COVID-19 Press & Publications
Stanford Infectious Diseases Grand Rounds
Presenters: Melisa Shah, Julie Parsonnet, Eran Bendavid, Taia Wang
Stanford Infectious Diseases Lecture Series
Presenter: Shanthi Kappagoda, MD
Date: July 14, 2020
COVID-19 Stanford Medical Grand Rounds
Covid-19 External Press
ABC7 | Feb. 4, 2020: Coronavirus: Can the outbreak affect pets? Expert explains
- For those worrying about if their pets can catch the coronavirus, Dr. Eran Bendavid says it's "exceptionally unlikely."
Vox | Feb. 13, 2020: “No handshakes, please”: The tech industry is terrified of the coronavirus
- Dr. Stan Deresinski explains transmission is primarily through respiratory droplets with handshakes being secondary, yet there is always a risk.
Bloomberg | Feb 16, 2020: Fears of Global Coronavirus Contagion as 3,000 Cruise Passengers Go Home
- Dr. Stan Deresinski warns there is a possibility anyone infected and asymptomatic could start a chain of infection wherever they return.
CBS SF Bay Area | Feb 26, 2020: San Francisco Declares Emergency Over ‘Growing Likelihood’ Of Coronavirus Cases
- Dr. Eran Bendavid forwarns everything he has seen thus far suggests the virus will spread in the U.S.
NBC Bay Area | Feb 28, 2020: Do You Really Need a Face Mask to Avoid Coronavirus Spread?
- Dr. Stan Deresinski responds to questions regarding a highly-coveted, new shopping item—the face mask.
KTVU Fox 2 | March 2, 2020: More coronavirus cases in Santa Clara County; total is now at nine
- Dr. Aruna Subramanian informs the importance of taking precautions, such as frequent hand-washing and social distancing.
Live Science | March 4, 2020: These 5 mistakes could worsen the coronavirus outbreak
- Dr. Stan Deresinski cautions why these mistakes are not only costly to yourself but others.
WSJ | March 24, 2020: Is the Coronavirus as Deadly as They Say?
- In this op-ed, Dr. Eran Bendavid estimates the Covid-19 fatality rate may be too high by orders of magnitude.
The New Yorker | April 6, 2020: The Quest for a Pandemic Pill
- Dr. Shirit Einav talks about the host-targeted drug approach.
ABC News | April 17, 2020: Scientists have strong evidence coronavirus originated naturally
- Dr. Bob Shafer discusses the origins of the novel coronavirus.
Pop Sugar | April 28, 2020: There's an Emerging, Promising Link Between Exercise and Your Immune Health
- Dr. Aruna Subramanian and Dr. Dean Winslow weigh in on the exercise benefits on psychological and immune health.
SF Chronicle | April 29, 2020: Gilead drug remdesivir shows promise in two coronavirus trials
- Dr. Aruna Subramanian discusses the promising results to the experimental coronavirus drug remdesivir.
SF Chronicle | May 14, 2020: Bay Area doctors prepare for coronavirus in looming flu season
- Dr. David Relman advises needed strategies for a resurgence of cases and a potentially much deadlier situation in the winter.
NBC Bay Area | June 15, 2020: Governor, Bay Area Health Experts Urge People to Wear Face Coverings
- Dr. Dean Winslow encourages mask wearing when social distancing is not an option.
The Washington Post | June 26, 2020: What is pool testing and how does it work?
- Dr. Benjamin Pinsky's lab did pool testing before a coronavirus test was available, proving it was not yet widespread December through February.
KTVU Fox 2 | July 1, 2020: Stanford researchers to start clinical trial of COVID-19 drug in pill form
- Dr. Aruna Subramanian is hopeful the results for a Favipiravir clinical trial will lessen the effects of the coronavirus.
Sports Illustrated | Sept. 2, 2020: Inside the COVID-19 Testing Advancements That Could Be Key to College Sports
- Dr. Benjamin Pinsky talks about the buzz test that sacrifices speed for accuracy.
Medical Daily | Oct. 13, 2020: Why Trump's 'Cure' Isn't Ready for Approval
- Dr. Aruna Subramanian discusses why she's skeptical about the president's drug cocktail being made availble to the public immediately.
