Conditions: COVID-19 SARS-CoV-2
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 263
Healthy volunteers: no

Brief summary:
This individually randomized telemedicine-based trial aims to evaluate the efficacy of a single dose of azithromycin for prevention of progression of COVID-19 in patients with a recent positive SARS-CoV-2 test who are not currently hospitalized.

Detailed description:
Identification of a safe, effective treatment for individuals with mild or moderate COVID-19 that prevents disease progression and reduces hospitalization would reduce the burden on the health system. High dose hydroxychloroquine is being evaluated for SARS-CoV-2 prevention and COVID-19 disease treatment, but has a high risk of a number of potentially severe adverse events. Recent evidence has indicated that the broad-spectrum macrolide azithromycin may have some activity against coronaviruses. Here we propose an individually-randomized, placebo-controlled trial to determine the efficacy of a single dose of azithromycin for prevention of COVID-19.

Potential participants will undergo remote eligibility screening with study staff prior to enrollment. Upon determination of eligibility and signing electronic informed consent documents, participants will be emailed baseline study forms and will be mailed their randomized study treatment. At the end of the study (21 days), participants will be emailed a final study questionnaire. Note that there will no contact between study staff and participants in this trial, minimizing risk of infection spread.

Arms:
arm 1: 1.2g of oral azithromycin arm 2: Matching placebo

Interventions: intervention 1: Azithromycin intervention 2: Placebos
Intervention descriptions: intervention 1: Participants will be shipped a single 1.2 g dose of oral azithromycin intervention 2: Participants will be shipped a dose of matching placebo

Protocol document:
Prot_000.pdf: 
Azithromycin for COVID-19 Trial in Outpatients Nationwide  
(ACTION) 
 
Manual of Operations and Procedures 
April 5, 2021  
NCT04332107 
 
The Francis I. Proctor Foundation, University of California, San Francisco 
Clinical Virology Laboratory, Stanford University Medical Center 
 
Catherine Oldenburg, ScD MPH 
Thuy Doan, MD, PhD 
Benjamin Pinsky, MD PhD 
Jessica Brogdon, MPH 
Ying Lin, MSPH 
Catherine Cook, MPH 
J. Daniel Kelly, MD 
Seth Blumberg, MD 
Travis Redd, MD 
Gerami Seitzman, MD 
Thomas M. Lietman, MD 
Benjamin F. Arnold, PhD 
Travis C. Porco, PhD 
Armin Hinterwirth, PhD 
Ariana Austin, MS 
Zhaoxia Zhou 
Lina Zhong, BS 
Kevin Ruder, BS 
Cindi Chen, MS 
Elodie Lebas, RN 
Fanice Nyatigo, BS 
 
 
 
 
 
 
 
 
 
 
 
 
 


Manual of Operations and Procedures v1.29 
2 
Table of Contents 
1 
Chapter 1: Overview ................................................................................................................................. 5 
1.1 
Executive Summary .................................................................................................................................... 5 
2 
Background ............................................................................................................................................... 5 
2.1 
Preliminary Studies .................................................................................................................................... 5 
2.2 
Objectives ................................................................................................................................................... 6 
3 
Chapter 2: Trial Design ............................................................................................................................. 6 
3.1 
Randomization ............................................................................................................................................ 7 
3.2 
Trial Profile ................................................................................................................................................ 8 
3.3 
Sub Studies ................................................................................................................................................. 9 
3.4 
Outcomes .................................................................................................................................................. 11 
3.4.1 
Primary Outcome ................................................................................................................................. 11 
3.4.2 
Secondary Outcomes ........................................................................................................................... 11 
3.5 
Sample Size ............................................................................................................................................... 12 
3.6 
Masking .................................................................................................................................................... 12 
3.7 
Study Period ............................................................................................................................................. 13 
3.8 
Main Study Timeline ................................................................................................................................. 14 
4 
Chapter 3: Study Eligibility ..................................................................................................................... 14 
4.1 
Inclusion Criteria ..................................................................................................................................... 14 
4.2 
Exclusion Criteria .................................................................................................................................... 14 
5 
Chapter 4: Study Methods ...................................................................................................................... 15 
5.1 
Recruitment .............................................................................................................................................. 15 
5.2 
Enrollment ................................................................................................................................................ 16 
5.2.1 
Informed Consent ................................................................................................................................ 16 
5.3 
Baseline Assessment ................................................................................................................................. 18 
5.4 
Treatment ................................................................................................................................................. 18 
5.5 
Day 3 Assessment ..................................................................................................................................... 18 
5.6 
Day 7 Assessment ..................................................................................................................................... 19 
5.7 
Day 14 Assessment ................................................................................................................................... 19 
5.8 
Day 21 Assessment ................................................................................................................................... 19 
5.9 
Reminders ................................................................................................................................................. 19 
5.10 
Kit Preparation ........................................................................................................................................ 20 
6 
Sample Collection Procedures ................................................................................................................. 21 
6.1 
Nasal Swab Collection ............................................................................................................................. 21 


Manual of Operations and Procedures v1.29 
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6.2 
Saliva Collection ...................................................................................................................................... 22 
6.3 
Rectal Swab Collection ............................................................................................................................ 22 
7 
Laboratory Procedures ........................................................................................................................... 24 
8 
Duties and Responsibilities of Staff ......................................................................................................... 25 
8.1 
Principal Investigators ............................................................................................................................. 25 
8.2 
Co-Investigators ....................................................................................................................................... 25 
8.3 
Study Coordinators .................................................................................................................................. 25 
8.4 
Biostatistician ........................................................................................................................................... 26 
8.5 
Data Analyst ............................................................................................................................................. 26 
8.6 
Laboratory Technicians ........................................................................................................................... 26 
9 
Statistical Methods .................................................................................................................................. 26 
10 
Study Medication ..................................................................................................................................... 26 
10.1 
Description ............................................................................................................................................... 27 
10.2 
Dosage ..................................................................................................................................................... 27 
10.3 
Medication Procurement/Donation .......................................................................................................... 27 
10.4 
Medication Quality Control ..................................................................................................................... 28 
10.4.1 
Drug Storage ................................................................................................................................... 28 
10.5 
Concurrent Medications ........................................................................................................................... 29 
10.6 
Measures of Treatment Compliance ......................................................................................................... 29 
11 
Adverse Event Monitoring and Safety Assessment ................................................................................. 29 
11.1 
Adverse Events ......................................................................................................................................... 29 
11.2 
Adverse Event Monitoring ........................................................................................................................ 30 
11.3 
Serious Adverse Events ............................................................................................................................ 31 
12 
Protection of Human Subjects ................................................................................................................. 32 
12.1 
Institutional Review Board Approval ....................................................................................................... 32 
12.2 
Informed Consent ..................................................................................................................................... 32 
12.3 
Risks and Benefits of Study Procedures ................................................................................................... 33 
13 
Study Monitoring .................................................................................................................................... 33 
13.1 
Protocol Violations .................................................................................................................................. 33 
14 
Data Collection, Management, and Security ........................................................................................... 34 
14.1 
Scope of the Data ..................................................................................................................................... 34 
14.2 
Data Storage, Management, and Security ................................................................................................ 34 
14.3 
Electronic Data Collection Forms ........................................................................................................... 34 


Manual of Operations and Procedures v1.29 
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14.4 
Data Review ............................................................................................................................................. 34 
14.5 
Data Entry ................................................................................................................................................ 34 
14.6 
Data Transfer ........................................................................................................................................... 35 
14.7 
Data Entry Errors .................................................................................................................................... 35 
14.8 
Data Consistency and Validity ................................................................................................................. 35 
14.9 
Data Preparation and Cleaning ............................................................................................................... 35 
14.10 
Monitoring ................................................................................................................................................ 36 
14.11 
Data Analysis ........................................................................................................................................... 36 
14.12 
Data Storage and Security ....................................................................................................................... 36 
15 
Data and Safety Monitoring Committee Charter .................................................................................... 37 
15.1 
DSMC Membership .................................................................................................................................. 37 
15.2 
Conflicts of Interest .................................................................................................................................. 37 
15.3 
Timing and Purpose of the DSMC Meetings ............................................................................................ 37 
15.4 
Procedures to Ensure Confidentiality and Proper Communication ......................................................... 38 
15.5 
Statistical Monitoring Guidelines ............................................................................................................. 39 
15.6 
DSMC Contact Information ..................................................................................................................... 39 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Manual of Operations and Procedures v1.29 
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Abbreviations 
 
