Preventive effectiveness of nasal interferon-gamma among adult volunteers against acute respiratory viral infections, including COVID-19

Резюме

Введение. Исследования in vitro показали высокую противовирусную активность экзогенных интерферонов при предварительной обработке клеток. Интерферон-гамма - уникальный иммунный интерферон, который активно экспрессируется у больных острыми респираторными вирусными инфекциями (ОРВИ), предотвращая тяжелое течение инфекции.

Цель работы - оценка безопасности и профилактической эффективности назального интерферона-гамма для защиты от ОРВИ, в том числе от COVID-19.

Материал и методы. В исследование были включены 630 взрослых добровольцев с отрицательным результатом ПЦР-теста на SARS-CoV-2, без респираторных симптомов и противопоказаний к применению интерферона-гамма. Участники были рандомизированы (1 : 1) в 2 группы: исследуемая - с применением профилактического курса назального интерферона-гамма, и группа сравнения - без курса профилактики. Всем участникам был выдан дневник для ежедневного мониторинга респираторных симптомов, нежелательных явлений и регистрации применения фармакотерапии.

Результаты. Анализ безопасности не выявил различий между группами (р = 1,000). В течение 28 дней в группе сравнения наблюдалась более высокая заболеваемость ОРВИ, в том числе COVID-19 (13 и 3 случая в группе сравнения и в исследуемой группе соответственно). Отношение шансов составило 0,224 [95 % доверительный интервал (ДИ) 0,040-0,826], p = 0,020. Общее количество случаев ОРВИ, в том числе COVID-19, в группе сравнения за 2 мес исследования было 26 (6 в исследуемой группе). Отношение шансов - 0, 233 (95 % ДИ 0,077-0,594; p = 0,001). Самый длительный период сохранения респираторных симптомов наблюдался в группе сравнения (7 и 4 дня в группе сравнения и в исследуемой группе соответственно, р = 0,034).

Заключение. Назальный интерферон-гамма как средство профилактики способствует снижению заболеваемости ОРВИ, в том числе COVID-19.

Ключевые слова:профилактика инфекций; респираторная инфекция; интерферон-гамма; здоровые добровольцы; ОРВИ; COVID-19

Для цитирования: Талызин П.А., Мясников А.Л., Бернс С.А., Ильина М.А., Комазов А.А., Лынев В.С., Екушева Е.В. Профилактическая эффективность назального интерферон-гамма у взрослых добровольцев при острых респираторных вирусных инфекциях, в том числе при COVID-19. Иммунология. 2022; 43 (3): 301-311. DOI: https://doi.org/10.33029/0206-4952-2022-43-3-301-311

Финансирование. Исследование RAIN-2020 выполнено при поддержке ООО "НПП "Фармаклон".

Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.

Вклад авторов. Сбор и обработка материала - Ильина М.А., Комазов А.А., Лынев В.С.; написание текста - Ильина М.А., Комазов А.А., Бернс С.А.; редактирование материала - Талызин П.А., Ильина М.А., Лынев В.С., Мясников А.Л., Бернс С.А., Комазов А.А.; утверждение окончательного варианта статьи - Талызин П.А., Мясников А.Л., Лынев В.С., Екушева Е.В.; ответственность за достоверность всех частей статьи - Бернс С.А., Мясников А.Л., Талызин П.А.

Introduction

The study of the effectiveness of various drugs [1-4] and micronutrients preventive action against COVID-19 in the period before and after SARS-CoV-2 infection is ongoing and is still an actual trend of research [5]. The development of vaccines continues, the duration of the protective immune response, and other unknown factors affecting individual population features of immune reaction are being studied [6-8].

What we strongly know today is that the tissues of the upper respiratory tract: the mucous membrane of the oro-, nasopharynx, - as well as the lung parenchyma are identified as the main targets of SARS-CoV-2 [9]. First, the SARS-CoV-2 virus persists in the pharynx, throat and lungs during the first week of infection and is well defined in a throat swab. In the experimental model on monkeys it was found that with an increase of the age of an infected animal there is a longer shedding of the virus from the upper respiratory tract [10]. This was also observed in patients infected with SARS-CoV и SARS-CoV-2 [11, 12]. Viral load is the highest at the beginning of the infection. In the nasopharyngeal region, there is a secretory function increase, a decrease in the number of mature ciliated cells, and the accumulation of deuterosomal and immature ciliates cells [13].

