4
ISSN: 2474-3658
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
DOI: 10.23937/2474-3658/1510233
Volume 7 | Issue 10
Open Access
Journal of
Infectious Diseases and Epidemiology
RANdOmisEd dRug TRiAl
A Randomized Controlled Trial of Ivermectin Monotherapy
versus Hydroxychloroquine, Ivermectin, and Azithromycin
Combination Therapy in COVID- 19 Patients in Nigeria
Babalola OE1*, Ndanusa YA2, Ajayi AA3, Ogedengbe JO4, Thairu Y4 and Omede O5
1
Bingham University, Karu, Nigeria
Al Ummah Foundation, Abuja, Nigeria
3
Baylor College of Medicine, Texas, USA
4
University of Abuja, Nigeria
5
Federal Ministry of Health, Abuja, Nigeria
2
Check for
updates
*Corresponding author: Olufemi Emmanuel Babalola, Bingham University, Karu, Nigeria
Abstract
The efficacy of Ivermectin (IVM) against SARS-CoV-2 has
been demonstrated in vitro, while several clinical studies
suggest that it is efficacious and safe in reducing morbidity
and mortality. Hydroxychloroquine (HCQ, Quinoric®), IVM
and Azithromycin(AZM, Zithromax®) (HIA therapy) is being
used in several low- and middle-income countries (LMIC)
where more expensive medications such as Remdesivir are
out of reach. In this study, we set out to compare the efficacy
of IVM monotherapy with HIA combination therapy.
Methods: This was a single-blind, randomized control trial,
of 2 parallel groups of COVID-19 Positive Nigerians. Thirty
(30) patients received Ivermectin (Mectizan®) 200 mcg/
kg daily for five days, while 31 patients received HIA triple
therapy. Viral cycle threshold (Ct) at pre-treatment baseline,
and days 2, 5, 14 and 21 were measured for E- and
N-genes (Envelope and Nucleocapsid genes respectively).
SpO2 (percentage saturation of oxygen in the blood) was
assessed on a daily basis, while inflammatory markers
such as Erythrocyte Sedimentation Rate (ESR), C-Reactive
Protein, and D-dimer and Neutrophil/Lymphocyte Ratios
(NLR), were assessed at baseline and day 7 post treatment.
Clinical status was self-assessed daily on a Likert scale.
Results: 2-way Repeated measures Analysis of Variance
(RMANOVA) did not show any difference between the
two groups. However, there was a significant time effect
(improvement over time) for SpO2, Ct N-gene, Ct E-gene
and clinical status in both groups, and significant reductions
in inflammatory markers by day 7 (P < 0.0001).
Conclusions: AZT + HCQ may be redundant adjuncts
in COVID-19 therapy. Improvements noted are likely due
in large part to Ivermectin virucidal and anti-inflammatory
actions.
Introduction
The World Health Organisation (WHO) declared
a COVID-19 pandemic caused by the severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2)
virus on March 11, 2020 [1]. Since then, there have
been global and massive disruptions in economic,
transportation, social interaction, political, and health
care delivery that is unprecedented and unparalleled in
recent human history. As of September 2021, more
than 223 million people have been infected with more
than 4.6 million deaths [2]. Robust measures including
vaccinations [2] have become available to stem
community transmission of the SARS-CoV-2 virus and
especially the more contagious Delta variant of SARSCoV-2 [3]. Recovery from the pandemic has, however
been slower than anticipated, owing to a combination
of vaccine hesitancy in high income countries, and also
by resource limitation and vaccine insufficiency for
the eligible population in the low- and middle-income
countries (LMIC). Other measures, in addition to public
Citation: Babalola OE, Ndanusa YA, Ajayi AA, Ogedengbe JO, Thairu Y, et al. (2021) A Randomized
Controlled Trial of Ivermectin Monotherapy versus Hydroxychloroquine, Ivermectin, and
Azithromycin Combination Therapy in COVID- 19 Patients in Nigeria. J Infect Dis Epidemiol 7:233. doi.
org/10.23937/2474-3658/1510233
Accepted: October 29, 2021: Published: October 31, 2021
Copyright: © 2021 Babalola OE, et al. This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original author and source are credited.
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
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health modalities, including chemoprophylaxis, and
continued treatment of COVID-19 with a variety of
repurposed drugs or their combinations have therefore
been employed. We have previously reported on the
beneficial effects of Ivermectin in mild to moderate
COVID-19 patients in a randomized controlled double
blind, dose response study [4]. We have also hypothesized
on the putative utility of an additive combination
Ivermectin with novel antiviral drug, molnupiravir [5].
