the data monitoring committee · z004 dr. anita ajit saibannavar, rcsm medical college & cpr...

ZingiVir-H in SARS-CoV-2 patients

Confidential property of PHRF. DMCR Version 1 dated 3 July 2020 Page 1

The Data Monitoring Committee

Interim Data Analysis Report

STUDY TITLE: RANDOMIZED CONTROLLED SINGLE BLINDED PROSPECTIVE

MULTI CENTRE CLINICAL TRIAL TO INVESTIGATE THE SAFETY AND

EFFICACY OF ZINGIVIR-H AS AN ADJUVANT THERAPY IN HOSPITALIZED

ADULTS DIAGNOSED WITH CORONAVIRUS DISEASE 2019 (COVID-19).

Protocol Number: PHRF 010-2020

Protocol Version: Version 1:1 dated 11 April 2020

Zingivir-H Drug License No: 50/25D/96

Study Sponsor: Pankajakasthuri Herbal Research Foundation



TABLE OF CONTENTS

S.No Particulars Page Number

1 DMC Committee Members 03

2 Clinical study design and Schematic Design of the study 04

3 Changes made in the Protocol or Study Procedures 05

4 Research Site Information 06

5 Start up Deliverables & Timelines 07

6 Information on patient screening 09

7 Eligibility Deviations 09

8 Baseline characteristics (pooled by treatment regimen) 10

9 Adherence to medication schedule (pooled by treatment

regimen)

11

10 Attendance at scheduled visits (pooled by treatment regimen) 11

11 Reporting delays for key events (pooled by treatment regimen) 11

12 Length of follow-up data available (pooled by treatment

regimen)

11

13 Statistical and Data modeling Assessments 12

14 Clinical Outcome assessments 31

15 Discussion 33



1. Data Monitoring Committee Members:

The DMC installed by PHRF is an independent multidisciplinary group consisting of

biostatisticians and clinicians that, collectively, has experience in the management of

patients with knowledge in Infectious disease and about COVID-19 (SARS COV2) and

in the conduct and monitoring of randomized clinical trials.

DMC Chair: Dr.V.Raman Kutty, M D, M Phil, M P H (Harvard), FIACS

Research Director, Amala Cancer Research Centre, Thrissur

Epidemiologist and data science consultant

Ex- Professor, Sree Chitra Tirunal Institute for Medical Sciences

and Technology,

Honorary Chairman, Health Action by People

Trivandrum 695011 INDIA

Phone: 91-471-2552774 (Office) / Mob.9847060199.

Email: [email protected]

DMC Physician Dr. K.P.Poulose, MD, Former Professor, Kottayam Medical

College & George Washington University, USA

Chief Physician, SUT Hospitals, Thiruvananthapuram

Ph: +91 9526769777 / Email: [email protected]

DMC Ayurvedic

Physician

Dr. K. G. Raveendran, Retd. Medical Director,

The Arya Vaidya Pharmacy, Coimbatore, India

Ph.9207091551./ Email: [email protected]

DMC Biostatistician Dr. Asha Kamath,

Associate Director

Professor & Head, Department of Data Science

Prasanna School of Public Health

Manipal Academy of Higher Education, Karnataka

Ph: +91 9448127056, Email: [email protected]

DMC Scientist /

Virologist

Dr. V. S. Sugunan

Former Scientist C, and Group Leader, Viral Hepatitis Lab,

Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram.

House No. 62, T.C. 11/1324, Bain‟s Compound, Nanthancode,

Trivandrum 695003;

Mob:9446551854 / Email: [email protected]

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]



2. Overall Clinical Study Design

This is a Randomized controlled, single blinded multi-center, comparative study of ZingiVir-H

as an adjuvant therapy in hospitalized adults diagnosed with coronavirus disease 2019 (COVID-

19). At inclusion, subjects who meet all inclusion criteria and no exclusion criteria will be

assigned, in either therapeutic arm (ZingiVir-H), to receive ZingiVir-H in a dose of 500 mg

tablet each consumed once in 3 hours ±1 hour between 6 AM and 9 PM in a given day (6AM,

9AM, 12Noon, 3PM, 6PM, 9PM) for a minimum duration of 10 days to Maximum 15 days OR

will be on a Placebo arm to receive placebo (without active ingredients) each consumed once in

3 hours ±1 hour between 6 AM and 9 PM in a given day (6AM, 9AM, 12Noon, 3PM, 6PM,

9PM) for a minimum duration of 10 days to Maximum 15 days. The allocation of study arm was

also prefixed as per the drug dispensing procedure whereas in a given site all ODD numbered

patients (001,003,005,007,009,011,013,015…..) and so on shall receive the study drug whereas

all EVEN number patients (002,004,006,008,010,012,014, 016….) and so on shall receive the

placebo. The patients who are involved in the study shall be blinded from the study drug

information. If in any case more than one patient got recruited in the same site in a given day, the

allocation of study arm is based on the time of signing the informed Consent Form (ICF).

