Evaluation of Prevalence and Risk Factors of Persistent SARS-CoV-2 Infection in Immunocompromised Patients
Conditions: Persistent COVID-19, B Cell Malignancies
Sponsor: Maddalena Giannella

Study code: PERsiCO 
Evaluation of prevalence and risk factors of persistent SARS-
CoV-2 infection in immunocompromised patients 
Author (s): 
Maddalena Giannella, Zeno Adrien Igor Pasquini, Alice Toschi, Pierluigi Viale 
Document: 
Protocol 
Version: 
1.0  
Release date: 
06-10-2023 
Numbers of pages: 
18 

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PROTOCOL SIGNATURES PAGE 
 
Protocol Code: PERsiCO 
 
 
                                                                                                                             11-Oct-2023 
(Author) Maddalena Giannella 
signature 
 
Date 
 
 
(Author) Zeno Adrien Igor Pasquini 
signature 
 
 
 
date 
(Author) Alice Toschi 
signature 
 
 
date 
 
(Author) Pierluigi Viale 
signature 
 
date 
 
 
 

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INVESTIGATOR’S STATEMENT: 
 
Protocol Code: PERsiCO 
 
I declare that I have read the protocol and agree to conduct this clinical study in accordance 
with all the requirements of the protocol and in accordance with the Guidelines of Good 
Clinical Practice (GCP) and the principles of the Declaration of Helsinki. 
 
Maddalena Giannella  
 
 
 
 
 
 
      11-Oct-2023 
(Principal Investigator) 
signature  
 
date 
 

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CONTENT INDEX 
1 
Study-specific abbrevetions and terms ............................................................................ 5 
2 
Introduction ....................................................................................................................... 6 
2.1 
Background and rationale ........................................................................................ 6 
2.2 
Importance of the study and its clinical relevance ................................................... 7 
3 
Objectives of the study ...................................................................................................... 8 
3.1 
Primary objective ..................................................................................................... 8 
3.2 
Secondary objective ................................................................................................. 8 
3.3 
Endpoints ................................................................................................................. 8 
4 
Investigational plan  ......................................................................................................... 9 
4.1 
Study type ................................................................................................................ 9 
4.2 
Mono or multicenter study ....................................................................................... 9 
4.2.1 Multicenter study coordination  ...................................................................... 9 
4.3 
Study design  ............................................................................................................ 9 
4.4 
Study population  ................................................................................................... 10 
4.4.1 Inclusion Criteria .......................................................................................... 10 
4.4.2 Exclusion Criteria ......................................................................................... 10 
4.4.3 Population size of the study and statistical power ........................................ 10 
4.5 
Study duration  ....................................................................................................... 11 
4.6 
Grants ..................................................................................................................... 11 
4.7 
Data management .................................................................................................. 11 
4.8 
Statistical Analysis Plan ........................................................................................ 12 
5 
Administrative procedures and declarations ................................................................ 13 
5.1 
Informed consent and consent to the processing of personal data ......................... 13 
5.1.1 
Methods of acquiring informed consent and consent to the processing 
of personal data ..................................................................................... 13 
5.2 
Study – specific insurance ..................................................................................... 13 
5.3 
Amendments to the protocol and changes to the conduct of the study .................. 13 
5.4 
Conclusion of the study ......................................................................................... 13 
5.5 
Publication policy .................................................................................................. 13 
5.6 
Documentation archive .......................................................................................... 14 
5.7 
Inspections/checks ................................................................................................. 14 
5.8 
Contact persons ...................................................................................................... 14 
6 
Bibliography .................................................................................................................... 15 

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1. Study-specific abbreviations and terms 
 
Anti-CD20 
Anti-cluster of differentiation 20 
AOU 
Azienda Ospedaliera-Universitaria 
CAR-T 
Chimeric antigen receptor T cell 
COVID-19 
Coronavirus disease 2019 
CT 
Cycle threshold 
HCT 
Hematopoietic Cell Transplant 
ICU 
Intensive care unit 
IRCCS 
Istituto di ricovero e cura a carattere scientifico 
LRTI 
Lower respiratory tract infection 
PCR 
Polymerase chain reaction 
SARS-CoV-2 
Severe acute respiratory syndrome coronavirus 2 
SOT 
Solid Organ Transplant 
WHO 
World Health Organization 
 

