Comparing the Efficacy and Safety of High-Titer Versus Low-Titer Anti-Influenza Immune Plasma for the Treatment of Severe Influenza A

National Institute of Allergy and Infectious Diseases (NIAID)138 enrolled

Overview

This study assessed the efficacy and safety of anti-influenza immune plasma, as an addition to standard of care antivirals, in participants hospitalized with severe influenza A infection.

Despite antivirals and vaccines, influenza is responsible for thousands of hospitalizations and deaths each year worldwide. Because of this, additional treatments for influenza are needed. One potential treatment may be the use of high-titer anti-influenza immune plasma. The purpose of this study is to evaluate the efficacy and safety of treatment with high-titer versus low-titer anti-influenza immune plasma, in addition to standard care, in participants hospitalized with severe influenza A infection. This study enrolled people aged 2 weeks or older who are hospitalized with severe influenza A infection. Participants were randomly assigned to receive either high-titer anti-influenza plasma or low-titer (control) anti-influenza plasma on Day 0. In addition, all participants received standard care antivirals. Participants were assessed on Day 0 (baseline) and on Days 1, 2, 3, 7, 14, and 28. For participants who were not hospitalized on Days 2, 14, and 28, researchers could contact participants by telephone. Study procedures included clinical assessments, blood collection, and oropharyngeal swabs.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

QUADRUPLE

Enrollment

138

Conditions

Influenza A Virus Infection

Interventions

High-titer anti-influenza plasmaBIOLOGICAL

Human plasma (FFP or FP24, 225-350 mL per unit or pediatric equivalent) with both an influenza A/H1N1 and A/H3N2 HAI titer of at least 1:80

Low-titer anti-influenza plasmaBIOLOGICAL

Human plasma (FFP or FP24, 225-350 mL per unit or pediatric equivalent) with both an influenza A/H1N1 and A/H3N2 HAI titer of 1:10 or less

Eligibility

Sex: ALLMin age: 2 Weeks

Medical Language ↔ Plain English

Inclusion Criteria for Enrollment (Screening): * Subjects must be aged 2 weeks or older. * Hospitalization due to signs and symptoms of influenza. \* Note: The decision for hospitalization will be made by the treating clinician. To be considered eligible, the hospitalization may either be an initial hospitalization, or a prolongation of a hospitalization due to a respiratory illness that was found to be from influenza. Influenza could be a component of a larger respiratory syndrome (i.e. COPD exacerbation thought to be triggered by influenza). However, respiratory syndromes that are not likely due to the virus should not be included (i.e. a subject that had mild influenza then developed pulmonary embolism and respiratory distress from the embolism). * Study plasma available on-site or available within 24 hours after randomization. * Not previously screened nor randomized in this study. * Willingness to have blood and respiratory samples obtained and stored. * Willingness to return for all required study visits and participate in study follow up. Inclusion Criteria for Randomization: * Locally determined positive test for influenza A (by polymerase chain reaction \[PCR\], other nucleic acid testing, or by rapid Ag) from a specimen obtained less than or equal to 48 hours prior to randomization. * Onset of illness less than or equal to 6 days before randomization, defined as when the subject first experienced at least one respiratory symptom or fever. * Note: For subjects with chronic respiratory symptoms (chronic cough, or COPD with baseline dyspnea), the onset of symptoms is defined as the point when the symptoms changed during this illness). Hospitalized due to influenza, with anticipated hospitalization for more than 24 hours after randomization. Criteria for hospitalization will be up to the individual treating clinician. * National Early Warning (NEW) or Pediatric Early Warning (PEW) score greater than or equal to 3 within 12 hours prior to randomization. * ABO-compatible plasma available on-site or available within 24 hours after randomization. Exclusion Criteria for Randomization: * Strong clinical evidence in the judgment of the site investigator that the etiology of illness is primarily bacterial super-infection in origin. Co-infection would be allowed, as there may be benefit to resolving influenza illness faster. Super-infection, where influenza illness occurred and is resolving, and new bacterial illness causing deterioration should be excluded (e.g., if the subject's respiratory infection is thought unlikely to benefit from additional antiviral therapy, this exclusion criteria would be met). * Prior treatment with any anti-influenza investigational drug, anti-influenza investigational intravenous immune globulin (IVIG), or anti-influenza investigational plasma therapy within 30 days prior to screening. Other investigational drug therapies (non-influenza) and administration of plasma and/or IVIG for non-influenza reasons are allowed. * History of allergic reaction to blood or plasma products (as judged by the site investigator). * A pre-existing condition or use of a medication that, in the opinion of the site investigator, may place the individual at a substantially increased risk of thrombosis (e.g., cryoglobulinemia, severe refractory hypertriglyceridemia, or clinically significant monoclonal gammopathy). Prior IVIG use alone would not meet exclusion criteria, but the investigator should consider the potential for a hyper-coagulable state. * Subjects who, in the judgment of the site investigator, will be unlikely to comply with the requirements of this protocol, including being not contactable following discharge from hospital. * Medical conditions for which receipt of 500-600 mL (or pediatric equivalent) of intravenous fluid may be dangerous to the subject (e.g., decompensated congestive heart failure).