After the publication of Gautret, et al. [6] and Raoult, et
al. [7] among others, doctors in many LMICs, including
in Nigeria, prescribed a cocktail of Ivermectin (IVM,
Mectizan®) combined with Hydroxychloroquine (HCQ,
Quinoric®) and Azithromycin (AZT, Zithromax®) to treat
early or mild COVID-19 patients. Other studies have
however suggested that HCQ is not useful as post
exposure prophylaxis and may be associated with ECG
anomalies in a proportion of patients [8,9].
Ivermectin has an in vitro IC50 for SARS-CoV-2 in
Vero-SLAM cells of 2.4 uM [10] and exerts inhibitory
SARS-CoV-2 effects by multifarious mechanisms,
including blocking viral entry, inhibiting viral nuclear
transport by Importin alpha and beta, and inhibiting
RNA dependent, RNA polymerase (RdRp) [11].
Chloroquine (CQ) and HCQ have an IC50 for inhibition
of SARS-CoV-2 in vitro of 42- 56.8 uM, and 9.2-11.2 uM
respectively [12] but CQ does not inhibit SARS-CoV-2
infection in human lung cells [13]. The mechanisms of
SARS-CoV-2 replication inhibition by CQ/HCQ include
blockade of viral cell invasion, via lipid rafts, interference
with viral endocytosis, binding to angiotensin-converting
enzyme 2 (ACE2) and viral spike protein, blockade of
endosomal acidification, and sequestration of Zinc ions
which block SARS-CoV-2 RdRp [14].
Azithromycin is a macrolide antibiotic, which has been
reported to inhibit SARS-CoV-2 in vitro in Vero cells and
in Caco-2 cells (human colorectal adenocarcinoma cells)
[15]. AZT has an IC50 of 2.1 uM, which is not dissimilar
from the molar value for IVM [16]. It is a weak base,
and thus inhibits the acidic dependent uncoating and
endocytosis of the SARS-CoV-2 virus. AZT binds the
spike protein S, thereby reducing binding to ACE2
receptor, limiting viral entry. The drug amplifies host
anti-viral defense, through increase in Interferon (IFN)
and inhibition of IL-6 production [17].
There are reports of the additive or synergistic
combination of AZT + HCQ in clinical trials in COVID-19
[6], even as other clinical trials, such as the RECOVERY
Collaborative Group showed no efficacy of HCQ in
hospitalized COVID-19 patients [18]. These disparate
findings make it imperative to assess the additive
or synergistic actions, if any, of the combinations of
repurposed drugs, used in COVID-19 treatment.
The purpose of the present study was to examine and
compare the clinical, virological and anti-inflammatory
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
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effects of Ivermectin alone, compared to Ivermectin +
HCQ + AZT triple therapy (HIA triple therapy or IVM+),
in RT PCR, SARS-CoV-2 positive patients with COVID 19
in a randomized controlled trial.
Hypothesis
Null hypothesis (H0): A combination of Ivermectin
plus Hydroxychloroquine plus Azithromycin is not more
efficacious in the treatment of patients with virology
proven COVID-19 disease compared to Ivermectin
alone.
Alternative Hypothesis (Ha): A combination of
Ivermectin and Hydroxychloroquine plus Azithromycin
is more efficacious in the treatment of patients with
virology proven COVID-19 disease.
Materials and Methods
Approval to carry out the research was obtained
from the University of Abuja Health Research Ethics
Committee. The study adhered to the tenets of the
Declaration of Helsinki. (https://www.wma.net/policiespost/wma-declaration-of-helsinki-ethical-principlesfor-medical-research-involving-human-subjects/).
Cases were enrolled between the 2nd of May until the
11th of June 2021.
Inclusion criteria
Consecutive COVID-19 positive patients of all ages
and gender notified to the Federal Capital Territory
COVID-19 Control Center based in Gwagwalada were
eligible for inclusion in the trial, provided informed
consent was not withheld.
Exclusion criteria
Were Lack of a positive COVID-19, refusal to give
informed consent, pregnancy, history of heart disease
and known or reported allergy to any of the trial
medications.
Study design
This was a single-blind, randomized, parallel group
study, of 2 groups of COVID-19 Positive Nigerian patients
with 30/31 subjects in each treatment arm. These are
designated arms ‘A’ and ‘B’
A. 30 patients received Ivermectin 200 mcg/kg daily for
five days
B. 31 patients received HIA triple therapy
a. Hydroxychloroquine 200 mg per day for three
days
b. Ivermectin 200 mcg/kg daily for five days,
c. Azithromycin 500 mg per day for three days.
All three are together referred to as HIA triple
therapy.
Average weight in the trial was 69.3 kg, ranging from
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51-86 kg. Based on the weight, the patients required an
average of 5 tablets of 3 mg of Ivermectin (15 mg) daily.
(Range 12-21 mg daily).
2. SpO2% was assessed using a pulse oximeter on a
daily basis at approximately the same time of the
day.