Whereas both the study groups shall be given standard of care of treatment as per the research

site policies or COVID-19 therapeutic management policies. These doses will be administered

orally. Blood samples for assessing CBC; safety laboratory tests and immunomodulatory

markers will be obtained between baseline assessments (Day-01), during the day-06 of inclusion,

at the end of the treatment day-15 and at the end of the study day-30. A NABL accredited

Dr.LalPathlabs is used as Central laboratory for the blood sample analysis services. No

diagnostic labs are identified to perform Interferon Alpha and thus Sponsor research laboratory

performs the assessment using commercially available kits. Safety-related assessments will

include reports of adverse events and clinical laboratory test results. The assessment of safety

and efficacy of the molecule in the patients shall be assessed for the whole study period.

Obtained data shall be modeled as per statistical assessment plans. Data monitoring committee is

formed and the study shall be performed as per their opinion taken into consideration.



3. Changes made in the Protocol or Study Procedures:

Few administrative changes were made in the study procedures as per government directives.

A) As per the recent notification issued by Ministry of Health & Family Welfare, Directorate

General of Health Services, EMR Division regarding the Guidance document on

appropriate management of suspect/confirmed cases of COVID-19 which waives off that

there will be no need for testing RT-PCR in patients prior to discharge for "mild/very

mild/pre-symptomatic" cases of COVID-19. Such patients can be discharged after 10

days of symptom onset and absence of fever for the last three days. "At the time of

discharge, the patient will be advised to follow the home isolation for further seven days.

Ref: https://www.mohfw.gov.in/pdf/FinalGuidanceonMangaementofCovidcasesversion2.pdf

Considering this guideline, the following procedure is included in the parent protocol PHRF-

010-2020 version 1.1 dated 11 April 2020. An RT-PCR test schedule shall be included in the

https://www.mohfw.gov.in/pdf/FinalGuidanceonMangaementofCovidcasesversion2.pdf



protocol for the study participants to understand the primary endpoint of our study. Accordingly

RTPCR test can be performed on the 4th, 8th, 12th & 15th day of the study period start from the

day of enrollment (Day-01) until the study subjects shown negative to COVID test. The RT-PCR

sampling can also be performed additionally on any days as per Investigator discretion. Day-01

stands at the day the subjects started consuming the study drug OR Placebo. The test sampling

shall be withdrawn as per the existing sampling for COVID diagnosis protocol.

B) Secondly as per the protocol Interleukin-7 test (IL-7) was considered as Inflammatory

markers to access the efficacy, which is waived off as per the present addendum. As

Interleukin-7 (IL-7) is not considered as significant inflammatory markers as per review

of literature, the test is waived off in the protocol and no protocol deviation shall be filed

on this behalf at study level.

C) Interferon Alpha is not performed in the Site or in Central Laboratory due to non-

availability of the test and thus the samples shall be shipped to Sponsor Research

laboratory for assessment as per recommended research protocols.

4. Research Site Information

Z001 DR. Madhu Kumar, KR Hospital, Mysore Medical College and Research Institute, Mysuru

Z002 Dr. Poorna Prasad, Sri Venkateshwara Hospital, #27, 29th Main Road, Rashtra Kuvempu

Nagara, BTM 2nd Stage, BTM Layout, Bangalore- 560076, India

Z003 Dr. Ambuj Garg, Consultant, Dept of Medicine, Sir Ganga Ram Hospital, SRGH Marg,

Rajinder Nagar, New Delhi-110060

Z004 Dr. Anita Ajit Saibannavar, RCSM Medical College & CPR Hospital, Bhausinghaji Road,

Dasara Chowk, Kolhapur District, Maharashtra State, INDIA- 416002, India

Z005 Dr. Aparna Prasanna Patanje, Assistant Prof. Depatment of Medicine, Krishna Institute of

Medical Sciences & Deemed University, Malkapur, NH 04, Karad, Satara- 415539

Maharashtra, India.

Z006 DR. Kannan Rajendran, Principal Investigator- Zingivir-H Study, Proffessor in Medicine,

Saveetha Medical College & Hospital, Saveetha Nagar, Thandalam, Chennai-105

Z007 Dr. Salim Sheikh, Consultant, ESIC Medical College and Hospital, Faridabad, Haryana.



5. Start up Deliverables & Timelines:

Start up Deliverables Comments

PI Qualifications All Principal Investigators have essential residency

qualifications in Modern Medicine and Experience to

Conduct Clinical Trials as per GCP and Regulatory

Guidelines.

Documents Obtained from

PI

Signed and dated

a) Non Disclosure Agreement

b) Financial Disclosure Form (FDA 3455)

c) Investigator Study Undertaking (FDA 1572)

d) Investigator consent on Protocol (PSP)

e) Filled in Feasibility forms

Research support &

Infrastructure at sites

Research activities of all Identified sites is managed by

Registered Site Management Organizations in Clinical

Research

Research Team As per AYUSH Guidelines in COVID trials.