Locations (30)

Outcomes

Primary Outcomes

Clinical Status at Day 7

The clinical status at Day 7 was based on a 6-point ordinal scale: 1. Death 2. In ICU 3. Non-ICU hospitalization, requiring supplemental oxygen (O2) 4. Non-ICU hospitalization, not requiring supplemental oxygen 5. Not hospitalized, but unable to resume normal activities 6. Not hospitalized with full resumption of normal activities A higher score corresponds to a better health outcome

Time frame: Day 7

Secondary Outcomes

Clinical Status at Day 1

The clinical status at Day 1 was based on a 6-point ordinal scale: 1. Death 2. In ICU 3. Non-ICU hospitalization, requiring supplemental oxygen (O2) 4. Non-ICU hospitalization, not requiring supplemental oxygen 5. Not hospitalized, but unable to resume normal activities 6. Not hospitalized with full resumption of normal activities A higher score corresponds to a better health outcome

Time frame: Day 1

Clinical Status at Day 2

The clinical status at Day 2 was based on a 6-point ordinal scale: 1. Death 2. In ICU 3. Non-ICU hospitalization, requiring supplemental oxygen (O2) 4. Non-ICU hospitalization, not requiring supplemental oxygen 5. Not hospitalized, but unable to resume normal activities 6. Not hospitalized with full resumption of normal activities A higher score corresponds to a better health outcome

Time frame: Day 2

Clinical Status at Day 3

The clinical status at Day 3 was based on a 6-point ordinal scale: 1. Death 2. In ICU 3. Non-ICU hospitalization, requiring supplemental oxygen (O2) 4. Non-ICU hospitalization, not requiring supplemental oxygen 5. Not hospitalized, but unable to resume normal activities 6. Not hospitalized with full resumption of normal activities A higher score corresponds to a better health outcome

Time frame: Day 3

Clinical Status at Day 14

The clinical status at Day 14 was based on a 6-point ordinal scale: 1. Death 2. In ICU 3. Non-ICU hospitalization, requiring supplemental oxygen (O2) 4. Non-ICU hospitalization, not requiring supplemental oxygen 5. Not hospitalized, but unable to resume normal activities 6. Not hospitalized with full resumption of normal activities A higher score corresponds to a better health outcome

Data from ClinicalTrials.gov

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University of Arizona Health Sciences Center

Tucson, Arizona, United States

UCLA Pediatrics Infectious Diseases

Los Angeles, California, United States

Naval Medical Center San Diego (NMCSD)

San Diego, California, United States

Children's Hospital Colorado

Aurora, Colorado, United States

University of Colorado Denver

Aurora, Colorado, United States

Bridgeport Hospital

Bridgeport, Connecticut, United States

University of Florida

Gainesville, Florida, United States

Rush University Medical Center

Chicago, Illinois, United States

University of Maryland Medical Center

Baltimore, Maryland, United States

Johns Hopkins University

Baltimore, Maryland, United States

...and 20 more locations

Clinical Status at Day 28

The clinical status at Day 28 was based on a 6-point ordinal scale: 1. Death 2. In ICU 3. Non-ICU hospitalization, requiring supplemental oxygen (O2) 4. Non-ICU hospitalization, not requiring supplemental oxygen 5. Not hospitalized, but unable to resume normal activities 6. Not hospitalized with full resumption of normal activities A higher score corresponds to a better health outcome

Time frame: Day 28

Duration of Initial Hospitalization

Duration (in days) of initial hospitalization, restricted to duration between randomization and last visit

Time frame: From Day 0 to Day 28

28-day Mortality

Number of deaths during study follow-up

Time frame: From Day 0 to Day 28

In-hospital Mortality During Initial Hospitalization

Number of deaths in the hospital during initial hospitalization

Time frame: From Day 0 to Day 28

Composite of Mortality and Hospitalization at Day 7, Day 14, Day 28

Two categories were considered for the composite of mortality and hospitalization: Dead or hospitalized Alive and not hospitalized

Time frame: Day 7, Day 14, Day 28

Change From Baseline to Day 3 and Day 7 in National Early Warning (NEW) Score

The National Early Warning (NEW) score was only measured for the adult participants. The range of the NEW score is from 0 to 20, with lower values representing a better outcome. Baseline is defined as the Day 0. Change was defined as the value at Day 3 or Day 7 minus the value at baseline.

Time frame: Day 0, Day 3, Day 7

Change From Baseline to Day 3 and Day 7 in Pediatric Early Warning (PEW) Score

The Pediatric Early Warning (PEW) score was only measured for the pediatric participants. The range is from 0 to 26, with lower values representing a better outcome. Baseline is defined as the Day 0. Change was defined as the value at Day 3 or Day 7 minus the value at baseline.

