key: cord-337677-ktktqs7b
authors: Pereda, R.; Gonzalez, D.; Rivero, H. B.; Rivero, J. C.; Perez, a.; Lopez, L. d. R.; Mezquia, N.; Venegas, R.; Betancourt, J. R.; Dominguez, R. E.
title: Therapeutic effectiveness of interferon alpha 2b treatment for COVID-19 patient recovery
date: 2020-08-04
journal: nan
DOI: 10.1101/2020.07.28.20157974
sha: 
doc_id: 337677
cord_uid: ktktqs7b

Background Effective antiviral treatments are required to contain the ongoing coronavirus disease 2019 (COVID-19) pandemic. A previous report in 814 patients COVID-19 positive in Cuba provided preliminary therapeutic efficacy evidence with interferon alpha-2b (IFN alpha-2b) from March 11 to April 14, 2020. This study, re-evaluates the contribution of IFN-2b on the evolution of all patients, after 98 days of the epidemic, in a period from March 11 to June 17, 2020. Method A prospective observational study was implemented to monitor a therapeutic intervention with IFN alpha-2b used in the national protocol for COVID-19 attending in Cuba. Were included patients with positive throat swab specimens by real time RT-PCR who gave informed consent and had no contraindications for IFN treatment. Patients received therapy as per the Cuban COVID protocol that included a combination of oral antivirals (lopinavir/ritonavir and chloroquine) with intramuscular or subcutaneous administration of IFN alpha-2b The primary endpoint was the proportion of patients discharged from hospital, secondary was the case fatality rate and several outcomes related to time variables were also evaluated. Results From March 11th until June 17th, 2295 patients had been confirmed SARS-CoV-2 positive in Cuba, 2165 were treated with Heberon Alpha R and 130 received the approved protocol without IFN. The proportion of fully recovered patients was higher in the IFN-treated compared with non-IFN treated group. Prior IFN treatment decreases the likelihood of intensive care and increases the survival after severe or critical diseases. The benefits of IFN were significantly supported by time variables analyzed. Conclusions This second report confirm the preliminary evidences from first for the therapeutic effectiveness of IFN alpha-2b for SARS-Cov-2 infection and postulated that Heberon Alpha R is the main component within the antiviral triad used as a therapeutic intervention in the Cuban protocol COVID-19.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint

The coronavirus disease 2019 (COVID- 19) emerged in China in December 2019 1 . The responsible virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), belongs to a distinct classification from the human severe acute respiratory syndrome CoV (SARS-CoV) and

Middle East respiratory syndrome CoV (MERS-CoV) 2 . The clinical spectrum of COVID-19 varies from asymptomatic infection or mild symptoms to severe acute respiratory illness and death 3 .

According to the COVID-19 situation report issued by World Health Organization (WHO) on 11 th July 2020, COVID-19 pandemic affects more than 213 countries around the world with more than 12 million cases have been diagnosed and over 556 thousand patients have died 4 . Effective antiviral treatments are required to contain the epidemics; several candidates are already being investigated, including type 1 interferon (IFN-α/) 5 .

At present, a RNA-dependent RNA polymerases (RdRp), remdesivir, is the first medicine against covid-19 approved in the European Union, mainly based on preliminary data from a trial published in the New England Journal of Medicine and limited to patients with severe disease 6 . Remdesivir has also been approved for emergency use in severely ill patients in the United States (US), India, and South Korea and has received full approval in Japan 7 . Favipiravir 8 , an anti-influenza medication that also is an RdRp inhibitor, was approved for medical use in Russia using a generic version named Avifavir.

