as out-patient anti-viral for mild COVID-19. There was limited data on their role in treating COVID-19 for hospitalized patients, especially among adult patients who are unvaccinated and had chronic respiratory diseases. Methods A territory-wide retrospective study was conducted in Hong Kong to compare the efficacy of NMV-r and MOL against COVID-19 in unvaccinated adult patients with asthma, chronic obstructive pulmonary disease, bronchiectasis and interstitial lung diseases presenting with moderate COVID-19 from 16th February 2022 to 15th March 2023. Results A total of 1354 patients were included, 738 received NMV-r and 616 received MOL. NMV-r was more effective in reducing 90-day mortality with adjusted hazard ratios (aHR) of 0.508 (95% confidence interval [CI] = 0.314-0.822, p = 0.006). Patients who received NMV-r also had significantly shorter length of stay (LOS) than those receiving MOL, with median LOS of 4 (Interquartile range [IQR] = 2-7) for NMV-r and 6 (IQR = 3-10) for MOL (p-value < 0.001). There was no statistically significant difference in the development of respiratory failure and severe respiratory failure in the two groups. Discussion NMV-r was more effective than MOL among unvaccinated adults with chronic respiratory diseases who were hospitalized for moderate COVID-19 without hypoxaemia on admission.
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Affiliation(s)
- Wang Chun Kwok
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Terence Chi Chun Tam
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - James Chung Man Ho
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - David Chi Leung Lam
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Mary Sau-Man Ip
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Pak Leung Ho
- Department of Microbiology and Carol Yu Centre for Infection, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
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10
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Yii YC, Shih HM, Chen CL, Lai ZL, Hsu YL, Lai CH, Hsueh PR, Cho DY. Effect of pre-hospitalization use of oral antiviral agents on reducing critical illness and mortality for patients with COVID-19 pneumonia. Int J Antimicrob Agents 2024; 63:107020. [PMID: 37898365 DOI: 10.1016/j.ijantimicag.2023.107020] [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: 08/15/2023] [Revised: 10/12/2023] [Accepted: 10/21/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVES This study aimed to evaluate the effect of administering nirmatrelvir/ritonavir and molnupiravir before hospitalisation on subsequent critical illness among patients with COVID-19 pneumonia. METHODS This retrospective cohort study included patients with COVID-19 pneumonia who required hospitalisation between 1 January 1 2022 and 31 August 2022. The primary outcomes were the development of critical illness, including intensive care unit admission, use of mechanical ventilation, or mortality. A multivariate logistic regression analysis was conducted to assess the varying risks of critical illness and mortality. A total of 1,011 COVID-19 patients were analysed. Among them, 304 (30.1%) received molnupiravir and 131 (13.0%) received nirmatrelvir/ritonavir before hospitalisation. RESULTS There were significant reductions for critical illness (adjusted odds ratio 0.29, 95% confidence interval 0.21-0.39, P < 0.001) and mortality (adjusted odds ratio 0.40, 95% confidence interval 0.27-0.59, P < 0.001) in patients receiving oral antivirals compared with those who did not. No significant differences in critical illness were observed between molnupiravir and nirmatrelvir/ritonavir. The combination of COVID-19 vaccines and oral antivirals can further reduce the risk of critical illness in high-risk populations. CONCLUSION Administering molnupiravir and nirmatrelvir/ritonavir before hospitalisation reduced the risk of COVID-19 patients with moderate to severe pneumonia progressing to critical illness and mortality.
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Affiliation(s)
- Yong-Cheng Yii
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Hong-Mo Shih
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Public Health, China Medical University, Taichung, Taiwan
| | - Chieh-Lung Chen
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Zi-Lun Lai
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Lung Hsu
- Division of Paediatric Infectious Disease, China Medical University Children's Hospital, Taichung, Taiwan
| | - Chia-Hong Lai
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Po-Ren Hsueh
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan.
