Covid Analysis, May 25, 2022, DRAFT
https://c19early.com/vameta.html
•Statistically significant improvements are seen for recovery, cases, and viral clearance. 4 studies from 3 independent teams in 3 different countries show statistically significant
improvements in isolation (2 for the most serious outcome).
•Meta analysis using the most serious outcome reported shows
50% [-9‑77%] improvement, without reaching statistical significance. Results are better for Randomized Controlled Trials, similar after exclusions, and better for peer-reviewed studies. Results are consistent with early treatment being more effective than late treatment.
•Sufficiency studies, analyzing outcomes based on serum levels,
show 73% [51‑85%] improvement for patients with higher vitamin A levels
(3 studies).
•While many treatments have some level
of efficacy, they do not replace vaccines and other measures to avoid
infection.
Only 25% of vitamin A
studies show zero events in the treatment arm.
Multiple treatments are typically used
in combination, and other treatments
may be more effective.
•No treatment, vaccine, or intervention is 100%
available and effective for all variants. All practical, effective, and safe
means should be used.
Denying the efficacy of treatments increases mortality, morbidity, collateral
damage, and endemic risk.
•All data to reproduce this paper and
sources are in the appendix.
Highlights
Vitamin A reduces
risk for COVID-19 with very high confidence for recovery, cases, and viral clearance, low confidence for pooled analysis, and very low confidence for ICU admission, hospitalization, and progression.
We show traditional outcome specific analyses and combined
evidence from all studies, incorporating treatment delay, a primary
confounding factor in COVID-19 studies.
Real-time updates and corrections,
transparent analysis with all results in the same format, consistent protocol
for 42
treatments.
Figure 1. A. Random effects
meta-analysis. This plot shows pooled effects, discussion can be found in the heterogeneity section,
and results for specific outcomes can be found in the individual outcome analyses.
Effect extraction is pre-specified, using the most serious outcome reported.
For details of effect extraction see the appendix.
B. Scatter plot showing the
distribution of effects reported in studies. C. History of all reported
effects (chronological within treatment stages).
Introduction
We analyze all significant studies
concerning the use of
vitamin A
for COVID-19.
Search methods, inclusion criteria, effect
extraction criteria (more serious outcomes have priority), all individual
study data, PRISMA answers, and statistical methods are detailed in
Appendix 1. We present random effects meta-analysis results for all
studies, for studies within each treatment stage, for individual outcomes, for
peer-reviewed studies, for Randomized Controlled Trials (RCTs), and after
exclusions.
Figure 2 shows stages of possible treatment for
COVID-19. Prophylaxis refers to regularly taking medication before
becoming sick, in order to prevent or minimize infection. Early
Treatment refers to treatment immediately or soon after symptoms appear,
while Late Treatment refers to more delayed treatment.
Figure 2. Treatment stages.
Preclinical Research
An In Vitro study supports the efficacy of vitamin A [Morita].
Preclinical research is an important part of the development of
treatments, however results may be very different in clinical trials.
Preclinical results are not used in this paper.
Results
Figure 3 shows a visual overview of the results, with details in
Table 1 and Table 2.
Figure 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13
show forest plots for a random effects meta-analysis of
all studies with pooled effects, mortality results, ICU admission, hospitalization, progression, recovery, cases, viral clearance, sufficiency studies, and peer reviewed studies.
Figure 3. Overview of results.
Treatment time | Number of studies reporting positive effects | Total number of studies | Percentage of studies reporting positive effects | Random effects meta-analysis results |
Early treatment | 2 | 2 | 100% |
79% improvement RR 0.21 [0.07‑0.61] p = 0.004 |
Late treatment | 2 | 3 | 66.7% |
48% improvement RR 0.52 [0.04‑7.80] p = 0.65 |
Prophylaxis | 3 | 3 | 100% |
49% improvement RR 0.51 [0.27‑0.99] p = 0.046 |
All studies | 7 | 8 | 87.5% |
50% improvement RR 0.50 [0.23‑1.09] p = 0.08 |
Table 1. Results by treatment stage.
Studies | Early treatment | Late treatment | Prophylaxis | Patients | Authors | |
All studies | 8 | 79% [39‑93%] | 48% [-680‑96%] | 49% [1‑73%] | 17,951 | 61 |
With exclusions | 5 | 67% [-57‑93%] | 87% [3‑98%] | 48% [-14‑76%] | 2,557 | 20 |
Peer-reviewed | 4 | 86% [39‑97%] | 89% [-98‑99%] | 24% [-23‑53%] | 17,575 | 47 |
Randomized Controlled TrialsRCTs | 2 | 87% [3‑98%] | 100 | 10 |
Table 2. Results by treatment stage for all studies and with different exclusions.