COVID-19: Coronavirus Disease 2019 
DCC: Data Coordinating Center  
DSMC: Data and Safety Monitoring Committee 
SAE: Serious Adverse Event 
SARS: Severe Acute Respiratory Syndrome 
SC: Steering Committee 
UCSF: University of California, San Francisco  
WHO: World Health Organization  
1 Chapter 1: Overview 
1.1 Executive Summary  
 
Identification of a safe, effective treatment for individuals with mild or moderate COVID-19 that 
prevents disease progression and reduces hospitalization would reduce the burden on the health 
system. High dose hydroxychloroquine is being evaluated for SARS-CoV-2 prevention and 
COVID-19 disease treatment but has a high risk of a number of potentially severe adverse 
events. Recent evidence has indicated that the broad-spectrum macrolide azithromycin may have 
some activity against coronaviruses. A large community randomized trial in Niger demonstrated 
reduced viral load among children with commensal coronaviruses (prior to the emergence of 
SARS-CoV-2) in communities receiving biannual mass azithromycin distribution compared to 
placebo (submitted). In SARS-CoV-2 patients in France, the addition of azithromycin to a 
hydroxychloroquine regimen appeared to decrease SARS-CoV-2 positivity by PCR compared to 
hydroxychloroquine-only and control patients.[6] Azithromycin is generally well-tolerated and 
may be an attractive option for treating patients with mild disease.[7–10]  
2 Background 
2.1 Preliminary Studies 
 
Azithromycin has activity against RNA viruses in vitro. 
 
Azithromycin reduces rhinovirus replication in cultured primary bronchial epithelial cells 1. 
Schogler and colleagues (2015) showed that rhinovirus viral load was decreased in both 
bronchial epithelial cells isolated from healthy controls and from patients with cystic fibrosis 
when pretreated with azithromycin. This antiviral action is associated with the induction of 
interferon pathways. Furthermore, treatment with azithromycin did not induce cell toxicity in 
primary cystic fibrosis bronchial cells. 
 
Azithromycin reduces Zika proliferation and virus-induced cytopathic effects in glial cell lines 
and human astrocytes2. Retallack and colleagues (2016) showed that Zika infection of cultured 
glial cells was inhibited with azithromycin in a dose-dependent manner. The EC50 ranges from 
2.1 µM to 5.1 µM, all within the plasma levels for the current dosing of azithromycin in humans. 
Azithromycin also decreased viral production.  


Manual of Operations and Procedures v1.29 
6 
 
Azithromycin inhibits Zika infection in Vero cells3. Li and colleague (2019) showed that Vero 
cells treated with azithromycin inhibited Zika infection at a late stage of the viral cycle. The 
inhibitor concentration (IC50) ranged from 1.23 to 4.97 µM. The pretreatment of azithromycin 
increased interferon pathway responses after Zika infection.  
 
Reduction of Alpha- and Betacoronavirus viral burden is associated with mass 
azithromycin treatment 
 
Nigerien children treated with biannual oral azithromycin had reduced coronavirus viral burden 
(MORDOR Group, under review).  At 24 months, NP swabs from children that underwent 4 
azithromycin treatments had an 8-fold reduction in Alphacoronavirus and a 14-fold reduction in 
Betacoronavirus (prior to SARS-CoV-2 identification) compared to NP swabs from children 
treated with placebo.  
 
Preliminary evidence has suggested that azithromycin may reduce viral load in patients 
with SARS-CoV-2 infection. Two non-randomized studies from France evaluated 
hydroxychloroquine in combination have been reported4, 5, one of which is unpublished. In the 
first study, patients received 600 mg hydroxychloroquine daily for ten days or no treatment. Six 
patients receiving hydroxychloroquine additionally received azithromycin (500 mg on Day 1, 
followed by 250 mg per day on Days 2 through 5). The primary outcome was virologic clearance 
at Day 6. At the end of the study, 70% of patients receiving hydroxychloroquine achieved 
virologic cure compared to 12.5% in the control group. Of those receiving azithromycin, 100% 
achieved virologic control at Day 6. While these results are hypothesis-generating that 
azithromycin may have effect on virologic outcomes in SARS-CoV-2 patients, this was a small 
non-randomized study with significant methodological limitations. The second study is an 
observational cohort study of 80 patients receiving hydroxychloroquine plus azithromycin. Of 
these, 81% had a favorable outcome, 15% required oxygen therapy, 3.8% were transferred to the 
ICU, and one patient died. Viral load decreased over time, and 93% had no detectable virus at 
Day 8. Taken together, these studies are hypothesis-generating that azithromycin may have some 
activity against SARS-CoV-2 infection. Randomized placebo-controlled trials are required to 
definitively evaluate the efficacy of azithromycin for COVID-19 disease progression. 
 
 
2.2 Objectives 
 
1: To determine if a single oral dose of azithromycin is effective for improving 
recovery in patients with a positive SARS-CoV-2 PCR test with mild or moderate 
disease. We will define improved recovery as symptom free at Day 14 post 
enrollment.  
 
3 Chapter 2: Trial Design 
 
This trial will be a scalable, remote trial to evaluate the efficacy of azithromycin for the 
prevention of COVID-19 disease progression and hospitalization. The entire trial will be 


Manual of Operations and Procedures v1.29 
7 
conducted remotely via mail, telephone, and email to minimize infection risk to patients and 
study staff. 
 
3.1 Randomization 
 
Participants will be randomized in a 2:1 fashion to one of two arms. Participants will be 
randomized to receive either a single oral dose of azithromycin (1.2 g) or oral placebo. 
Participants will be randomized by the study biostatistician. The randomization will be 
implemented into REDCap. The randomization will be masked by treatment letters: AAA, 
BBB,CCC, HHH, TTT, or VVV. The masked study coordinator will send the participant their 
corresponding study treatment. The coordinator will determine the participant’s allocation by the 
patient’s REDCap record ID. Packaged study treatment will not identify whether the patient 
received azithromycin or placebo. Every attempt will be made to preserve masking and we will 
use a matching placebo to ensure masking of investigators and participants. Laboratory staff will 
be masked for all laboratory outcomes. The use of a 2:1 ratio results in a small loss in statistical 
power, however the increased probability of receiving study drug balances the loss in power with 
ethics if azithromycin were shown to be efficacious and may make enrollment in the trial more 
acceptable to patients. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Manual of Operations and Procedures v1.29 
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3.2 Trial Profile 
 
Patients with Positive SARS-
CoV-2 PCR Test Identified 
 
 
Remote Screening and Informed 
Consent 
 
 
Baseline Questionnaire  
(Day 0) 
 
 
Treatment (Shipped to 
Participant’s Home; Day 1) 
 
 
3 Day Follow-Up 
Adverse Events  
Nasal Swab  
Rectal Swab  
Saliva Swab  
 
 
7 Day Follow-Up 
Questionnaire 
 
 
14 Day Follow-Up 
 Questionnaire 
 
21 Day Follow-Up 
Final Questionnaire  
 
 
TRIAL AT A GLANCE 
 
Randomization: Individually randomized 2:1, azithromycin : placebo 
 
Intervention Arms:  
• A single, oral 1.2 g dose of azithromycin, OR 
• A single oral dose of placebo 
 
Patient Population: Patients in the United States with a positive SARS-CoV-2 PCR test with 
mild or moderate symptoms who are not hospitalized at enrollment 
 
Primary Outcome: Hospitalization by or before Day 14 
 


Manual of Operations and Procedures v1.29 
9 
 
3.3 Sub Studies 
 
Swab Sub-Study 
We will randomly select participants to collect additional swab samples in a sub-study. In 
addition to the regular treatment and questionnaire activities, the participants of the sub-study 
may be asked to:  
 
1. Self-collect a nasal, rectal, and/or saliva swab at baseline, days 3, 7, and/or 14   
 
Participants may participate in the main study swabs at Day 3 or the swab sub-study or they may 
opt not to collect swabs at all. Participants in the sub-study will not collect double swabs at day 
3. Swabs will only be collected once.  
 