Covid-19 Stanford Press
Stanford plans to enroll about 1,000 people as part of a large Phase 3 trial to determine whether a vaccine can protect against infection with the coronavirus.
OCT 30 2020 | by KRISTA CONGER
Stanford Medicine has joined a large, Phase 3 clinical trial of an experimental vaccine against COVID-19.
The trial will test whether the vaccine, which is produced by the Janssen Pharmaceutical Companies of Johnson & Johnson, protects people from the disease. It will enroll some 60,000 people at about 180 sites around the world. The Stanford site is expected to enroll about 1,000 participants.
Participants will receive either the vaccine or a placebo, and their health and immune responses will be monitored for about one year after their initial visits. If any participants become ill with symptoms of COVID-19, a health care provider will go to their homes to assess their health and collect a nasal sample to test for the presence of the novel coronavirus. If they are infected, Stanford physicians will monitor their disease progression.
“We’re enrolling a wide variety of participants, but we are particularly interested in those who feel like their home or workplace exposure puts them at risk,” said Philip Grant, MD, assistant professor of medicine and the trial’s principal investigator at Stanford. “Teachers, grocery store workers, people who live in multigenerational households, health care workers and students on campus would all be good candidates for participation.”
Participants will be followed for two years and one month. They are expected to visit the trial site eight times: six in the first year and two in the second year. The initial visit will last about two hours; subsequent visits will consist of a short blood draw and symptom screening. If a participant develops COVID-19 during the study period, additional visits may be required.
The Janssen vaccine uses the shell of a virus called an adenovirus, but the adenovirus genes have been replaced with genetic material that serves as a blueprint for the spike protein of the SARS-CoV2 coronavirus. After injection, the modified adenovirus delivers the blueprint for the spike protein into the cells of trial participants. The cells generate the protein, which alerts the immune system to prepare to fight off infection by the coronavirus. A similar technique has been used for vaccines against other diseases, including Ebola.
“This modified virus can’t replicate inside the body after injection, but it produces a strong immune response to the spike protein, similar to that seen in people who have recovered from an infection with SARS-CoV-2,” Grant said. “Our hope is that the immune response will provide durable protection against subsequent infection with COVID-19.”
Initial Phase 1 and 2 trials of the Janssen vaccine uncovered no major side effects or safety concerns when used in humans, and animal studies suggested that, unlike other vaccine candidates, one dose of the Janssen vaccine was sufficient to trigger a potentially protective immune response.
For information about enrolling, https://www.ensemblestudy.com/.
Stanford plans to enroll about 1,000 people as part of a large Phase 3 trial to determine whether a vaccine can protect against infection with the coronavirus.
OCT 6 2020 | by TAMMER BAGDASARIAN
A Stanford-led study earlier this year sought to assess the local prevalence of COVID-19. (Photo: KATE SELIG/The Stanford Daily)
Stanford researchers are conducting inpatient and outpatient clinical trials of Regeneron’s REGN-COV2, an experimental “antibody cocktail” administered to President Donald Trump.
Stanford researchers noted that many of the newest drugs Trump has access to are still being tested in clinical trials and are unavailable to most COVID-19 patients.
The University joins 84 sites across the country in conducting clinical trials of the REGN-COV2 drug. Early results from outpatient trials, in which the drug is administered to non-hospitalized COVID-19 patients, suggest that the drug may aid the recovery of patients with mild to moderate symptoms.
“Those who received the antibodies did much better in terms of having the amount of virus that they have come down quickly and having their symptoms resolved faster,” said infectious disease clinical professor Aruna Subramanian.
For the past three weeks, the School of Medicine has been administering the treatment intravenously to outpatients who have received their first positive COVID-19 test result within seven days of starting treatment.
The medical school is also conducting inpatient trials, which study the effects of the drug on hospitalized patients, but the results have not yet been released. Subramanian, who is the principal investigator in the inpatient clinical trial, said that she expects similar results to those of the outpatient trial.
REGN-COV2 is designed to boost patient immune systems by introducing two monoclonal, or cloned, antibodies — one copied from a recovered COVID-19 patient and another from a genetically modified mouse. The antibodies bind to spike proteins, which the virus uses to attach to host receptors, preventing the virus from interacting with human cells. The two antibodies target different parts of the virus, giving the immune system the ability to defend itself with a “one-two punch,” according to professor of pediatrics and health research and policy Yvonne Maldonado, who is codirecting the REGN-COV2 outpatient clinical trial.