Figure 4. Random effects meta-analysis for all studies with pooled effects.
This plot shows pooled effects, discussion can be found in the heterogeneity section,
and results for specific outcomes can be found in the individual outcome analyses.
Effect extraction is pre-specified, using the most serious outcome reported.
For details of effect extraction see the appendix.
Figure 5. Random effects meta-analysis for mortality results.
Figure 6. Random effects meta-analysis for ICU admission.
Figure 7. Random effects meta-analysis for hospitalization.
Figure 8. Random effects meta-analysis for progression.
Figure 9. Random effects meta-analysis for recovery.
Figure 10. Random effects meta-analysis for cases.
Figure 11. Random effects meta-analysis for viral clearance.
Figure 12. Random effects meta-analysis for sufficiency studies.
Effect extraction is pre-specified, using the most serious outcome reported,
see the appendix for details.
Figure 13. Random effects meta-analysis for peer reviewed studies.
[Zeraatkar] analyze 356 COVID-19 trials, finding no
significant evidence that peer-reviewed studies are more trustworthy.
They also show extremely slow review times during a pandemic. Authors
recommend using preprint evidence, with appropriate checks for potential
falsified data, which provides higher certainty much earlier.
Effect extraction is pre-specified, using the most serious outcome reported,
see the appendix for details.
Exclusions
To avoid bias in the selection of studies, we analyze all
non-retracted studies. Here we show the results after excluding studies with
major issues likely to alter results, non-standard studies, and studies where
very minimal detail is currently available. Our bias evaluation is based on
analysis of each study and identifying when there is a significant chance that
limitations will substantially change the outcome of the study. We believe
this can be more valuable than checklist-based approaches such as Cochrane
GRADE, which may underemphasize serious issues not captured in the checklists,
overemphasize issues unlikely to alter outcomes in specific cases (for
example, lack of blinding for an objective mortality outcome, or certain
specifics of randomization with a very large effect size), or be easily
influenced by potential bias. However, they can also be very high
quality.
The studies excluded are as below.
Figure 14 shows a forest plot for random
effects meta-analysis of all studies after exclusions.
[Al-Sumiadai], minimal details of groups provided.
[Holt], significant unadjusted confounding possible.
[Sarohan], unadjusted results with no group details.
Figure 14. Random effects meta-analysis for all studies after exclusions.
This plot shows pooled effects, discussion can be found in the heterogeneity section,
and results for specific outcomes can be found in the individual outcome analyses.
Effect extraction is pre-specified, using the most serious outcome reported.
For details of effect extraction see the appendix.
Randomized Controlled Trials (RCTs)
Figure 15 shows the distribution of results for Randomized Controlled Trials and other studies, and
a chronological history of results.
The median effect size for
RCTs is 87% improvement,
compared to 67% for other studies.
Figure 16 shows a forest plot for random
effects meta-analysis of all Randomized Controlled Trials.
Table 3 summarizes the results.
Figure 15. The distribution of results for Randomized Controlled Trials and other studies, and
a chronological history of results.
Figure 16. Random effects meta-analysis for all Randomized Controlled Trials.
This plot shows pooled effects, discussion can be found in the heterogeneity section,
and results for specific outcomes can be found in the individual outcome analyses.
Effect extraction is pre-specified, using the most serious outcome reported.
For details of effect extraction see the appendix.
Treatment time | Number of studies reporting positive effects | Total number of studies | Percentage of studies reporting positive effects | Random effects meta-analysis results |
Randomized Controlled Trials | 2 | 2 | 100% |
87% improvement RR 0.13 [0.02‑0.97] p = 0.046 |
RCT mortality results | 2 | 2 | 100% |
87% improvement RR 0.13 [0.02‑0.97] p = 0.046 |
Table 3. Randomized Controlled Trial results.
Heterogeneity
Heterogeneity in COVID-19 studies arises from many factors including:
Treatment delay.
The time between infection
or the onset of symptoms and treatment may critically affect how well a
treatment works. For example an antiviral may be very effective when used
early but may not be effective in late stage disease, and may even be harmful.