IFN-α, a member of the first line of natural antiviral defense activates the innate immune response against the virus and the mechanism of inhibition of viral replication 9 . After COVID-19 outbreak, a strong anti-SARS-CoV-2 activity in cultured cells has been reported for IFN-α, demonstrating its therapeutic potency for COVID-19 10 . Guidelines issued by the expert committee of WHO identified IFN-α2b as a potential antiviral for the treatment and prevention of COVID-19 11 . Early on in the . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint outbreak, the Chinese government recommended the use of IFN-α for the treatment of COVID-19 12 . Several ongoing clinical studies evaluating IFN-α2b for the treatment of COVID-19 are registered at clinicaltrials.gov 13 and already provided clinical evidences for therapeutic efficacy 14 .

Heberon ® Alpha R is a human recombinant IFN-α2b formulation produced by the Center for Genetic Engineering and Biotechnology, Havana, Cuba, with demonstrated antiviral efficacy and a proven safety profile over 34 years 15 and is one of the drugs used in the Cuban protocol 16 

Two groups of individuals were admitted to the hospital, according to the case classification criteria defined in the Cuban protocol: 1) people with suspected COVID-19 due to clinical respiratory symptoms, such as fever, fatigue, cough, headache, shortness of breath and nasal discharge in the last 14 days; 2) subjects who had contact with a patient with confirmed or is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. Individuals themselves, parents or legal representative had to give informed consent and have no contraindications for treatment with IFN described in the product information sheet, to receive Heberon ® Alpha R as approved in the Cuban protocol for COVID-19. Patients in severe COVID-19, with contraindications or who did not consent to receive IFN were treated with the Cuban protocol lacking IFN, i.e. only LPV/RTV and CQ. For those cases in treatment ongoing whose disease progressed to become severe and critical, requiring intensive care unit (ICU) support, treatment with Heberon ® Alpha R was promptly stopped.

Addition of Heberon ® Alpha R to the Cuban protocol was approved by the Cuban National Regulatory Authority which maintained surveillance of the scientific evidence obtained. The protocol of this study was evaluated and approved by a centralized Research Ethics Committee, is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. Hematological and biochemical profiles were assessed at admission and every 48 hours using routine clinical laboratory procedures. Chest radiological evaluation and cardiovascular function monitoring by electrocardiogram was made before treatment and daily after started it.

The primary endpoint was the proportion of patients discharged from hospital (i.e. discharge criteria were according to clinical, radiological and laboratory evaluations). Clinical criteria: patient in stable condition and afebrile for more than 3 days, regular breathing and normal respiratory . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint rate, clear conscience, unaffected speech and normal diet. Radiological criteria: significant improvement without signs of organ dysfunction in lung images. Laboratory criteria: Two consecutive PCR (-) with at least 24 hours apart. The secondary endpoint was the case fatality rate, (CFR), defined as the number of confirmed deaths divided by the number of confirmed cases.

The time elapsed to the hospital discharged was an endpoint for all patients. A threshold time definition was according the patient clinical classification: for symptomatic subject was defined as the number of days elapsed from the onset of symptoms up to meet discharged criteria; for asymptomatic the timeline began on hospital day admission. The full recovery time after COVID-19 diagnostic by PCR (+) was also endpoint for all cases. Date of confirmed PCR (+) was considered as date of onset of COVID-19 and the need of treatment, an appropriate time to match point the disease course between all patients. Endpoints applied to cohort requiring ICU were the days from symptom onset and hospital admittance to ICU admission and the time to death from these three timelines.

Descriptive statistics (Tables, group means and interquartile range reported in the text) convey the data as-is. The endpoints were adjusted by age, sex, and the presence of comorbidities. Note that age was considered at every 10-year age interval from older than 19 years. From contingency tables chi-square calculator tests and Fisher exact test calculator for association between two categorical variables were used. The odds ratio (OR) was applied as a measure of association between treatments and outcomes. The non-parametric Mann-Whitney U test was used for comparing independents samples is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. 