Time frame: Day 0, Day 3, Day 7

Duration of Supplemental Oxygen

Duration (in days) of total supplemental oxygen use among those participants who required new or increased oxygen at randomization. The duration is restricted to duration between randomization and last visit.

Time frame: From Day 0 to Day 28 visit. The window of the Day 28 visit was 28-32 days from study entry.

Incidence of New Oxygen Use During the Study

Incidence of new oxygen use during the study among those participants who did not require oxygen at randomization

Time frame: From Day 0 to Day 28

Duration of Intensive Care Unit (ICU) Stay

Duration (in days) of ICU stay among those participants who were in ICU at randomization. The duration is restricted to duration between randomization and last visit.

Time frame: From Day 0 to Day 28

Incidence of New ICU Admission Use During the Study

Incidence of new ICU admission during the study among those participants who were not in ICU at randomization

Time frame: From Day 0 to Day 28

Duration of Mechanical Ventilation Use

Duration (in days) of mechanical ventilation use among those participants who were on mechanical ventilation at randomization. The duration is restricted to duration between randomization and last visit.

Time frame: From Day 0 to Day 28 visit. The window of the Day 28 visit was 28-32 days from study entry

Incidence of New Mechanical Ventilation Use Stay Use During the Study

Incidence of new mechanical ventilation use during the study among those participants who were not on mechanical ventilation at randomization

Time frame: From Day 0 to Day 28

Duration of Acute Respiratory Distress Syndrome (ARDS)

Duration (in days) of ARDS use among those participants with ARDS at randomization. The duration is restricted to duration between randomization and last visit.

Time frame: From Day 0 to Day 28

Incidence of New ARDS During the Study

Incidence of new ARDS during the study among those participants without ARDS at randomization

Time frame: From Day 0 to Day 28

Duration of Extracorporeal Membrane Oxygenation (ECMO)

Duration (in days) of ECMO use among those participants on ECMO at randomization. The duration is restricted to duration between randomization and last visit.

Time frame: From Day 0 to Day 28

Incidence of New ECMO Use During the Study

Incidence of new ECMO use during the study among those participants not on ECMO at randomization

Time frame: From Day 0 to Day 28

Change From Baseline to Day 3 and Day 7 in Sequential Organ Failure Assessment (SOFA) Score

The Sequential Organ Failure Assessment (SOFA) score was only measured for the adult participants. The range is from 0 to 24, with lower values representing a better outcome. Baseline is defined as the Day 0. Change was defined as the value at Day 3 or Day 7 minus the value at baseline.

Time frame: Day 0, Day 3, Day 7

Change From Baseline to Day 3 and Day 7 in Pediatric Logistic Organ Dysfunction (PELOD) Score

The Pediatric Logistic Organ Dysfunction (PELOD) score was only measured for the pediatric participants. The range is from 0 to 71, with lower values representing a better outcome. Baseline is defined as the Day 0. Change was defined as the value at Day 3 or Day 7 minus the value at baseline.

Time frame: Day 0, Day 3, Day 7

Disposition After Initial Hospitalization

Disposition at discharge after initial hospitalization was categorized as follows: Death, Ongoing at 28 days, Chronic nursing facility, Rehabilitation, Home with home health care, Home without assistance. The number of deaths at discharge after initial hospitalization do not necessarily match the overall number of deaths.

Time frame: From Day 0 to Day 28

Detectable Influenza Virus at Day 3

Detectable influenza virus at Day 3 in oropharyngeal samples

Time frame: Day 3

Hemagglutination Inhibition Assay (HAI) Titers at Days 1, 3, 7 for A/H1N1

Hemagglutination inhibition assay (HAI) titers as measured by serial dilutions at Days 1, 3, 7 for A/H1N1. HAI for A/H1N1 was tested in all influenza seasons while the study was ongoing.

Time frame: Day 1, Day 3, Day 7

Hemagglutination Inhibition Assay (HAI) Titers at Days 1, 3, 7 for A/HongKong/4801/2014 H3N2

Hemagglutination inhibition assay (HAI) titers as measured by serial dilutions at Days 1, 3, 7 for A/HongKong/4801/2014 H3N2. HAI for A/HongKong/4801/2014 H3N2 was tested in all influenza seasons while the study was ongoing.

Time frame: Day 1, Day 3, Day 7

Number of Participants With Grade 3 and 4 Adverse Events (AEs).

Number of participants with reported grade 3 and 4 adverse events (AEs) throughout the study duration. In cases where participants had multiple reports of grade 3 and 4 AEs, they were only counted once.

Time frame: From Day 0 to Day 28

Number of Participants With Serious Adverse Events (SAEs).

Number of participants with reported serious adverse events (SAEs) throughout the study duration.

Time frame: From Day 0 to Day 28