The figure below outlines the possible paths for participants interested in collecting swabs.  
 
Participants may: 
1) Only collect swabs at Day 3 as part of the main study. These participants will collect up 
to 3 swabs total.  
2) Collect swabs at Baseline, Day 3, Day 7, and/or Day 14 as part of the sub-study. These 
participants will collect up to 4 nasal swabs, 4 rectal swabs, and 4 saliva swabs (up to 12 
swabs total).  
 
Patients may also opt not to collect swabs. All patients will be randomized in the same fashion as 
one group, despite the patient’s decision to collect swabs or not.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Manual of Operations and Procedures v1.29 
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Figure 1:  
 
 
 
We plan to place patients into one of three groups for the swab sub-study or a fourth group into 
the main study. The first 300 participants agreeing to take part in the sub-study will be in Group 
1. The next 300 will be in Group 2. The last 300 will be in Group 3. All other willing participants 
will be placed in Group 4 as part of the main study. The groups are outlined bellowed: 
 
Group 1=  
• Nasal Swab at Day 0 
• Nasal & Saliva Swab at Day 3 
Group 2= 
• Nasal & Saliva Swab at Day 3 
• Nasal Swab at Day 7 
Group 3= 
• Nasal, Saliva, Rectal Swab at Day 3 
• Nasal, Saliva, Rectal Swab at Day 14 
 
Participants who are willing to take part in the main study swabs but not in the sub-study swab 
group will be placed in Group 4 automatically. 
 
Group 4= 
• Nasal, Saliva, Rectal Swab at Day 3 
 
 


Manual of Operations and Procedures v1.29 
11 
 
Hospitalization Verification Sub-Study 
Proof of hospitalization in a sub-set of participants would be beneficial to validate the primary 
outcome. Therefore, we will randomly select participants who have been hospitalized for the 
hospitalization verification sub-study. We will request to access patient medical records for these 
selected patients. All participants for the trial will be requested to sign the UCSF HIPAA 
Authorization form for permission to use personal health information for research. We will also 
use the US National Death Index to link patient deaths to our study.  
 
3.4 Outcomes 
 
3.4.1 Primary Outcome 
 
The primary outcome will be a symptom-based outcome. We will conduct a binary 
assessment of whether the participant is symptom free at Day 14 (yes or no) post 
enrollment.  
 
3.4.2 Secondary Outcomes 
 
Secondary outcomes will include  
• Hospitalization: Defined as any visit to the emergency room or other hospital setting 
that resulted in a stay of 24 hours or more.  
• Adverse events: we will conduct an adverse event survey at Day 3 after treatment, 
including gastrointestinal side effects (nausea, vomiting, diarrhea, abdominal pain) and 
rash. We note that some COVID-19 patients report gastrointestinal symptoms, and this 
survey will provide data on whether azithromycin causes additional gastrointestinal 
effects beyond those symptoms. 
• Prevalence of positive swabs: we will compare the prevalence of SARS-CoV-2 positive 
swabs at Day 3 after treatment in self-collected nasal, saliva, and rectal swabs in 
azithromycin compared to placebo-treated participants. 
• Viral load: we will assess viral load by RT-PCR in self-collected nasal, saliva, and rectal 
swabs at Day 3 after treatment. 
• Mortality: we will collect emergency contact/next of kin information during the baseline 
questionnaire. We will follow-up with the emergency contact if participants are lost to 
follow-up at the Day 14 questionnaire to assess mortality and hospitalization outcomes. 
• Genetic macrolide resistance determinants: We will evaluate the prevalence of genetic 
macrolide resistance determinants ermB, mefA/E, and mphA by targeted PCR in rectal 
samples collected at Day 3 after treatment. 
• COVID-19 symptoms: we will ask patients about COVID-19 symptomology during 
each online questionnaire, including cough, fever, myalgia, anosmia, shortness of breath 
(and related abilities such as ability to walk across a room or up a flight of stairs), fatigue, 
conjunctivitis, and orthostatic symptoms. 


Manual of Operations and Procedures v1.29 
12 
• Number of emergency room visits: during each online questionnaire we will survey 
patients about any emergency room visits (with stays <24 hours) that occurred since their 
last survey. 
• Number of household members with COVID-19 (confirmed or symptomatic): during 
each online questionnaire we will ask participants how many of their household members 
have symptoms of COVID-19 or confirmed disease. 
• Death: we will attempt to link deaths among participants to the National Death Index.  
 
3.5 Sample Size 
 
The COVID-19 epidemic is changing rapidly over time. We propose a group sequential design 
with a flexible sample size that is adaptive to changing trial parameters over time with no 
maximum sample size. These designs are used in outbreak trials due to uncertainty with respect 
to parameters such as incidence and severity of outcomes. Full details on the sample size are 
provided in the Statistical Analysis Plan. In brief, the trial will employee a committee that is 
masked to results by arm that will evaluate the sample size on a weekly basis to evaluate the 
sample size based on the probability of hospitalization and enrollment.   
 
On December 2, 2020 the DSMC members agreed to revise the sample size and primary 
outcome of the trial. Our re-estimated sample size of N=455 would allow for detection of a 15% 
absolute difference in probability of being symptom free at 14 days assuming that 50% in the 
placebo arm are symptom free (this is based on the current overall percent of participants who 
are symptom free at 14 days in ACTION). Because ACTION is enrolling more slowly than we 
had anticipated and we are planning a smaller sample size and we are also planning a single 
interim analysis at approximately 50% enrollment (N=230 participants), testing for efficacy at 
p=0.001, and then assess the final outcome at p=0.049. 
 
3.6 Masking 
 
Investigators and participants will be masked to the treatment allocation. The following study 
procedures will be in place to ensure double-blind administration of study treatments.  
• Access to the randomization code will be controlled 
• A taste-matching placebo will be utilized 
• Packaging and labeling of test and control treatments will be identical to maintain the 
blind. 
The study blind will be broken upon completion of the clinical study and after the study 
database has been locked.  
 
During the study, the blind may be broken only in emergencies when knowledge of the 
patient’s treatment group is necessary for further patient management. When possible, the 
investigators should discuss the emergency with the Medical Monitor prior to unblinding.  
 
3.6.1 Unmasking Protocol  
 


Manual of Operations and Procedures v1.29 
13 
If a patient and/or their doctor is concerned about a potential drug interaction or other medical 
issue, a discussion regarding a decision to unmask may come up. 
 
If the patient has already taken the study medication: 
 
1. Dr. Thuy Doan (PI) speaks with the patient and/or their treating doctor about the specific case.  
The decision will be made between the patient, the treating physician, and Dr. Doan about 
whether unmasking is necessary. 
 
2. If no unmasking is required at the time, the issue is resolved. The patient and treating doctor 
can get back in touch if necessary. 
 
3. If unmasking is required, we will take the following steps: 
 
a. We will only unmask a treating physician who is responsible for the patient’s COVID care if 
deemed to be necessary for the care and safety of that patient. We will not directly unmask a 
patient. However, the treatin physician may unmask the patient. The study team should advise 
the patient that it is very important that they do not inform us of what thei study treatment was. 
As we are not involved in the patient’s care, there is no reason for us to know their treatment 
assignment. 
 
b. The study team will inform Dr. Ben Arnold (ACTION biostatistician) of the patient’s ID 
number and their treatment letters. 
 
c. Dr. Arnold will call the patient’s physician and relay this information to the physician. He will 
reiterate that the patient’s physician should not disclose the treatment assignment to anyone on 
the study team except for him. Dr. Arnold will have information available to him including the 
study dosing (1.2 g single dose as powder for oral suspension), when the patient was enrolled, 
and when the patient took the study drug (if known). 
 
d. Dr. Arnold or his delegate will document the incident in an event log. 
 
e. Study staff will check in with the patient, encourage the participant to continue participating in 
the study, and remind them not to inform the study team of their treatment assignment.  
 