The Cuban protocol 17 To begin treatment, two clinical forms of uncomplicated disease were predominated: 1) minimally symptomatic disease according to nonspecific signs such as fever, cough, sore throat, nasal congestion, slight headache and malaise, without dehydration, dyspnea, or sepsis evidences; 2) mild pneumonia, due to the presence of the above symptoms and polypnea with partial oxygen saturation (SpO 2 ) above 90%, but without signs of respiratory failure or severity.

In 44 (1.9%) patients a severe pneumonia was detected before start treatment and their hospital admission was directly to ICU due to positive clinical symptoms, chest radiological imaging and respiratory rate over 30 breaths / min, limitation of thoracic expandability, central cyanosis, SpO 2 below 90% and pleuritic pain. Acute respiratory distress syndrome (ARDS) associated was found in 17 of these (38.6%) patients. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. 

The median age of all cases was 45 years (range 19 days to 101 years; interquartile range, 28-58 years) with a non-significant difference between the sexes (p=0.511). In the distribution of patients by sex, the numbers of men (p=0.006) at ages 61-70 and women (p=0.035) above age 90 were significantly higher. Both (p=0.445) women and men peaks COVID-19 incidence at ages 51-60. Comorbidities were present in 339 (14.8%) patients with a similar incidence between the sexes (p=0.923) and significant higher in those over age 51 not treated with IFN. The main underlying diseases were high blood pressure (7.9%), diabetes mellitus (4.2%) and ischemic heart disease (3.2%). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. 

On the cut-off date analyzed in this report, the Cuban Overall CFR was 3.70% and 0.92% for patients treated with IFN alpha-2b. Both data were lower than those reported at the same time by 

To better address the influence of IFN treatment on CFR, we considered the clinical status of patients in the context of severity of disease, using admission to ICU as an appropriate time point to match the criterion for worsened disease. During the course of treatment, 180 patients (7.8% of all the COVID-19 cases) were admitted to the ICU ( Table 2) . Notably, only 77 had been treated with IFN, representing 3.6% of the total number of this treatment cohort in the study. IFN treatment was withdrawn for those patients who progressed to severe or critical disease.

Nevertheless, the CFR in presence of ARDS was lower in IFN previously treated individuals (10;

. CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint After CFR correction analysis done without considered these patients, the IFN cohort maintained a significant outcome compared to IFN non-treated individuals (p=3.0 x 10 -5 ).

Patients died from COVID-19 in Cuba were adults. Thereby, the analysis related to age and lethality was made at every 10-year age interval from older than 19 years. Ages 51-60 were the only ones lacking significant association to CFR. There were 47 deceases in ages 71-90, 55.3% is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint 13 from overall. Deaths predominated in male (p=0.042), patients with comorbidities (p=1.0 x 10 -5 ) and symptomatic individuals (p=1.0 x 10 -5 ). In male over 51 years, arterial hypertension represented the major risk predictors for death.

IFN-related CFR was affected by ages 61-70 (p=0.007) and ages 81-90 (p=2.0 x 10 -4 ). However, the effects of IFN treatment remain significant regardless of age interval compared to those not treated with IFN (p-values ranged 1.5 x 10 -2 to 1.0 x 10 -5 ). Although the IFN-related CFR was affected by comorbidities (p=1.0 x 10 -5 ), did not negate or eliminate the difference in CFR between IFN treated individuals and those not treated with IFN (p =1.0 x 10 -5 ). No association was found between sex and lethality in those treated with IFN (p=0.138).

Our previous report in 814 patients COVID-19 positive in Cuba provided preliminary therapeutic efficacy evidence with IFN-α2b from March 11 to April 14, 2020 17 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint Ours two reports on the intramuscular administration for IFN-α2b contrast with the earlier published findings of inhaled IFN-α2b 14 . An aerosol administration has the advantage of specifically targeting the respiratory tract; however, the pharmacodynamics and pharmacokinetics of this mode of administration are not known 9 . Conversely, intramuscular and subcutaneous administration are well described for Heberon ® Alpha R and their safety profiles has been extensively studied by pharmacodynamics and pharmacokinetics and have already proven safe in a considerable number of clinical trials 16 .