Study Deliverables Comments

Site qualification

Assessments

A telephonic evaluation is made based on the project feasibility

submitted by the Investigator and team. Feasible sites with project

execution capabilities were selected.

Ethics Committee Documents submitted electronically to all ethics committee through

Investigators. Expedite review request was made as per ICMR

guidelines to Ethics Committee on COVID research studies

evaluation. Few Ethics Committee gave expedite approval and Few

are yet to give the approval for the study conduct.

Site Training and

Initiation of the

Project

Once after Ethics Committee approval the sites and investigation team

is provided with telephonic training on Protocol, Study procedures

including consenting research subjects and documentation, Study drug

dispensing procedure, Laboratory assessments, Blood sampling



procedures, Handing AE/SAE‟s in the study, Data capturing

requirements etcetera.

Study execution

and Safety

measures

The study participants are insured in the study to compensate them on

any trial related injury. A study grant per patient is allocated to the site

for the HR efforts. The study shall be conducted by a trained research

team as per the delegation of responsibilities by the Chief Investigator.

Study Data

Collection

Study specific Case Report forms (CRF) are designed for data capture.

The data points shall be captured in the CRF from the corresponding

Patient source data by the research staff at site. CRF data will be 100%

audited by the sponsor representative and will retrieve the filled in

CRF pages for data analysis. For the Interim analysis the available/

required data is collected through digital sources, without auditing the

source notes.

Safety data

Collection and

reporting

As per the clinical study protocol and applicable regulatory guidelines,

the participating sites were given special guidance and training on

contemporary approaches in the collection, reporting of adverse events

(AEs) and Adverse Drug reactions (ADRs) in the present study with a

primary efficacy outcome. The sites are elaborated on adverse events/

serious adverse events collection methods, steps to reduce information

loss on AE /ADR when analyzing at patient level, assessment of

severity and causality, reporting criteria, analysis methods and

presentation of AE data. AE data were collected (mode of collection,

timing) and defined (coding, attribution); how AEs were assessed in

terms of severity of the event or relatedness to the medical

intervention; AE analysis plan if any; how events were selected for

inclusion in the final analysis of data are explained.



Project timelines

6. Information on patient screening plan:

S.No Patient Information Z001 Z002 Z003 Z004 Z005 Z006

1 Site Initiation dates 25-Apr-20 27-May-20

28-May-20

18-Jun-20

2 First patient in (FPI) 3-May-20 15-Jun-20 19-Jun-20

3 Total Patient Allocated 35 05 20 30 10 30

4 Total Patient Screened 020 002 025 015

5

Total Patient

Randomized 030 0 018 030

The Interim analysis is performed with 42 patients (37.5% of Sample size) considering the

results available until 01 July 2020.

7. Eligibility Deviations:

The study recommends to inclusion of adult population between age 18 and age 60. All the

study subjects are confirmed with the eligibility of participation and included in the study.



For Seven subjects the most recent RT-PCR reports showing the COVID+ results was taken

into account as eligibility for inclusion. However these patient data points shall be included

in the “Per Protocol Assessment Criteria” during the final analysis. There are few protocol

deviations reported in the study in missing blood sampling procedures and visit day

deviations from the protocol timelines are captured in the site specific protocol deviation

forms and kept for audit trial. All protocol deviations shall be reported in the final data

analysis.

8. Baseline characteristics (pooled by treatment regimen)

RT-PCR test assuring the subjects test positive for COVID-19 within 120 hrs before

randomization.

Demographics

Medical history (all known information regarding the subject‟s health history/relevant

surgeries/interventions prior to signing the informed consent).

Vital signs: Body temperature, Pulse – beats per minute (BPM), Blood Pressure (BP)

mmHg, Respirations – breaths per

Concomitant medications (including medications, fluids and blood products administered

within the 7 days prior to randomization).

Documentation of any other infection if available (site of infection and, if available:

positive culture results, prior antibiotics, sensitivity of cultured organism to antibiotics,

nonmedical treatment such as surgery or drainage).

Physical Examination including the following: general appearance, Head, Eye, Ear Nose

Throat (HEENT), neck, respiratory, cardiovascular, chest, abdomen, lymphatic,

musculoskeletal and extremities, skin and neurologic examination. Height and weight

(baseline dry weight).

Blood will be obtained for following laboratory tests:

o Complete Blood Count with differential (Hemoglobin, Hematocrit, and WBC

with differential count) & ESR

o Serum Chemistry- Creatinine, Urea, CRP, ALT, AST, Alkaline Phosphatase,

Albumin, total bilirubin



o Pregnancy test; Serum or Urine human Chorionic Gonadotropin (hCG) -

Pregnancy test only required for woman of childbearing potential on the day of

randomization

o Immunomodulatory markers, IL6, Interferon α, IgG, IgM

9. Adherence to medication schedule (pooled by treatment regimen)

As per the data collected from the research sites based on the Investigational Product

dispensing log and compliance log it is confirmed that the patients are regular with the study

medications. No irritation or any difficulty has been reported from the study participants on

their drug consumption.