Patients across the board were also availed Standard
of Care for COVID-19 patients in Nigeria including
Zinc Sulfate, and vitamin C. The use of Ventilators and
Oxygen was applied as needed. Three patients required
oxygen therapy, one in the IVM group and two in the
IVM+. They had baseline SpO2% (percentage saturation
of oxygen in the blood) of 94, 78 and 89 respectively.
3. Symptom check list was assessed at baseline.
These included the following:
Patients were to have ECG done in case they
developed palpitations. None of the patients required
this.
A GeneXpert machine was used to measure
quantitative Reverse Transcriptase Polymerase Chain
Reaction (qRT-PCR). Two different RNA particles
are measured: N-gene (Nucleocapsid) and E-gene
(Envelope). A semiquantitative measure of cycle
threshold (Ct) values was assessed. (Time to detection is
quantified by the machine. The longer it takes, the lower
the viral load) All two marker genes must be negative
before a patient is deemed negative for SARS-CoV-2. A
Ct of 38 or more is regarded as negative for the E-gene,
while Ct of 40 or more is regarded as negative for the
N-gene. (As suggested by the virology laboratory of the
Abuja University Teaching Hospital. It is noteworthy
that other laboratories use a lower cut-off point of 35).
Sample size determination
The study was designed to detect a difference of 15%
in the negativity rate by day 5 after dosing between the
two arms [4], using the Wang and Chow formula [19],
giving a total of 58 patients which was rounded up to
60. However, 65 patients were recruited in the end, of
which 4 were dropped as a result of allergy to HCQ.
Randomization
A standard clinical pharmacological randomization
tool was applied. Sequential patients were assigned
by chance to one of 2 treatments, A, B. Patients were
asked to select from a pot of rolled papers labelled A
or B. The numbers of papers labeled A or B were equal.
This sequence was followed until the sample of 30/31
was attained in each of the 2 groups.
Blinding
This was designed as a single-blind trial. The study
was unmasked at the end of the trial after the analysis.
However, arrangement was in place to unmask the trial
in the event of a very Serious Adverse Event.
Parameters measured
1. Viral load was assessed at enrolment (baseline)
day 0, day 2, day 5, day 14 and day 21 after dosing.
Proportion with negative PCR outcomes at days
2, 5, 14 and 21 were assessed for the two groups.
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
• Respiratory symptoms: Cough
• GIT symptoms: Nausea, vomiting, diarrhea,
abdominal pain
• CVS: Tiredness, lassitude, dyspnea
• CNS: Headache, Anosmia, Ageusia
• MSS: Myalgia
The following serious adverse events were
monitored: Dizziness, diarrhea, vomiting, nausea,
appetite loss, stomach pain, tiredness, others (to be
specified)
4. Inflammatory markers were measured at baseline
and day 7. These were Erythrocyte Sedimentation
Rate (ESR), C-reactive Protein (CRP), and D-Dimer.
5. Hematological variables were measured at
baseline and day 7, including Hemoglobin, White
Blood Cells, Neutrophils, Lymphocytes and
Platelet count. The Neutrophil/Lymphocyte ratio
(NLR) was assessed as a measure of systemic
inflammation.
Statistical analyses
Data was gathered into android tablets on JotForm
platform and uploaded in real time unto the internet
cloud, making it accessible by all researchers on the
team. The data was ultimately translated into Excel and
cleaned. Data was subsequently updated into STATA
analysis package Stata/IC 16.1 for Mac (Intel 64-bit) and
prepared for analysis.
Descriptive and inferential statistics (both parametric
and non-parametric) was performed. Analysis of
variance/Student t-test, and Chi-squared test were
performed to assess effects of treatment on
1. Change in Viral load over time.
2. Change in Oxygen saturation over time.
3. Proportion negative at fixed end points.
4. Change in levels of inflammatory markers and
hematological variables.
5. Change in clinical status over time using Likert
scale: 1) Much worse/Very Bad; 2) Worse/Bad; 3)
No change/average; 4) Improved/Good; 5) Much
improved/Very good.
6. Disposition of patients was assessed on a daily
basis with regards to whether 1. Treatment
is maintained, 2. Patient is well enough to be
discharged from active care, 3. Patient is referred
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for further treatment in Intensive care, or 4. The
patient is deceased.
Repeated Measures Analysis of Variance (RMANOVA)
was carried out to simultaneously measure Treatment
(A v B) differences as Treatment effect and changes
over time, as TIME effect. Time × Treatment interaction
(whether treatment effects vary with time) was
measured simultaneously on all test subjects at once for
parameters indicated.
Statistical rejection of the null hypothesis was p <
0.05 and the 95% confidence Intervals quoted.
A Serious Adverse Event form was designed and
completed for every case enrolled into the trial.
Detailed clinical description of such adverse events was
captured and evaluated. Immediate steps were taken to
ameliorate such incidents.