The key explaining the large recovery of patients after used IFN-α2b in our data is a therapeutic is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint even when it has disappeared from the blood circulation. As a result, a sustained therapeutic response is expressed clinically thought a long-term viral clearance after treatment. Neither of these two favorable events is possible with generic antiviral drugs like favipiravir, whose depend on permanent level in blood for achieve therapeutic activity.

Demographic distribution of patients included in this study conformed to findings in China 23 , in several European 24 and Latin-American 25 countries and the US 26 reporting a slightly higher number for male confirmed and CFR compared to females. Older persons with pre-existing hypertension and/or diabetes were more prevalent in our no-IFN treated cohort and this agerelated trend of co-morbidities was similar to data reported by Zhou F et al 14 .

The proportion (10%) of confirmed COVID-19 children in Cuba seems notably when pediatrics reviews show that pediatric population have so far accounted for 1%-5% of diagnosed COVID-19 cases around globe 27 The above can be explained by the methodology implemented by the Cuban protocol in which an early epidemiological screening was carried out independently of the presence of clinical symptoms and most of the patients were admitted to hospital and SARS-CoV-2 confirmed in the asymptomatic phase.

Data analyses in this study were limited, because the study includes unbalanced demographics between treatment arms of unequal size and endpoint outcomes, namely hospital discharge (recovery) and CFR for a large number of the cases remained unknown at the time of study termination. Regardless of the identified limitations, this report provides evidence of the effectiveness of IFN-α2b as an antiviral treatment for SARS-CoV-2 infection and suggests that the use of Heberon ® Alpha R at the doses and therapeutic regimen employed may contribute to recovery from COVID-19. Furthers studies are needed for additional efficacy and safety profile evaluation of Heberon ® Alpha R, specifically a randomized clinical trial for comparison with other potential antivirals. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint Contributors DG, RV, BJR and DRE were responsible for patient care and treatment, RHB, RJC, OA, LLR and MN made clinical oversight and clinical data collection, PR led the working group, analyzed and conducted data analysis, data interpretation, literature searches and manuscript writing.

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint

Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia

2020) A Comprehensive Literature Review on the Clinical Presentation, and Management of the Pandemic Coronavirus Disease 2019 (COVID-19)

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020

Coronavirus disease (COVID-2019) situation reports-173

Clinical studies related to the coronavirus disease (COVID-19)

ACTT-1 Study Group Members. ACTT-1 Study Group Members Remdesivir for the treatment of covid-19: preliminary report

Covid-19: Selected NHS patients will be treated with remdesivir

Favipiravir (T-705), a novel viral RNA polymerase inhibitor

Type 1 interferons as a potential treatment against COVID-19

Antiviral activities of type I interferons to SARS-CoV-2 infection

Clinical management of severe acute respiratory infection when novel coronavirus ( 2019-nCoV) infection is suspected: interim guidance

Chinese Guidelines Related to Novel Coronavirus Pneumonia

A brief review of antiviral drugs evaluated in registered clinical trials for COVID-19

Interferon-α2b treatment for COVID-19

Cuban interferon alpha-2b. Thirty years as an effective and safe drug

Therapeutic effectiveness of interferon-alpha2b against COVID-19: the Cuban experience

Cuban Public Registry of Clinical Trials. (w.d.). Ministry of Public Health

Closing part of the day June 17 at 12 midnight

Coronavirus disease (COVID-2019) situation reports-149

PAHO COVID-19 Daily Update: 17

Can interferons stop COVID-19 before it takes hold?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges

Impact of sex and gender on COVID-19 outcomes in Europe

It is made available under a perpetuity.is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint It is made available under a perpetuity.is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted August 4, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted August 4, 2020. . https://doi.org/10.1101/2020.07.28.20157974 doi: medRxiv preprint