If the patient has not yet taken the study medication: 
 
1. Dr. Doan will speak with the patient and/or the patient’s treating physician about the study. 
The decision will remain with the patient and their doctor as to whether the patient takes the 
study medication. No unmasking will occur, as any potential concerns can be avoided by simply 
not taking the study medication. We will ask the patient to document that they did not take the 
study medication on their follow-up form and the study team will document the event and the 
study team will encourage the patient to continue in the trial. 
 
3.7 Study Period  
 


Manual of Operations and Procedures v1.29 
14 
Each participant will be in the study for a total of 21 days.  
 
3.8 Main Study Timeline  
 
Timepoint 
Activity 
Day 0 
• Eligibility Screening 
• Informed Consent 
• Baseline Questionnaire 
• Randomization 
Day 1 
• Treatment 
Day 3 
• Adverse events questionnaire 
• Self-collected nasal swab (opt-in) 
• Self-collected saliva swab (opt-in) 
• Self-collected rectal swab (opt-in) 
Day 7 
• Hospitalization and symptoms questionnaire 
Day 14 
• Hospitalization and symptoms questionnaire (primary endpoint) 
Day 21 
• Hospitalization and symptoms questionnaire 
 
4 Chapter 3: Study Eligibility  
 
4.1 Inclusion Criteria 
 
Participants must meet the following inclusion criteria to be eligible for this study: 
• Evidence of a positive SARS-CoV-2 test and test results received within the previous 
seven days  
• Not currently hospitalized  
• Willing and able to receive study drug by mail 
• Willing and able to return the internet-based study questionnaires at baseline, day 3,  
7, 14, and 21 days via email or over the phone.  
• No known allergy or other contraindication to macrolides 
• No known history of prolongation of the QT interval (eg. History of torsades de 
pointes, congenital long QT syndrome, bradyarrhthmia).  
• No recent use of hydroxychloroquine within the past 7 days for participants >55 years 
of age.  
• Not currently taking nelfinavir or warfarin (Coumadin) 
• Age 18 years or older at the time of enrollment 
• Not currently pregnant  
• Provision of informed consent 
 
4.2 Exclusion Criteria  
 
Participants will be excluded if they meet any of the following criteria:  


Manual of Operations and Procedures v1.29 
15 
• Negative or no SARS-CoV-2 test and test results not received within the previous 
seven days 
• Currently hospitalized 
• Not willing and able to receive study drug by mail 
• Not willing and able to return the internet-based study questionnaires at baseline, 3, 7, 
14 and 21 days via email or over the phone 
• Known allergy or contraindication to macrolides 
• History of known prolongation of the QT interval (e.g., history of torsades de pointes, 
congenital long QT syndrome, bradyarrhthmia) 
• Recent use of hydroxychloroquine (past 7 days) for participants >55 years of age 
• Currently taking nelfinavir or warfarin 
• Younger than 18 years old at the time of enrollment 
• Currently pregnant  
• No provision of informed consent  
5 Chapter 4: Study Methods  
 
5.1 Recruitment 
 
We will employ several recruitment methods for this trial.  
 
A. Stanford University Clinical Virology Laboratory  
The primary method of recruitment is in partnership with laboratories performing SARS-CoV-2 
testing. Patients with a positive SARS-CoV-2 test will be identified from the laboratory, and with 
receipt of a positive test, patients will be sent an email or letter inviting them to contact the study 
staff for screening and enrollment if interested.  
 
The Clinical Virology Laboratory at Stanford University, which conducts the vast majority of 
Northern California’s SARS-CoV-2 testing will be our first laboratory partner. Recruitment 
could be expanded to include additional laboratories nationwide.  
 
B. Flyers/Social Media 
We will also use flyers to advertise the study at COVID-19 testing locations and public spaces.  
Social media platforms will also be used such as Facebook, Twitter, and Instagram. We will also 
use social media to create an online ad campaign for the study. Please see the appendix for a 
template of the social media documents.  
 
C. Study Website 
We will create a study specific website designed to recruit participants and provide more 
information about the study. The website can be found here: https://proctor.ucsf.edu/action-trial. 
The link to the REDCap screening questionnaire can be found directly on the website. The 
website also contains contact information, frequently asked questions, and eligibility criteria.  
 
Participants can contact study staff if they are interested by phone at 415-326-3761 or by 
emailing ACTIONTrial@ucsf.edu.  


Manual of Operations and Procedures v1.29 
16 
 
D. Open Door Health, Rhode Island  
Open Door Health in Providence, Rhode Island will also assist with recruitment activities for this 
project. Open Door Health is one of the first primary care centers in Rhode Island that is 
dedicated to serving LGBTQ+ Rhode Islanders. The facility serves a large Black, 
Hispanic/Latinx, and immigrant population. The coordinators at Open Door Health will help 
recruit participants by passing out flyers and providing COVID positive patients with the study 
email and phone number.  
 
E. Every Door Direct Mail with USPS  
Every Door Direct Mail, or EDDM, is targeted marketing with the US postal service. We will 
create a postcard advertising the study. We will then work with the US postal service to deliver 
the postcard to residences along mail routes in selected zip codes. The postcard will contain 
study info, the study website, and the study contact info. Interested participants can call or email 
us directly or visit the study website. See the appendix for an example of the postcard used.  
 
F. WebMD  
WebMD is an online platform for news and information regarding human health. WebMD 
publishes COVID-19 specific information which reaches approximately 14 million people per 
month. Advertising ACTION on WebMD’s COVID content pages enables us to reach potential 
participants nationwide. We will place electronic ads as banners on their website. Interested 
participants can click ‘learn more’ and then they will be directed to the study screening form.  
 
5.2 Enrollment 
 
Interested participants will be remotely screened for eligibility prior to enrollment. Participants 
can be screened by phone or by an electronic REDCap form accessible from the study website. If 
eligible, study staff will call the participant and collect informed consent electronically via 
DocuSign. Upon determining eligibility and signing electronic informed consent documents, 
study staff will ask the participant to provide their mailing address. Study staff will then mail the 
participant their randomized treatment allocation, self swabbing materials, and email an 
electronic baseline questionnaire. No contact between study staff and participants in this trial will 
take place as to minimize risk of infection spread. At the end of the screening questionnaire, we 
will collect phone number and email information from the eligible participants. We will also 
require patients to provide proof of their positive test result by uploading documentation through 
REDCap.  
 
The data analyst will inform the coordinator daily of the new eligible participants. Coordinators 
will then call participants to review the study and informed consent form.  
 
5.2.1 Informed Consent 
 
Consent scripts will be submitted and approved by the UCSF IRB committee in San Francisco, 
California prior to study implementation. The informed consent document will be sent 
electronically to eligible participants with the Experimental Subject’s Bill of Rights. Children 
under the age of 18 will not be eligible. All participants will be informed about the possible risks 


Manual of Operations and Procedures v1.29 
17 
and benefits of treatment. If the participant wishes to withdraw themselves from the study, they 
may do so at any time.  
 
The informed consent form will be sent electronically to the participant’s email address via 
DocuSign while the coordinator is on the phone with the patient. The coordinator will review the 
form with the patient. If the patient wishes to participate, they will sign the form electronically. 
Electronic signed consent forms will be uploaded to the UCSF Box account for ACTION.  
 