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2. Introduction 
 
2.1 Background and rationale 
Although the impact of COVID-19 has been significantly reduced thanks to the 
effectiveness of vaccination and antiviral treatments, the risk of breakthrough infection 
remains higher in the immunocompromised population [1].  
Immunocompromised patients are at increased risk for SARS-CoV-2-associated morbidity 
and mortality due to immunologic deficits that limit normal immune response and viral 
clearance [2-3]. Furthermore, the type of immunosuppression and the treatments performed 
significantly impact the natural trajectory of the COVID-19 infection, as in the case of 
patients with impaired adaptive humoral immunity who are relatively protected from acute 
infectious toxicity but have a high risk of prolonged viral shedding, viral rebound, and 
chronic infection [2-3].  
In this group of patients, also known as “long persisters”, we find especially 
haematological patients with B cell malignancies or undergoing B cell targeting therapies 
such as anti-CD20 and CAR-T cell therapy. These patients, in addition to the 
complications related to SARS-CoV-2 infection itself, represent a particularly interesting 
population as the lack of viral clearance can lead to delays in life-saving treatments. 
Despite major advances in our understanding of COVID-19, there is still a lack of 
consensus on how to define the condition of persistent infection in immunocompromised 
patients, also called “protracted SARS-CoV-2 infection” or “persistent inflammatory sero-
negative COVID” [4-5]. In particular, two recent studies have tried to distinguish this 
phenomenon from "long COVID-19" and "post-COVID-19 condition", which is defined by 
the WHO as a syndrome that occurs in individuals who have contracted COVID-19 in the 
previous 3 months and have at least 2 months of ongoing symptoms (such as fatigue, 
dyspnoea, and cognitive dysfunction), with no alternative diagnoses [6]. Both studies [4-5] 
suggest the use of diagnostic criteria that combine baseline host immunodeficiency, clinical 
signs and virological data, which we can summarize as follows: 
o Host criterion: underlying immunosuppression such as HCT, CAR T-cell 
recipient, lymphoma or B-cell malignancy, SOT, Anti-CD20 therapy or other 
B/T cell targeted therapies, primary and acquired immunodeficiencies. 
o Clinical criterion: persistent/relapsing symptoms (fever, dyspnea, hypoxemia) 
and/or persistent/relapsing changes on chest-X ray or CT scan after extensive 
negative infectious work up. 
o Virological criterion: persistently positive SARS-CoV-2 PCR ≥ 21 days. 
Although 21 days may not be a particularly long duration in this type of patient, in this 
study we will use this time reference to identify patients with persistent infection. 
Current COVID-19 treatment guidelines recommend the use of a single agent within few 
days of symptoms for all the patients with mild disease but with risk factors for progression 

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to severe disease, including immunocompromised condition. Remdesivir remains the only 
approved antiviral to treat hospitalized patients with COVID-19 in case of progression to 
LRTI and, in any case, after 10 days from diagnosis patients are no longer eligible for any 
treatment. Moreover, specific indications for immunocompromised patients are limited to 
the use of long-acting monoclonal antibodies as SARS-CoV-2 pre-exposure prophylaxis 
for individuals who may have an inadequate immune response to COVID-19 vaccination. 
It should also be specified that there is currently insufficient evidence to guide clinical 
recommendations for other treatments in immunocompromised patients [7]. 
However, in clinical practice, it appears clear that such recommendations are not sufficient 
to guarantee the cure of SARS-CoV-2 infection in immunocompromised patients, in 
particular in the “long persisters” population. Currently in literature, only case reports or 
small case series have described the prevalence and the management of patients with 
persisting infection. These studies show a wide variability of therapeutic approaches 
ranging from the adoption of repeated or prolonged cycles of remdesivir [8-10] or 
nirmatrelvir/ritonavir [11], dual antiviral therapy [12-13] and combination therapy with 
antiviral and monoclonal antibodies [14-16]. These case reports show variable success 
rates and highlight the need for larger studies focused on immunocompromised patients, to 
identify the best therapeutic approach in this population. 
With this premise, we would like to conduct an observational study on 
immunocompromised patients, and specifically on haematological patients with B cell 
malignancies diagnosed with SARS-CoV-2 infection, with the aims of assessing the 
prevalence of those with persisting COVID-19, associated risk factors and describe the 
different clinical managements and their related outcomes. 
 
