Grant M. Gallagher

The debate about hydroxychloroquine’s effectiveness against COVID-19 continues, but for how long? A study unveiled yesterday added to the preponderance of evidence showing hydroxychloroquine isn’t effective. “We launched this trial not knowing what the answer was for the question: Does hydroxychloroquine prevent COVID-19 disease after exposure?” That’s what David Boulware, MD, MPH, told 

 found that hydroxychloroquine is not likely to be an effective prophylaxis against COVID-19. “We designed a double-blind placebo-controlled trial to find out what the answer was,” Boulware continued. “While we are disappointed that this did not work, we are pleased that we found the answer.”

Why does this matter? Because Boulware’s findings came to light just a day after 

 assessment of hydroxychloroquine based on potentially faulty data from Surgisphere

Boulware’s trial consisted of non-hospitalized adults who indicated a high-risk or moderate-risk exposure to COVID-19 through the household or an occupational setting. They were provided the study drug or placebo by mail within 4 days of exposure. This leaves the prophylactic treatment to take place before symptoms typically develop.

The trial consisted of non-hospitalized adults who indicated a high-risk or moderate-risk exposure to COVID-19 through the household or an occupational setting. They were provided the study drug or placebo by mail within 4 days of exposure. This leaves the prophylactic treatment to take place before symptoms typically develop.

The randomized placebo-controlled trial launched on March 17. The trial enrolled 821 participants from across Canada and the United States. Half of the participants received 5 days of hydroxychloroquine while the other half received 5 days of a placebo.

Out of 821 participants, COVID-19 like-illness developed in 107 (13%) participants.

Notably, polymerase-chain-reaction assay confirmation was only available for about 3% of participants. Incidence of likely COVID-19, however, did not differ significantly between participants receiving hydroxychloroquine (49 of 414 [11.8%]) and those receiving placebo (58 of 407 [14.3%]).

Side effects were more common in patients receiving hydroxychloroquine (40.1%) than placebo (16.8%), but no serious adverse effects (including serious heart complications) were reported.

“Our team at the University of Minnesota has just concluded the first randomized, placebo-controlled, double-blind clinical trial of hydroxychloroquine as post-exposure prophylaxis in SARS-CoV-2,” the study’s second author, Matthew Pullen, MD, said. “After examining the data of our 821 participants, we did not find a significant difference in the risk of infection following exposure in those taking hydroxychloroquine and those taking placebo. We also did not find an association between hydroxychloroquine and serious adverse effects in our study population.”

 published alongside the results in the 

questioned how the results would impact clinical trials going forward.

“On June 1, 2020, ClinicalTrials.gov listed a remarkable 203 Covid-19 trials with hydroxychloroquine, 60 of which were focused on prophylaxis,” wrote Myron S. Cohen, MD, in the editorial. “An important question is to what extent the article by Boulware et al. should affect planned or ongoing hydroxychloroquine trials?”

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Matthew Pullen, MD: “After examining the data of our 821 participants, we did not find a significant difference in the risk of infection following exposure in those taking hydroxychloroquine and those taking placebo."

Hydroxychloroquine Fails to Show Efficacy for COVID-19 Prophylaxis

Navigating shifting guidelines and recommendations about COVID-19 is a central challenge for clinicians on the frontlines of the COVID-19 pandemic response.

 partnered with Physicians’ Education Resource

to host a live CME-certified webinar. The program offered a diverse look at just what it’s like on the frontlines of the COVID-19 pandemic-from the ICU to the lab. 

, PhD, MPH, MA, CIC, a hospital epidemiologist and infection preventionist. Popescu opened the discussion by providing an infection preventionist’s perspective.

As the US Centers for Disease Control and Prevention and World Health Organization guidance changes, infection prevention efforts have become complicated. Each state in the United States is facing a different and unique challenge.

Learning as we go requires being communicative and empathetic, Popescu explained.

, MD, MS, FACP, assistant professor of medicine, University of Nebraska Medical Center, was the first speaker. She shared her experiences working in a critical care role.

Cawcutt also emphasized the theme of navigating ever-changing information. In particular, she highlighted debates about mechanisms of COVID-19 transmission. This focused on the complexities of aerosolization and droplet versus airborne personal protective equipment precautions.

Cawcutt added that the shortage of ventilators and sedative medications used during intubation points to concerns about early guidance which suggested ICU patients be placed on a ventilator as soon as possible. Cawcutt also suggested that noninvasive ventilation should be explored further as an option.