Oseltamivir, for example, is generally only considered effective for influenza
when used within 0-36 or 0-48 hours [McLean, Treanor].
Figure 17 shows a mixed-effects meta-regression for efficacy
as a function of treatment delay in COVID-19 studies from 42 treatments, showing
that efficacy declines rapidly with treatment delay. Early treatment is
critical for COVID-19.
Figure 17. Meta-regression
showing efficacy as a function of treatment delay in COVID-19 studies from 42 treatments. Early
treatment is critical.
Patient demographics.
Details of the
patient population including age and comorbidities may critically affect how
well a treatment works. For example, many COVID-19 studies with relatively
young low-comorbidity patients show all patients recovering quickly with or
without treatment. In such cases, there is little room for an effective
treatment to improve results (as in [López-Medina]).Effect measured.
Efficacy may differ
significantly depending on the effect measured, for example a treatment may be
very effective at reducing mortality, but less effective at minimizing cases
or hospitalization. Or a treatment may have no effect on viral clearance while
still being effective at reducing mortality.Variants.
There are many different
variants of SARS-CoV-2 and efficacy may depend critically on the distribution
of variants encountered by the patients in a study. For example, the Gamma
variant shows significantly different characteristics
[Faria, Karita, Nonaka, Zavascki]. Different mechanisms of action may be
more or less effective depending on variants, for example the viral entry
process for the omicron variant has moved towards TMPRSS2-independent fusion,
suggesting that TMPRSS2 inhibitors may be less effective
[Peacock, Willett].Regimen.
Effectiveness may depend strongly on the dosage and treatment regimen.
Treatments.
The use of other
treatments may significantly affect outcomes, including anything from
supplements, other medications, or other kinds of treatment such as prone
positioning.The distribution of studies will alter the outcome of a meta
analysis. Consider a simplified example where everything is equal except for
the treatment delay, and effectiveness decreases to zero or below with
increasing delay. If there are many studies using very late treatment, the
outcome may be negative, even though the treatment may be very effective when
used earlier.
In general, by combining heterogeneous studies, as all meta
analyses do, we run the risk of obscuring an effect by including studies where
the treatment is less effective, not effective, or harmful.
When including studies where a treatment is less effective we
expect the estimated effect size to be lower than that for the optimal case.
We do not a priori expect that pooling all studies will create a
positive result for an effective treatment. Looking at all studies is valuable
for providing an overview of all research, important to avoid cherry-picking,
and informative when a positive result is found despite combining less-optimal
situations. However, the resulting estimate does not apply to specific cases
such as
early treatment in high-risk populations.
Discussion
Publication bias.
Publishing is often biased
towards positive results, however evidence suggests that there may be a negative bias for
inexpensive treatments for COVID-19. Both negative and positive results are
very important for COVID-19, media in many countries prioritizes negative
results for inexpensive treatments (inverting the typical incentive for
scientists that value media recognition), and there are many reports of
difficulty publishing positive results
[Boulware, Meeus, Meneguesso].
For vitamin A, there is currently not
enough data to evaluate publication bias with high confidence.
One method to evaluate bias is to compare prospective vs.
retrospective studies. Prospective studies are more likely to be published
regardless of the result, while retrospective studies are more likely to
exhibit bias. For example, researchers may perform preliminary analysis with
minimal effort and the results may influence their decision to continue.
Retrospective studies also provide more opportunities for the specifics of
data extraction and adjustments to influence results.
67% of retrospective studies
report a statistically significant positive effect for
one or more outcomes, compared to
100% of prospective studies, consistent with a bias toward publishing negative results.
The median effect size for
retrospective studies is 21% improvement,
compared to 67% for prospective
studies, suggesting a potential bias towards publishing results showing lower efficacy.
Figure 18 shows a scatter plot of
results for prospective and retrospective treatment studies.
Figure 18. Prospective vs. retrospective studies.
Funnel plot analysis.
Funnel
plots have traditionally been used for analyzing publication bias. This is
invalid for COVID-19 acute treatment trials — the underlying assumptions
are invalid, which we can demonstrate with a simple example. Consider a set of
hypothetical perfect trials with no bias. Figure 19 plot A
shows a funnel plot for a simulation of 80 perfect trials, with random group
sizes, and each patient's outcome randomly sampled (10% control event
probability, and a 30% effect size for treatment). Analysis shows no asymmetry
(p > 0.05). In plot B, we add a single typical variation in COVID-19 treatment
trials — treatment delay. Consider that efficacy varies from 90% for
treatment within 24 hours, reducing to 10% when treatment is delayed 3 days.