Although the drug is still in the clinical trial stages of development and has not been authorized for emergency use, it is available through a “compassionate use” request, which is granted under rare circumstances on a case-by-case basis. The Food and Drug Administration (FDA) granted such a request to Regeneron which allowed Trump to have access to the drug. Trump was administered the maximum dosage of 8 grams, according to a statement released by the White House on Friday. In the clinical trials, patients are randomized to receive an infusion of 8 grams, 2.4 grams or a placebo.
“Eight grams is a lot of antibody to give somebody,” Maldonado said. “We generally don’t give that much protein infusion to people, and we still don’t know which one is more effective, and [Regeneron] is studying whether a lower dose would be as effective.”
REGN-COV2 is just one of several drugs that Trump took while in the hospital. In addition to the antibody cocktail, he received dexamethasone and remdesivir, an antiviral medication studied by Stanford researchers in April.
Clinical professor of infectious disease Shanthi Kappogoda, who has helped develop COVID-19 treatment guideline, said that doctors generally administer the remdesivir and dexamethasone treatments to patients who need significant supplemental oxygen or who have an abnormal chest X-ray.
“Remdesivir and steroids are the standard of care for a moderate to severe case of COVID-19 pneumonia,” Kappogoda said. “It seems that either he was really sick and he needed them still in the hospital or he wasn’t that sick and was getting them at an earlier stage.”
Subramanian criticized a tweet that Trump sent advising Americans not to let the virus “dominate your lives,” adding that even if Trump makes a full recovery, he should not be advising the country to take the virus lightly.
“Not everybody has access to [his treatment options],” Subramanian said. “He got them extremely early, and he got them when other sick people are only maybe getting placebo. We have had patients die on the study, and we don’t know the efficacy yet.”
Stanford researchers are seeking approval from the FDA to conduct another clinical trial of the REGN-COV2 drug, which they hope will begin within the next month. The trial would test the efficacy of the antibody drug on people who have been in “close household contact” with COVID-19 carriers, but who have not yet tested positive for the virus, according to Maldonado. The trial would test the short- and long-term efficacy of the drug’s potential to prevent infections in the first place.
It’s time to get a flu shot. In a Q&A, Shanthi Kappagoda, MD, clinical associate professor of infectious diseases, explains why it’s especially important to be vaccinated this year.
SEP 23 2020 | by MANDY ERICKSON
By getting a flu vaccination, "you are not just protecting yourself; you are also protecting other people you may come into contact with," Shanthi Kappagoda said.
In this year of shuttered schools, empty restaurants, mask wearing and hand sanitizing, nearly all the inoculation talk has centered on the development of a coronavirus vaccine: When will it be ready so we can get back to normal?
Thinking about the flu shot may seem trivial by comparison.
But Shanthi Kappagoda, MD, a clinical associate professor of medicine who cares for patients at Stanford Health Care's Infectious Disease Clinic, says that it’s critical to be vaccinated against the flu this year to stay as healthy as possible during the pandemic, protect people who are vulnerable, and keep hospitals from being inundated with both flu and COVID-19 patients. The flu season peaks from December through February in the United States, sickens between 9 million and 49 million people each year, and sends an average of 200,000 to the hospital annually, according to the Centers for Disease Control and Prevention.
Associate editor Mandy Erickson recently reached out to Kappagoda to get her thoughts on the convergence of flu season and the COVID-19 pandemic.
1. Why is it important to get a flu shot when everyone’s social distancing?
Unfortunately, I don’t think everyone is social distancing. There is still a risk of getting the flu this year, especially with the holidays coming up.
The flu is most dangerous for older adults and young children. By being vaccinated, you are not just protecting yourself; you are also protecting other people you may come into contact with, including people who are not able to get the vaccine.
In addition, every fall and winter, hospitals see an increase in patients because of the flu, and there’s concern they will become overwhelmed with COVID-19 and flu patients.
2. Do we know the risks of having flu and COVID-19 at the same time?
There have been only a handful of reports in medical literature about patients infected with SARS-CoV2, the virus that causes COVID-19, and an influenza virus at the same time. Several patients ended up in intensive care, but because the numbers are so small, and most reports are on hospitalized patients and not outpatients, I don’t think we know enough about this topic yet to draw any conclusions.