5.2.1.1 Informed Consent for Spanish Speaking Participants 
 
We will utilize the UCSF IRB’s “preferred method” of informed consent for Spanish speakers. A 
qualified translator will translate all study documents including the informed consent 
document, the study surveys, the patient instructions, and all study documents. Spanish 
speaking participants will be called over the telephone with a study staff member and a 
qualified medical interpreter. The communication plan is outlined below: 
 
1. If a participant submits a screening form, the study staff will contact the medical 
interpreter to set up a time to call the participant. Once a time is established, the study 
staff will call or text the participant in Spanish to confirm the time.  
2. If a Spanish speaking potential participant calls the study phone number, the study staff 
member will attempt to communicate that we will call back with the interpreter. A 
follow-up text will be sent in Spanish confirming a time the medical interpreter will call 
back to review the study and informed consent.  
3. If a participant submits an English screening form, we will follow the steps from item #1 
listed above and move this participant into the Spanish REDCAP project for ACTION. The 
English record ID for this participant will be deleted after transferring their information 
to the Spanish REDCAP project. This ensures that the participant will receive all study 
documents in Spanish throughout the study.  
 
5.2.1.2 Informed Consent for Non-English and Non-Spanish Speakers 
 
We will utilize the IRB’s “short form method” to consent non-english and non-spanish speakers. 
The Experimental Subject’s Bill of Rights form will be presented to the subject in their primary 
language. An interpreter will translate the UCSF IRB approved consent form to the subject. The 
consent discussion will occur with the study staff member, interpreter, and subject on the 
phone simultaneously. The subject will sign the Bill of Rights form and the interpreter obtaining 
consent will sign the English consent form.  
 
5.2.1.3 Informed Consent for Computer Illiterate Participants 
 
Some participants may be unable to navigate email and DocuSign to provide their electronic 
signature on the consent document. In this case, several steps will be taken in order to obtain 
informed consent from these participants.  


Manual of Operations and Procedures v1.29 
18 
1. The translator or coordinator will review the steps from the document “How to use 
DocuSign” over the phone with the participant. See appendix for this document.  
2. If the participant is still unable to use email and/or DocuSign, we will ask if there is 
anyone in the subject’s household who could assist them with using the computer to 
open the ICF document. The participant will sign on their own.  
3. If the subject is still unable to navigate the consent form, we will explain that we will 
mail them two paper copies of the consent form with FedEx Priority First Overnight mail. 
We will call the participant back when they have received the package and review the 
consent form with them while they have the paper copy in front of them. We will then 
ask them to sign one copy of the consent form and mail it back to us in a provided pre-
paid FedEx envelope. The participant will place the package outside their front door and 
the UCSF coordinator will organize the FedEx pick up for them. The participant keeps the 
second copy of the ICF.  
 
 
5.3 Baseline Assessment 
 
Once a participant is determined eligible for the study and informed consent has been signed, 
they will be asked to complete an electronic baseline questionnaire via REDCap. Participants 
will be asked to provide information about their health and contact information in order to 
facilitate follow-up. Next of kin information will be collected in the event that the patient is 
unresponsive due to hospitalization or death. Please see the questionnaire in the appendix.  
 
Participants unable or unwilling to electronically complete the questionnaires themselves may 
call the study coordinator who can fill out the survey on their behalf over the phone. Participants 
may also utilize a designated alternate, such as a family member, to fill out the electronic 
questionnaire on their behalf. The coordinator will make a note on the patient Masterfile if they 
filled out a questionnaire on the subject’s behalf.  
 
A sub-set of participants in the swab sub-study will be asked to collect a nasal swab at baseline.  
 
5.4 Treatment  
 
Participants will receive a single oral dose of azithromycin (1.2 g) or placebo in the mail directly 
to their home. The treatment will come as an oral suspension. The patients will receive 
instructions for how to administer the treatment.  Participants will be unaware if they have 
received azithromycin or placebo. Details on study medication are outlined in Chapter 7. Only 
eligible participants will be treated.  
 
5.5 Day 3 Assessment  
 
Three days after treatment, participants will be asked to complete a brief adverse event survey.  
They will also be asked to self-collect sample specimens, if they are willing to.  The first will be 
a nasal swab. The second will be a saliva swab. The third swab will be a rectal swab. The swab 


Manual of Operations and Procedures v1.29 
19 
kits will be mailed to the patient directly. Patients will have detailed instructions outlining how to 
collect the swabs.  The swab procedure is outlined in Chapter 6. After collecting the swabs, the 
patient will mail the specimens back to the UCSF Proctor Foundation for analysis. Directions for 
shipping the samples back to the Proctor Foundation will be provided. We will mail participants 
pre-assembled category B biological substance shipping materials and a pre-paid shipping slip. 
Participants will call FedEx directly to schedule a pick-up or they will contact the study 
coordinator to schedule the pick-up for them.  
 
Participants may opt out of the swab collection if they wish to do so. During the initial screening 
questionnaire, we will ask if participants are willing to collect the swabs. Participants can still 
participate in the trial, opting to only receive the medication and not perform the swabs. 
 
Some participants may be willing to participate in the swab sub-study (determined at consent). 
These patients will be asked to collect saliva, rectal, and nasal swabs at Day 3. They will only 
collect these swabs once, and they will not collect Day 3 swabs as part of the main study.  
 
 
5.6 Day 7 Assessment 
 
Participants will complete a questionnaire 7 days post baseline. The questionnaire will ask about 
the patient’s health status and hospitalization status. The REDCap questionnaire will be sent 
electronically to the patient’s email address.  
 
A small subgroup of patients (100 per arm) will be asked to collect a rectal, saliva, and nasal 
swab at the Day 7 timepoint.  
 
5.7 Day 14 Assessment 
 
Participants will complete an electronic follow-up questionnaire at 14 days post treatment. This 
is our primary endpoint. We will contact the next of kin provided by the participant during 
enrollment for vital status and hospitalization information for participants who do not return their 
electronic questionnaire within 4 days of the due date.  
 
A small subgroup of patients (100 per arm) will be asked to collect a rectal, saliva, and nasal 
swab at the Day 14 timepoint.  
 
5.8 Day 21 Assessment  
 
A final electronic REDCap survey will be sent to participants at day 21. This is the final study 
questionnaire. The questionnaire will be similar to the Day 14 survey. Information about the 
patient’s health and hospitalization status will be collected.  
 
5.9 Reminders 
 


Manual of Operations and Procedures v1.29 
20 
Participants will be sent reminders if the questionnaires are not completed. The first reminder 
will be sent via email 1 day after non-completion. A text reminder will be sent 2 days after non-
completion. A study coordinator will call the participant if the questionnaire is not completed 
within 3 days. If the respondent fails to answer the 14-day timepoint questionnaire, the study 
coordinator will call the next-of-kin emergency contact if the questionnaire is not completed 
within 4 days of the due date.  
 
5.10 Kit Preparation 
  
Laboratory staff at the F.I Proctor Foundation will prepare the patient kits to be sent to the 
participant’s residence. Each kit will include all materials necessary for the trial. The kit will 
include: 
• The treatment allocation 
• Swabs 
• Cryogenic tubes with Zymo media 
• Gloves 
• Scissors 
• Instructions for each swab collection procedure and patient handbook 
• Parafilm 
• Ziploc bags 
• Category B Biological Substance Packaging for UN3373 materials 
• Pre-paid shipping labels 
• Patient Healthcare Provider Cards 
 
The coordinator will sign out kits by scanning a barcode on a REDCap form when the kit is 
mailed to the patient. Study laboratory staff will sign in kits when they arrive from the 
participant. A barcode will once again be scanned into a REDCap form. Each kit will have a  
color coded sticker on the outside to identify which swab group the participant is in. The color 
scheme is:  
 
Red: Group 1  
Green: Group 2 
Yellow: Group 3, Day 3 
Blue: Group 3, Day 14 
Blank: Group 4 
 
Patient ID numbers will be generated by REDCap. The patient ID number will link the 
participant to the study questionnaires, treatment allocation, and swabs.  
 