In plot B, each trial's treatment delay is randomly selected. Analysis now
shows highly significant asymmetry, p < 0.0001, with six variants of
Egger's test all showing p < 0.05
[Egger, Harbord, Macaskill, Moreno, Peters, Rothstein, Rücker, Stanley].
Note that these tests fail even though treatment delay is uniformly
distributed. In reality treatment delay is more complex — each trial has
a different distribution of delays across patients, and the distribution
across trials may be biased (e.g., late treatment trials may be more common).
Similarly, many other variations in trials may produce asymmetry, including
dose, administration, duration of treatment, differences in SOC,
comorbidities, age, variants, and bias in design, implementation, analysis,
and reporting.Figure 19. Example funnel plot analysis for
simulated perfect trials.
Conflicts of interest.
Pharmaceutical drug
trials often have conflicts of interest whereby sponsors or trial staff have a
financial interest in the outcome being positive. Vitamin A for COVID-19
lacks this because it is
an inexpensive and widely available supplement.
In contrast, most COVID-19 vitamin A trials have been run by
physicians on the front lines with the primary goal of finding the best
methods to save human lives and minimize the collateral damage caused by
COVID-19. While pharmaceutical companies are careful to run trials under
optimal conditions (for example, restricting patients to those most likely to
benefit, only including patients that can be treated soon after onset when
necessary, and ensuring accurate dosing), not all vitamin A trials
represent the optimal conditions for efficacy.Early/late vs. mild/moderate/severe.
Some analyses classify treatment based on early/late administration (as we do
here), while others distinguish between mild/moderate/severe cases. We note
that viral load does not indicate degree of symptoms — for example
patients may have a high viral load while being asymptomatic. With regard to
treatments that have antiviral properties, timing of treatment is
critical — late administration may be less helpful regardless of
severity.Notes.
1 of 8 studies
combine treatments. The results of
vitamin A
alone may differ.
1 of 2 RCTs use combined treatment.
Conclusion
Statistically significant improvements are seen for recovery, cases, and viral clearance. 4 studies from 3 independent teams in 3 different countries show statistically significant
improvements in isolation (2 for the most serious outcome).
Meta analysis using the most serious outcome reported shows
50% [-9‑77%] improvement, without reaching statistical significance. Results are better for Randomized Controlled Trials, similar after exclusions, and better for peer-reviewed studies. Results are consistent with early treatment being more effective than late treatment.
Sufficiency studies, analyzing outcomes based on serum levels,
show 73% [51‑85%] improvement for patients with higher vitamin A levels
(3 studies).
Study Notes
[Al-Sumiadai (C)]
Treatment and prophylaxis studies of vitamin A in Iraq.
The treatment study contained 100 patients, 50 treated with 200,000IU vitamin A for two days, showing lower progression to severe disease, and shorter duration of symptoms.
The prophylaxis study contained 209 contacts of COVID-19 patients, 97 treated with vitamin A, showing significantly lower cases with treatment, and shorter duration of symptoms.
The treatment study contained 100 patients, 50 treated with 200,000IU vitamin A for two days, showing lower progression to severe disease, and shorter duration of symptoms.
The prophylaxis study contained 209 contacts of COVID-19 patients, 97 treated with vitamin A, showing significantly lower cases with treatment, and shorter duration of symptoms.
[Al-Sumiadai (B)]
Treatment and prophylaxis studies of vitamin A in Iraq.
The treatment study contained 100 patients, 50 treated with 200,000IU vitamin A for two days, showing lower progression to severe disease, and shorter duration of symptoms.
The prophylaxis study contained 209 contacts of COVID-19 patients, 97 treated with vitamin A, showing significantly lower cases with treatment, and shorter duration of symptoms.
The treatment study contained 100 patients, 50 treated with 200,000IU vitamin A for two days, showing lower progression to severe disease, and shorter duration of symptoms.
The prophylaxis study contained 209 contacts of COVID-19 patients, 97 treated with vitamin A, showing significantly lower cases with treatment, and shorter duration of symptoms.
[Al-Sumiadai]
Retrospective 70 severe condition patients treated with vitamin A (200,000IU for two days), salbutamol, and budesonide, and 70 patients not treated with vitamin A, showing significantly lower mortality with the addition of vitamin A.