Results
The baseline values for both arms of the study were
compared to assess the adequacy of randomisation
(Table 1). The findings suggest that there are no
significant differences in the two groups (Ivermectin
only IVM and the HIA triple therapy (IVM+) group) with
regards to all the variables. Age and sex were similar,
as were dose of Ivermectin based on weight, need for
Table 1: Baseline variables.
Variable
IVM
IVM + HCQ + AZM
Overall
P value (test)
Total Numbers
30
31
61
Mean Age (SD) years.
41.6 (2.6)
39.2 (2.9)
40.4 (1.9)
0.558 (ttest)
Sex (Male %)
20 (66)
19 (61)
39 (63)
0.662 (chi2)
Dose of Ivermectin (number of 3 mg tablets)
5.07 (0.12)
5.07 (0.13)
5.07 (0.69)
0.98 (ttest)
Oxygen use
1
2
3
0.573 (chi2)
Ventilator
2
0
2
0.144 (PearsonChi)
Vaccination
0
0
0
Hematology
Hemoglobin g/dl
12.9 (2.4)
12.6 (2.4)
12.7 (2.4)
0.577
WBC × 109 cells/liter
9.76 (2.84)
9.33 (2.13)
9.53 (2.49)
0.501
Lymphocyte × 10 cells/liter
32.4 (13.0)
37.4 (13.6)
34.9 (13.5)
0.150
Neutrophils
58.6 (15.3)
59.8 (12.5)
59.2 (13.9)
0.723
Neutrophil to Lymphocyte ratio(NLR)
2.49
2.05
2.27
0.443
Platelet count
211.5 (62.3)
196.9 (55.5)
204.1 (58.9)
0.341
N-gene CT
27.4 (1.03)
25.7 (1.14)
26.5 (6.02)
0.27 (ttest)
E-gene CT
21.2 (0.75)
20.7 (20.9)
21
0.654
ESR ml/h Westergren
12.8 (0.51)
12.7 (0.43)
12.78 (0.33)
0.816 (ttest)
C-reactive Protein mg/l
14.7 (1.01)
14.7 (1.01)
14.67 (0.71)
0.995 (ttest)
D-dimer ng/ml FEU (Fibrinogen equivalent Unit) 223.9 (18.8)
220.5 (21.6)
222.2 (28.2)
0.525 (ttest)
SpO2%
93.8 (3.5)
92.0 (4.7)
92.9 (4.2)
0.09 (ttest)
Diarrhea
6 (20)
8 (27.6)
14 (23.7)
0.493 (chi2)
Anosmia
6 (20)
6 (20)
12 (20)
1.000 (chi2)
Ageusia
5 (16.7)
6 (19.3)
11 (18.0)
0.785
9
× 10 cells/liter
9
× 10 cells/liter
9
Viral Load Cycle Threshold Ct.
Inflammatory markers
Symptoms at baseline (%)
(Fisher’s exact)
Dyspnea
8 (26.7)
7 (23.3)
15 (25)
0.766
(Fisher’s exact)
Headache
14 (46.7)
16 (53.3)
30 (50)
0.606
(Fisher’s exact)
Cough
20 (66.7)
24 (77.4)
44 (72.1)
0.349
IVM: Ivermectin; HCQ: Hydroxychloroquine; AZM: Azithromycin.
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supplemental oxygen, and need for ventilator. None of
the patients had been vaccinated. Hematological indices
such as hemoglobin, White Blood Count, Lymphocyte
and Neutrophil count, and Neutrophil/Lymphocyte
ratio, as well as Platelet count were comparable for
both groups. There was also no difference with regards
to viral load at baseline for both the N-gene and E-gene.
Inflammatory markers such as ESR, C-reactive protein,
D-dimer values were also similar in both groups. SpO2
was slightly higher for the Ivermectin only (IVM) group
(93.8% versus 92.0%) but the difference was not
statistically significant (p = 0.09). Clinical symptoms
at baseline such as diarrhea (23.7%), anosmia (20%),
ageusia (18%), dyspnea (25%), headache (50%) and
cough (72.1%) were similar in both groups. Therefore,
cough was the most common symptom with which
patients presented, but was slightly less common in the
IVM group.
Description of the study population (Table 1)
Considering the two groups together, the average
age of participants was 40.4 years, with more males
(63%) than females. Figure 1 depicts the age distribution
of the study participants. It indicates that the modal age
group is between 25-30 years.
Based on the weight, the patients required an
average of 5 tablets of 3 mg each (15 mg) daily. The
hematological indices were within normal limits at
baseline. These included Hemoglobin Hb, White Blood
Cell count, Lymphocyte count, Neutrophil count,
Neutrophil to Lymphocyte Ratio, and Platelet count.
Viral loads at baseline were moderately high with mean
CT counts of 26.5 and 21 for N and E-genes respectively.