2.2 Importance of the study and its clinical relevance 
This study is part of the EU H2020 project “Connecting European Cohorts to Increase 
Common and Effective Response to SARS-CoV-2 Pandemic: ORCHESTRA” (Grant 
Agreement n. 101016167), which addresses task 4.6 “Prevalence, risk factors and 
therapeutic management of persisting COVID-19 in fragile patients”. 
 
We deem that the results of our study could help improve the management of 
immunocompromised patients at risk for developing persisting COVID-19, Indeed, by 
describing the burden, host, risk factors, therapeutic management and outcome of 
immunocompromised patients with persisting COVID-19, we may inform future 
interventional studies and current clinical practice regarding a currently unmet need with 
controversial evidence. 

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3. Objectives of the study 
3.1 Primary objective 
The primary objective of this study is to describe the prevalence of SARS-CoV-2 
persisting infection and the related risk factors in immunocompromised patients with B 
cell malignancies or undergoing B cell targeting therapies. 
3.2 Secondary objectives 
The secondary objective of the study is to describe and compare between patients with and 
without persisting COVID-19 the clinical, virological and radiological outcomes and the 
different therapeutic approaches performed. 
3.3 Endpoints 
The first primary endpoint variable will be the prevalence of persisting SARS-CoV-2 
infection among the immunocompromised patients defined as the persistence or the 
recurrence of symptoms and signs (fever, dyspnea, hypoxemia, changes on chest-X ray or 
CT scan) and positive SARS-CoV-2 PCR ≥ 21 days after the time 0 (day of the first test 
positive for SARS-CoV2 infection). 
The endpoints for the secondary objectives are:  
- 
Duration of treatment carried out to address the persistent COVID-19 condition 
and treatment-related adverse effects. 
- 
Duration of viral shedding, defined as the number of days between the first 
positive test and first negative PCR test. 
- 
Duration of symptoms, defined as the number of days between symptoms onset 
and the clinical cure. 
- 
Prevalence of imaging alterations, defined as the presence of new ground-glass 
and/or crazy paving and/or interstitial infiltrates at chest CT scan during the 
persisting infection (starting from 21 days after the first positive test until viral 
clearance). 
- 
Re-infection within 120 days, define as new positive test with or without 
symptoms after viral clearance has been achieved. 
- 
All-cause 120-day mortality. 
 

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4. Investigational plan 
 
4.1 Study type 
Cross-sectional study .............................................  
 
Retrospective Case-control study ........................... 
 
Retrospective cohort study ....................................  
 
Prospective cohort study ........................................  
 
Retrospective and prospective cohort study ........... 
 
Descriptive pilot/feasibility study .........................  
 
Qualitative study ....................................................  
 
 
4.2 Mono or multicenter study 
Monocentric ............................................................ 
  
National multicenter ............................................... 
  
International multicenter ................................... 
 
4.2.1 Multicenter study coordination 
Alma Mater Studiorum – University of Bologna (UNIBO), Department of Medical and 
Surgical Sciences is the promoter of this study. The clinical center affiliated to 
UNIBO, which is the Infectious Disease Unit, IRCCS Azienda Ospedaliero-
Universitaria di Bologna (IRCCS AOU of Bologna) Policlinico di Sant’Orsola, will be 
the coordinator center. Other clinical centers will be invited to share their data under 
the terms and conditions described in this protocol.  
 
