key: cord-0992987-2a8hojse
authors: Das, Rashmi Ranjan; Behera, Bijayini; Mishra, Baijayantimala; Naik, Sushree Samiksha
title: Effect of Chloroquine and Hydroxychloroquine on COVID-19 Virological Outcomes: An Updated Meta-Analysis
date: 2020-11-30
journal: Indian Journal of Medical Microbiology
DOI: 10.4103/ijmm.ijmm_20_330
sha: 88ea5003310ce56ed7c1272b527b6a1dc600b51a
doc_id: 992987
cord_uid: 2a8hojse

Abstract As anti-malarial drugs have been found to inhibit Corona viruses in vitro, studies have evaluated the effect of these drugs inCOVID-19 infection. We conducted an updated meta-analysis of clinical trials and observational studies published till June 2020. Patients with reverse transcription polymerase chain reaction (RT-PCR) confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (COVID-19) infection were included. The drugs used in the intervention group are Chloroquine (CQ)/Hydroxychloroquine (HCQ) with or without Azithromycin. The primary outcome is time to achieve virological cure. Of 1040 citations, 11 studies provided data of 1215 patients. Compared to control, CQ/HCQ has no significant effect on the time to negative COVID-19 RT-PCR results, neither in clinical trials (mean difference [MD] 1.55; 95% confidence interval [CI] - 0.7 to 3.79; P = 0.18; n = 180), nor in observational studies (MD 1.14; 95%CI - 11.98 to 14.26; P = 0.86, n = 407). CQ/HCQ did not affect the virological cure after day 3, 7, 10, 14, 21 and 28; except after day 5, as shown by a single small non-randomised trial (odds ratio [OR] 9.33; 95% CI 1.51 to 57.65; P = 0.02, n = 30). Pooled data from 2 observational studies showed a significant effect of CQ/HCQ on virological cure by after day 10 (OR 7.86; 95% CI 4.4 to 14.04, P < 0.001, n = 373) and day 14 (OR 6.37; 95% CI 3.01 to 13.48, P < 0.001, n = 407). The GRADE evidence generated was of “very low-quality/certainty”. To conclude, CQ/HCQ does not affect the time to virological cure compared to usual/standard of care in COVID-19 infection. Recurrent infection in a smaller number of patients was noted in the CQ/HCQ group. As the evidence generated was of “very low-quality/certainty)”, large good quality studies are needed to confirm the present findings.

compared to a control arm or parallel intervention, to treat patients with COVID-19. [4, [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] However, the results have been contradictory. A published rapid systematic review including data from three studies found no role of anti-malarial drugs on the virological outcomes in patients with COVID-19 infection. [25] After publication of this review, many studies (both observational studies and clinical trials) with larger sample sizes have been published. The present updated meta-analysis has included these larger studies to evaluate the effect of the anti-malarial drugs (CQ and HCQ) to inform clinical practice, and guide the international agencies to formulate recommendation.

Both clinical trials and observational studies comparing anti-malarial drugs (CQ and HCQ) alone or in combination with other drugs versus control (standard of care) or other treatment were included.

Children (age >12 years) and adults with reverse transcription-polymerase chain reaction (RT-PCR) confirmed SARS CoV-2 (COVID- 19) cases treated in the hospital were included. Exclusion criteria were allergy to these anti-malarial drugs, hearing loss, retinopathy and severe neuro-psychiatric diseases.

Anti-malarial drugs (CQ and HCQ) administered (with or without Azithormycin) in various dose schedules to patients with SARS-CoV-2 (COVID- 19) infection. [13] Control group patients received usual/standard of care as per the hospital/ institute policy or government guideline. Studies comparing different doses (high-dose versus low-dose of anti-malarial drugs) were also included. Definition of outcome measures: Virological cure is defined as non-detection (negative report) of COVID-19 by RT-PCR in two consecutive respiratory specimens (naso-pharyngeal swabs, throat swabs, nasal swab, broncho-alveolar lavage fluid and tracheal aspirate) taken 24 h apart. Recurrence of infection is defined as detection (positive report) of COVID-19 by RT-PCR in any of the above specimens collected from a patient at any time point after documentation of virological cure. [26] Search methodology 