Following Cawcutt, there was a presentation on hydroxychloroquine by Matthew F. Pullen, MD, infectious diseases and international medicine physician at the University of Minnesota.

Pullen is part of a group conducting a randomized control trial of hydroxychloroquine as a post-exposure preventative measure for COVID-19. After the original Severe Acute Respiratory Syndrome outbreak, hydroxychloroquine was found useful against SARS-CoV-1 

There are only, so far, small studies presenting human data. Pullen emphasized the need to operate based on evidence, bringing up his ongoing trial.

The last presentation was by Mohini Lata, RN, MSN, registered nurse at Kaiser Permanente in the ICU.

Lata’s presentation emphasized that frontline health care workers are the heart of a health care organization. Patients don’t have families visiting and patients are scared and feel alone, Lata explained. Because of this, it helps to remember that a patient is someone’s loved one and treat them accordingly.

The panic on social media that treats COVID-19 as a death sentence is counterproductive to these efforts, Lata pointed out.

If a patient loses the battle in their mind, that’s half of the clinical battle lost, she said. Reassuring patients and families is vital to patients maintaining the energy needed to overcome their illness.

The presentations were followed by a Q&A from the clinician audience.

Webinar Recap: COVID-19 As Seen by Those on the Frontlines

It’s going to kill 4 million people this year, according to the World Health Organization (WHO). In 2018, 10 million people fell ill with it and 1.5 million died. It’s the world’s worst infectious disease and today’s the day when the world began fighting back. 

On March 24, 1882 Robert Koch, MD, announced the discovery of 

, which causes tuberculosis (TB). It had previously been believed by many that TB was inherited rather than being an infectious disease.

 is “It’s Time.” The WHO said in a statement that it wants to accelerate “the TB response to save lives and end suffering, building on high level commitments by Heads of State at the 2018 UN High-Level Meeting on TB.” 

The “It’s Time”theme highlights that now is the time to scale up access to prevention and treatment, to ensure sustainable resources are dedicated to TB research, and to ramp up an equitable global strategy to control an infectious disease that is responsible for immense social burdens.

 to address this decade, noting that TB, HIV, viral hepatitis, and malaria will lead to an estimated 4 million deaths in 2020.

“CDC [US Centers for Disease Control and Prevention] joins the global community to recognize World Tuberculosis (TB) Day-an important moment to unite in renewed commitment to ending TB, an airborne disease that knows no borders,” according to the CDC statement.

presented a range of information on TB, from both the US and global health figures.

“In 2019, a provisional total of 8,920 TB cases were reported in the United States (incidence = 2.7 cases per 100,000 persons), a 1.1% decrease from the 9021 cases reported during 2018 and the lowest number of U.S. cases recorded since reporting began in 1953,” the authors wrote.

The report also detailed that the 10 million cases and 1.5 million deaths from TB worldwide in 2018 represent 2% and 5% declines from 2017, respectively.

In addition, about 862,000 reported TB infections occurred 

 In 2018, 1.8 million people living with HIV began TB preventative treatment, which is an 88% increase from 2017.

Past research has shown that in TB-endemic areas, 

Beware of the World's Most Deadly Infectious Disease: Tuberculosis

The deadly and dangerous coronavirus has touched ground in the United States. The US Centers for Disease Control and Prevention (CDC) has officially confirmed the first case of novel coronavirus (2019-nCoV) or Wuhan coronavirus in the United States.

CDC and Washington state officials said in a telebriefing that the patient is a male US resident who arrived at Seattle-Tacoma airport on January 15, 2020. The patient did not have a fever at the time of arrival, and the flight was not a direct flight from Wuhan.

Additionally, the patient did not go to implicated animal markets in Wuhan, nor did he report close contact with an ill individual.

The patient had apparently researched the virus online, and upon developing symptoms reached out to his health care provider on January 19th. 2019-nCoV was confirmed on the 20th using samples shipped overnight. Public health officials from Washington indicated that the patient was hospitalized out of precaution but in overall good condition. 

A CDC team has been deployed to Washington for investigation, including contact tracing.

New cases of the 2019-nCoV outbreak have also been confirmed globally, including outside of the city of Wuhan, according to Chinese state media outlet Xinhua News Agency.

As of January 20, World Health Organization (WHO) officials have confirmed at least 278 cases of 2019-nCoV infection. So far, 6 people have died. Cases have now been reported outside Wuhan, including in the capital city of Beijing.

Reporting by WHO also mentioned confirmed cases in Japan, Thailand, and South Korea.