4.3 Study design 
Spontaneous international multicenter retrospective and prospective observational study. 
The retrospective recruitment period will span from 1.01.2022 to the date of authorisation 
by hospital directorates following the Ethics Committees’ approvals. This period has been 
established considering the prevalent diffusion of the omicron variant and its subvariants, 
which has led to significant changes in the clinical manifestations of COVID-19. The 
prospective recruitment will be carried out over the 12 months immediately following the 
retrospective period.  
During the study period, screening for persisting SARS-CoV-2 infection and therapeutic 
management of all patients will be carried out by the attending physicians according to 
routine practice.  

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4.4 Study population 
All immunocompromised adults (≥18 years) with a new SARS-CoV-2 infection assessed 
during the study period, hospitalized or followed as outpatients in the Haematological 
Units of the participating centers, will be screened for inclusion.  
4.4.1 Inclusion Criteria 
- Diagnosis of B cell malignancies or previous treatment with B cell targeting 
therapies. 
- Diagnosis of proven SARS-CoV-2 infection confirmed by a PCR test (only the first 
infection during the study period will be considered, re-infection will be counted as a 
secondary endpoint). 
- Provision of signed and dated informed consent. 
4.4.2 Exclusion Criteria 
- None 
4.4.3 Population size of the study and statistical power 
According to the records of the Haematology Unit of IRCCS AOU of Bologna, from 
January 2022 to December 2022, 250 patients with underlying B cell malignancies 
have been diagnosed with SARS-CoV2 infection and we estimate that approximately 
30% had viral shedding longer than 21 days. Thus, we deem that at the end of the 
study period, approximately 500 patients will be enrolled from IRCCS AOU of 
Bologna of which about 150 with prolonged infection. Considering the epidemiology 
of the other participating centers, we expect to reach an overall cohort of about 1000 
immunocompromised patients with SARS-CoV-2 infection, with approximately 300 
prolonged infections.  
Power analysis carried out using Stata v.17.0 showed that a sample size of 1,000 
allows to obtain power=80% and alpha=0.05 for a log-rank test comparing 120-days 
mortality, with a 300/700 allocation ratio, when the difference in mortality rates is at 
least 4% and mortality rate in the non-persistent COVID is as low as 3%, or when the 
difference in mortality rates is at least 5% and mortality rate in the non-persistent 
COVID is at least 4%. 
 
Estimated sample sizes for two-sample comparison of survivor functions 
Log-rank test, Freedman method 
H0: HR = 1  versus  Ha: HR != 1 
 
  +-------------------------------------------------------------------------------------------------+ 
  |   alpha   power       N      N1      N2  nratio       E   delta  hratio      s1      s2    Pr_E | 
  |-------------------------------------------------------------------------------------------------| 
  |     .05      .8     897     627     270     .43      59   2.054   2.054     .95      .9  .06503 | 
  |     .05      .8   1,343     939     404     .43      84   1.839   1.839     .95     .91  .06203 | 
  |     .05      .8   2,282   1,596     686     .43     135   1.626   1.626     .95     .92  .05902 | 
  |     .05      .8   4,900   3,426   1,474     .43     275   1.415   1.415     .95     .93  .05601 | 
  |     .05      .8   18662   13050   5,612     .43     990   1.206   1.206     .95     .94  .05301 | 
  |     .05      .8       .       .       .     .43       .       1       1     .95     .95       . | 
  |     .05      .8     561     392     169     .43      33   2.581   2.581     .96      .9  .05804 | 
  |     .05      .8     768     537     231     .43      43    2.31    2.31     .96     .91  .05503 | 
  |     .05      .8   1,140     797     343     .43      60   2.043   2.043     .96     .92  .05203 | 