Each sample will be coded with a unique number. Swabs will be coded as a 6 digit number 
starting with a letter. For example, nasal swabs will be coded as N123456. Rectal swabs will be 
coded as R123456. Saliva swabs will be coded as S123456.  These codes will also be generated 
by Zhaoxia Zhou.  
 


Manual of Operations and Procedures v1.29 
21 
Healthcare provider cards will be provided in each kit. Participants will be instructed to provide 
this card to their healthcare provider in the event that they seek medical attention while in the 
study. The card will contain contact information that the provider may call to find out which 
medication, azithromycin or placebo, the patient has received as part of this study.  
 
5.11 Drawing Prizes 
 
A random drawing will be included in this study. The drawing will be open to all individuals in 
the study, individuals who are invited to participate in the study but decline, prospective subjects 
who are ineligible, subjects who withdraw from the study, and any individual who asks to be 
included. Winners will receive a gift card valued at $100.00. We will select one winner after 
every 500 people are included in the drawing. Winners will be notified by telephone or email, 
and the gift card will be mailed to their home address.  
 
The odds of winning will be about 1 in 500. We will continue to do the drawing throughout the 
time that we are recruiting participants for this study.  
 
For any drawing, the odds of winning a prize depend on how many people are entered in the 
drawing. As we do not know how many people will participate in this study related drawing, we 
cannot predict what will be the odds of winning a prize.  
 
5.12 Emergency Room Follow-Up 
 
Participants who report an emergency room visit during their follow-up surveys will be re-
contacted by the study team by phone or email. The participant will be asked to provide more 
detail regarding their emergency room visit. The study team member will ask the participant the 
primary reason for their emergency room visit, which interventions they received, and any other 
relevant information such as how long they were in the ER for. The participant’s responses will 
be recorded in RedCap. 
 
6 Sample Collection Procedures  
 
6.1 Nasal Swab Collection 
 
Willing participants will collect a self nasal swab on Day 3 of the study. A small group of 200 
participants will be asked to collect a nasal swab at day 7 and day 14 too.  
 
Participants will be instructed to:  
 
1. Wash hands with soap and water. 
2. Place the collection tube (labeled “NASAL”) that is half-filled with clear liquid into the 
Styrofoam block and loosen but do not remove the cap. 
3. Blow your nose to get rid of excess mucus. 
4. Insert swab into one nostril, not too far, just so the cotton tip is inside your nose. 


Manual of Operations and Procedures v1.29 
22 
5. Rotate the swab against the nostril wall. Turn the swab a full 360°  a total of two times. 
6. Using the same swab, repeat steps 4 and 5 in the other nostril. 
7. Open the tube and place the cotton end of the swab into the tube up to the marked line. 
8. Break the swab stick by bending to snap the swab. 
9. Put the cap back on the tube, making sure it is closed tightly and will not leak or spill and 
remove the tube from the Styrofoam block. 
10. Gently stretch the parafilm around the seal on the tube. The film should stretch and stick 
to itself as you wrap the film around the tube. 
11. Place the sealed tube back inside the provided kit bag and seal it shut. 
12. Place the sealed kit bag into the provided biohazard bag. 
13. Wash hands with soap and water.  
 
 
6.2 Saliva Collection  
 
Participants will also self collect a saliva swab on Day 3 of the study. The instructions will be 
included in the kit mailed to the participant’s home. A small group of 200 participants will be 
asked to collect saliva at Day 7 and Day 14 as well. The instructions to collect a saliva swab are:  
 
1. Wash hands with soap and water. 
2. Place the collection tube (labeled “SALIVA”) that is half-filled with clear liquid into the 
Styrofoam block and loosen but do not remove the cap. 
3. Open the swab and place the cotton end of the swab beneath your tongue. 
4. Keep the swab under your tongue for one (1) minute. Do not move the swab to other 
parts of the mouth. 
5. Open the tube and place the cotton end of the swab into the tube. 
6. Cut the swab using the provided scissors one finger width above the end of the cotton (~1 
inch from cotton tip). See handout for scale (if needed). Allow the cotton end of the swab 
to gently fall the rest of the way into the tube. Dispose of the swab handle in the trash. 
7. Put the cap back on the tube, making sure it is closed tightly and will not leak or spill and 
remove the tube from the Styrofoam block. 
8. Gently stretch the parafilm around the seal on the tube. The film should stretch and stick 
to itself as you wrap the film around the tube. 
9. Place the sealed tube back inside the provided kit bag and seal it shut. 
10. Place the sealed kit bag into the provided biohazard bag. 
11. Wash hands with soap and water. 
 
 
6.3 Rectal Swab Collection 
 
A rectal sample will be collected from a small subset of about 300 participants. The first 300 
participants included in the study will be asked to collect a rectal swab during day 3 of the study.  
Additionally, a small group of 200 participants will be asked to collect a rectal swab at day 7 and 
day 14 as well. The steps for collection, processing, and storage include: 
 
1. Take the provided swab package. 


Manual of Operations and Procedures v1.29 
23 
2. Position for the swab  
a. The patient should stand in a squatting position.  
3. Carefully remove the swab from the package and be sure the cotton tip is not touched.  
4. Insert the tip of the swab into the patient’s anus only as far as needed to make contact 
with fecal material (1 to 3 cm). Rotate the swab 180 degrees.  
5. The tip should be a brownish color when removed from the patient. 
6. Place the swab into the preservative into the collection tube. Be sure the swab is fully 
submerged in the liquid preservative and then break the swab off using the pre-scored 
breaking point.  
a. If the swab cannot be broken off while the tip is fully submerged in the liquid, 
twirl the swab in the liquid first.  
7. Tightly screw the cap back on the collection tube. 
8. Wrap the area where the cap meets the tube with Parafilm to ensure the sample will not 
leak. 
9. Place the tube in the rectal swab container.  
 
All samples will be sent to the Coordinating Center. These samples are stored and shipped at 
ambient temperature using Category B Biological Substance shippers and pre-paid packaging 
slips. The instructions for shipping will be clearly marked in the instruction packet given to 
participants.  
 
 
Packing Instructions: 
1. Make sure the ULINE 6 cell absorbent sheet (white 
pouch) contains each of the samples you have collected. 
Make sure each sample is in a separate pouch. (See 
Figure 1). 
2. Insert fully prepared absorbent sheet into the provided 
biohazard bag (See Figure 2). 
3. Seal specimen bag by following instructions printed on 
the front of the bag.  
4. Insert one sheet of the provided bubble wrap inside the 
bottom of the ULINE shipping box. 
5. Place sealed biohazard bag should be placed on top of the 
bottom layer of bubble wrap. 
6. Place the second sheet of bubble wrap on top of the 
sealed specimen bag. 
7. Fold the top of the box down and insert each of the tabs 
into the sides of the box to fully close. (See Figure 5). 


Manual of Operations and Procedures v1.29 
24 
8. Seal the box with tape to make sure it does not open 
during shipping. 
9. On top of the ULINE shipping box, remove or black out 
the old shipping label. 
10. Take the new shipping label, provided with the kit and fill 
out your NAME, ADDRESS, AND PHONE NUMBER 
under the FROM section (Section 1). Be sure to press 
hard with a ballpoint pen. Everything else on the shipping 
label will be filled out for you. 
11. Remove the top sheet of the shipping label to keep for 
your records. There should be two sheets remaining on 
the shipping label. Do not remove the FedEx copy. 
12. Flip the label over and peel the backing off of the label. 
The back of the label should be sticky. 
13. Stick the new label over the old label. Press down firmly 
on all corners to make sure it sticks. 
14. Proceed to the shipping instructions to send your samples 
back to UCSF. 
 
Shipping Instructions: 
 
There are two ways to ship your samples back to UCSF. Each are described below: 
 
1. Coordinator Assisted Shipping 
a. Contact the UCSF study coordinators at 415-326-3761 or 
ACTIONTrial@ucsf.edu 
b. The coordinators will take down your information and schedule a pickup at your 
house. Prepare to receive another call for further information about your samples’ 
pick up. 
 
