1 The efficacy of Chloroquine derivatives in COVID-19: a meta-analysis based on the first available

2

3. 3  Matthieu Million

4. 4  aIHU-Méditerranée Infection, Marseille, France

5. 5  bAix Marseille Univ, IRD, AP-HM, MEPHI, Marseille, France

6. 6  cAix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France

7

8. 8  Running title: Efficacy of Chloroquine derivatives in COVID-19

9. 9  Keywords: coronavirus, COVID-19, SARS-CoV-2, Hydroxychloroquine, Chloroquine, meta-analysis

10. 10  Corresponding author: Didier Raoult, IHU - Méditerranée Infection, 19-21 boulevard Jean Moulin,

11. 11  13005 Marseille, France. Tel.: +33 413 732 401, Fax: +33 413 732 402;

12. 12  E-mail: didier.raoult@gmail.com

13. 13  Text word count: 976

14. 14  Running title: Chloroquine derivatives efficacy in COVID-19

a,b*

a,c* a,b , Philippe Gautret , Didier Raoult

reports

15. 15  Introduction

16. 16  We are currently facing a pandemic involving a newly discovered coronavirus (SARS-CoV-2) which

17. 17  putting our societies to the test in many ways. Despite controversy, only two drugs, namely

18. 18  hydroxychloroquine (HCQ) and chloroquine (CQ), have been used by physicians on a large-scale basis

19. 19  as treatment for COVID-19 [1]. According to the Sermo Real Time Covid-19 Barometer

20. 20  (https://www.sermo.com/, consulted 20 April), for over 20,000 physicians across 30 countries,

21. 21  chloroquine derivatives are the first medication used to treat COVID-19 patients in ICUs (67%), the

22. 22  second medication in other hospital settings (66%), and the third in outpatient settings (40%). While

23. 23  many countries recommend it for treating COVID-19, certain Western countries do not

24. 24  (https://www.mediterranee-infection.com/coronavirus-pays-ou-lhydroxychloroquine-est-

25. 25  recommandee/). It is therefore urgent to evaluate the efficacy of these medications against clinical,

26. 26  biological, radiological and virological outcomes of the disease. A large number of randomised clinical

27. 27  trials (RCTs) aimed at challenging the antiviral action of the two drugs against a placebo or other

28. 28  potentially active drugs are ongoing. Some of these studies have been published in peer-reviewed

29. 29  journals or released as pre-prints on various websites [2-5]. In this paper, we present the conclusions

30. 30  of a preliminary meta-analysis addressing this issue.

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32. 32  Methods

33. 33  We conducted a meta-analysis of comparative studies between two groups that were

34. 34  expected to be similar with respect to demographics, chronic conditions and clinical presentation at

35. 35  enrolment. One group was treated with HCQ or CQ and one group was not treated with these

36. 36  molecules. The keywords “hydroxychloroquine”, “chloroquine”, “coronavirus”, “COVID-19” and

37. 37  “SARS-Cov-2” were used in the PubMed, Google Scholar and Google search engines without any

38. 38  restrictions as to date or language. Preprints were also included. Non-comparative (single-arm)

39. 39  studies were excluded.

40. 40  Articles published in peer-reviewed journals, pre-prints and articles available on the internet,

41. 41  even when not published on official websites, were included. The following outcomes were

42. 42  considered: death, transfer to intensive care unit (ICU), clinical and radiological worsening, length of

43. 43  stay in hospital, and persistence of viral shedding as assessed by PCR. A randomised model was used

44. 44  with Comprehensive Meta-Analysis v3 (Biostat, Englewood, NJ, USA). This software made it possible

45. 45  to include dichotomous outcomes (number of events out of the total) and quantitative outcomes

46. 46  (mean in each group, sample size, p-value). According to Borenstein et al. [6], if a treatment is truly

47. 47  ineffective, half the comparisons would be expected to lie on either side of the no-effect line. This

48. 48  can be formally tested by comparing the number of comparisons in one direction versus the null

49. 49  value of 50% (sign test). This sign test was performed using the binomial distance as reported by

50. 50  Borenstein [6]. A p-value < 0.05 was considered significant.

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52. 52  Results

53. 53  Ten comparative studies were identified involving 1,642 patients (965 patients treated with a

54. 54  chloroquine derivative) from five countries (Brazil, China, France, Iran, and USA) (Table S1). The 10

55. 55  studies included three published papers, five pre-prints published on MedRxiv, one submitted paper

56. 56  that was neither published nor a pre-print, and one unpublished paper that was not a pre-print, both

57. 57  of which were available on the internet (uniform resource locator (url) provided in the

58. 58  supplementary data). All but one paper (in Chinese) were written in English. The four studies from

59. 59  China and the one from Iran were conducted on patients treated with several antivirals

60. 60  (lopinavir/ritonavir, oseltamivir, ribavirine, umifenovir and nebulisation of interferon aerosol) in

61. 61  addition to chloroquine derivatives. Two studies were conducted in France, including one in Paris and

62. 62  our seminal study in Marseille and other locations in southern France. Four RCTs were included in

63. 63  this analysis [2-5].