Since the beginning of the spread of COVID-19, there have been many reports of a mild and asymptomatic disease [10]. There is an assumption that the T-cells eliminate the viral pathogen from the body so quickly that the activation of the B-cells simply does not have time to occur. Thus, the infectious process gets localized without the development of the disease and without the production of a significant level of specific antibodies. It is possible that such a response can be "trained" by modulating T-cell immunity [14].

Thus, SARS-CoV-2 primarily affects T-lymphocytes, especially CD4+- and CD8+-T-cells, which leads to a decrease in interferon-gamma production, as well as a T-cells number decrease. There is a violation of cellular antiviral immunity, noticeable from the early stages of infection by the levels of cytokine proteins, as well as an early strong increase of IgG titer [15, 16]. In addition, one should not underestimate the effect of antibody-dependent enhancement (ADE) of infection [17], which is possible in the presence of cross-reacting antibodies [18], including against the background of the use of vaccines [17]. In such conditions, increased attention should be paid to the of the cellular immunity modulation. Taken together, these data show that airway epithelial cells are indeed capable of eliciting an effective immune response to SARS-CoV-2, but interferon status in relation to the viral replication level is critical for determining the course of infection. It led us to the hypothesis that nasal interferon-gamma might be a successful preventive agent.

In this regard, we conducted a randomized open-label clinical trial RAIN-2020 to evaluate the safety and effectiveness of preventive therapy with Ingaron® (nasal interferon-gamma) in adult volunteers. RAIN-2020 study was registered at clinicaltrials.gov (NCT05054114).

The aim of the work is to evaluate the safety and preventive effectiveness of nasal interferon-gamma for protection against acute respiratory viral infection (ARVI), including COVID-19.

Material and methods

Study participants. The study was approved by the Moscow City Independent Ethics Committee (extract No.5 from the protocol No.72 from November 24, 2020), which performed ethics support of the study. The study was conducted in accordance with Study Protocol version 2.0, Declaration of Helsinki WMA (ICH Harmonized Tripartite Guideline for GCP) and current local regulatory requirements. All the participants provided written informed consent to participate. Totally 630 participants from 18 to 86 years were enrolled and randomized into 2 groups (1:1): I - study group and II - group of comparison. The study was performed on the basis of the City Clinical Hospital named after M.E. Zhadkevich Moscow City Health Department (Moscow, Russia) in the period Dec 2020 - May 2021.

Study design. Randomized, open-label, controlled trial.

Inclusion criteria:

1. Volunteers of both sexes over 18 years of age.

2. Obtaining written informed consent.

3. Ability and consent to participate in the trial.

4. Absence of respiratory symptoms.

5. Negative result of PCR studies for the presence of SARS-CoV-2 RNA in biomaterial samples obtained by nasopharyngeal smear.

Non-inclusion criteria (evaluated at screening):

1. Comorbidities that may distort the results of the trial, limit the volunteer’s rights, or put them at greater risk.

2. Contraindications to the use of the study product.

3. Individual intolerance to the study product.

4. Pregnancy or breastfeeding.

5. Doubtful result of PCR test in nasopharyngeal smear.

6. Participation in a clinical study using experimental therapy within 30 days prior to the enrollment in the study.

7. Failure to follow reliable contraceptive measures (for participants with reproductive potential).

Exclusion criteria (evaluated at study visits after screening): A participant of the protocol was excluded from the study in case of the use of unpermitted therapy (described in the "Study Therapy" section), withdrawal of informed consent, low compliance with drug use (50 % or less) or protocol procedures, development of intolerance to study therapy, contraindications to use (for the study group), development of comorbidities that, in the opinion of the investigator, could distort the results of the study, limit the rights of the volunteer or expose them to a greater risk, in case of the participation in another clinical study, as well as the refusal to comply with contraceptive measures or in case of pregnancy.