| | - Der-Yang Cho
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
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Zhong X, Wang C, Huang L, Zhao Y, Li T, He J, Zhang X. Evaluation of the efficacy and safety of nirmatrelvir/ritonavir co-administration inpatients with rheumatic disease infected with SARS-CoV-2: a real-world study. Front Pharmacol 2023; 14:1288402. [PMID: 38125894 PMCID: PMC10730682 DOI: 10.3389/fphar.2023.1288402] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background: The breakthrough development of novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccines and oral antivirals have played a critical role in curtailing the spread of the pandemic and dramatically reducing the morbidity and mortality rates among those infected. Among these oral antivirals, nirmatrelvir/ritonavir (NR) has been repurposed successfully for use against coronavirus disease-2019 (COVID-19) and is now readily available on the market with promising therapeutic effects. The availability of convenient and effective NR treatments for COVID-19 greatly mitigates the severity of the epidemic and contributes to an early end to the pandemic. Furthermore, certain patient subgroups, specifically those with rheumatic disease (RD) who are currently undergoing intensive immunodeficiency and/or immunosuppressive treatments, continue to be vulnerable and at a higher risk of experiencing severe consequences from COVID-19. Additionally, it has also been observed that NR exhibited prevalent drug-drug interactions of clinical significance, and more instances of COVID-19 rebound were being recognized with increasing frequency. Methods: A retrospective cohort study was conducted on a real-world RD population who were infected with SARS-CoV-2 and treated with NR. The time of symptom resolution, length of hospitalization, and response rate were assessed. Results were compared among the standard regimen and non-standard regimen groups, early NR regimen and late NR regimen groups, and the NR indication regimen and NR non-indication regimen groups. During the course, all grades of adverse drug reactions (ADRs) directly associated with NR administration and associated with drug-drug interactions (DDIs) were also monitored. Results: A total of 32 patients with RD, who were infected with SARS-CoV-2 and received NR, were retrospectively identified and divided into different groups. We found that the standard regimen group and the early NR regimen group had a shorter median time of symptom resolution compared to the control group [9.0 (interquartile range [IQR], 8.3-11.3) vs. 21.5 (IQR16.0-24.0) days, p < 0.001 and 9.0 (IQR 8.3-11.3) vs. 23.0 (IQR 18.0-24.0) days, p = 0.0]. We further found that even if the NR administration time exceeds 5 days, patients with RD who receive the NR indication regimen can still derive certain benefits from it. The proportion of patients who showed symptom improvement was higher in the NR indication regimen compared to the NR non-indication regimen group (n = 13/17 vs. 3/6, 76.5% vs. 50.0%) at the end of follow-up, and there was a statistical difference (p = 0.0) in the response rate of patients between the two groups. We also analyzed the effect of comorbidities on patient response rates and found that the percentage of patients who showed symptom improvement was higher in the group with <4 comorbidities compared to the group with ≥ 4 comorbidities (n = 7/7 vs. 16/25, 100.0% vs. 64.0%) at the end of follow-up. During the course, all grades of ADRs and grade ≥3ADRs directly associated with NR administration were not observed in any of the 32 cases. Despite discontinuing warfarin prior to NR application (using NR immediately on the first day of warfarin withdrawal), one patient still experienced an increased international normalized ratio [INR, 5.32(0.90-1.20)] and coagulation disorders (weak positive fecal occult blood test) on the second day after using NR. The INR levels decreased to nearly normal values, and coagulation disorders returned to normal after 2 days of discontinuing NR (the seventh day after the initial administration of NR). Conclusion: We showed NR therapy to be associated with a favorable outcome and an acceptable safety profile in an immunosuppressed population with RD during the Omicron surge. Early use of NR (within 5 days of symptom onset) could improve the prognosis of patients. NR administration for symptoms and confirmed SARS-CoV-2 infection after >5 days may also mitigate progression to severe disease and is a viable strategy. Our results highlight the importance of early utilization and/or NR indication, which may yield clinical advantages for patients with RD infected with SARS-CoV-2.