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  |     .05      .8   1,918   1,341     577     .43      94   1.778   1.778     .96     .93  .04902 | 
  |     .05      .8   4,070   2,846   1,224     .43     188   1.516   1.516     .96     .94  .04601 | 
  |     .05      .8   15304   10702   4,602     .43     659   1.257   1.257     .96     .95  .04301 | 
  |     .05      .8     367     256     111     .43      19   3.459   3.459     .97      .9  .05105 | 
  |     .05      .8     471     329     142     .43      23   3.096   3.096     .97     .91  .04804 | 
  |     .05      .8     638     446     192     .43      29   2.737   2.737     .97     .92  .04503 | 
  |     .05      .8     933     652     281     .43      40   2.383   2.383     .97     .93  .04203 | 
  |     .05      .8   1,545   1,080     465     .43      61   2.031   2.031     .97     .94  .03902 | 
  |     .05      .8   3,221   2,252     969     .43     116   1.684   1.684     .97     .95  .03601 | 
  +------------------------------------------------------------------------------------------------- 
s1, s2 = survival rates in groups 1 and 2 
N1, N2 = sample size required in groups 1 and 2. 
As regards the analysis on prevalence of imaging alterations, due to the larger 
expected difference between the two groups, the population size of 1,000 is 
completely adequate. 
4.5 Study duration 
The study will be composed by: 
 a prospective recruitment period of 1 year after Ethics Committes’ approvals and 
directorates’ permissions to conduct the study (during which retrospective data 
will also be collected); 
 Follow-up period of 120-days from the diagnosis of SARS-CoV-2 infection; 
 Data collection and analysis, that will last 6 months 
For an overall duration of approximately 22 months  
4.6 Funding 
Is there any funding for the study? 
No  ............................................................................ 
 
Yes, with internal grants .......................................... 
  
Yes, by institutional third parties ............................. 
  
Yes, from private third parties ............................. 
 
4.7 Data management 
Pseudonymized data will be collected using a pre-established electronic case report form 
(eCRF) developed using the REDCap capture tool hosted by CINECA, the Italian partner 
in charge of data management within the EU H2020 ORCHESTRA project. All centers 
will enter their data locally on the eCRF through internet connection. The principal 
investigator and/or her/his delegate will have access to all data in order to check for data 
integrity and advancement of data collection. Data sources will be clinical charts and 
hospital electronic records. 
During all the study period, the principal investigator will inform investigators about the 
status of patient enrolment, follow-up, and data collection by newsletter periodically.  
At the end of data collection, the principal investigator will be responsible for reviewing 
all data for integrity and accuracy. Queries will be generated and when necessary sent to 

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the local investigators for reviewing incomplete or inaccurate data. The database will be 
locked after fulfilment of all the queries. 
4.8 Statistical Analysis Plan 
Patients’ characteristics will be summarized using absolute frequencies and percentages 
(categorical variables) and mean±standard deviation or median and interquartile range 
(scale variables, according to their distribution). 
The prevalence of persisting SARS-CoV-2 infection among the immunocompromised 
patients will be obtained as the ratio of the number of patients with evidence of persisting 
SARS-CoV-2 infection on the total number of enrolled patients. 
As for the analysis of risk factors for persisting COVID, comparisons between COVID-
persistent and non-persistent patients will be carried out by means of survival analyses for 
all outcomes expressed as durations (time-to-event analyses). These outcomes will be 
compared by estimating Kaplan-Meier curves, calculating log-rank tests and multiple Cox 
regressions in which COVID persistance will be the main risk factor and including the 
confounders and effect modifiers listed below. 
- 
Age 
- 
Sex 
- 
Comorbidities (Charlson Comorbidity Index) 
- 
Underlying hematologic disease state 
- 
Chemotherapy treatments performed 
- 
Duration of Hospital stay 
- 
Admissions to intensive care 
- 
Days with central venous catheter 
- 
Bacterial and fungal superinfections 
- 
Vaccination status 
- 
Previous SARS-CoV-2 infections 
- 
Serological status (anti-SARS-CoV-2 antibodies) 
 
Re-infection and imaging alterations rates will be calculated as the ratio of the number of 
events to the overall number of patients, and the comparison between persisters and non-
persisters will be carried out by calculating the corresponding risk ratios. A multiple 
logistic regression model will assess the relationship between exposure and re-infection 
(image alteration) net of the potential confounders.  
For secondary aims, the secondary endpoints will be described just for the patients with 
peristing COVID, categorical variables will be reported as number and relative 

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frequencies, continuous variables will be reported as mean±SD or median and IQR 
according with their distribution.  