3. How do the flu and COVID-19 differ?
As far as symptoms, loss of taste and sense of smell appears to be more common with COVID-19 than with influenza, but it’s important to know that not everyone with COVID-19 notices a change in their sense of taste or smell.
Other important differences relate to transmission, which is why it has been so hard to control COVID-19. The period of time that you are infectious appears to be longer with COVID-19 than with influenza. With a flu, people typically become contagious about a day before they have symptoms and remain contagious for about seven days after symptoms start. With COVID-19, our best estimate is that you can become infectious about two days before symptoms start, and remain contagious for up to 10 days afterward, although new information is coming out on this topic frequently.
There also appears to be a greater number of asymptomatic COVID-19 cases than asymptomatic flu cases. And the death rate for COVID-19 appears to be higher than the death rate for flu. There also appears to be more super-spreading events with COVID-19 than with flu: It seems to be transmitted more easily through the air, although both viruses are primarily spread by droplets. Finally, the risk of complications and death in healthy infants and children appears to be higher for flu than for COVID-19.
4. Is COVID-19 changing anything about this year’s flu vaccine?
The flu vaccine was developed this year in the same way it’s developed every year. The four strains of influenza that are going into this year’s flu shot were decided on in March, and the vaccine was distributed starting this month. I think it is unlikely that vaccinating for flu would cause any shortages or changes to the rollout of a COVID-19 vaccine.
Given concerns about an overburdened hospital system this fall and winter with admissions for both COVID-19 and influenza, an increased amount of flu vaccine is being made. The CDC reports that there will be 194 million to 198 million doses of flu vaccine available for this season, which is a record number. Unfortunately, only about 40% to 50% of adults in the United States get the vaccine, with rates commonly lower among low-income people and people of color — those most impacted by COVID-19.
5. Why do we need to get a flu shot every year?
The antibodies your immune system makes in response to the vaccine last only about six months. But also, influenza is a very tricky virus. Individual strains circulating in the community switch from year to year, so the vaccine from last year may not contain the strains that are circulating this year. In addition, individual strains of the virus constantly mutate, enabling them to evade our immune system and cause disease.
Stanford Health Care patients can contact their primary care physicians for information about scheduling a flu vaccination, which will be offered at clinics and drive-up locations. Stanford Health Care also addresses frequently asked questions about the vaccination.
Rosenkranz Prize Winner Leads Effort to Protect Health-Care Workers from COVID-19 in Under-Resourced Countries
Stanford postdoc Ashley Styczynski and collaborators build a website devoted to protecting health-care workers in under-resourced countries, using infographics and videos to show them how to create, wear and preserve personal protective equipment.
AUG 22 2020 | by BETH DUFF-BROWN
Ashley Styczynski shows her Bengali tutor, Marioum Akhi, how to properly use a mask during the COVID-19 pandemic.
Stanford postdoc Ashley Styczynski was working on newborn antimicrobial resistance in Bangladesh when the pandemic hit. The infectious disease physician realized she had to switch gears and began working with the ministry of health to prepare hospitals for the onslaught of COVID-19 patients.
“During my trainings on infection control in Bangladeshi hospitals, I learned that many health-care workers were paralyzed by the fear of not knowing how to protect themselves against COVID-19 while caring for patients, especially during shortages of PPE,” she said. “I think this has substantially contributed to the large number of health-care workers becoming infected during the pandemic. In fact, Bangladesh has the highest rate of physician mortality from COVID of any country.”
So Styczynski turned to her Stanford colleagues back home and proposed a set of infographics that could help health-care workers in Bangladesh and other under-resourced countries. Armed with a seed grant from the Stanford Center for Innovation in Global Health, they have established a website devoted to the creation and use of personal protective equipment (PPE). Bangladesh Ministry of Health has adopted their guidelines and Styczynski hopes other health ministries will do the same.
“I want them to be a tool to empower health-care workers — not just in Bangladesh but also in other low- and middle-income countries — to protect themselves with whatever resources they have access to,” Styczynski said. She said the team of collaborators from Stanford grew when researchers from other institutions heard about the research and wanted to get involved.