Randomization of the study participants was performed in accordance with the randomization list via telephone randomization service.

Study therapy. We used Ingaron® (interferon-gamma human recombinant) 100,000 IU for nasal introduction produced by SPP Pharmaclon Ltd. (Russia). The drug is indicated to prevent and treat influenza and other acute respiratory viral infections.

Participants of the study group had to adhere to the following use of the study drug: once in the morning every other day, 3 drops in each nasal passage 30 minutes before breakfast for 10 days, followed by a break of 7 days and the 2nd 10-day intake cycle. The regimen was chosen according to the official instructions for the medical use of medicinal product as it is indicated for the prevention. All instillations had to be recorded in a diary to assess the participant’s compliance. Participants of the group of comparison didn’t receive the study drug.

In the study group that received the study drug, the use of other antiviral, immunomodulatory drugs, proven or potentially having preventive effects against ARVI, including COVID-19, was not allowed. In the group of comparison the use of only interferon-gamma was prohibited.

Laboratory research. Sampes of biomaterial, obtained using a nasopharyngeal swab, were transported to the DiaLab Plus central laboratory, which has a license and a certificate of conformity, where they were tested with a reagent kit for detecting SARS-CoV-2 RNA and similar SARS-CoV by reverse transcription and real-time polymerase chain reaction (PCR) (SARS-CoV-2/SARS-CoV) produced by DNA-Technology TS Ltd. (Russia) (RU No. RZN 2020/9948 of 04/01/2020), in accordance with the protocol. The analysis for IgG and IgM antibodies to coronavirus was carried out on the basis of a research center with the use of the automatic immunochemiluminescent analyzer CL-2000i (Shenzhen Mindray Bio-Medical Electronics Co., Ltd., China).

Statistical analysis. The statistical analysis was performed with Statistical Package (R: A language and environment for statistical computing. R Core Team. R Foundation for Statistical Computing, Austria) version 4.1.0. P-values less than 0.05 were considered significant with confidence interval of 95 % (95 % CI). For numerical parameters, the following are presented: number of non-missing values (N); arithmetic mean (M) and standard deviation (SD). For qualitative variables, the absolute amount is given in the format n, as well as the proportion (%). If statistically significant differences were found between groups, the estimate of the magnitude of the difference was calculated using 95 % CI.

Sample size. For sample size calculation we used 80 % power, and one-sided 5 % level of significance. The sample size was counted on the basis of minimal difference of incidence in 3 %.

Safety and effectiveness analysis

Safety was assessed by adverse events and clinically significant changes in laboratory parameters, with the definition of severity according to the CTCAE 4.03.

As the primary criterium of effectiveness served the part of the participants with acute respiratory viral infection cases, including COVID-19, detected during the first 28 days of study. The criteria were chosen in accordance with the international guidelines [19]. The cases were detected on the basis of source medical records, including laboratory PCR test results or CT conclusion, and participants’ diaries.

In cases of a positive PCR result, regardless of the presence of clinical symptoms; or the appearance of clinical symptoms in the absence of a PCR result or in the case of a negative result, - at any stage of the study, a completion visit was conducted at the end of the quarantine period (at least 14 days from the date of signing the Consent for treatment of new coronavirus infection COVID-19 on an outpatient basis and compliance with the isolation or discharge from hospital), in which the patient returned the participant’s diary and reported his condition and hospitalization information (if applied) to the investigator.

The definition of the case of COVID-19 was carried out according to the current version of the "Interim Guidelines for the Prevention, Diagnosis and Treatment of Novel Coronavirus Infection (COVID-19)" at the time of the study.

Suspected case of COVID-19. Body temperature above 37.5 °С in addition to one or more of the following (in the absence of other known causes that explain the clinical picture, regardless of the epidemiological history):

· cough (dry or scanty sputum);

· shortness of breath;

· chest congestion;

· SpO2 ≤ 95 %;

· sore throat;

· nasal congestion or mild rhinorrhea;

· violation or loss of smell;

· loss of taste;

· conjunctivitis;

· weakness;

· myalgia;

· headache;

· vomiting;

· diarrhea;

· skin rash.