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5. Administrative procedures and declarations 
5.1 Informed consent and consent to the processing of personal data 
The study protocol, any protocol amendment, informed consent, consent to the processing 
of personal data and any other information for patients must be approved by the Ethics 
Committee. 
To participate in the study, each patient must provide written informed consent as well as 
consent to the processing of their personal data. In case it will be not possible to acquire 
informed consent (e.g. deceased or untraceable patients), data will be collected 
anonymously, meaning that possible patient identifiers will be removed. 
 
5.1.1 Methods of acquiring informed consent and consent to the processing of 
personal data 
Informed consent will be obtained by local investigators in collaboration with the 
attending physicians. For the retrospective cohort, it will be obtained during the 
standard scheduled follow-up visits. However, for those cases where it will not be 
possible to acquire consent, anonymized data (thus lacking a key that indirectly 
identifies the patient) may be recorded in the CRF. For the prospective cohort, 
informed consent will be administered to the patients at the enrolment. Only patients 
who will provide informed consent will be enrolled. 
 
5.2 Study – specific insurance 
Considering the nature of the study, a specific insurance is considered unnecessary.  
5.3 Amendments to the protocol and changes to the conduct of the study 
If during the enrolment period, the principal and local investigators will agree that any 
deviation from the original protocol is needed to reach the predefined sample size and/or 
to avoid bias in the assessment of outcomes, the protocol will be revised and an 
amendment will be submitted to Ethic Committees.  
5.4 Conclusion of the study 
After the lock of database, preliminary results will be shared with all the investigators in 
order to plan publication and other dissemination activities. These results will be used to 
communicate to local Ethic Committees the conclusion of the study. 
5.5 Publication policy 
Preliminary results will be revised by all the investigators in order to refine statical 
analysis, and to plan publication and other dissemination activities (presentation of results 
at International Congresses of Infectious Diseases and Transplant Societies).  

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For authorship, Recommendations for the Conduct, Reporting, Editing and Publication of 
Scholarly Work in Medical Journals (ICMJE Recommendations) will be followed. The 
ICMJE recommends that authorship be based on the following criteria: 
- 
Substantial contributions to the conception or design of the work; or the acquisition, 
analysis, or interpretation of data for the work; AND 
- 
Drafting the work or revising it critically for important intellectual content; AND 
- 
Final approval of the version to be published; AND 
- 
Agreement to be accountable for all aspects of the work in ensuring that questions 
related to the accuracy or integrity of any part of the work are appropriately investigated 
and resolved. 
According to the rules of good scientific practice, the principal investigator can claim the 
position of last author if he/she is not already first author. In the case of several research 
project leaders, they should agree on the last authorship among themselves at an early 
stage; in this context, shared first and last authorships should also be considered. As a 
rule, the "corresponding author" should be the research project leader with primary 
responsibility. The middle group of co-authors will be included according to contribution 
to the manuscript as the ICMJE recommendations.  
5.6 Documentation archive 
The principal investigator is responsible for the archiviation and conservation of the 
essential documents of the study, before, during and after the study conduction, according 
to the Italian law and good clinical practice.  
Patient data will be gathered pseudo-anonymously, included subjects will be identified by 
a number/code. Principal and local investigators will keep the original data of the patient 
and his personal informed consent in a safe place. 
5.7 Inspections/checks 
If a regulatory authority will request an inspection, the principal investigator will soon 
inform the Ethic Committee.  
5.8 Contact persons 
Contacts (telephone numbers and emails) of the involved physicians are reported in the 
Investigator Folder for the local center. 
 

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6. Bibliography 
 
1. Sun J, Zheng Q, Madhira V, Olex AL, Anzalone AJ, Vinson A, Singh JA, French E, 
Abraham AG, Mathew J, Safdar N, Agarwal G, Fitzgerald KC, Singh N, Topaloglu U, 
Chute CG, Mannon RB, Kirk GD, Patel RC; National COVID Cohort Collaborative 
(N3C) Consortium. Association Between Immune Dysfunction and COVID-19 
Breakthrough Infection After SARS-CoV-2 Vaccination in the US. JAMA Intern Med. 
2022 
Feb 
1;182(2):153-162. 
doi: 
10.1001/jamainternmed.2021.7024. 
PMID: 
34962505; PMCID: PMC8715386. 
 