The website also includes a video on PPE donning-and-doffing techniques, illustrations for building ultraviolet germicidal irradiation (UVGI) cabinets to decontaminate masks, and the PPE infographics in other languages.
Stephen P. Luby, MD, a core faculty member at Stanford Health Policy and senior fellow at the Freeman Spogli Institute for International Studies and the Woods Institute for the Environment, said the project grew out of Styczynski’s background in infectious disease epidemiology and her deep engagement with collaborators in Bangladesh.
“These scientifically sound, easy-to-understand visuals provide a clear example of how deep engagement in a high-need context allows Stanford researchers to make contributions that impact lives globally,” Luby said.
Styczynski is this year’s Rosenkranz Prize winner for her ongoing research into why Bangladesh is among the top 10 countries with the highest number of stillbirths. She believes intrauterine infections may be an underrecognized factor contributing to the stillbirths and is performing metagenomic sequencing on placental tissues of stillborn babies to examine the genetic and bacterial diversity.
She recently returned to the States to marry her now-husband, Adam Gsellman, a graphic designer who did all the infographics pro bono for the project. Styczynski met him in Bangladesh, where he was working at an IT startup focused on developing travel management software.
“After having lived in Bangladesh for nearly 6 years, he is intimately connected to the country and cares deeply about the people there as well,” she said.
Other Stanford faculty involved in the project include bioengineer Manu Prakash, one of the inventors of the cheap paper microscope, the Foldscope, now used around the world, and Thomas Baer, director of the Stanford Photonics Research Center.
During the initial planning stages, Styczynski connected with Thomas Weiser, MD, MPH, a general and trauma surgeon at Stanford Medicine and the consulting medical officer for Lifebox, a nonprofit working to improve surgical safety in resource-limited settings.
"Lifebox's work is focused on infection prevention in surgery, including decontamination of surgical instruments and appropriate PPE use for surgery,” Weiser said. "We had experience doing this in the operating room, so with Ashley's help we expanded the work to include other health-care workers at risk of infection."
He added that COVID-19 presented them with additional challenges.
"But we felt it was important to prepare the surgical ecosystem to help respond to the new demands for PPE and decontamination processes that would need to be put in place," he said.
A team of Stanford researchers is working with the State of California on a new COVID-19 assessment tool to help hospitals and public health officials in their pandemic preparedness planning.
JUL 13 2020 | by BETH DUFF-BROWN
As the COVID-19 pandemic begins to spike again in California, a team of Stanford modeling experts is working around the clock to pump data into a new assessment tool that is helping California hospitals and public health officials determine their next moves.
The California COVID Assessment Tool, or CalCAT, contains assessments of the spread of COVID-19 in short-term forecasts of disease trends, and presents scenarios of the course of the disease across the 21 counties that represent 95% of the cumulative cases in the Golden State.
Instead of relying on one or two projection models — as some countries and U.S. states did when the pandemic first hit their shores — the CalCAT tool incorporates COVID-19 estimates from a number of respected organizations, including Stanford, UCLA, MIT, Johns Hopkins University and the Imperial College of London. The RAND Corporation focuses on long-term scenarios if shelter-in-place orders are lifted and non-essential business and schools reopen.
“It’s like using the wisdom of the crowd,” said Jeremy Goldhaber-Fiebert, an associate professor of medicine at Stanford Health Policy and one of the principal investigators of the Stanford-CIDE Coronavirus Simulation Model, or SC-COSMO. “Instead of hanging your hat on one model, you’re looking at a range of predictions to help you do planning and forecasting — and leverage the whole community of researchers and analysts who are working on this problem.”
The SC-COSMO project has pulled in Stanford faculty, researchers, graduate and medical students to work on the disease estimates. They are also working with the California prison system and public health officials in India and Mexico to help prevent the spread of COVID-19.
The SC-COSMO model also incorporates non-pharmaceutical interventions, such as recommendations on social distancing, and the timing and effects on reductions in contacts which may differ by demography.
When Governor Gavin Newsom unveiled CalCAT at a news conference in late June, he instructed all state agencies and departments to make COVID-19 data publicly accessible, provided it does not include information that would violate privacy.
“California is home to some of the world’s most accomplished researchers, technologists, scientists, acclaimed universities, and leading technology companies,” Newsom. “While these models and forecasts make different assumptions, all of them show that individual actions can dramatically change the trajectory of the virus.”