All these indices were similar in both groups.
With regards to the inflammatory markers,
Erythrocyte Sedimentation Rate was within normal
range, but the C-Reactive Protein was higher than
normal at 14.6 mg/l, compared with a normal range of
less than 10 mg/l.
D-dimer is the degradation product of factor XIII
crosslinked fibrin. It reflects ongoing activation of the
hemostatic system. The reference concentration of
D-dimer is < 250 ng/mL.
A mean study D-dimer level of 222.2 ng/ml was thus
within normal limits.
Mean entry SpO2% was low at 92.9%. Three of the
patients had entry values of less than 80.
In the Federal Capital Territory (FCT) where this
study took place, there are six Area councils (local
governments). The most urbanized local governments
are Abuja Municipal Area Council (AMAC) and
Gwagwalada Area Council, where the teaching hospital
and the main COVID isolation center is located. The
majority of the patients come from these two urbanized
area councils (Local Governments) (Figure 2).
Differential change in parameters with time over
the two arms
Table 2 quantifies changes over time, particularly
between baseline and day 7. (Except for viral genes CT,
which compares baseline and day 2).
Figure 1: Histogram depicting age distribution of the patients.
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Figure 2: Distribution of patients by Area Council within the Federal Capital Territory.
Table 2: Changes in Laboratory parameters (mean values) in both arms of the study over time.
Parameter
Baseline
Day 7
Change Baseline-day P value
7. (*day 2-baseline)
Top: Day 7-baseline
Bottom: Difference between
arms at day 7
Inflammatory markers
ESR
Study Total
12.8
11.4
1.37
0.0025*
IVM
12.9
10.98
1.88
0.257
IVM+
12.7
11.91
0.86
Study total
14.7
5.6
9.00
< 0.0001*
IVM
14.7
5.9
6.9
0.743
IVM+
14.7
5.4
7.4
Study total
221.8
171.2
50.55
< 0.0001*
IVM
223.9
164.5
59.4
0.221
IVM+
220.6
178.1
41.7
Study Total
12.7
12.1
0.56
0.138
IVM
12.9
12.3
0.67
0.615
IVM+
12.6
12.1
0.44
Study Total
9.5
7.9
1.62
0.0002*
IVM
9.8
8.0
1.75
0.75
IVM+
9.3
7.8
1.49
34.9
33.5
1.3
C-reactive Protein
D-Dimer FEU
Hematology
Hemoglobin
WBC
Lymphocytes
Study total
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IVM
32.4
32.7
-0.27
IVM+
37.3
34.4
2.2
Study total
59.2
51.8
7.31
0.0006*
IVM
58.6
51.7
6.9
0.838
IVM+
59.8
52.1
7.7
0.233
Neutrophils
Neutrophil to Lymphocyte ratio (NLR)
Study total
1.70
1.55
0.15
0.9102
IVM
1.81
1.58
0.23
0.499
IVM+
1.60
1.52
0.08
Platelet count × 109/liter
Study total
204.1
153.8
49.7
< 0.0001*
IVM
211.5
148.8
62.7
0.155
IVM+
197
158.7
36.8
Viral Cycle threshold (Ct)
N-Gene
Study total
26.5
33.8
7.04*
< 0.0001*
IVM
27.4
33.7
6.42*
0.425
33.8
7.68
*
IVM+
25.7
E-gene Viral Cycle Time
Study total
20.9
28.6
7.62*
< 0.0001*
IVM
21.2
27.8
6.53*
0.133
20.7
29.5
8.71
*
Study total
92.9
97.7
4.78
< 0.0001*
IVM
93.8
97.8
3.5
0.0189*
IVM+
92
97.5
6
IVM+
SpO2
Figure 3: Change in N-gene cycle threshold over time using Adjusted Predictions of treatment-by-Day interaction with 95%
Confidence Interval error bars.
RMANOVA n = 30 No significant treatment effect, but a significant Time effect, p < 0.0001 ANOVA. There was no timetreatment interaction.
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A Repeated Measures Analysis of Variance
(RMANOVA) was carried out on the cycle Threshold
times for the N and E-genes respectively taking account
of baseline (day 0), day 2, day 5 and day 14. There
was a steady increase in CT values in both arms of the
study. This increase was already significant by day 2
(p < 0.0001). Figure 3 and Figure 4 indicate change in
N-gene and E-Gene cycle threshold respectively over
time using adjusted predictions of treatment-by-day
interaction with 95% confidence interval error bars.
In both situations, there is no treatment difference
between the IVM and IVM+ group. However, there is a
significant time effect (p < 0.0001).