10. Attendance at scheduled visits (pooled by treatment regimen)

Considering the administrative regulations made in various districts in different manner,

there are few lapses in the patient visit to the hospital to complete study procedures as per the

protocol. The study team attempted to make home visit to reach out to few patients to

perform the study procedure and blood sampling. The missed visits and the data are captured

as protocol deviations. Corrective actions are taken to make sure that all patients shall

comply with the study procedures.

11. Reporting delays for key events (pooled by treatment regimen)

There are no study specific events happened which require immediate attention of sponsor.

However few patients in site Z001, are included by a research site based on the recently

available RT-PCR results to confirm the patient as COVID positive and not the first RTPCR

results, whereas for those patients appropriate protocol waiver obtained from the sponsor to

include such patients into the study.

12. Length of follow-up data available (pooled by treatment regimen)

Few patients who are enrolled in the study have passed the 30 day follow-up visit. Those

patients completed the study without any safety issues. Few non-significant increases in the

lab values are identified in the study patients as per study Investigator discretion.



13. Statistical / Data modeling assessments:

Survival Analysis

A total of 42 patients underwent randomization; 22 patients were assigned to the ZingiVir-H

group and 20 to the Placebo group. The primary efficacy analysis was done on an intention-to-

treat basis with all randomly assigned patients. Time to clinical improvement was assessed after

all patients had PCR negative; no clinical improvement or death was considered as right-

censored. Time to clinical improvement was portrayed by the Kaplan-Meier plot and compared

with a log-rank test. The HR and 95% CI for clinical improvement is calculated by Cox

proportional hazards model. Other analyses include subgroup analyses for those requiring

medical care other than ZingiVir-H (Ordinal Scale -5) and those not receiving medical care

other than ZingiVir-H (Ordinal Scale -6).

The median age of study patients is 31.5 (Inter Quartile Range (IQR) 25-42), in which for the

treatment group the median age is 30.5 (IQR 25-42) and that of Placebo is 32 ( IQR 24 - 40).

Preliminary results from the 42 patients with data available after randomization indicated that

those who received ZingiVir-H had a median recovery time of 4 days (95% Confidence interval

(CI) 3-5) as compared with 6.5 days (95% CI 4-11) in those who received Placebo.

Fig: Assessment of Median Recovery time- Zingivir-H arm vs Placebo arm Patients



Fig: Assessment of Overall Median Recovery time- All study participants

The overall median recovery time is also evaluated and it is obtained as 5 days (95% CI 4-5).

The corresponding figure is provided below

The Log-Rank test is performed to verify the significance of recovery time over ZingiVir-H and

Placebo and it was resulted with a P-value 0.00028 (|z|) TreatZingiVir-H 1.4163 4.1219 0.4011 3.531 0.000414 *** --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 4.122 0.2426 1.878 9.048 Concordance= 0.668 (se = 0.044 ) Likelihood ratio test= 13.87 on 1 df, p=2e-04 Wald test = 12.47 on 1 df, p=4e-04 Score (logrank) test = 14.24 on 1 df, p=2e-04



PH assumption Verification for the Log-rank test: The data is satisfied with the assumption for

performing the log-rank test (P-Value = 0.52>0.05) (Schoenfeld Residual Test)

chisqdf p Treat 1.24 1 0.27 GLOBAL 1.24 1 0.27 Cox proportional hazards model including age as a covariate

coxph(formula = Surv(Days, Status) ~ Treat + Age, data = trial) n= 42, number of events= 37 coefexp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 1.446201 4.246950 0.408653 3.539 0.000402 *** Age 0.007268 1.007295 0.016102 0.451 0.651715 --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 4.247 0.2355 1.906 9.461 Age 1.007 0.9928 0.976 1.040 Concordance= 0.686 (se = 0.046 ) Likelihood ratio test= 14.08 on 2 df, p=9e-04 Wald test = 12.55 on 2 df, p=0.002 Score (logrank) test = 14.36 on 2 df, p=8e-04

Even though the inclusion of Age in the model is not at all a significant (P-value =

0.651715>0.05) element, a minute increment can be observed in the hazard ratio after the

inclusion.

Sub Group Analysis – Based Ordinal Scale These results are based on the criteria of inclusion (ordinal scale 5 and 6). In the case of ordinal

scale 5 (Hospitalized, not requiring supplemental oxygen-requiring ongoing medical care) there

were 30 patients and under ordinal scale 6 (Hospitalized, not requiring supplemental oxygen-not

requiring ongoing medical care other than ZingiVir-H) there are 12 patients. The median age of

group corresponding to ordinal scale 5 is 30 (IQR 25 – 42) and that of the group corresponding

to 6 is 33 (IQR 24.75 – 40.75).