Probable case of COVID-19. Body temperature above 37.5 °С in addition to one or more of the following:

· cough (dry or scanty sputum);

· shortness of breath;

· chest congestion;

· SpO2 ≤ 95 %;

· sore throat;

· nasal congestion or mild rhinorrhea;

· violation or loss of smell;

· loss of taste;

· conjunctivitis;

· weakness;

· myalgia;

· headache;

· vomiting;

· diarrhea;

· skin rash.

If at least one of the epidemiological signs is present:

· return from overseas travel 14 days prior to symptom onset;

· having close contact in the past 14 days with a person under surveillance for COVID-19 who subsequently fell ill;

· having close contact in the past 14 days with a person who has been laboratory-confirmed with COVID-19;

· having occupational contacts with individuals who have a suspected or confirmed case of COVID-19.

Or in combination with characteristic changes in the lungs according to computed tomography (CT), regardless of the results of a single laboratory test for the presence of SARS-CoV-2 RNA and epidemiological history.

Also, a probable case of COVID-19 included a clinical case in the presence of the clinical manifestations described above (fever in combination with one or more signs) with characteristic changes in the lungs according to X-ray studies, if it was impossible to conduct a laboratory test for the presence of SARS-CoV-2 RNA.

Confirmed case of COVID-19. A positive laboratory test result for the presence of SARS-CoV-2 RNA using nucleic acid amplification methods or SARS-CoV-2 antigen using ICA, regardless of clinical manifestations, or a positive result for antibodies of the IgA, IgM and/or IgG class in patients with clinically confirmed COVID-19 infection.

In case of symptoms of acute respiratory viral infections (ARVI) characteristic of a suspected case of COVID-19, accompanied by a negative PCR test result, registered during or after the prophylactic course (during the period of participation in the study after randomization until the end of the observation period), in the period from the 10th to the 21st day from the moment the first symptom of ARVI appeared, the patient could additionally undergo a quantitative test for the presence of IgM and IgG antibodies to SARS-CoV-2 by ELISA in order to additionally check and identify cases of COVID-19. When interpreting the results, it was necessary to take into account the possibility of obtaining false positive results (for example, the presence of "cross-reactive" antibodies). If the results were difficult to interpret, it was allowed to conduct a repeated ELISA study using the same test systems after 5-7 days in order to assess the dynamics of the indicators.

Secondary criteria of effectiveness included the part of the participants with acute respiratory viral infection cases, including COVID-19, detected during the overall period of study (2 months); the part of the participants with COVID-19 cases, detected during the over-all period of study (2 months); the length of symptoms in participants with cases.

Results

Participants characteristics

Mean age of the recruited participants was 43.8 ± 12.6 years. Mean age of study group was 43.3 ± 12.4 years, while mean age of group of comparison was 44.3 ± 12.8 years. The participants consisted of men and women (63 % vs. 37 %) having ARVI in average 1-2 times a year. The majority of participants in both groups were not smokers (78 %) (table 1).

Table 1. Distribution of baseline characteristics of study participants

*Here and in all tables: p-values < 0.05 were considered significant with confidence interval of 95 %.

At the time of enrollment in the study 100 % of participants had a favorable epidemiological history of COVID-19. 95 % of participants used masks for non-specific protection. Among the comorbidities, diseases of cardiovascular and gastrointestinal systems prevailed. Most of the participants in the group of comparison did not take any drugs to prevent ARVI (one participant used Arbidol, another - Anaferon). There were no statistically significant differences between groups for key baseline characteristics.

Safety analysis

The groups didn’t have statistically significant differences in the number of participants who suffered from adverse events (14 vs. 17 participants in the study group and the group of comparison respectively, p = 0.713). The number of registered adverse events (AE) was also comparable between two groups and did not exceed 10 % (table 2). There were no serious adverse events (SAE) reported during the study1.

1 Serious adverse event was defined as death, life-threatening, hospitalization or prolongation of hospitalization, disability, congenital anomalies, or other clinically significant event.