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Affiliation(s)
- Xue Zhong
- Department of Pharmacy, Peking University People’s Hospital, Beijing, China
| | - Chao Wang
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Lin Huang
- Department of Pharmacy, Peking University People’s Hospital, Beijing, China
| | - Yue Zhao
- School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Tianyi Li
- College of Pharmaceutical Engineering of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jing He
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
| | - Xiaohong Zhang
- Department of Pharmacy, Peking University People’s Hospital, Beijing, China
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Reis S, Metzendorf MI, Kuehn R, Popp M, Gagyor I, Kranke P, Meybohm P, Skoetz N, Weibel S. Nirmatrelvir combined with ritonavir for preventing and treating COVID-19. Cochrane Database Syst Rev 2023; 11:CD015395. [PMID: 38032024 PMCID: PMC10688265 DOI: 10.1002/14651858.cd015395.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID-19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable. OBJECTIVES To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID-19 or preventing SARS-CoV-2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in-between publication of review updates. SEARCH METHODS We searched the Cochrane COVID-19 Study Register, Scopus, and World Health Organization COVID-19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID-19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS-CoV-2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID-19; 2. to treat inpatients with moderate to severe COVID-19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS-CoV-2 infection in postexposure prophylaxis (PEP); and 4. pre-exposure prophylaxis (PrEP) scenarios: SARS-CoV-2 infection, development of COVID-19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially-disadvantaged people with comorbidities, populations from low-income countries and low- to middle-income countries, and people from different ethnic and racial backgrounds. MAIN RESULTS As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID-19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS-CoV-2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID-19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all-cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low-certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low-certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low-certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment-emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate-certainty evidence), and probably increases treatment-related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate-certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate-certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID-19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all-cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low-certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low-certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low-certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all-cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity-related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS-CoV-2 infection (PrEP and PEP) No studies available. AUTHORS' CONCLUSIONS Low-certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all-cause mortality and hospital admission or death in high-risk, unvaccinated COVID-19 outpatients infected with the Delta variant of SARS-CoV-2. There is low- to moderate-certainty evidence of the safety of nirmatrelvir/ritonavir. Very low-certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all-cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID-19 inpatients infected with the Omicron variant of SARS-CoV-2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS-CoV-2 infection. We are continually updating our search and making search results available on the OSF platform.
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Affiliation(s)
- Stefanie Reis
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Rebecca Kuehn
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maria Popp
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Ildiko Gagyor
- Department of General Practice, University Hospital Würzburg, Würzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Department of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology, University of Cologne, Cologne, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
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Karniadakis I, Mazonakis N, Tsioutis C, Papadakis M, Markaki I, Spernovasilis N. Oral Molnupiravir and Nirmatrelvir/Ritonavir for the Treatment of COVID-19: A Literature Review with a Focus on Real-World Evidence. Infect Dis Rep 2023; 15:662-678. [PMID: 37987399 PMCID: PMC10660858 DOI: 10.3390/idr15060061] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023] Open
Abstract
Vaccines remain the cornerstone of medical prevention and are highly effective in reducing the risk of severe disease and death due to coronavirus disease 2019 (COVID-19). In the context of expanding the therapeutic armamentarium against COVID-19, molnupiravir (Lagevrio) and ritonavir-boosted nirmatrelvir (Paxlovid) were developed, constituting the first effective oral treatments against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this narrative review, we retrospectively inquired into the clinical trials and real-world studies investigating the efficacy of these agents. Overall, clinical trials and real-world studies have demonstrated the efficacy of both agents in reducing hospitalization and death rates in COVID-19 patients. As per current recommendations, their use is suggested in patients with mild to moderate symptoms who are at high risk of developing severe disease. Nevertheless, limited data exist regarding their efficacy in specific subpopulations, such as immunocompromised patients, those with severe kidney disease, pregnant women, and children.
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Affiliation(s)
- Ioannis Karniadakis
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK;
| | - Nikolaos Mazonakis
- Internal Medicine Department, Thoracic Diseases General Hospital Sotiria, 11527 Athens, Greece; (N.M.); (I.M.)
| | - Constantinos Tsioutis
- School of Medicine, European University Cyprus, 6 Diogenis St., Nicosia 2404, Cyprus
| | - Michail Papadakis
- 3rd Internal Medicine Department & Diabetes Center, General Hospital of Nikaia Piraeus “Agios Panteleimon”, 18454 Piraeus, Greece;
| | - Ioulia Markaki
- Internal Medicine Department, Thoracic Diseases General Hospital Sotiria, 11527 Athens, Greece; (N.M.); (I.M.)