Fig: Assessment of Median Recovery time- Zingivir-H arm vs Placebo arm in Patients

randomized at Ordinal Scale - 5



From the above two figures and from the analysis it is observed that the overall median recovery

time is 5 days ( 95% CI 4 – 6). Corresponding to ZingiVir-H had a median recovery time of 5

days (95% CI 3-5) and that of Placebo 9 days. The Log-Rank test results in significant P-Value

= 0.00014(|z|) TreatZingiVir-H 2.061 7.853 0.589 3.499 0.000467 *** --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 7.853 0.1273 2.476 24.91 Concordance= 0.718 (se = 0.045 ) Likelihood ratio test= 16.44 on 1 df, p=5e-05 Wald test = 12.24 on 1 df, p=5e-04 Score (logrank) test = 15.62 on 1 df, p=8e-05

PH verification for Log-Rank Test (Schoenfeld Residual Test)

chisqdf p Treat 0.246 1 0.62 GLOBAL 0.246 1 0.62

Cox proportional hazards model including age as a covariate

coxph(formula = Surv(Days, Status) ~ Treat + Age, data = trial) n= 30, number of events= 26 coefexp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 2.16932 8.75229 0.60974 3.558 0.000374 *** Age 0.01980 1.02000 0.02162 0.916 0.359721 --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 8.752 0.1143 2.6492 28.916 Age 1.020 0.9804 0.9777 1.064 Concordance= 0.749 (se = 0.057 ) Likelihood ratio test= 17.26 on 2 df, p=2e-04



Wald test = 12.67 on 2 df, p=0.002 Score (logrank) test = 16.12 on 2 df, p=3e-04

Fig: Assessment of Median Recovery time- Zingivir-H arm vs Placebo arm in Patients

randomized at Ordinal Scale - 6

From the above two figures and from the analysis it is observed that the overall median recovery

time is 3.5 days (95% CI 2 – 5). Corresponding to ZingiVir-H had a median recovery time of 2

days and that of Placebo 5 days. The Log-Rank test resulted in a significant P-Value 0.02 (



H is less than that of Placebo Group when the treatment group is receiving only ZingiVir-H

and it is also statistically significant (P-Value 0.02 |z|) TreatZingiVir-H 1.6494 5.2036 0.7813 2.111 0.0348 * --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 5.204 0.1922 1.125 24.06 Concordance= 0.709 (se = 0.079 ) Likelihood ratio test= 4.35 on 1 df, p=0.04 Wald test = 4.46 on 1 df, p=0.03 Score (logrank) test = 5.42 on 1 df, p=0.02 PH Verification for Log Rank Test (Schoenfeld Residual Test)

chisqdf p Treat 0.0408 1 0.84 GLOBAL 0.0408 1 0.84

Cox proportional hazards model including age as a covariate

coxph(formula = Surv(Days, Status) ~ Treat + Age, data = trial) n= 12, number of events= 11 coefexp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 1.82988 6.23315 0.83430 2.193 0.0283 * Age -0.02479 0.97551 0.02950 -0.840 0.4006 --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 6.2332 0.1604 1.2149 31.979 Age 0.9755 1.0251 0.9207 1.034 Concordance= 0.727 (se = 0.119 ) Likelihood ratio test= 5.13 on 2 df, p=0.08 Wald test = 4.84 on 2 df, p=0.09 Score (logrank) test = 5.95 on 2 df, p=0.05 Concordance= 0.759 (se = 0.148 ) Likelihood ratio test= 4.66 on 2 df, p=0.1



Wald test = 3.52 on 2 df, p=0.2 Score (logrank) test = 4.88 on 2 df, p=0.09

Analysis of Temperature of the Patients

The temperature of the patients is taking on Day 1, Day 3, and Day 5 of the trial. For this interim

analysis, we have obtained these values of 27 patients only. A summary Statistics of this is given

below.

Summary statistics-Whole

time variable n mean sd Day1 score 27 98.3 0.653 Day3 score 27 97.9 0.575 Day5 score 27 97.8 0.623

Summary statistics – Corresponding to Treatment

Treat time variable n mean sd ZingiVir-H Day1 score 14 98.2 0.589 ZingiVir-H Day3 score 14 97.9 0.594 ZingiVir-H Day5 score 14 97.8 0.63 Placebo Day1 score 13 98.4 0.734 Placebo Day3 score 13 98.0 0.566 Placebo Day5 score 13 97.8 0.64

Fig: Graphical Representation on assessment of temperature in study patients

The graph of reduction in the temperature of all patients considered for the trial is given below



Fig: Graphical Assessment of temperature- Zingivir-H arm vs Placebo arm

The graph of reduction in temperature corresponding to each treatment is provided in the next

graph



The Normality assumption for conducting a Repeated Measures ANOVA is rejected for the Day