Table 2. The total number of adverse events detected in study participants

AE - adverse event; SAE - serious adverse event.

Effectiveness analysis

1. Percentage of participants with ARVI (28 days)

The total number of infected in the period of 28-day prevention course was 16. The largest number occurred in the group of comparison - 13 cases (4.1 %). There was a more than 4 times decrease in the incidence rate in the study group [in total 3 cases (1.0 %), p = 0.020 relative to the group of comparison; odds ratio was 0.224 (95 % CI: 0.040 0.826)].

Additional sensitivity analysis

Due to the enrollment of both vaccinated against COVID-19 and not vaccinated participants the study sample presented heterogeneous group in terms of this parameter.

Therefore, we decided to confirm the reliability of the results obtained depending on the vaccination status. Thus, as part of the additional analysis, 2 more datasets were formed. Dataset 1: A subgroup of participants vaccinated with at least one dose (both before and during study participation) was excluded from both groups, the NV ("not vaccinated") subgroup. Dataset 2: A subgroup of only those participants who were vaccinated after enrollment in the study were excluded from both groups, the BE_NV ("before the study vaccinated" and "not vaccinated") subgroup. The distribution of participants by vaccination status is shown in table 3.

Table 3. Distribution of study participants in various subgroups by vaccination status

n - the number of participants vaccinated or not.

Note. Here and in table 4: N - total number of participants; ITT - subgroup "intention-to-treat" including all enrolled to the study and randomized participants; NV - modified ITT subgroup including only not vaccinated participants; NV_BE - modified ITT subgroup including not vaccinated and vaccinated before enrollment in the study, and excluding vaccinated during the study.

The results of the analysis of effectiveness of prophylactic therapy in all subgroups are shown in table 4.

Accordingly, the chances of contracting ARVI, including COVID-19, during the period of prophylactic administration of the study drug (within 28 days) in the group of comparison are also 4 times higher than in the study group (odds ratio 0.22-0.26) regardless of vaccination status.

Table 4. Results of the analysis of effectiveness of prophylactic therapy in various subgroups of study participants

2. Percentage of participants with ARVI (2 months)

The odds ratio of contracting ARVI estimated at the end of the study was of the similar value - 0.233 (95 % CI: 0.077; 0.594; p = 0.001). The total number of cases in the group of comparison was 26 and the total number of participants with respiratory disease fixed was 25. The total number of cases and patients with ARVI in the study group was 6. Accordingly, the chances of ARVI infection, including COVID-19, during the period of prophylactic use of the drug within 1 month after its completion were 4 times lower.

3. Percentage of participants with COVID-19

During the study, 2 cases of confirmed COVID-19 were registered in the group of comparison. In addition, 2 suspicious and 1 probable cases of COVID-19 were recorded - totally 5. In the study group, 1 suspicious case was registered. Thus, the overall incidence of COVID-19 was 0.3 % and 1.6 % in the study group and group of comparison respectively (p > 0.05).

4. Duration of infection symptoms

Data related to the duration of disease symptoms among infected participants were analyzed (table 5). The average duration of symptoms in the study group was 4 (2-8) days, in the group of comparison - 7 (1-24) days (p = 0.0340). An average 3-day reduction of disease duration was detected.

Table 5. The nature of the symptoms of the disease

5. The frequency of complications

All cases of the disease recorded during the study were assessed as cases of mild severity, without a complicated course, therefore no comparative analysis was carried out for this parameter.

Discussion

One of the unique immune effects of interferon-gamma is the ability to stimulate antigen presentation to immune cells. This mechanism dramatically increases the ability of immune system to respond to any pathogen, and is mediated by major histocompatibility complex (MHC) molecules of classes I and II. Interferon-gamma is able, unlike other interferons, to increase the expression of both I and II classes MHC molecules on different cells. Moreover, the induction of the expression of these molecules occurs even on those cells that do not express them constitutively [19]. It should be said that cells infected with SARS-CoV-2 express predominantly MHCI and poorly express the MHCII genes, which was first shown in the work of Ziegler C.G.K. et al [13]. In addition, activation of MHC-II mediated immune mechanisms can limit viral penetration, which also indicates the protective potential of interferon-gamma [20, 21].