The CalCAT tool includes:
- “Nowcasts,” the rate at which COVID-19 is estimated to be spreading;
- Short-term forecasts, which show what various models predict will happen over the next few weeks in California;
- And scenarios showing what could happen over the next few months under various conditions.
Some 20 Stanford faculty and graduate, law and medical students are involved in the project.
“I love modeling infectious diseases because I get to focus on impactful research and work with great, interdisciplinary teams of researchers like the SC-COSMO team,” said Anneke Claypool, a PhD student in management science and engineering. “COVID-19 has affected everyone’s daily life — and I’m glad to be helping the state of California fight this deadly virus.”
The project provides the state with county-level COVID-19 estimates, including the number of infections and detected cases and projections of future needs for hospitals. They are also developing intuitive tools for those who are not themselves modeling experts.
Tess Ryckman, a PhD student at Stanford Health Policy focused on decision science, said working on the team has taught her new skills and burnished her expertise. "I’ve been on an accelerated learning trajectory these past few months and have picked up a lot of coding and modeling skills that will be valuable for me not only in my current research but in future career,” she said. “I also feel that I’m putting a lot of what I’ve learned during my PhD training to good use by applying it to such a pressing and important issue.”
How to Read CalCAT — Ingredients of a Model
For those who aren’t modeling experts, reading the CalCAT tool can be challenging.
Goldhaber-Fiebert explains that the main measurement of the tool is the effective reproduction number — known as the R-effective — which is the average number of people onto which each infected person is likely to pass the virus. It also represents the rate at which COVID-19 is spreading.
He explains that if the R-effective is above 1, that means the infection is growing and would be one signal for concern. That might help the state focus on the counties that are of particular concern and hospitals prepare their ICUs and build up their PPE supply.
As of Tuesday, July 13, for example, the R-effective number was 1.09 for Los Angeles County, as compared to 1.05 in San Francisco County. The overall R-effective for California was 1.12.
The team gets its data from a bundle of data sources.
“The first is paying attention to the clinical and epidemiological literature that’s being published and pre-published, and that’s where Jason comes in.” Jason Andrews, another principal investigator for the SC-COSMO modeling project, is an infectious disease physician and associate professor of medicine at Stanford Medicine.
They also get secure data feeds from the state. Then the team data analysts, SHP’s Kim Babiarz and Lea Prince, do a granular analysis case, testing, hospitalization, and death series to create targets for model calibration and refine model inputs.
Researchers want to determine whether favipiravir, an oral drug, is effective in reducing the severity of symptoms and shortening the duration of COVID-19.
JUN 30 2020 | by TRACIE WHITE
Stanford Medicine researchers are launching a clinical trial to test whether an oral drug can reduce symptoms and viral shedding in people with COVID-19.
The researchers aim to enroll 120 participants, beginning July 6, who have been recently diagnosed with the disease but not been hospitalized.
Favipiravir, an antiviral medication, was first approved to treat influenza in Japan. Researchers are hoping it will be effective in reducing the severity of symptoms and in shortening the duration of COVID-19, which could help limit spread of the coronavirus, said Aruna Subramanian, MD, clinical professor of medicine.
“We hope that this drug can help to reduce transmission within families, groups and schools,” said Subramanian, one of the investigators for the study. “Plus, it would be really nice to have pills that can be given early on to make people get better faster.”
Yvonne Maldonado, MD, professor of pediatrics and of health research and policy, is the principal investigator for the double-blind, placebo-controlled trial.
The drug has not been approved by the Food and Drug Administration. There are other trials investigating the drug, but this is the first time it will be tested in outpatients in the U.S., Subramanian said. It has been approved to treat COVID-19 in Russia, China and India.
“Many really important studies are going on right now to help us understand how to emerge from this pandemic,” said Marisa Holubar, MD, clinical associate professor of infectious disease and an investigator for the study. “These early-phase studies are important to inform larger clinical trials. We need to understand if favipiravir shortens the duration of viral shedding. It could be a key to protecting both ourselves and the broader community.”
Yvonne Maldonado is the principal investigator of the double-blind, placebo-controlled trial.
Viral shedding is the release of a virus into the environment from an infected person.