2. Self-Schedule Shipping 
a. Call FedEx at 1-800-463-3339 
b. Say “schedule pick-up”. 
c. Say “I don’t have an account number, use tracking number” 
d. Continue scheduling a time that works for you. When you are finished, leave your 
package outside your door. 
The total process should take five to ten minutes. If you are uncomfortable with 
this method please call the study coordinators instead as mentioned above. 
 
7 Laboratory Procedures  
 
All laboratory processing will be done at the conclusion of the trial. Samples will be de-
identified. All laboratory personnel will be masked and samples will be processed in a 
randomized fashion.  
 


Manual of Operations and Procedures v1.29 
25 
Nasal swabs are placed in Zymo, which inactivated all infectious agents, including SARS-CoV-
2. RNA will be extracted and subjected to RT-PCR to detect the E gene of SARS-CoV-2. 
 
E Gene Primers and Probes 
Sequence (5’ to 3’) 
SARS-CoV-2_E_Fwd 
ACAGGTACGTTAATAGTTAATAGCGT 
SARS-CoV-2_E_Rev 
ATATTGCAGCAGTACGCACACA 
 
Probe 
Sequence (5’ to 3’) 
SARS-CoV-2_E_Prb-FAM 
ACACTAGCCATCCTTACTGCGCTTCG 
 
 
8 Duties and Responsibilities of Staff 
 
8.1 
Principal Investigators  
The principal investigators of this trial are Thuy Doan, MD, PhD and Catherine Oldenburg, ScD.  
- 
Develop study design, specific aims, and outcome measurements, with the help of the 
biostatistician, study coordinators, and partners 
- 
Obtain grant funding with help of partners 
- 
Ensure that the staff follow the protocol and properly execute all areas of research 
- 
Ensure that all ethical approvals are maintained 
- 
Write or add major contributions to all study-related publications 
- 
Ensure proper masking procedures for staff involved in the study 
- 
Supervise all aspects of the study 
8.2 
Co-Investigators 
- 
Assume responsibility for the study in the absence of the Principal Investigators 
- 
Supervise team members to ensure conformity to study procedures 
- 
Assist in study design and development of statistical analysis plan 
- 
Contribute to major decisions regarding the study 
8.3 
Study Coordinators  
- 
Ensure the execution of the study per protocol 
- 
Coordinate with outside laboratory sites 
- 
Manage correspondence with participants 
- 
Maintain all ethical clearances for the study, including IRB renewals, DSMC approvals, 
and FDA requirements 
- 
Prepare all forms and documents needed  
- 
Screen potentially eligible participants 
- 
Collect informed consent from participants 
- 
Arrange logistics for mailing participants their study kits 
- 
Purchase, maintain, and organize study supplies 
- 
Maintain communication and partnership with Princiapl Investigators regarding all study 
activities and plans  


Manual of Operations and Procedures v1.29 
26 
- 
Appropriately back up forms and data 
8.4 
Biostatistician  
- 
Create the statistical analysis plan (SAP) 
- 
Prepare the randomization allocation list 
- 
Receive all study data and review for quality control purposes 
- 
Ensure appropriate masking 
- 
Prepare data analysis plan for DSMC meetings, oversee analysis and prepare all 
presented data for DSMC meetings, reports, publications, and FDA reports.  
8.5 
Data Analyst  
- 
Create and maintain the database for all collection and results related data for the study 
- 
Monitor correct receipt of data after each collection visit 
- 
Develop consistency checks in the data management 
- 
Verify data inconsistencies with study coordinator  
- 
Analyze and provide data regarding collection and results for study staff when needed, 
such as for publications, DSMC meetings, or other reports 
- 
Back up all data appropriately  
- 
Follow up on any missing data or lab results  
8.6 
Laboratory Technicians 
- 
Prepare patient study kits with all materials needed for the study 
- 
Organize study supplies 
- 
Prepare patient information sheets and swab instructions  
- 
Scan swabs received from the participants into the REDCap database 
- 
Assist with laboratory analysis of samples 
- 
Assist with biobanking and storage of specimens 
9 Statistical Methods  
 
Please see the Statistical Analysis Plan for details on pre-specified statistical methods for this trial.  
 
The primary analysis will estimate the risk difference (RD) and risk ratio (RR) comparing 
azithromycin to placebo. We will estimate these parameters using a logistic regression model 
with a single covariate for treatment arm. We will estimate the RD and RR from the logistic 
regression using marginal standardization, and a bootstrap for 95% confidence intervals [5,6]. 
We will compute P-values for differences between arms using a permutation test with the 
difference between arms as the test statistic and 10,000 iterations. 
 
The secondary analysis of viral load will compare log transformed values of relative read and 
number of reads using a t-test. We will compute P-values for differences between arms using a 
permutation test with the difference between arms as the test statistic and 10,000 iterations. 
 
Determination of statistical significance for the primary and secondary analysis will follow the 
final alpha-spending function determined by the group sequential design. 
 
10 Study Medication 
 


Manual of Operations and Procedures v1.29 
27 
The study drug product will be obtained from Pfizer, Inc. Participants enrolled in the study will 
be offered a dose of oral azithromycin or placebo determined by their randomization allocation. 
We will monitor adverse events following treatment as described in Chapter 9.  
 
10.1 Description  
 
Azithromycin, or Zithromax, is supplied as an oral suspension in bottles containing azithromycin 
dehydrate powder equivalent to 1200 mg per bottle and the following inactive ingredients: 
sucrose, tribasic anhydrous sodium phosphate, hydroxypropyl cellulose, xanthan gum; FD&C 
Red #40, and flavoring including spray dried artificial cherry, crème de vanilla, and banana. 
After constitution, a 5 mL suspension contains 200 mg of azithromycin. This study will utilize 
the European Union formulation of the drug, which is comparable to the United States 
formulation.  
 
10.2 Dosage 
 
Azithromycin and placebo will be administered as a single oral 1.2 g dose. Individuals who are 
allergic to macrolides/azalides will not be enrolled in the study. We propose providing a 1.2 gm 
oral dose depending on immediate availability and formulation for azithromycin and placebo. A 
single 1 g dose of azithromycin in adults is approved for many common indications, including 
Chlamydia trachomatis urethritis and chancroid. This is also the dose used for treatment of 
trachoma, an ocular infection caused by Chlamydia trachomatis.  
 
The efficacy of azithromycin for prevention of COVID-19 progression in SARS-CoV-2 positive 
patients is unknown, as is optimal dosing. Approved oral dosing for other indications includes: 
• 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 
• A single dose, give from 1 gm to 2 gm 
 
Single dose regimens have clear advantages in adherence and regimen completion. The long 
half-life of azithromycin (68 hours for a single oral 500 mg dose) facilitates single dosing. 
However, this may come at the cost of increased risk of gastrointestinal symptoms.   
 
The comparator group for this trial will be a masked placebo. We propose to use placebo due to 
the lack of safety and efficacy data for azithromycin in COVID-19 patients and because data 
generated by uncontrolled studies is unreliable. 
 
10.3 Medication Procurement/Donation 
 
Azithromycin and the placebo have been donated by the Pfizer Corporation. There will be no 
costs to acquiring the study medication. Pfizer, Inc. will ship azithromycin and placebo to the 
Proctor Foundation and study staff will send the treatment directly to patients. The lot numbers 
from the first shipment of drug are: 
 
Placebo: P9640004 
Azithromycin: 838900 


Manual of Operations and Procedures v1.29 
28 
 
10.4 Medication Quality Control  
 
Medication will be stored at the Proctor Foundation between the temperature of 15oC to 300C.  
The study coordinator and other staff will regularly check and record the study medication 
expiration dates. Expired medication will be discarded. The drug expires on November 30, 2021.  
 
10.4.1 Drug Storage 
 
The initial drug shipment from Pfizer, Inc.  on May 22, 2020 will include 4, 707 bottles of 
azithromycin (98 cartons)  and 2,352 bottles of placebo (49 cartons). The drug will be stored at 
the UCSF Proctor Foundation at 513 Parnassus Avenue MedSci S347 San Francisco, CA 94143. 
The drug will be kept between 59oF and 85oF in a locked room. Temperature will be monitored 
using a data logger. Data from the temperature data logger will be uploaded on a monthly basis.  
 