[Beigmohammadi]
Small RCT 60 ICU patients in Iran, 30 treated with vitamins A, B, C, D, and E, showing significant improvement in SOFA score and several inflammatory markers at day 7 with treatment.
5,000 IU vitamin A daily, 600,000 IU vitamin D once, 300 IU of vitamin E twice a day, 500 mg vitamin C four times a day, and one ampule daily of B vitamins [thiamine nitrate 3.1 mg, sodium riboflavin phosphate 4.9 mg (corresponding to vitamin B2 3.6 mg), nicotinamide 40 mg, pyridoxine hydrochloride 4.9 mg (corresponding to vitamin B6 4.0 mg), sodium pantothenate 16.5 mg (corresponding to pantothenic acid 15 mg), sodium ascorbate 113 mg (corresponding to vitamin C 100 mg), biotin 60 μg, folic acid 400 μg, and cyanocobalamin 5 μg]. IRCT20200319046819N [irct.ir].
5,000 IU vitamin A daily, 600,000 IU vitamin D once, 300 IU of vitamin E twice a day, 500 mg vitamin C four times a day, and one ampule daily of B vitamins [thiamine nitrate 3.1 mg, sodium riboflavin phosphate 4.9 mg (corresponding to vitamin B2 3.6 mg), nicotinamide 40 mg, pyridoxine hydrochloride 4.9 mg (corresponding to vitamin B6 4.0 mg), sodium pantothenate 16.5 mg (corresponding to pantothenic acid 15 mg), sodium ascorbate 113 mg (corresponding to vitamin C 100 mg), biotin 60 μg, folic acid 400 μg, and cyanocobalamin 5 μg]. IRCT20200319046819N [irct.ir].
[Elkazzaz]
RCT with 20 13-cis-retinoic acid patients and 20 control patients, showing faster recovery and viral clearance with treatment. Aerosolized 13-cis-retinoic acid with increasing dose from 0.2 mg/kg/day to 4 mg/kg/day for 14 days, plus oral 13-cis-retinoic acid 20 mg/day. 13-cis retinoic acid is a synthetic vitamin A derivative, and is teratogenic. NCT04353180.
[Holt]
Prospective survey-based study with 15,227 people in the UK, showing lower risk of COVID-19 cases with vitamin A, vitamin D, zinc, selenium, probiotics, and inhaled corticosteroids; and higher risk with metformin and vitamin C. Statistical significance was not reached for any of these. Except for vitamin D, the results for treatments we follow were only adjusted for age, sex, duration of participation, and test frequency. NCT04330599. COVIDENCE UK.
[Nimer]
Retrospective survey based analysis of 2,148 COVID-19 recovered patients in Jordan, showing no significant differences in the risk of severity and hospitalization with vitamin A prophylaxis.
[Sarohan]
Retrospective 27 severe COVID-19 patients and 23 non-COVID-19 patients, showing signifcantly lower vitamin A levels in COVID-19 patients (0.37mg/L vs. 0.52 mg/L, p<0.001). 10 of 27 COVID-19 patients received vitamin A, with higher mortality. Group details are not provided but authors note that 8 of 10 had comorbidities.
[Tepasse]
Prospective analysis of 40 hospitalized patients and 47 age-matched convalescent patients, showing significantly lower vitamin A levels in critical patients, and significantly lower vitamin A levels in hospitalized patients vs. controls. Low vitamin A levels were significantly associated with ARDS and mortality in hospitalized patients.
[Tomasa-Irriguible]
Retrospective 120 hospitalized patients in Spain showing vitamin A deficiency associated with higher ICU admission.
[Voelkle]
Prospective study of 57 consecutive hospitalized COVID-19 patients in Switzerland, showing higher risk of mortality/ICU admission with vitamin A, vitamin D, and zinc deficiency, with statistical significance only for vitamin A and zinc. Adjustments only considered age.
We performed ongoing searches of PubMed, medRxiv,
ClinicalTrials.gov, The Cochrane Library, Google Scholar, Collabovid, Research
Square, ScienceDirect, Oxford University Press, the reference lists of other
studies and meta-analyses, and submissions to the site c19early.com. Search terms were vitamin A, filtered for papers containing the terms COVID-19 or SARS-CoV-2. Automated searches are performed
every few hours with notification of new matches.
All studies regarding the use of vitamin A for COVID-19 that report
a comparison with a control group are included in the main analysis.
Sensitivity analysis is performed, excluding studies with major issues,
epidemiological studies, and studies with minimal available information.