| | - Nikolaos Spernovasilis
- Department of Infectious Diseases, German Oncology Center, Agios Athanasios, Limassol 4108, Cyprus;
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14
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Wan EYF, Yan VKC, Wong ZCT, Chui CSL, Lai FTT, Li X, Wong CKH, Hung IFN, Lau CS, Wong ICK, Chan EWY. Effectiveness of molnupiravir vs nirmatrelvir-ritonavir in non-hospitalised and hospitalised patients with COVID-19: a target trial emulation study. EClinicalMedicine 2023; 64:102225. [PMID: 37753272 PMCID: PMC10518465 DOI: 10.1016/j.eclinm.2023.102225] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/28/2023] Open
Abstract
Background Molnupiravir and nirmatrelvir-ritonavir have emerged as promising options for COVID-19 treatment, but direct comparisons of their effectiveness have been limited. This study aimed to compare the effectiveness of these two oral antiviral drugs in non-hospitalised and hospitalised patients with COVID-19. Methods In this target trial emulation study, we used data from a territory-wide electronic health records database on eligible patients aged ≥18 years infected with COVID-19 who were prescribed either molnupiravir or nirmatrelvir-ritonavir within five days of infection between 16 March 2022 and 31 December 2022 in the non-hospitalised and hospitalised settings in Hong Kong. A sequence trial approach and 1:1 propensity score matching was applied based on age, sex, number of COVID-19 vaccine doses received, Charlson comorbidity index, comorbidities, and drug use within past 90 days. Cox regression adjusted with patients' characteristics was used to compare the risk of effectiveness outcomes (all-cause mortality, intensive care unit (ICU) admission or ventilatory support and hospitalisation) between groups. Subgroup analyses included age (<70; ≥70 years); sex, Charlson comorbidity index (<4; ≥4), and number of COVID-19 vaccine doses received (0-1; ≥2 doses). Findings A total of 63,522 non-hospitalised (nirmatrelvir-ritonavir: 31,761; molnupiravir: 31,761) and 11,784 hospitalised (nirmatrelvir-ritonavir: 5892; molnupiravir: 5892) patients were included. In non-hospitalised setting, 336 events of all-cause mortality (nirmatrelvir-ritonavir: 71, 0.22%; molnupiravir: 265, 0.83%), 162 events of ICU admission or ventilatory support (nirmatrelvir-ritonavir: 71, 0.22%; molnupiravir: 91, 0.29%), and 4890 events of hospitalisation (nirmatrelvir-ritonavir: 1853, 5.83%; molnupiravir: 3037, 9.56%) were observed. Lower risks of all-cause mortality (absolute risk reduction (ARR) at 28 days: 0.61%, 95% CI: 0.50-0.72; HR: 0.43, 95% CI: 0.33-0.56) and hospital admission (ARR at 28 days: 3.73%, 95% CI: 3.31-4.14; HR: 0.72, 95% CI: 0.67-0.76) were observed in nirmatrelvir-ritonavir users compared to molnupiravir users. In hospitalised setting, 509 events of all-cause mortality (nirmatrelvir-ritonavir: 176, 2.99%; molnupiravir: 333, 5.65%), and 50 events of ICU admission or ventilatory support (nirmatrelvir-ritonavir: 26, 0.44%; molnupiravir: 24, 0.41%) were observed. Risk of all-cause mortality was lower for nirmatrelvir-ritonavir users than for molnupiravir users (ARR at 28 days: 2.66%, 95% CI: 1.93-3.40; HR: 0.59, 95% CI: 0.49-0.71). In both settings, there was no difference in the risk of intensive care unit admission or ventilatory support between groups. The findings were consistent across all subgroup's analyses. Interpretation Our analyses suggest that nirmatrelvir-ritonavir was more effective than molnupiravir in reducing the risk of all-cause mortality in both non-hospitalised and hospitalised patients. When neither drug is contraindicated, nirmatrelvir-ritonavir may be considered the more effective option. Funding HMRF Research on COVID-19, The Hong Kong Special Administrative Region (HKSAR) Government; Collaborative Research Fund, University Grants Committee, the HKSAR Government; and Research Grant from the Food and Health Bureau, the HKSAR Government; the Laboratory of Data Discovery for Health (D24H) funded by the AIR@InnoHK administered by Innovation and Technology Commission.