The outbreak was originally tied to a seafood market in Wuhan.

On January 19, WHO wrote on Twitter that an animal source was likely the primary source of 2019-CoV. The tweet also indicated that human transmission is occurring in this outbreak, which has since been validated by official Chinese sources.

“It has been confirmed that 2 people in Guangdong province were infected through human-to-human transmission," said Zhong Nanshan, MD, in a CCTV news conference reported on by China Daily. Zhong was the pulmonologist who discovered severe acute respiratory syndrome (SARS) in 2003.

Daniel Lucey, MD, MPH, adjunct professor of infectious diseases at Georgetown University Medical Center, explained that this confirmation was not surprising.

“Obviously, now there's been a lot of patients in the past 3 days reported from Wuhan…you [also] have patients elsewhere, in Shanghai and Beijing, in Guangdong Province. And a lot of [patients] came from Wuhan, but not from that market, it’s been closed since January 1st.”

Earlier public statements were cautious about the possibility of human transmission, despite the likelihood it would become an issue.

“There were some statements from China saying, ‘we've got things under control. There's no evidence of significant person-to-person spread,’ but that made me a little bit nervous. What does that mean, ‘significant person-to-person spread?’ And that it’s only in Wuhan. But all that changed, of course, over the weekend,” Lucey, a spokesperson for the Infectious Diseases Society of America said.

Overall, however, China appears to be taking a different approach from the early days of the SARS response. The Chinese government has modernized its public health infrastructure and participated in international epidemic responses to train health care workers.

“China has worked a lot over the last 17 years, for not just the next SARS-like coronavirus, but for any kind of disease, like pandemic flu in 2009. They sent people to West Africa, Sierra Leone and Liberia-where I worked with patients with Ebola in 2014-to work with patients and at the same time to gain experience,” Lucey explained.

“So, just like the United States really started doing more and better things after the anthrax attacks in 2001, I think China started doing more to fight off infectious diseases starting in 2003.”

Several countries in the region are relaying details about cases exported from China. On January 17, WHO summarized information from the Japanese Ministry of Health, Labor, and Welfare concerning a male patient between the age of 30-39 years, living in Japan.

According to the WHO statement, the case-patient in Japan had traveled to Wuhan in late December and developed a fever on January 3rd. He did not visit the Huanan Seafood Wholesale Market or any animal markets in Wuhan, and instead indicated close contact with a person who had pneumonia. On January 15th, testing identified a small amount of 2019-nCoV RNA.

WHO also reported case details from the Thai Ministry of Public Health. A 61-year-old Chinese woman with a fever, who had been living in Wuhan, traveled to Thailand on January 8. The illness was detected by surveillance activities at the airport of arrival and the patient was hospitalized the same day. The patient reported visiting a local fresh market on a regular basis, but had not visited the market associated with most cases. Genetic samples tested positive for coronaviruses on January 12th.

On January 17th, the US Centers for Disease Control and Prevention (CDC) and the Department of Homeland Security’s Customs and Border Protection announced health screenings for travelers from Wuhan at 3 US airports.

“We fully anticipate that there'll be at least 1 person with this new virus that arrives in the United States. I think it's good to be as informed and aware as possible...I know that the CDC has daily conferences sharing information with the WHO. So that's a very important and positive thing,” Lucey said on January 20th in an interview with Contagion®.
	WHO Reaction

The WHO also announced on January 20th that WHO Director-General Tedros Adhanom Ghebreyesus, PhD, would convene an emergency committee on January 22nd to ascertain whether 2019-nCoV constitutes a public health emergency of international concern.

The declaration of a public health emergency of international concern would lead to WHO making advisory statements on travel and outbreak response. The last time China faced a highly publicized outbreak, the mechanism for declaring a public health emergency of international concern did not yet exist.

“That was really catalyzed by the SARS epidemic, people said we need to have a more formalized system to declare whether an epidemic is really a global public health concern. And then, what are the rules for the temporary recommendations…so it's a really big, major significant event that's going to occur this Wednesday,” Lucey commented.

In pointing to the memory of SARS, however, Lucey noted that the United States saw only 28 cases of probable SARS in 2003, without any deaths.

Health officials closely monitoring the situation.

Author | Grant M. Gallagher

Articles

Hydroxychloroquine Fails to Show Efficacy for COVID-19 Prophylaxis

Webinar Recap: COVID-19 As Seen by Those on the Frontlines

Beware of the World's Most Deadly Infectious Disease: Tuberculosis

Coronavirus Case Confirmed in Washington State