Data extraction was done using a data extraction form that was designed and pilot tested a priori. Two authors (BB and BM) independently extracted the following information from each study: author year, country, study design, setting (hospital or community), method of recruitment, inclusion criteria, risk of bias, participants (age, sex, sample size, disease severity), intervention (dosage, duration, frequency, and co-intervention if any), outcomes (outcome definition, valid unit of measurement, time points of collection, and reporting), loss to follow-up and key conclusions. Any disagreements between the two review authors were resolved through discussion with the third author (RRD).

Two review authors independently (BB, SSN) assessed the methodological quality of the selected trials by using Cochrane Handbook, [27] and of observational studies by Newcastle Ottawa Scale. [28] Quality assessment was undertaken using the ROBINS-I tool for non-randomised trials. [29] Any disagreements between the two review authors were resolved through discussion with the third author (RRD).

Data were analysed using Review Manager (RevMan) V.5.1. [30] Data were pooled and expressed as mean difference (MD) with 95% confidence interval (CI), if continuous; odds ratio (OR) with 95% CI, if categorical. All the analyses were by Generic Inverse Variance method using random effects weighting, [31] where the log RRs for cohort studies or log ORs for case-control studies were weighted by the inverse of the variance to obtain a pooled RR estimate. A P < 0.05 was considered statistically significant. Inter-study heterogeneity was assessed by Cochrane's Q (Chi-square P < 0.10) and quantified by I 2 . An I² ≥50% indicated 'substantial' heterogeneity and ≥75% indicated 'considerable' heterogeneity. [32] 

To assess the quality of evidence, we used GRADE Profiler software (V.3.2) (Hamilton, Canada). [33, 34] The software uses five parameters for rating the quality of evidence (risk of bias, inconsistency of results, indirectness of evidence, imprecision of results and publication bias), and does rating as-no, serious and very serious limitation.

Of 1040 total citations retrieved, the full text of 15 papers was assessed for eligibility, and 4 studies were excluded [ Figure 1 ]. Of the remaining 11 eligible studies (n = 1215), 6 were published in peer-reviewed journals, [4, [15] [16] [17] [18] [19] and 5 in pre-print servers (not peer-reviewed). [20] [21] [22] [23] [24] We contacted the authors of these 5 studies to provide us the permission to use their data in the meta-analysis, but only one study author responded. [20] Hence, we included the data of this study along with other published studies (in peer-reviewed journals) in the present meta-analysis [ Table 1 ], and described the characteristics of rest 4 studies [21] [22] [23] [24] [ Table 2 ]. Of the 7 included studies (n = 726), 5 clinical trials provide data of 319 patients, and the 2 observational studies provided data of 407 patients. [4, [15] [16] [17] [18] [19] [20] A total of 415 patients received HCQ or CQ (clinical trials = 195, observational studies = 220), and 6 received a combination of HCQ plus Azithromycin (in one non-RCT [non-randomised controlled trials]). [4] The studies were conducted in the following countries: Chin (n = 4, 575 patients), Brazil (n = 1, 81 patients), France (n = 1, 36 patients) and UAE (n = 1, 34 patients). One trial compared high versus low-dose of Chloroquine. [18] Of the 5 clinical trials, 2 were double-blind and 1 was a non-RCT.

As shown in Table 1 , the age of included participants, severity of illness, dose schedule and timing of the administration of intervention (HCQ/CQ) varied widely among the studies. Contrary to CQ, the dose schedule of HCQ varied widely. No study was able to start the intervention (HCQ/CQ) in the early phase of illness (within 48 h of symptom onset), which is regarded as the golden window for antiviral treatment (e.g. in influenza). [35] 

The details have been provided in Supplemental file [Appendix 2]. Except one trial, [18] others had low to high-risk of bias in different domains. One non-RCT had serious risk of biases in all the domains. [4] All the observational studies were at a high risk of bias for selection of controls, and a low risk of bias for the exposure parameters.