64. 64  When considering all ten included studies (Figure 1, Table S2), chloroquine derivatives were

65. 65  associated with a lower need for hospitalisation (n = 1, Odds ratio (OR) 0.35, p = .024), shorter

66. 66  duration of cough (n = 1, OR 0.13, p = .001), shorter duration of fever (n = 1, OR 0.14, p = .001),

67. 67  decreased C-reactive protein level (n = 1, OR 0.55, p = .045), and increased hospital discharge (n = 1,

68. 68  OR 0.05, p =.050). CQ derivatives were associated with a beneficial effect (OR < 1) for 11 of the 12

69. 69  outcomes analysed (Figure 1). Of the 25 comparisons made, 19 were favourable (Table S1).

70. 70  Accordingly, the two-sided sign-test p-value was 0.015. The fatality rate was analysed in two studies

71. 71  with an opposite direction of effect. The study reporting an increased fatality rate was suspected of

72. 72  scientific misconduct (patients were significantly more severe in the treated group [7]). No significant

73. 73  negative effect was observed.

74. 74  Three studies were identified with potential scientific misconduct as patients in the untreated group

75. 75  were treated [7], patients were treated after ventilation [8], and patients were significantly more

76. 76  severe in the treated group at baseline [8,9]. After excluding these three studies which had a very

77. 77  high risk of bias, seven studies, including 18 comparisons were analysed (Figure 2, Table S3). The

78. 78  favourable effects on the need for hospitalisation, duration of cough, duration of fever, C-reactive

79. 79  protein levels, and hospital discharge rate, were unchanged. However, a significant beneficial effect

80. 80  was also observed for clinical cure (n = 2, OR 0.48, p = .022) and for the outcome “death or transfer

81. 81  to the intensive care unit” (n = 1, OR 0.04, p < .001). In this subgroup analysis, the direction of effect

82. 82  was favourable for all 11 outcomes analysed. Of the 18 comparisons made, 15 were favourable

83. 83  (Table S1). The two-sided sign-test p-value was 0.0075. All data extracted from the articles and

84. 84  entered in the software are provided in supplementary files (Tables S1 and S4 to S7).

85

86. 86  Discussion

87. 87  Chloroquine derivatives present a paradox. On one hand, the heterogeneity of patients and

88. 88  treatment make it difficult to obtain a clear picture while the epidemic is still ongoing. Under these

89. 89  conditions, a meta-analysis allowing for the combination of different studies makes it possible to

90. 90  identify a general trend. This makes it possible to reconcile the chloroquine derivative efficacy that

91. 91  many doctors have perceived with the results of the first published studies. This meta-analysis is

92. 92  based on several studies, including four RCTs, and identifies a favourable trend toward the benefit of

93. 93  chloroquine derivatives in the treatment of COVID-19 patients, enabling us to make a grade I

94. 94  recommendation for its use against the disease.

95. 95  Acknowledgements

96. 96  We thank Christian Devaux for helpful interactions and Fanyu Huang for Chinese to English

97. 97  translation of the study by Chen J et al. [3]. This work has received financial support from the French

98. 98  Government through the Agence Nationale pour la Recherche (ANR), including the “Programme

99. 99  d’Investissement d’Avenir” under the reference Méditerranée Infection 10-IAHU-03 and from the

100. 100  Méditerranée Infection foundation.

101

102. 102  Author contributions

103. 103  MM, PG and DR wrote the MS. MM and PG performed the meta-analysis, DR supervised the study.

104

105. 105  Competing interest declaration

106. 106  No competing interest to declare.

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142. 142  Figure legends

143. 143  Figure 1. Forest plot reporting all comparisons of the efficacy of chloroquine derivatives in humans

144. 144  infected with COVID-19

145. 145  CI: Confidence interval, CT: computed tomography, ICU: Intensive care unit. Viral load persistence

146. 146  was assessed by polymerase chain reaction. Very high risk of bias: studies with possible scientific

147. 147  misconduct (treated group were more severe at baseline, treatment took place after ventilation,

148. 148  patients in the “untreated” group were treated).

149

150. 150  Figure 2. Forest plot reporting comparisons of the efficacy of chloroquine derivatives in humans

151. 151  infected with COVID-19 after the exclusion of three studies with very high risk of bias

152. 152  CI: Confidence interval, CT: computed tomography, ICU: Intensive care unit. Viral load persistence

153. 153  was assessed by polymerase chain reaction.