Table 3 indicates the progression of PCR test change
from ‘positive’ to ‘negative’ as the days went by. This
assumes a cutoff of N-Ct > 38 and E-Ct > 40. negative,
one in each arm. (Other authors use a cutoff point of
> 35 Ct as negative) RMANOVA of the N-Ct and E-Ct
genes time-treatment interactions suggested that there
was no treatment difference between the two arms,
but there was a significant time effect in both arms,
p < 0.0001. There was also minimal time × treatment
interaction (Figure 3 and Figure 4).
Figure 4: Change in E-gene cycle threshold over time using Adjusted Predictions of treatment-by-Day interaction with 95%
Confidence Interval error bars.
RMANOVA. n = 30. No Treatment Effect by 2-way repeated measures ANOVA. There was a significant Time effect, p <
0.0001 ANOVA. No time × treatment interactions.
Table 3: RT-PCR results (Positive/Negative) by Day in the study by treatment arm.
Day
Arm
Rt PCR Positive
Rt PCR Negative
Total
(Row%)
Baseline
Day 2
Day 5
P value
(OR 95%CI)
IVM
30
0 (0)
30
IVM+
31
0 (0)
31
Total
61
0 (0)
61
IVM
30
0 (0)
30
IVM+
29
1 (3.33)
30
Total
59
1 (1.67)
60
IVM
21
9 (30.0)
30 (100)
0.584
IVM+
19
11(36.7)
30 (100)
(1.35, 0.403-4.571)
Total
40
20 (34.5)
60 (100)
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0.313
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DOI: 10.23937/2474-3658/1510233
Day 14
IVM
1 (3.5)
ISSN: 2474-3658
28 (96.6)
29
1.000
(1. 0.012-81.2)
Day 21
IVM+
1 (3.5)
28 (96.6)
29
Total
2
56 (96.6)
58
IVM
0
29 (100)
29
IVM+
0
29 (100)
29
Total
0
58
58
Figure 5: Change in arterial oxygen saturation SpO2 over time using Adjusted Predictions of treatment-by-Day interaction
with 95% Confidence Interval error bars.
Changes in SpO2%: RMANOVA analysis suggests that
there is a significant time effect in both arms with a
steady increase in SpO2%, p < 0.0001. There is a weak
treatment × time interaction p = 0.10 from Likelihood
Ratio Test. But there was no significant treatment
difference between the two arms, p = 0.797 (Figure 5,
Table 2 and Table 4).
Changes in laboratory parameters (Table 2)
Inflammatory markers: For the two arms of the
study, there was a statistically significant drop in the
levels of all the inflammatory markers by day 7 relative
to baseline. (ESR p < 0.0025, D-dimer p < 0.0001and CRP,
p < 0.0001) (Figure 6, Figure 7 and Figure 8). The drop
was steeper in the IVM arm (except for CRP where the
drop was parallel), but the difference between the two
groups was not statistically significant both at baseline
and by Day 7.
Hematological variables were assessed. There was
an insignificant drop in Hemoglobin levels by day 7 in
both arms P = 0.138. But there was a significant drop
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
in the WBC count overall (p < 0.0002), with a similar
degree of drop in both arms.
There was overall no statistically significant decrease
in the lymphocyte count. However, there was a slight
increase in the IVM arm of 0.27 × 109 cells/l as opposed
to a decrease in the IVM+ arm (2.2 × 109). This difference
in direction did not achieve statistical significance p =
0.233. Difference -3.16, 95% CI -8.42-2.49.
There was however a significant decrease in the
Neutrophil count across both arms compared to
baseline (p = 0.0006) with a consequent decrease in the
Neutrophil to Lymphocyte ratios, more so in the IVM
arm. 0.23 versus 0.08.
There was also a significant drop in the platelet counts
across arms (p < 0.0001) more so in the IVM arm (47%
drop) than the IVM+ arm (18.7% drop). However, the
difference in percentage drop did not achieve statistical
significance (p = 0.155). Figure 9 (Actual difference was
25.8 95%CI -10.0-61.8).
Change in clinical status with time (Figure 10)
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Table 4: Trend in Mean Percentage Saturation of Oxygen (SpO2%) by days after treatment.
Day
IVM
IVM+
Number of patients
Baseline
93.8
92
60 (30/30)
Day 1
94.3
92.9
58 (29/29)
Day 2
95.1
93.4
58 (29/29)
Day 3
96
94.7
58 (29/29)
Day 4
96.5
95.8
58 (29/29)
Day 5
96.8
96.1
58 (29/29)
Day 6
97.7
96.9
54 (27/27)
Day 7
97.8
97.5
49 (24/25)
Total (IVM/IVM+)
Table 5: Extract from Ivermectin treatment for COVID-19: real time meta-analysis of 64 studies.