3 data (P-Value 0.0347



Pairwise Wilcoxon signed-rank test between groups revealed statistically significant differences

in temperature is existing between Day 1 and Day 5 (P-Value = 0.025



4 Treat:time 2 50 3.498575e-02 12.47538 7.010957e-02 9.323831e-01 0.001184817 $`Mauchly's Test for Sphericity` Effect W p p



Fig: Assessment of the level of InterLeukin-6 in the study patients

Fig: Assessment of the level of IL6 in the patients treated with Zingivir-H arm vs Placebo

arm



In the present study the level of Interleukin expression was high on the day of randomization in

both the arms. Interestingly there was a downfall of IL-6 expression in Zingivir-H treated group

when compare with the placebo arm from day 01 to day 15 and further seems to be a surge on

day 30 data. Whereas in case of placebo arm controlled patients there is a fall in the IL6 level on

the day 6 followed by a storm raise more than the day 01 level and even incremented on day 30.

It is evident from the data that the immunomodulatory effect of Zingivir-H in regulating the

cytokine expression in patients, which is comparatively very less in patients on placebo with

standard of care. It is evident from the results that Zingivir-H may control the overproduction of

pro-inflammatory cytokines by monocytes.

(Ref: Giuseppe Magro; 2020, SARS-CoV-2 and COVID-19: Is interleukin-6 (IL-6) the „culprit

lesion‟ of ARDS onset? What is there besides Tocilizumab? SGP130Fc. Cytokine,Volume 2,

Issue 2)

CRP Assessment

The main pathological changes of COVID-19 are lung and immune system damage. C-reactive

protein (CRP) levels can be used in the early diagnosis of lung infiltrates, and Covid patients

presenting with severe pneumonia had high CRP levels. CRP levels are correlated with the level

of inflammation, and its concentration level is not affected by factors such as age, sex, and

physical condition. CRP levels can activate the complement pathway and enhance phagocytosis,

thus clearing the pathogenic microorganisms invading the body. We assessed the correlation

between CRP levels and the immunomodulatory efficacy of Zingivir-H in regulating CRP level

in treated patients (L. Wang; 2020)



Fig: Assessment of the level of C - Reactive Protein (CRP) in the study patients

Fig: Assessment of the level of CRP in the patients treated with Zingivir-H arm vs Placebo

arm



In the present study the level of CRP expression was comparatively high in the Zingivir-H

treated patient population than placebo on the day of randomization. Surprisingly there wassurge

in the CRP expression in Zingivir-H treated group when compare with the placebo arm between

day 01 to day 6 and further reduced to normal level in day 15 data. Whereas in case of placebo

arm controlled patients there is no significant fluctuations in the CRP level during the treatment

period from day 01 to day 30. It is evident from the data that the effect of Zingivir-H in

activating the CRP expression in patients, which is comparatively very less in patients on

placebo with standard of care. Pulmonary diseases with inflammatory features usually raise

serum CRP level in response to inflammatory cytokines such as IL-6 indicated excessive

inflammatory response, which was consistent with raised serum pro-inflammatory cytokines

observed in COVID-19 patients.

L. Wang; 2020. C-reactive protein levels in the early stage of COVID-19.Med Mal Infect. 2020

Jun; 50(4): 332–334.

ESR Assessment

Erythrocyte Sedimentation Ratio ESR is known to be affected by other numerous physiological

and pathophysiological conditions, thus narrowing its utility to several specific clinical

conditions related with COVID-19.

Fig: Assessment of the level of ESR in the study patients



Fig: Assessment of the level of ESR in the patients treated with Zingivir-H arm vs Placebo

arm

In the present study the level of ESR expression was comparatively high in the Zingivir-H

treated patient population than placebo on the day of randomization (day 1) to day 30. ESR

expression in Zingivir-H treated group and in the placebo group is comparatively similar in

which there was a surge in the ESR level between day 01 and day 06 which may be due to

inflammatory response and further reduced to normal level in day 15 data and day 30 data in

both Zingivir-H treated and Placebo controlled group. It is evident from the data that ESR as

possible inflammatory marker in features observed in COVID-19 patients.

Expression of Immunoglobulin (IgG & IgM)

Similar to common acute viral infections, the antibody profile against SARS-CoV virus has a

typical pattern of IgM and IgG production. IgM levels increased during the first week after

SARS‐CoV‐2 infection and then reduced to near‐background levels in most patients. IgG was

detectable after few days onset of infection and was maintained at a high level for a long period.

The positive rates of IgM and/or IgG antibody detections were not significantly different among

the mild, severe and critical disease groups. Severe and critical cases had higher IgM levels than



mild cases, whereas the IgG level in critical cases was lower than those in both mild and severe

cases. This might be because of the high disease activity and/or a compromised immune

response in critical cases.