An important difference between SARS-CoV-2 and other epidemically important coronavirus strains consists in the viral antigen detection in the nasal ciliated epithelium, which is associated with a high risk of viral transmission [10]. Active viral replication in the upper respiratory tract is of great epidemiological significance, posing a threat of viral dissipation [22-24], but can be reversible [25]. In this respect a nasal form of the drug administration has also essential benefits. First, it is associated with a more favorable safety profile. Second, the drug form is convenient for use, doesn’t require injection with violation of the integrity of skin and doesn’t irritate gastrointestinal tract. But one of the main advantages is undoubtedly contribution to the protection of nasal mucosa epithelium, serving as an additional barrier, which leads to a faster viral elimination, prevents viral penetration, provides protection by stimulating immunity directly at the "gateway" for infection, and reduces the risks of infection transmission. The mucosal immunity increases the effectiveness of protection against infection and reduces the likelihood of developing ADE associated with immunopathological action of IgG antibodies [26].

Preclinical studies showed that pretreatment with exogenous interferon blocks SARS-CoV-2 infection [27-29]. Then the drug for intranasal administration based on recombinant interferon-gamma was clinically studied for effectiveness of prophylactic administration during an epidemic rise of influenza and ARVI prevalence. According to the placebo-controlled randomized study, the incidence during the prophylaxis period and within 1 month after 2 ten-day cycles of drug use was decreased by more than 2 times. Among those who did get sick, a complicated course of infection was observed 2 times less often [30].

Now we conducted a study over the period of 2020-2021, and observed that interferon-gamma is associated with a fourfold reduced risk of ARVI among adults (adjusted for vaccination status) during the prophylaxis period and within 1 month after 2 ten-day cycles of drug use.

Thus, our results are consistent with studies performed earlier [30-32] and demonstrate considerable reductions of ARVI in adults and the prolonged prevention effect lasting for at least 1 month after the drug course. Thus, we confirmed those findings and further showed their independency of a volunteer’s vaccination status. This is the first large-scale study to examine preventive effect of interferon-gamma in adults. The findings emphasize the presence of effective and easy preventive strategies giving additional support to vaccination defense.

Our study had limitations that merit emphasis. First, an important limitation was the potential for misclassification of ARVI diagnosis because laboratory and CT testing was not always done to confirm a COVID-19 case. Given that the incidence of COVID-19 in the general population is about 5 %, it can be assumed that a significant proportion of cases classified as ARVI might be not confirmed cases of COVID-19. Anyways, we used a validated case definition method to identify COVID-19 (suspicious, likely, or confirmed case) according to the actual during the study Guidelines version [33], however, on the basis of data available for analysis. Second, we didn’t distinguish the type of COVID-19 vaccine received in vaccinated. The last, we didn’t consider the period between vaccination and randomization as the proportion of participants vaccinated was about the fifth part in both groups showing a balanced sample. It would be crucial to study combined use of interferon-gamma with vaccine in a separate prospective study.

Although its limitations are important to consider, the study provides an estimate of interferon-gamma preventive effect in a large population sample with a controlled randomized study design.

Conclusion

Nasal interferon-gamma might be considered as a safe and effective tool for the prevention of acute respiratory viral infections, including COVID-19, in the adult population, regardless of vaccination status. The study allows us to conclude that the incidence rate is reduced not only in the period of prophylactic administration of the drug, but also during the month following the period of use.

Acknowledgments

Authors are grateful to the research team of the site engaged in the protocol.

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Главный редактор
ГЛАВНЫЙ РЕДАКТОР
Хаитов Муса Рахимович

Член-корреспондент РАН, доктор медицинских наук, профессор, директор ФГБУ «ГНЦ Институт иммунологии» ФМБА России

Редакционная коллегия журнала «Иммунология» и ФГБУ «ГНЦ Институт иммунологии» ФМБА России с прискорбием сообщают, что 11.03.2022 г. скончался Президент журнала «Иммунология», научный руководитель Института академик РАН Хаитов Рахим Мусаевич
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