Parameter
Number of
studies
Relative Risk (95%CI)
Total number of
patients
Percentage
improvement
Mortality
26
0.44 (0.32-0.60)
36,163
56%
Recovery overall
21
0.48 (0.35-0.67)
3932
52%
Recovery early treatment
11
0.34 (0.19-0.63)
2048
66%
Recovery late treatment
10
0.67 (0.53-0.86)
1878
33%
Viral clearance
21
0.41 (0.29-0.57)
2,296
59%
Prophylaxis
14
0.14 (0.08-0.25)
13,052
86%
Extracted from https://ivmmeta.com [30] October 29th 2021. This meta-analysis includes Babalola, et al. [4].
Figure 6: Change in D-Dimer levels from baseline to Day 7 in the two treatment arms IVM and IVM+.
The clinical status was reported by the patients on
a Likert scale in response to the question ‘How do you
feel today?’ ranging from 1 (much worse) to 5 (much
improved). Figure 10 indicates that in both arms
there was a steady progress in mean wellness scores.
Assuming no time treatment/interaction, there is no
difference between the two groups p = 0.760. However,
there is a significant improvement with time in both
arms. p = 0.102 by day 2 and p = 0.000 by day 5. By
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
day 11, average Likert scores was over 4.5 in both arms
marginally higher in the IVM+ arm (p = 0.0731).
The likelihood of being discharged by day 7 in
either arm of the study: Patients were discharged after
negative PCR test, their perception of wellness, and
the absence of concerning signs and symptoms such as
fever, cough, myalgia and malaise. 63% of patients in
the IVM arm were discharged as compared to 44% in
the IVM+ arm by day 7. OR 2.13 (95% CI 0.63-7.27) p =
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Figure 7: Change in C-Reactive Protein levels from baseline to Day 7 in the two treatment arms IVM and IVM+.
Figure 8: Change in ESR levels from baseline to day 7 p = 0.0025.
0.172. Thus, there is a weak suggestion that patients are
more likely to be discharged by day 7 in the IVM arm,
but this did not achieve significance (Table 4).
Complaints/Adverse events were recorded on a daily
basis and depicted in Figure 11. It is difficult to know
which complaints are due to the disease and which are
due to the drug, but all are assessed together. A total
of 11 patients had complaints of one form or the other
on the first day of treatment, 8 in the IVM group and 3
in the IVM+ group. Complaints in IVM group included
tiredness (4), and one each of stomach pain, nausea,
vomiting and dizziness. Only 3 people had complaints
in the IVM+ group, of stomach pain. By day 2, 4 people
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
still complained of tiredness, and two of stomach pain
in the IVM arm, while 3 people complained of tiredness
in the IVM+ arm. There was an overall decrease in the
number of complaints by day 5, by which time only 3
people complained.
Overall, there were 23 complaint events in the IVM
group compared to 14 in the IVM+ group. However,
four subjects in the IVM+ group had been dropped from
the study because of reaction to HCQ, and do not form
part of this analysis. Their reaction, mainly consisting of
itchiness, had not responded to Loratadine. Two other
subjects developed severe itching around the armpits
attributable to HCQ, but were successfully treated with
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Figure 9: Changes in platelet count from baseline to day 7.
Figure 10: Self-reported Clinical status of patients over time using Adjusted Predictions of treatment-by-Day interaction with
95% Confidence Interval error bars. 1- Much worse/very bad; 5- Much improved/Very good.
Loratadine, and so continued in the study and form part
of this analysis.
Discussion
The clinical, virological, inflammatory, and respiratory
(SpO2%) comparative assessments, which are hard end
points of our randomized controlled study, did not show
a significant difference between IVM monotherapy and
HIA triple therapy in the RT PCR positive COVID-19
patients. This finding indicates that a combination of
AZT + HCQ did not confer any additive benefit to IVM
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
in virucidal action against SARS-CoV-2. The results
however, confirm and extend our earlier results on the
anti-SARS-CoV-2 efficacy of Ivermectin alone [4].
In this study, we demonstrate further that Ivermectin
alone, or with HIA rapidly increased the cycle time (Ct) of
the N-gene (nucleocapsid) and the E-gene (envelope) of
the SARS-CoV-2 and achieved significant COVID negativity
on Day 7 on RMANOVA (Figure 3 and Figure 4).
The possible explanation of the lack of additional or
superior efficacy of HIA over IVM is not clear. First, it can
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Figure 11: Occurrence of Adverse reactions/ main clinical complaints.
Key: Ad1 significant complaints on day 1 in IVM group
Bd1 significant complaints on day 1 in IVM+ group
Ad2 significant complaints on day 2 in IVM group etc…..
be postulated that, IVM with its multiple mechanisms
of anti-SARS-CoV-2 actions [4,5], which incidentally
includes the modes of action both of AZT and HCQ
[6-9,14,15], early onset pharmacodynamics and near
maximal efficacy, leaves no opportunity for enhanced
efficacy for Azithromycin and HCQ, which have a higher
IC50 for SARS-CoV-2 inhibition [12,13]. It is likely that
drugs with divergent mechanisms of Anti SARS-CoV-2
such as Molnupiravir [5], may exhibit synergism in
virucidal activity when combined with IVM.