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Affiliation(s)
- Eric Yuk Fai Wan
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, Department of Family Medicine and Primary Care, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Vincent Ka Chun Yan
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
| | - Zoey Cho Ting Wong
- Li Ka Shing Faculty of Medicine, Department of Family Medicine and Primary Care, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Celine Sze Ling Chui
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, School of Nursing, The University of Hong Kong, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, School of Public Health, The University of Hong Kong, Hong Kong SAR, China
| | - Francisco Tsz Tsun Lai
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
| | - Xue Li
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Carlos King Ho Wong
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, Department of Family Medicine and Primary Care, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ivan Fan Ngai Hung
- Li Ka Shing Faculty of Medicine, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chak Sing Lau
- Li Ka Shing Faculty of Medicine, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ian Chi Kei Wong
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Aston Pharmacy School, Aston University, Birmingham B4 7ET, UK
| | - Esther Wai Yin Chan
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- The University of Hong Kong, Shenzhen Institute of Research and Innovation, Shenzhen, China
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15
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Focosi D, Nicastri E. Effectiveness of Molnupiravir and Nirmatrelvir-Ritonavir in Hospitalized Patients With COVID-19. Ann Intern Med 2023; 176:eL230264. [PMID: 37844308 DOI: 10.7326/l23-0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Banks, Pisa University Hospital, Pisa, Italy
| | - Emanuele Nicastri
- "Lazzaro Spallanzani" National Institute for Infectious Disease IRCCS, Rome, Italy
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16
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Sun Y, Dian Y, Gao Q, Deng G. Immunophenotyping characteristics and outcome of COVID-19 patients: peripheral blood CD8+T cell as a prognostic biomarker for patients with Nirmatrelvir. Front Immunol 2023; 14:1227905. [PMID: 37799722 PMCID: PMC10547864 DOI: 10.3389/fimmu.2023.1227905] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/01/2023] [Indexed: 10/07/2023] Open
Abstract
Background Nirmatrelvir has been authorized for the treatment of both hospitalized and non-hospitalized COVID-19 patients. However, the association between T lymphocyte subsets and the outcome of hospitalized COVID-19 patients treated with oral Nirmatrelvir has not been investigated. The objective of this study was to examine whether lymphocyte subsets could serve as biomarkers to assess the risk of mortality in COVID-19 patients undergoing Nirmatrelvir treatment, with the aim of enhancing medication management for COVID-19 patients. Methods We conducted a retrospective cohort study at the Xiangya Hospital of Central South University in China between December 5, 2022 and January 31, 2023. The study reported demographic, clinical, T lymphocyte subsets, and inflammatory cytokine data of COVID-19 patients. We evaluated the associations of T lymphocyte subsets on admission with the composite outcome or death of patients using univariate and multivariable Cox regression analyses with hazards ratios (HRs) and 95% confidence intervals (CIs). Results We identified 2118 hospitalized COVID-19 patients during the study period, and conducted a follow-up of up to 38 days. Of these, 131 patients received Nirmatrelvir, with 56 (42.7%) in the composite outcome group, and 75 (57.3%) in the non-composite outcome group. Additionally, 101 (77.1%) patients were discharged, while 30 (22.9%) died. Our results showed a significant decrease in the CD3+, CD4+, and CD8+ T cell counts of patients in the composite outcome group and mortality group compared to the non-composite outcome group and discharged group, respectively. Multivariate Cox regression analysis showed that the significant decrease in CD8+ T cell count in peripheral blood was independently associated with the composite outcome in COVID-19 patients treated with Nirmatrelvir, with an HR of 1.96 (95%CI: 1.01-3.80). The significant decrease in CD4+ and CD8+ T cell counts in peripheral blood increased the hazard of developing mortality, with HRs of 6.48 (95%CI: 1.47-28.63) and 3.75 (95%CI: 1.27-11.11), respectively. Conclusion Our study revealed a significant positive correlation between a decrease in CD8+ T cell counts and progression and mortality of hospitalized COVID-19 patients treated with Nirmatrelvir. Lower counts (/μL) of CD8+ T cell (<201) were associated with a higher risk of in-hospital severity and death. Our findings may provide valuable references for physicians in optimizing the use of Nirmatrelvir.
