Efficacy of hydroxychloroquine for post-exposure prophylaxis to prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among adults exposed to coronavirus disease (COVID-19): a structured summary of a study protocol for a randomised controlled trial
Authors: Barnabas Ruanne V. , Brown Elizabeth , Bershteyn Anna , Miller R. Scott , Wener Mark , Celum Connie , Wald Anna , Chu Helen , Wesche David , Baeten Jared M. ,   for the Hydroxychloroquine COVID-19 PEP Study Team
Published: June 2020

Abstract
Objectives
Primary Objective
• To test the efficacy of Hydroxychloroquine (HCQ) (400 mg orally daily for 3 days then 200 mg orally daily for an additional 11 days, to complete 14 days) to prevent incident SARS-CoV-2 infection, compared to ascorbic acid among contacts of persons with SARS-CoV-2 infection
Secondary objectives
• To determine the safety and tolerability of HCQ as SARS-CoV-2 Post-exposure Prophylaxis (PEP) in adults
• To test the efficacy of HCQ (400 mg orally daily for 3 days then 200 mg orally daily for an additional 11 days, to complete 14 days) to prevent incident SARS-CoV-2 infection 2 weeks after completing therapy, compared to ascorbic acid among contacts of persons with SARS-CoV-2 infection
• To test the efficacy of HCQ to shorten the duration of SARS-CoV-2 shedding among those with SARS-CoV-2 infection in the HCQ PEP group
• To test the efficacy of HCQ to prevent incident COVID-19

Trial design
This is a randomized, multi-center, placebo-equivalent (ascorbic acid) controlled, blinded study of HCQ PEP for the prevention of SARS-CoV-2 infection in adults exposed to the virus.

Participants
This study will enroll up to 2000 asymptomatic adults 18 to 80 years of age (inclusive) at baseline who are close contacts of persons with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 or clinically suspected COVID-19 and a pending SARS-CoV-2 PCR test. This multisite trial will be conducted at seven sites in Seattle (UW), Los Angeles (UCLA), New Orleans (Tulane), Baltimore (UMB), New York City (NYU), Syracuse (SUNY-Upstate), and Boston (BMC).
Inclusion criteria
Participants are eligible to be included in the study only if all of the following criteria apply:
Men or women 18 to 80 years of age inclusive, at the time of signing the informed consentWilling and able to provide informed consentHad a close contact of a person (index) with known PCR-confirmed SARS-CoV-2 infection or index who is currently being assessed for COVID-19
Close contact is defined as:
Household contact (i.e., residing with the index case in the 14 days prior to index diagnosis or prolonged exposure within a residence/vehicle/enclosed space without maintaining social distance)Medical staff, first responders, or other care persons who cared for the index case without personal protection (mask and gloves)Less than 4 days since last exposure (close contact with a person with SARS-CoV-2 infection) to the index caseAccess to device and internet for Telehealth visitsNot planning to take HCQ in addition to the study medication
Exclusion criteria
Participants are excluded from the study if any of the following criteria apply:
Known hypersensitivity to HCQ or other 4-aminoquinoline compoundsCurrently hospitalizedSymptomatic with subjective fever, cough, or shortness of breathCurrent medications exclude concomitant use of HCQConcomitant use of other anti-malarial treatment or chemoprophylaxis, including chloroquine, mefloquine, artemether, or lumefantrine.History of retinopathy of any etiologyPsoriasisPorphyriaKnown bone marrow disorders with significant neutropenia (polymorphonuclear leukocytes <1500) or thrombocytopenia (<100 K)Concomitant use of digoxin, cyclosporin, cimetidine, amiodarone, or tamoxifenKnown moderate or severe liver diseaseKnown long QT syndromeSevere renal impairmentUse of any investigational or non-registered drug or vaccine within 30 days preceding the first dose of the study drugs or planned use during the study period

Intervention and comparator
Households will be randomized 1:1 (at the level of household), with close contact participants receiving one of the following therapies:
•HCQ 400 mg orally daily for 3 days then 200 mg orally daily for an additional 11 days
•Placebo-like control (ascorbic acid) 500 mg orally daily for 3 days then 250 mg orally daily for 11 days

Main outcomes
The primary outcome of the study is the incidence of SARS-CoV-2 infection through day 14 among participants who are SARS-CoV-2 negative at baseline by randomization group.

Randomisation
Participants will be randomized in a 1:1 ratio to HCQ or ascorbic acid at the level of the household (all eligible participants in 1 household will receive the same intervention). The randomization code and resulting allocation list will be generated and maintained by the Study Statistician. The list will be blocked and stratified by site and contact type (household versus healthcare worker).

Blinding (masking)
This is a blinded study.
HCQ and ascorbic acid will appear similar, and taste will be partially masked as HCQ can be bitter and ascorbic acid will be sour.
The participants will be blinded to their randomization group once assigned. Study team members, apart from the Study Pharmacist and the unblinded statistical staff, will be blinded. Laboratory staff are blinded to the group allocation.

Numbers to be randomised (sample size)
The sample size for the study is N=2 000 participants randomized 1:1 to either HCZ (n=1 000) and ascorbic acid (n=1 000).

Trial status
Protocol version: 1.2
05 April 2020
Recruitment is ongoing, started March 31 and anticipated end date is September 30, 2020.

Trial registration
ClinicalTrials.gov, Protocol Registry Number: NCT04328961
Date of registration: April 1, 2020, retrospectively registered

Full protocol
The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.