2. DeWolf S, Laracy JC, Perales MA, Kamboj M, van den Brink MRM, Vardhana S. 
SARS-CoV-2 
in 
immunocompromised 
individuals. 
Immunity. 
2022 
Oct 
11;55(10):1779-1798. doi: 10.1016/j.immuni.2022.09.006. Epub 2022 Sep 13. PMID: 
36182669; PMCID: PMC9468314. 
 
3. Lee CY, Shah MK, Hoyos D, Solovyov A, Douglas M, Taur Y, Maslak P, Babady NE, 
Greenbaum B, Kamboj M, Vardhana SA. Prolonged SARS-CoV-2 Infection in 
Patients with Lymphoid Malignancies. Cancer Discov. 2022 Jan;12(1):62-73. doi: 
10.1158/2159-8290.CD-21-1033. Epub 2021 Nov 9. PMID: 34753749; PMCID: 
PMC8758535. 
 
4. Dioverti, V., Salto-Alejandre, S. & Haidar, G. Immunocompromised Patients with 
Protracted COVID-19: a Review of “Long Persisters”. Curr Transpl Rep 9, 209–218 
(2022). https://doi.org/10.1007/s40472-022-00385-y 
 
5. Belkin A, Leibowitz A, Shargian L, Yahav D. The unique presentation of SARS-CoV-
2 Infection in patients with B-cell depletion: definition of 'persistent inflammatory 
sero-negative 
COVID'. 
Clin 
Microbiol 
Infect. 
2023 
Jan;29(1):1-3. 
doi: 
10.1016/j.cmi.2022.10.007. Epub 2022 Oct 6. PMID: 36209993; PMCID: 
PMC9535925. 
 
6. World Health Organization (WHO) clinical case defnition working group on post 
COVID-19 condition. A clinical case defnition of post COVID-19 condition by a 
Delphi consensus, 6 October 2021. https://www.who.int/publications/i/item/WHO-
2019-
 
nCoV Post_COVID-19_condition-Clinical_case_defnition-2021.1 
 
7. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) 
Treatment 
Guidelines. 
National 
Institutes 
of 
Health. 
Available 
at 
https://www.covid19treatmentguidelines.nih.gov/. Accessed 14/01/2023. 
 
8. Monrad I, Sahlertz SR, Nielsen SSF, Pedersen LØ, Petersen MS, Kobel CM, 
Tarpgaard IH, Storgaard M, Mortensen KL, Schleimann MH, Tolstrup M, Vibholm 
LK. Persistent Severe Acute Respiratory Syndrome Coronavirus 2 Infection in 
Immunocompromised Host Displaying Treatment Induced Viral Evolution. Open 

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Version 1.0     06/10/2023 
 
Forum Infect Dis. 2021 Jun 4;8(7):ofab295. doi: 10.1093/ofid/ofab295. PMID: 
34258320; PMCID: PMC8244814. 
 
9. Martinez MA, Chen TY, Choi H, Hwang M, Navarathna D, Hao L, Gale M Jr, Camus 
G, Ramirez HE, Jinadatha C. Extended Remdesivir Infusion for Persistent 
Coronavirus Disease 2019 Infection. Open Forum Infect Dis. 2022 Jul 
29;9(8):ofac382. 
doi: 
10.1093/ofid/ofac382. 
PMID: 
36039098; 
PMCID: 
PMC9384609. 
 
10. Helleberg M, Niemann CU, Moestrup KS, Kirk O, Lebech AM, Lane C, Lundgren J. 
Persistent COVID-19 in an Immunocompromised Patient Temporarily Responsive to 
Two Courses of Remdesivir Therapy. J Infect Dis. 2020 Sep 1;222(7):1103-1107. doi: 
10.1093/infdis/jiaa446. PMID: 32702095; PMCID: PMC7454684. 
 