This is a living analysis and is updated regularly.
We extracted effect sizes and associated data from all studies.
If studies report multiple kinds of effects then the most serious
outcome is used in pooled analysis, while other outcomes are included in the
outcome specific analyses. For example, if effects for mortality and cases are
both reported, the effect for mortality is used, this may be different to the
effect that a study focused on.
If symptomatic
results are reported at multiple times, we used the latest time, for example
if mortality results are provided at 14 days and 28 days, the results at 28
days are used. Mortality alone is preferred over combined outcomes.
Outcomes with zero events in both arms were not used (the next most serious
outcome is used — no studies were excluded). For example, in low-risk
populations with no mortality, a reduction in mortality with treatment is not
possible, however a reduction in hospitalization, for example, is still
valuable.
Clinical outcome is considered more important than PCR testing status. When
basically all patients recover in both treatment and control groups,
preference for viral clearance and recovery is given to results mid-recovery
where available (after most or all patients have recovered there is no room
for an effective treatment to do better).
If only individual symptom data is available, the most serious symptom has
priority, for example difficulty breathing or low SpO2 is more
important than cough.
When results provide an odds ratio, we computed the relative risk when
possible, or converted to a relative risk according to [Zhang].
Reported confidence intervals and p-values were used when available,
using adjusted values when provided. If multiple types of adjustments are
reported including propensity score matching (PSM), the PSM results are used.
Adjusted primary outcome results have preference over unadjusted results for a more
serious outcome when the adjustments significantly alter results.
When needed, conversion between reported p-values and confidence
intervals followed [Altman, Altman (B)], and Fisher's exact test was
used to calculate p-values for event data. If continuity correction for
zero values is required, we use the reciprocal of the opposite arm with the
sum of the correction factors equal to 1 [Sweeting].
Results are expressed with RR < 1.0 favoring treatment, and using the risk of
a negative outcome when applicable (for example, the risk of death rather than
the risk of survival). If studies only report relative continuous values such
as relative times, the ratio of the time for the treatment group versus the
time for the control group is used. Calculations are done in Python
(3.9.12) with
scipy (1.8.0), pythonmeta (1.26), numpy (1.22.2), statsmodels (0.14.0), and plotly (5.6.0).
Forest plots are computed using PythonMeta [Deng]
with the DerSimonian and Laird random effects model (the fixed effect
assumption is not plausible in this case) and inverse variance weighting.
Mixed-effects meta-regression results are computed with R (4.1.2) using the metafor
(3.0-2) and rms (6.2-0) packages, and using the most serious sufficiently powered outcome.
We received no funding, this research is done in our spare
time. We have no affiliations with any pharmaceutical companies or political
parties.
We have classified studies as early treatment if most patients
are not already at a severe stage at the time of treatment (for example based
on oxygen status or lung involvement), and treatment started within 5 days of
the onset of symptoms. If studies contain a mix of early treatment and late
treatment patients, we consider the treatment time of patients contributing
most to the events (for example, consider a study where most patients are
treated early but late treatment patients are included, and all mortality
events were observed with late treatment patients).
We note that a shorter time may be preferable. Antivirals are typically only
considered effective when used within a shorter timeframe, for example 0-36 or
0-48 hours for oseltamivir, with longer delays not being effective
[McLean, Treanor].
A summary of study results is below. Please submit
updates and corrections at https://c19early.com/vameta.html.
Effect extraction follows pre-specified rules as detailed above
and gives priority to more serious outcomes.
For pooled analyses, the first (most serious) outcome is used, which may
differ from the effect a paper focuses on.
Other outcomes are used in outcome specific analyses.
[Al-Sumiadai (B)], 1/31/2021, prospective, Iraq, Middle East, preprint, 3 authors. | risk of progression, 66.7% lower, RR 0.33, p = 0.27, treatment 2 of 50 (4.0%), control 6 of 50 (12.0%), NNT 13, progression to severe disease. |
[Al-Sumiadai], 12/31/2020, retrospective, Iraq, Middle East, peer-reviewed, 3 authors, excluded in exclusion analyses: minimal details of groups provided. | risk of death, 85.7% lower, RR 0.14, p = 0.002, treatment 2 of 70 (2.9%), control 14 of 70 (20.0%), NNT 5.8. |
Effect extraction follows pre-specified rules as detailed above
and gives priority to more serious outcomes.