Stanford participated in earlier clinical trials that found that another antiviral, remdesivir, was effective in treating coronavirus patients. That drug has since been approved for use in the U.S. but is not available orally and, so far, can be administered only intravenously and only to those in a hospital.
“Favipiravir could be very important for symptom relief, especially for patients with mild cases who can have symptoms for a long time,” Subramanian said. “We’ve seen a number of symptoms continue, such as coughs, shortness of breath, fatigue.”
At a molecular level, the drug works by blocking a viral enzyme that makes viral RNA, halting the virus’s ability to replicate itself, Holubar said. Like other antivirals, it’s presumed to work better the earlier it’s prescribed.
Researchers are enrolling those who have been diagnosed with COVID-19 within the past 72 hours. Each participant will receive either a 10-day course of favipiravir or a placebo, and they will be evaluated for health outcomes over 28 days.
People can enroll by emailing email@example.com.
With no approved treatments for COVID-19, Stanford Medicine has joined large-scale clinical trials to determine if remdesivir, an experimental anti-viral medication, works.
APR 17 2020 | by TRACIE WHITE
Philip Grant and Aruna Subramanian are conducting a clinical trial of remdesivir at Stanford as part of a multicenter study of the drug sponsored Gilead Sciences.
In early March, when patients with the coronavirus started arriving at Stanford Hospital, a team of infectious disease researchers at the university put their heads together and made a quick decision. Among the potential treatments for COVID-19, the disease caused by the virus, their first choice to investigate was the experimental anti-viral drug remdesivir. They jumped right in.
Within a week, Stanford Medicine had joined a number of other medical centers around the world in global trials sponsored by Gilead Sciences Inc., the maker of the drug, which is not yet approved as a treatment for COVID-19. By the end of March, the infectious disease doctors had enrolled 30 participants in two trials — one for severe and the other for moderately ill patients — who were receiving the drug intravenously. In addition, another group of Stanford scientists began enrolling participants in a similar, large-scale clinical trial of remdesivir, this one sponsored by the National Institutes of Health.
“We brought this on fast,” said Aruna Subramanian, MD, clinical professor of infectious disease and principal investigator of the Gilead trials at Stanford. “We got everything together in a week and were ready to roll. This was record time. This type of thing normally takes two to three months to get on board.”
More Worldwide push
During normal times, a phase 3 clinical trial — the final step in the process of drug approval — typically takes months of planning, after years of research, before it’s underway. But these aren’t normal times. With a fast-moving pandemic bearing down and no approved treatments available, researchers are, like everyone else, desperate for answers, and they have ramped up their efforts to find solutions. Remdesivir jumped to the top of the list of potential treatments in part because it was farthest along in the approval process, Subramanian said. By the end of February, as the virus spread in the United States, there were at least five clinical trials of remdesivir underway. China initiated the first two studies in February, followed later that month by the Gilead trials for severe and moderate patients and the NIH trial. By the end of March, Gilead had expanded to 100 testing sites both in the United States and abroad, and the NIH trial had expanded to 60 sites, 50 of those in the United States.
Gilead recently reported that it is expecting to have preliminary data from the study of severe patients by the end of April. The two studies in China, though, were halted due to lack of patients. “We urgently need a safe and effective treatment for COVID-19,” said Anthony Fauci, MD, the director of the National Institute of Allergy and Infectious Diseases, in a press release announcing the start of the NIH’s remdesivir trial. “A randomized, placebo-controlled trial is the gold standard for determining if an experimental treatment can benefit patients.” That same month, while speaking about the coronavirus, Bruce Aylward of the World Health Organization announced, “There’s only one drug right now that we think may have real efficacy, and that’s remdesivir.”
How does remdesivir work?
There are multiple reasons for remdesivir’s current reputation as a potential treatment for COVID-19, among them the anecdotal stories that have appeared in the media. While the drug is not commercially available, it is being used to treat patients with COVID-19 through a compassionate care program on a case-by-case basis, with approval from the Food and Drug Administration. In late January, reports out of Washington State that the first person in the nation diagnosed with COVID-19 had been treated with remdesivir, and recovered, made headlines. But scientists are quick to warn against basing treatment guidelines on anecdotal evidence and reports in the news media.