Fig: Assessment of the level of IgG antibody in the study patients

Fig: Assessment of the level of IgG in patients treated with Zingivir-H arm vs Placebo arm



Fig: Assessment of the level of IgM antibody in the study patients

Fig: Assessment of the level of IgM in patients treated with Zingivir-H arm vs Placebo arm

In the present study the IgG level of Zingivir-H treated patients maintains normal level

throughout the study, whereas a surge in the IgG expression is seen after Day 15 towards day 30,

which explains the antibody expressions of IgG at a high level for a longer duration. IgM

maintain a gradual fall in Zingivir treated group and sees a surge in Placebo group between Day

01 and 06. Further both the arms register fall in the value once reaches Day 30.



14. Clinical Outcome

Ordinal scales are frequently used in clinical trials to quantify outcomes which are non-

dimensional. They may be regarded as either single state or transition measures based on

whether they assess the outcome at a single point in time or directly examine change which

has occurred between two points in time. Each has unique structural and operating

characteristics, so that different methodological standards for their construction and

utilization are required.

Patients were assessed once daily by the investigator and study team on their compliance

with the study drug consumption and for any adverse events. Serial Nasopharyngeal swab

samples were obtained on day 5, on completion of 4 days of study drug consumption

(either Zingivir-H or its Placebo) and on days 8, 10, and once after 3 days until discharge

COVID Negative. These N/T swab samples were obtained for all 42 patients who were still

active at every time point. Laboratory samples were assessed for the patients before the

start of the drug on Day 01, Day 06 or the date of discharge whichever comes earlier, Day

15 End of treatment day for safety analysis and in Day 30 for safety analysis. The available

data for Day 01 and day 07 of all accessing patients are taken into consideration for the

interim assessments. Clinical and laboratory data were recorded on patient specific source

documents and the data modeling information shall be transcribed to study specific logs

and paper case record forms and then Entered into an electronic database and statistically

validated by trial staff.

The primary end point was the time to clinical improvement, defined as the time from

randomization to an improvement of two points (from the status at randomization) on a

seven-category ordinal scale and discharge from the hospital whichever came first. The

seven-category ordinal scale consisted of the following categories:

1. Death

2. Hospitalized & on invasive mechanical ventilation or Extracorporeal Membrane

Oxygenation (ECMO)

3. Hospitalized, on non-invasive ventilation or high flow oxygen devices



4. Hospitalized, requiring low flow supplemental oxygen

5. Hospitalized, not requiring supplemental oxygen - requiring ongoing medical care

(Coronavirus (COVID-19) related or otherwise)

6. Hospitalized, not requiring supplemental oxygen - no longer required ongoing medical care

(other than per protocol ZingiVir-H administration)

7. Discharge from hospital.

Criteria 5 As per the discretion of Investigator in the participating sites the patients are

categorized as 5 If the patients are symptomatic with mild fever on admission, tiredness and

dry cough. Few people were also experience mild respiratory distress. Those patients are

categorized as if they required add-on medications along with the study drug. The data

information on concomitant medications administered along with the study drug will be

obtained during the retrieval of case report forms from sites after data audit. The detailed

information of medical history and concomitant medications shall be included in the final

analysis.

Criteria 6 Patients are considered that the patients are very mild and asymptomatic cases on

admission. They seem as health individual with intermittent tiredness. Few people also

experience mild fever as well and later become asymptomatic and was not on any medication

other than study drug was also enrolled into the study. Those patients are categorized as if they

may not require medications. The data information on concomitant medications administered

if any during the time of admission along with the study drug will be obtained during the

retrieval of case report forms from sites after data audit. The detailed information of medical

history and concomitant medications shall be included in the final analysis.

Safety outcomes

Safety outcomes included adverse events that occurred during treatment, serious adverse

events, and premature discontinuation of treatment. In the present study NO adverse

events, serious adverse events (SAE) or adverse drug reaction are reported in the treated

patients until 01 July 2020. It is anticipated that few AE information might be missed

inadvertently by the site when analyzing at patient level which would not be identified or

not reported till date. It was also observed that there was a raise in the electrolytes level

(Phosphorous, Sodium) in few Zingivir-H treated patients, which was discussed with the



investigation team and found to be not-significant and documented accordingly in the

patient source notes. Any such events shall be identified and will be reported during site

data audit and the analysis will be included in the final data modeling and analysis.

Primary efficacy analysis

Primary efficacy analysis was on an intention-to-treat basis and included all the patients

who had undergone randomization. The time to clinical improvement was assessed after all

patients who had tested for RT-PCR after consumption of study drug (Either Zingivir-H or

Placebo) for duration of minimum Three days.