For pooled analyses, the first (most serious) outcome is used, which may
differ from the effect a paper focuses on.
Other outcomes are used in outcome specific analyses.
[Beigmohammadi], 11/14/2021, Single Blind Randomized Controlled Trial, Iran, Middle East, peer-reviewed, 6 authors, this trial uses multiple treatments in the treatment arm (combined with vitamins B, C, D, E) - results of individual treatments may vary. | risk of death, 88.9% lower, RR 0.11, p = 0.11, treatment 0 of 30 (0.0%), control 4 of 30 (13.3%), NNT 7.5, relative risk is not 0 because of continuity correction due to zero events (with reciprocal of the contrasting arm). |
risk of hospitalization >7 days, 41.0% lower, RR 0.59, p = 0.25, treatment 4 of 30 (13.3%), control 16 of 30 (53.3%), NNT 2.5, adjusted per study, odds ratio converted to relative risk. | |
relative SOFA score @day 7, 45.5% better, RR 0.55, p < 0.001, treatment 30, control 30. | |
[Elkazzaz], 3/8/2022, Randomized Controlled Trial, Egypt, Africa, preprint, 4 authors, study period June 2020 - August 2020, trial NCT04353180. | risk of death, 85.7% lower, RR 0.14, p = 0.23, treatment 0 of 20 (0.0%), control 3 of 20 (15.0%), NNT 6.7, relative risk is not 0 because of continuity correction due to zero events (with reciprocal of the contrasting arm). |
risk of ICU admission, 66.7% lower, RR 0.33, p = 0.24, treatment 2 of 20 (10.0%), control 6 of 20 (30.0%), NNT 5.0. | |
recovery time, 35.4% lower, relative time 0.65, p < 0.001, treatment mean 16.3 (±4.5) n=20, control mean 25.23 (±4.72) n=20. | |
time to viral-, 44.0% lower, relative time 0.56, p < 0.001, treatment mean 13.36 (±1.49) n=20, control mean 23.85 (±4.0) n=20. | |
[Sarohan], 2/1/2021, retrospective, Turkey, Europe, preprint, 4 authors, excluded in exclusion analyses: unadjusted results with no group details. | risk of death, 282.5% higher, RR 3.83, p = 0.001, treatment 9 of 10 (90.0%), control 4 of 17 (23.5%). |
Effect extraction follows pre-specified rules as detailed above
and gives priority to more serious outcomes.
For pooled analyses, the first (most serious) outcome is used, which may
differ from the effect a paper focuses on.
Other outcomes are used in outcome specific analyses.
[Al-Sumiadai (C)], 1/31/2021, prospective, Iraq, Middle East, preprint, 3 authors. | risk of case, 64.5% lower, RR 0.36, p < 0.001, treatment 20 of 97 (20.6%), control 65 of 112 (58.0%), NNT 2.7. |
[Holt], 3/30/2021, prospective, United Kingdom, Europe, peer-reviewed, 34 authors, study period 1 May, 2020 - 5 February, 2021, trial NCT04330599, excluded in exclusion analyses: significant unadjusted confounding possible. | risk of case, 56.3% lower, RR 0.44, p = 0.41, treatment 1 of 91 (1.1%), control 445 of 15,136 (2.9%), NNT 54, adjusted per study, odds ratio converted to relative risk, minimally adjusted, group sizes approximated. |
[Nimer], 2/28/2022, retrospective, Jordan, Middle East, peer-reviewed, survey, 4 authors, study period March 2021 - July 2021. | risk of hospitalization, 21.2% lower, RR 0.79, p = 0.40, treatment 15 of 144 (10.4%), control 204 of 2,004 (10.2%), adjusted per study, odds ratio converted to relative risk, multivariable. |
risk of severe case, 20.8% lower, RR 0.79, p = 0.36, treatment 17 of 144 (11.8%), control 243 of 2,004 (12.1%), adjusted per study, odds ratio converted to relative risk, multivariable. |
Supplementary Data
References
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Please send us corrections, updates, or comments. Vaccines and
treatments are both valuable and complementary. All practical, effective, and
safe means should be used. No treatment, vaccine, or intervention is 100%
available and effective for all current and future variants. Denying the
efficacy of any method increases mortality, morbidity, collateral damage, and
the risk of endemic status. We do not provide medical advice. Before taking
any medication, consult a qualified physician who can provide personalized
advice and details of risks and benefits based on your medical history and
situation. FLCCC and WCH
provide treatment protocols.