Primary outcomes 1. Time to virological cure (days): The pooled result from 2 RCTs showed no significant difference between the HCQ group and control group [MD 1.55 (95% CI -0.7 to 3.79), P = 0.18) [ Figure 2 ]. The pooled result from two observational studies also showed no significant difference between the HCQ group and control group [MD 1.14 (95% CI -11.98 to 14.26), P = 0.86) [ Figure 3 ].

1. Proportion of patients with virological cure after days 3, 5, 7, 10, 14, 21 and 28: Compared to control, CQ/HCQ did not affect the virological cure after days 3, 7, 21 and 28 [ Table 3 ]. However, the pooled data from 2 observational studies showed a significant effect of CQ/HCQ on virological cure after 10 and 14 days [ Table 4 ].

studies reported this outcome. [4, 19] In one study, 1 of 20 patients (5%) in the HCQ group tested positive on day 8 (was negative on day 6). [4] In the other study, 3 of 197 patients (1.5%) in the CQ group tested positive (from faecal sample, not from naso-pharyngeal samples) within 7 days following hospital discharge.

The evidence generated was of 'very low-quality' for all the outcomes (primary and secondary). A detailed analysis of the summary of evidence is provided in Table 5 .

After an extensive search of the literature we could find 11 studies (n = 1215) eligible for inclusion in the review. Compared to control, CQ/HCQ has no significant effect on the time to negative COVID-19 RT-PCR results. CQ/HCQ des not affect the virological cure after days 3, 7, 10, 14, 21 and 28 (except after day 5 as shown by a single, small non-RCT). However, pooled data from 2 observational studies showed a significant effect of CQ/HCQ on virological cure after 10 and 14 days. Two studies reported repeat COVID-19 positive with all the patients belonging to the CQ/HCQ group. The GRADE evidence generated for all outcomes was of 'very low-quality'.

It has to be kept in mind that, the anti-viral action of anti-malarial drugs against COVID-19 is still largely unknown. [36] The dose schedule of CQ was nearly uniform, however, the dose of schedule of HCQ varied widely among the included studies (except one large study, the cumulative dose in remaining of the studies was equal to or higher than the recommended). The median time from onset of symptom to admission or treatment initiation was nearly ≤8 days in all but 2 studies. Except one study, others used CQ/HCQ within 48 h of admission/hospitalization. This might be due to the fact that starting anti-viral drugs (including HCQ/CQ) after 48 h of symptom onset might not be beneficial as the golden window for antiviral treatment (e.g. in influenza) is lost. However, this is difficult in a hospitalised setting (may be possible in outpatient or community setting). Another important point is that, the patients included in the present study were having comorbidities, and were on multiple drugs. The interactions between these drugs, and CQ/HCQ in affecting the action of the later on COVID-19 are unknown at present. Moreover, as none of the studies measured the blood level of these drugs, it is difficult to conclude this (at least to some extent). In two studies, recurrent COVID-19 

The studies were variable in many aspects (blinding of participants and outcome assessors, patient selection, severity of illness, dose schedule of the anti-malarial drugs, timing of 

Chen 2020 [21] China RCT 62 (nonsevere cases) HCQ 200 mg BID for 5 days None

Chen 2020 [22] China Observational study 284 (all severity) CQ for 7 days CQ does not enhance viral clearance Feng 2020 [23] China Observational study 50 (all severity) CQ for 7 days Chloroquine deserves further investigation Shabrawishi 2020 [24] Saudi-Arabia