Of the 42 patients who are assessed for Interim data analysis (100%) underwent

randomization, 22 patients were assigned to receive Zingivir-H and Standard of care and 20

patients to Placebo and standard care alone. All the 42 patients assigned to receive study

drug received standard of care treatment as per hospital and COVID protocol. All the

patients comply on study drug consumption after randomization. The statistical analysis of

this data reported that ZingiVir-H has a median recovery time of 4 days and that of Placebo is

6.5. In the case of patients require medical care along with medicine, has the Median recovery

time 5 days for ZingiVir-H and 9 days for the Placebo group and it is statistically significant

based on the Log-Rank test. Similarly, in the case of patients requiring only medicine, has the

median recovery time 3.5 for ZingiVir-H and 5 for placebo. The Log-Rank test leads to the

conclusion that the median recovery time is significantly different among the ZingiVir-H

group and Placebo group and specifically it is less for the ZingiVir-H group. It is also proved

that age is not contributing any significant information in the model improvement. The

temperature analysis shows that there is a gradual decrease in the temperature in both of the

groups and it is statistically significant. The pairwise comparison shows that a significant

difference in temperature is existing between Day1 and Day 5. A total of 22 patients (52.3 %)

of evaluated patients who had a diagnostic respiratory tract sample that was positive on

RT-PCR had a negative RT-PCR result on the throat swab taken after a median recovery

time of four days of Zingivir-H treatment P-value 0.00028 (



standard supportive care is clearly associated with clinical improvement or mortality in

seriously ill patients with Covid-19 from placebo arm that associated with standard care

alone. No mortality or serious adverse events reported in the subjects participated in this

trial which indicates that the patients enrolled are asymptomatic, mild and moderate

population.

Our patient population was heterogeneous with regard to duration and severity of illness at

enrollment. In a post hoc subgroup analysis, the difference in evident clinical improvement

between the Zingivir-H group and the Placebo group was observed to be numerically

greater among patients treated within 5 days after the onset of symptoms than among those

treated later is not analysed in the present data report, which shall be included in the final

analysis. The question of whether earlier Zingivir-H treatment in Covid-19 patients once

receipt of RTPCR positive results could have any clinical benefit is an important one that

requires further analysis. In addition, we found that the numbers of Zingivir-H recipients

are more who have symptomatic and co-morbid complications or requiring noninvasive

oxygen saturations when compare with patients in placebo arm. These observations are

hypothesis-generating and require additional subjects to determine whether Zingivir can be

a recommended treatment option for even old age population and with even moderate

illness and such treatment can be given at a certain stage of illness can reduce some

complications in Covid-19 patients.

We did not discuss in the interim report that adding Zingivir-H treatment shall reduce the

viral RNA loads as compared with standard supportive care alone. As we will be assessing

Interferon alpha quantification test results as the indirect marker for viral load analysis only

in the final analysis to ensure the immuno marker expression pattern in any such viral

clearance events in both the arms. The reasons for the antiviral effect of Zingivir-H

molecule could be as predicted in our earlier studies and as per the known significant effect

of active ingredients in the Zingivir-H molecule. RTPCR NP Swab were taken

intermittently (on days 1, 6, 8, 11, 14 and until the results become negative) in most of the

study patients. Since we are not keen to understand the viral load clearance on daily basis

we avoid taking more frequent sampling in the first 5 days which could have provided

more detailed characterization of viral load kinetics in the two groups over this critical

period.



All patients enrolled into the study are regular with the course of administration and no

deviations recorded from the site on IP consumption. No significant gastrointestinal

adverse events, including anorexia, nausea, and abdominal discomfort, or diarrhea, gastritis

are reported in the study. In fact patients felt rejuvenation on consumption of Zingivir-H

tablets, which we may release the patients response on as drug efficacy questionnaire as

feed back during the final analysis. There was clinically non significant elevation of few

electrolytes in Zingivir-H treatment arm due to the methylation of mercury and arsenic. We

have also noticed such elevation got subsided in the 30th day. Laboratory test are

performed in the trials to understand the immunomodulatory and hematological variations

in patients treated with Zingivir-H arm in comparison with Placebo arm. The analysis of

important hematological parameters including CRP, ESR, IL6, IgG and IgM reveals the

potential immunomodulatory role of Zingivir-H drug.

The characteristics of the patients at baseline were generally balanced across the two

groups. We did not observe differences between groups in the frequency of use of

concurrent pharmacologic interventions in this present interim analysis.

Numerous challenges are encountered during this trial. The trial is continuing during the

time of restricted travel, and hospitals restricted the entrance of nonessential personnel,

training, site initiation visits, and monitoring visits often were performed remotely.

Research staff was often assigned other clinical duties, and staff illnesses strained research

resources. Many sites did not have adequate supplies of personal protective equipment and

trial-related supplies, such as swabs. The research team also faces challenges in accessing

patients for blood sampling and to follow up on study procedures in patients who got

discharged and in home quarantine. However, research teams were motivated to find

creative solutions to overcome these challenges to the maximum.

In conclusion, we found that Zingivir-H treatment has significantly accelerated clinical

improvement; reduce mortality or viral clearance in patients with asymptomatic, mild to

moderate Covid-19 patients with or without any comorbidities. These Interim data in

37.5% of randomized sample size populations in the study shall reveal positive signs to

continue with the clinical trial activity in rest of the population and to continue further with

a randomized double-blind study on Zingivir-H molecule as an antiviral therapy in Covid

patients.