11. Graziani L, Gori L, Manciulli T, Basile G, Campolmi I, Borchi B, di Dio M, Mattei M, 
Ciurleo G, Ciliberti M, Malentacchi F, Coppi M, Morettini A, Parronchi P, Rossolini 
GM, Bartoloni A, Tomassetti S, Spinicci M. Successful use of nirmatrelvir/ritonavir in 
immunocompromised patients with persistent and/or relapsing COVID-19. J 
Antimicrob Chemother. 2022 Dec 21:dkac433. doi: 10.1093/jac/dkac433. Epub ahead 
of print. PMID: 36544352. 
 
12. Trottier CA, Wong B, Kohli R, Boomsma C, Magro F, Kher S, Anderlind C, Golan Y. 
Dual antiviral therapy for persistent COVID-19 and associated organizing pneumonia 
in an immunocompromised host. Clin Infect Dis. 2022 Oct 25:ciac847. doi: 
10.1093/cid/ciac847. Epub ahead of print. PMID: 36281907; PMCID: PMC9620374. 
 
13. Ford ES, Simmons W, Karmarkar EN, Yoke LH, Braimah AB, Orozco JJ, Ghiuzeli 
CM, Barnhill S, Sack CL, Benditt JO, Roychoudhury P, Greninger AL, Shapiro AE, 
Hammond JL, Rusnak JM, Dolsten M, Boeckh M, Liu C, Cheng GS, Corey L. 
Successful treatment of prolonged, severe COVID-19 lower respiratory tract disease in 
a B-cell ALL patient with an extended course of remdesivir and nirmatrelvir/ritonavir. 
Clin Infect Dis. 2022 Nov 3:ciac868. doi: 10.1093/cid/ciac868. Epub ahead of print. 
PMID: 36326680. 
 
14. Brown LK, Moran E, Goodman A, Baxendale H, Bermingham W, Buckland M, 
AbdulKhaliq I, Jarvis H, Hunter M, Karanam S, Patel A, Jenkins M, Robbins A, Khan 
S, Simpson T, Jolles S, Underwood J, Savic S, Richter A, Shields A, Brown M, Lowe 
DM. Treatment of chronic or relapsing COVID-19 in immunodeficiency. J Allergy 
Clin Immunol. 2022 Feb;149(2):557-561.e1. doi: 10.1016/j.jaci.2021.10.031. Epub 
2021 Nov 12. PMID: 34780850; PMCID: PMC8585958. 
 
15. D'Abramo A, Vita S, Maffongelli G, Mariano A, Agrati C, Castilletti C, Goletti D, 
Ippolito G, Nicastri E; Spallanzani COVID-19 Case Investigation Team. Prolonged 
and severe SARS-CoV-2 infection in patients under B-cell-depleting drug successfully 

PERsiCO 
Confidential - All rights reserved 
Page 18 of 18 
 
 
  
 
Study Protocol 
 
Version 1.0     06/10/2023 
 
treated: A tailored approach. Int J Infect Dis. 2021 Jun;107:247-250. doi: 
10.1016/j.ijid.2021.04.068. Epub 2021 Apr 24. PMID: 33901654; PMCID: 
PMC8065233. 
 
16. Scaglione V, Rotundo S, Marascio N, De Marco C, Lionello R, Veneziano C, 
Berardelli L, Quirino A, Olivadese V, Serapide F, Tassone B, Morrone HL, Davoli C, 
La Gamba V, Bruni A, Cesana BM, Matera G, Russo A, Costanzo FS, Viglietto G, 
Trecarichi EM, Torti C; IDTM U. M. G. COVID-19 Group. Lessons learned and 
implications of early therapies for coronavirus disease in a territorial service centre in 
the Calabria region: a retrospective study. BMC Infect Dis. 2022 Oct 20;22(1):793. 
doi: 10.1186/s12879-022-07774-9. Erratum in: BMC Infect Dis. 2022 Nov 
24;22(1):883. PMID: 36266619; PMCID: PMC9583059.