Observational study 93 (mild and moderate cases) Study population 802 per 1000 161 more per 1000 (from 122 more to 180 more) *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI), **Secondary outcomes: pooled results from minimum 2 studies are reported here. GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect, Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate, Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate, Very low quality: We are very uncertain about the estimate. a Open label trials with difference in the dose schedule of intervention and time to start of intervention, b Sample size was less with wider 95% CI that includes line of no effect, c The results from both the studies were contradictory, d Case-control studies, e One study was small with very significant cure rate, f 95% was wider, g In one trial, all patients in both the groups were cured. CI: Confidence interval; OR: Odds ratio; MD: Mean difference, RCT: Randomised controlled trial administration, etc). Due to lack of paediatric data, the results of present review cannot be extrapolated to this population. concLuSIonS CQ/HCQ does not affect the time to virological cure compared to usual/standard of care used in the treatment of COVID-19 infection at present. Recurrent infection in a smaller number of patients was noted in the CQ/HCQ group. Good quality and multi-centric RCTs are required for any firm conclusion to be drawn or recommendation to be made during the on-going pandemic.

Characteristics of and important lessons from thecoronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese center for disease control and prevention

COVID-19 in India

The rationale for potential pharmacotherapy of COVID-19

Hydroxychloroquine and azithromycin as a treatment of COVID-19: Results of an open-label non-randomized clinical trial

Efficacy & safety of anti-malarial drugs (Chloroquine, and Hydroxy-chloroquine) in treatment of COVID-19 infection: A systematic review & metaanalysis

Antiviral activity of chloroquine against human coronavirus OC43 infection in newborn mice

Chloroquine is a potent inhibitor of SARS coronavirus infection and spread

Receptor recognition by the novel coronavirus from Wuhan: An analysis based on decade-long structural studies of SARS coronavirus

A pneumonia outbreak associated with a new coronavirus of probable bat origin

New insights on the antiviral effects of chloroquine against coronavirus: What to expect for COVID-19?

Quinoline-based antimalarial drugs: A novel class of autophagy inhibitors

Should chloroquine and hydroxychloroquine be used to treat COVID-19? A rapid review

In vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Aminoquinolines against coronavirus disease 2019 (COVID-19): Chloroquine or hydroxychloroquine

A pilot study of hydroxychloroquine in treatment of patients with moderate COVID-19

Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: Open label, randomised controlled trial

Treating COVID-19 with Chloroquine

Effect of high vs. low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: A randomized clinical trial

Preliminary evidence from a multicenter prospective observational study of the safety and efficacy of chloroquine for the treatment of COVID-19

Hydroxychloroquine is associated with slower viral clearance in clinical COVID-19 patients with mild to moderate disease: A retrospective study

Efficacy of hydroxychloroquine in patients with COVID-19: Results of a randomized clinical trial

Associations of clinical characteristics and antiviral drugs with viral RNA clearance in patients with COVID-19 in Guangzhou, China: A retrospective cohort study

The use of adjuvant therapy in preventing progression to severe pneumonia in patients with coronavirus disease 2019: A multicenter data analysis

Negative nasopharyngeal SARS-CoV-2 PCR conversion in Response to different therapeutic interventions

Virological and clinical cure in COVID-19 patients treated with hydroxychloroquine: A systematic review and meta-analysis

Chinese Clinical Guidance for COVID-19 Pneumonia Diagnosis and Treatment

The cochrane collaboration's tool for assessing risk of bias in randomised trials

The Newcastle Ottawa scale (NOS) for assessing the Quality of Nonrandomised Studies in Meta-Analysis

ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions

Review Manager (RevMan) Computer program. Ver. 5.3. Copenhagen: The Nordic Cochrane Centre

Fixed-versus random-effects models in meta-analysis: Model properties and an empirical comparison of differences in results

Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0. The Cochrane Collaboration

GRADEpro Guideline Development Tool Software

GRADE Handbook for Grading Quality of Evidence and Strength of Recommendations

Expert Panel of the Infectious Diseases Society of

Seasonal influenza in adults and children-diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: Clinical practice guidelines of the Infectious Diseases Society of America

Of chloroquine and COVID-19

We would like to thank Dr Nishant P Jaiswal, Evidence based health informatics unit, Department of Telemedicine, PGIMER, Chandigarh, for the help in the database search.

Nil.

There are no conflicts of interest.