Although some studies indicated the benefit of AZT +
HCQ in COVID-19 [6,20], this is not a universal finding
[21]. HCQ was discontinued in the RECOVERY study
because of lack of efficacy and cardiac adverse effects
[18].
Additionally, it has been reported that HCQ/CQ does
not inhibit SARS-CoV-2 in human lung cells/Calu-2 cells
[13].
HCQ is also less efficient in blocking viral cell entry
in Vero-6 cells and in inhibiting viral replication in the
lungs [12,22].
It is thus plausible that AZT + HCQ was effectively
a placebo in the combination and did not exert any
independent virucidal activity.
CQ/HCQ exerted no cardiac adverse effects which
had been reported in other populations, as no patient
had any cardiac dysrhythmic symptoms. This safe
cardiac trend is compatible with the experience with
chloroquine treatment of malaria in this hyperendemic
zone for more than half a century. Inter-ethnic
differences in QT elongation response to chloroquine
Babalola et al. J Infect Dis Epidemiol 2021, 7:233
has also been noted by Shah, et al. [23], who suggest
that Africans may not be as prone as Caucasians to CQ
induced cardiotoxicity.
IVM and HIA were associated with improved SpO2%
over 7 days by RMANOVA (Figure 5). Although no
treatment difference was discernible, the time effect
of p < 0.0001 was likely due to the treatment with
Ivermectin in both arms, as it was shown to increase
SpO2% in our earlier study [4] . This is highly suggestive of
a prevention or reversal of any respiratory vascular
damage, which is a hallmark of COVID-19.
In addition, Osman, et al. and Annunziata, et al. have
documented changes in SpO2 in non-ivermectin treated
COVID-10 patients [24,25]. These two studies show
unequivocally that there is an initial dip in SpO2 towards
day 8 before a recovery towards day 14. This contrasts
with our study in which SpO2 increases from day 1 on
ivermectin and is at normal levels by day 7 in both arms
of the study. The mechanism of this effect on SpO2 by
ivermectin is a subject of ongoing investigations.
IVM and HIA were both associated with significantly
reduced pro-inflammatory markers CRP, ESR and
D-dimer (Figure 6, Figure 7 and Figure 8) indicative of
antithrombotic and cytokine reduction effects of
Ivermectin via STAT-3 inhibition as we have previously
suggested [4].
Possible side effects of Ivermectin: As noted
above, there was an overall decrease in the number
of complaints by day 5. This suggests that the dose of
Ivermectin used in this study is safe and efficacious.
Duration of treatment with ivermectin: In our
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previous study, we had utilized a twice weekly 12 mg
dose of ivermectin. However, we felt that a five-day
course would probably help in the build-up of ivermectin
to therapeutic doses and hence utilized this regime in
this study. Ahmed, et al. [26] had equally used a five-day
Ivermectin regime and did not report serious adverse
events of concern.
Inhibition of efficacy: We did not see evidence of
inhibition of efficacy in this study. There appears to be
a marginal increase in likelihood of RT-PCR negativity by
day 5 in the IVM+ arm, but this did not achieve statistical
significance. Reduction in level of inflammatory markers
was less for the IVM+ group, but this did not achieve
statistical significance.
We have had no non-ivermectin controls in this study
for ethical reasons. Our own previous study [4] and
meta-analysis by Kory, et al. [27], Bryant, et al. [28] and
Hill, et al. [29], as well as information obtainable from
the ivmmeta.com website [30], details the advantages
of ivermectin over controls in terms of mortality, viral
clearance, clinical recovery and prophylaxis. A summary
of these improvements as obtained from the October
29 2021 edition of the ivmmeta.com website is detailed
in Table 5. It suggests a 56% improvement in mortality,
52% improvement in recovery, 59% improvement in
viral clearance and 86% improvement in prophylaxis.
Hence, we felt justified in not using a non-ivermectin
control in this study.
In conclusion, there was no significant treatment
difference between IVM monotherapy and HIA triple
therapy, thus suggesting that AZT + HCQ may be
redundant adjuncts in COVID-19 therapy in Nigerians
and elsewhere. There was a highly significant time
effect (p < 0.0001 RMANOVA) indicating that the
improvements in SARS-CoV-2 N and E-gene Ct, as well
as the SpO2% are likely due in large part to Ivermectin
virucidal and anti-inflammatory actions.
Acknowledgments
Tobi Babalola for work on the data collection
platform. Professor Simon Cousens (LSHTM) for help
with statistical analysis.
Trial ID
PACTR202108891693522.
Funding
This project was funded by the Central Bank of
Nigeria Health Sector Research and Development
Intervention Scheme.
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