“We have had patients hospitalized at Stanford who got remdesivir under compassionate care guidelines,” said Stanley Deresinski, MD, associate chief of the division of infectious diseases at Stanford. “Some got better. Some got worse. At this point, we just don’t know. We hope to have results soon for remdesivir, and by then we should have another trial in the works for the next best thing.”
An illustration of SARS-CoV-2, the novel coronavirus.
Alissa Eckert and Dan Higgins/Centers for Disease Control and Prevention
At Stanford, the team of infectious disease scientists running the Gilead trials say that, like other scientists, they picked remdesivir as their first choice based on promising results from years of lab and animal research. Often referred to as the Ebola drug, remdesivir was also previously tested in a clinical trial for treating that disease. It failed to show that it was effective for Ebola in comparison with two other drugs, but based on the study, it’s generally known to be safe in humans, said Philip Grant, MD, assistant professor of infectious diseases at the School of Medicine and co-principal investigator of the Gilead trial.
For years, remdesivir has shown potential in cell cultures and animals infected by other coronaviruses, such as SARS and MERS, said Robert Shafer, MD, professor of medicine at the School of Medicine, whose lab recently created a coronavirus anti-viral research database. “Remdesivir looks very good in the lab. In cell cultures, it’s also been more active in fighting the coronavirus than other drugs. That’s why I think it’s promising. I’m looking forward to seeing what the clinical trials show.”
A coronavirus infection occurs when the germ enters the body’s airways through the nose, mouth or eyes, then lodges in the cells in the lining of the lung’s airways, where it quickly starts to make millions of copies of itself, wreaking havoc on the lungs, Subramanian said.
The virus makes copies of itself by inserting its own genes into the human cell’s genetic machinery, basically hijacking the replication process of the human cell. Remdesivir, like other anti-virals, is designed to target the system the virus uses to replicate, acting as a cap that prevents the virus from making new copies of itself or infecting other cells. Whether this works in people to reduce symptoms of COVID-19 or shorten the length of the disease is not known yet.
“We need the data, the scientific rigor of doing randomized clinical trials,” said Robert Harrington, MD, the Arthur L. Bloomfield Professor in Medicine and chair of the department of medicine at Stanford. “That’s how clinical science and patient care advances. We can’t depend on anecdotal stories in order to practice the best clinical medicine. We have to wait for the science.”
Other potential treatments
But scientists around the world aren’t standing still, waiting for the results of remdesivir trials. All kinds of studies are moving ahead at breakneck speed to find the next best treatment or vaccine for the disease.
“A variety of drugs have been suggested,” Deresinski said. “Hydroxychloroquine has been known for 50 years to have nonspecific anti-viral properties. But for now, remdesivir is our preferred agent.”
The anti-malarial drugs chloroquine and hydroxychloroquine also have made headlines as potential treatments for COVID-19. The drugs are currently used off-label in certain cases to treat the disease. But with only a few anecdotal studies showing benefits, they have not received approval from the FDA for COVID-19. Reports have warned of dangerous side effects that need to be studied before widespread use. Recently, a small study of chloroquine in Brazil was halted for safety reasons due to high doses causing irregular heart rhythms. “Chloroquine is being used a little bit too widely without proper study,” Subramanian said, adding that there’s also a growing concern that stockpiling and hoarding of the drugs are limiting supplies for people with lupus and rheumatoid arthritis who are prescribed the medication. “We prefer to be data-driven as much as possible.”
The next step for FDA approval of these anti-malarial drugs to treat — or prevent — COVID-19 depends on data-driven evidence from similar large-scale clinical trials, some of which are currently in the planning process. Whether chloroquine is Stanford’s next best guess for potential treatment, though, is still up for debate.
“Ours is an adaptive trial, which means that if remdesivir doesn’t work, we can quickly move on to testing the next, most promising drug without any gap in time,” said Neera Ahuja, MD, principal investigator of the NIH-sponsored remdesivir trial at Stanford and chief of the division of hospital medicine. She is working with Kari Nadeau, MD, PhD, professor of medicine and of pediatrics, and others on the trial, which includes participants recruited at Stanford Health Care – ValleyCare.
“We’re hopeful about remdesivir, but we are already planning for what the next drug might be,” Ahuja said. “We want patients to get any possible treatments that might benefit them as soon as possible.”