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Affiliation(s)
- Yuming Sun
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China
- National Engineering Research Centre of Personalized Diagnostic and Therapeutic Technology, Changsha, China
- Furong Laboratory, Changsha, Hunan, China
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Hunan Engineering Research Centre of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital, Changsha, China
- Department of Plastic and Cosmetic Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yating Dian
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China
- National Engineering Research Centre of Personalized Diagnostic and Therapeutic Technology, Changsha, China
- Furong Laboratory, Changsha, Hunan, China
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Hunan Engineering Research Centre of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital, Changsha, China
| | - Qian Gao
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China
- National Engineering Research Centre of Personalized Diagnostic and Therapeutic Technology, Changsha, China
- Furong Laboratory, Changsha, Hunan, China
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Hunan Engineering Research Centre of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital, Changsha, China
- Clinical Laboratory Department, Xiangya Hospital, Central South University, Changsha, China
| | - Guangtong Deng
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China
- National Engineering Research Centre of Personalized Diagnostic and Therapeutic Technology, Changsha, China
- Furong Laboratory, Changsha, Hunan, China
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Hunan Engineering Research Centre of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital, Changsha, China
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17
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Rzymski P, Pokorska-Śpiewak M, Jackowska T, Kuchar E, Nitsch-Osuch A, Pawłowska M, Babicki M, Jaroszewicz J, Szenborn L, Wysocki J, Flisiak R. Key Considerations during the Transition from the Acute Phase of the COVID-19 Pandemic: A Narrative Review. Vaccines (Basel) 2023; 11:1502. [PMID: 37766178 PMCID: PMC10537111 DOI: 10.3390/vaccines11091502] [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: 08/12/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
The COVID-19 pandemic has been met with an unprecedented response from the scientific community, leading to the development, investigation, and authorization of vaccines and antivirals, ultimately reducing the impact of SARS-CoV-2 on global public health. However, SARS-CoV-2 is far from being eradicated, continues to evolve, and causes substantial health and economic burdens. In this narrative review, we posit essential points on SARS-CoV-2 and its responsible management during the transition from the acute phase of the COVID-19 pandemic. As discussed, despite Omicron (sub)variant(s) causing clinically milder infections, SARS-CoV-2 is far from being a negligible pathogen. It requires continued genomic surveillance, particularly if one considers that its future (sub)lineages do not necessarily have to be milder. Antivirals and vaccines remain the essential elements in COVID-19 management. However, the former could benefit from further development and improvements in dosing, while the seasonal administration of the latter requires simplification to increase interest and tackle vaccine hesitancy. It is also essential to ensure the accessibility of COVID-19 pharmaceuticals and vaccines in low-income countries and improve the understanding of their use in the context of the long-term goals of SARS-CoV-2 management. Regardless of location, the primary role of COVID-19 awareness and education must be played by healthcare workers, who directly communicate with patients and serve as role models for healthy behaviors.
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Affiliation(s)
- Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, 60-806 Poznań, Poland
| | - Maria Pokorska-Śpiewak
- Department of Children’s Infectious Diseases, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Teresa Jackowska
- Department of Pediatrics, Centre for Postgraduate Medical Education, 01-813 Warsaw, Poland;
| | - Ernest Kuchar
- Department of Pediatrics with Clinical Assessment Unit, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Aneta Nitsch-Osuch
- Department of Social Medicine and Public Health, Medical University of Warsaw, 02-007 Warsaw, Poland;
| | - Małgorzata Pawłowska
- Department of Infectious Diseases and Hepatology, Faculty of Medicine, Collegium Medicum, Nicolaus Copernicus University, 85-067 Bydgoszcz, Poland;
| | - Mateusz Babicki
- Department of Family Medicine, Wroclaw Medical University, 51-141 Wroclaw, Poland;
| | - Jerzy Jaroszewicz
- Department of Infectious Diseases and Hepatology, Medical University of Silesia, 41-902 Bytom, Poland;
| | - Leszek Szenborn
- Department of Pediatric Infectious Diseases, Wrocław Medical University, 50-367 Wroclaw, Poland;
| | - Jacek Wysocki
- Department of Preventive Medicine, Poznan University of Medical Sciences, 61-701 Poznań, Poland;
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, 15-089 Bialystok, Poland;
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