The coordinator will maintain a smaller supply of drug stock at her place of residence until the 
shelter-in place order is lifted. The coordinator will keep at least 15 bottles of each treatment 
letter in stock at 487 Sherwood Drive Sausalito, CA 94965. Temperature will be monitored at 
this location using a data logger. The temperature information will be uploaded monthly.  
 
Logs will be maintained at both locations regarding stock and drug delivery on a weekly basis.  
 
10.5 Packaging and Labeling  
 
The study drug will be relabeled and packaged by UCSF laboratory personnel. Laboratory staff 
will completely remove the Zithromax labels and place the study label stickers on the bottle. The 
labels will indicate one of 6 letters: AAA, BBB, CCC, HHH, TTT, or VVV.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Manual of Operations and Procedures v1.29 
29 
Labeling Example: 
 
 
 
Once re-labeled, the drug will be given to the study coordinator. The study coordinator will place 
the corresponding treatment allocation into each participant’s kit prior to sending it to the 
participant’s address. The coordinator will use REDCap to determine each participant’s 
treatment allocation letter.  
 
10.6 Concurrent Medications 
 
Participants are free to seek treatment for their COVID-19 symptoms outside of the study. 
Participants will be advised to avoid antacids containing aluminum or magnesium while in the 
study. Participants will be asked about concurrent medications taken at the follow-up 
questionnaires.  
 
10.7 Measures of Treatment Compliance 
 
Subjects will be asked to confirm if they took the study drug and on which date during the Day 3 
questionnaire.  
 
11 Adverse Event Monitoring and Safety Assessment  
 
11.1 Adverse Events 
 
Azithromycin has been extensively studied in humans for many indications, including 
community-acquired pneumonia and urethritis and cervicitis caused by Chlamydia trachomatis 
and Neisseria gonorrhoeae. Azithromycin is generally well-tolerated. The most common adverse 
events following azithromycin are diarrhea (5 to 14%), nausea (3 to 18%), abdominal pain (3 to 
7%), and vomiting (2 to 7%). Rarer side effects include abnormal liver function, allergic 


Manual of Operations and Procedures v1.29 
30 
reactions, and prolongation of the QT interval. Diarrhea due to Clostridium difficile has been 
reported in rare cases.  
 
Participants who are over 55 years of age and have taken hydroxychloroquine within the past 7 
days will be excluded from this study due to concerns of QT prolongation.  
 
Azithromycin is contraindicated in patients with known hypersensitivity to azithromycin, 
erythromycin, any macrolide or ketolide drug.  
 
Azithromycin is also contraindicated in patients with a history of cholestatic jaundice/hepatic 
dysfunction associated with prior use of azithromycin. 
 
The common adverse reactions that may occur will be explained in detail to the participants 
during the informed consent process. Participants will report any adverse events they have 
experienced during the Day 3 questionnaire. If a participant has a serious adverse event or any 
other concerns, they will be advised to contact their healthcare provider and/or 911. Participants 
can also email or call the study staff if they have any concerns.  
 
Some adverse reactions were reported with azithromycin during the post-marketing period in 
adult and/or pediatric patients for which a causal relationship may not be established. These 
symptoms include: 
 
Allergic: Arthralgia, edema, urticaria, and angioedema. 
Cardiovascular: Arrhythmias including ventricular tachycardia and hypotension. There have 
been reports of QT prolongation and torsades de pointes. 
Gastrointestinal: Anorexia, constipation, dyspepsia, flatulence, vomiting/diarrhea, 
pseudomembranous colitis, pancreatitis, oral candidiasis, pyloric stenosis, and reports of tongue 
discoloration. 
General: Asthenia, paresthesia, fatigue, malaise, and anaphylaxis.  
Genitourinary: Interstitial nephritis and acute renal failure and vaginitis. 
Hematopoietic: Thrombocytopenia. 
Liver/Biliary: Abnormal liver function, hepatitis, cholestatic jaundice, hepatic necrosis, and 
hepatic failure. [see Warnings and Precautions (5.2)] 
Nervous System: Convulsions, dizziness/vertigo, headache, somnolence, hyperactivity, 
nervousness, agitation, and syncope. 
Psychiatric: Aggressive reaction and anxiety. 
Skin/Appendages: Pruritus serious skin reactions including erythema multiforme, AGEP, 
Stevens-Johnson Syndrome, toxic epidermal necrolysis, and DRESS. 
Special Senses: Hearing disturbances including hearing loss, deafness and/or tinnitus, and reports 
of taste/smell perversion and/or loss 
 
 
11.2 Adverse Event Monitoring  
 
Adverse events will be formally monitored using an electronic questionnaire at Day 3. 
Participants will be asked to report any adverse events they have experienced since taking the 


Manual of Operations and Procedures v1.29 
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study drug. Participants will be asked if they have experienced the following adverse events 
since they last completed the study questionnaire: 
• Nausea 
• Vomiting 
• Diarrhea 
• Rash 
• Abdominal pain 
• Other 
 
During the informed consent procedure, participants will be instructed that participation in the 
trial does not replace or represent their medical care. While there will be a study email address 
which participants can use to contact study investigators, it is not monitored full-time and is not a 
replacement for medical care, nor can the study staff offer medical advice. Participants will be 
instructed to contact their medical care provider for medical advice or call 911 in case of 
emergency. 
 
Participants do not have to wait until the Day 3 questionnaire to report adverse events. 
Participants will be encouraged to contact the study staff at any time for any adverse events or 
concerns.  
 
11.3 Serious Adverse Events 
 
A Medical Monitor for the trial will be designated by the study lead investigators. The Medical 
Monitor will review all SAE’s that occur and evaluate the likelihood of an association to the 
study drug. If deemed possibly related to the study drug by the Medical Monitor, the SAE will be 
forwarded to the DSMC and IRB if necessary. The Medical Monitor for this study will be Dr. 
Dan Kelly, an internal medicine and infectious disease specialist at UCSF.  The Medical Monitor 
will review serious adverse event cases ideally within 24 to 48 hours. Other adverse events will 
be analyzed by arm at the end of the study or per request from the DSMC.  
 
Any serious adverse events will be reported to Pfizer. An ISR SAE Form (Investigator-
Sponsored Research Serious Adverse Events Form) will be completed by study personnel for 
each event and sent to SAEFaxmailbox@Pfizer.com.  
 
An SAE is defined as any adverse event that: 
• Results in death 
• Is life-threatening (i.e., causes an immediate risk of death) 
• Results in persistent or significant disability or incapacity  
• Results in a congenital anomaly or birth defect 
• Changes the risk/benefit ratio of the study 
• Any cardiovascular related or unrelated serious adverse event 
 
Or that is considered to be: 
 
• An important medical event 


Manual of Operations and Procedures v1.29 
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Serious adverse events will be reported to Pfizer,  the Data and Safety Monitoring Board and the 
Institutional Review Board at the University of California, San Francisco. Any event deemed to 
be definitely, probably, or possibly related and is serious or unexpected will be reported to the 
IRB within 5 days. Deaths and life-threatening events will be reported immediately. 
 
UCSF will be responsible for discerning which medical occurrences meet the serious adverse 
event criteria. UCSF personnel will then fill out an ISR SAE form and submit to Pfizer no later 
than 48 hours from UCSF’s awareness date. UCSF awareness date should be noted on the ISR 
form. UCSF will report SAEs around the clock, 7 days a week. UCSF should not report duplicate 
reportings of SAEs and provide the causality determined by the Medical Monitor.  
 
Serious adverse events will also be reported to the Food and Drug Administration (FDA). UCSF 
will be in compliance with the FDCA (21 USC 301 et seq) and Title 21 of the code of federal 
regulations. UCSF will report any unexpected fatal or life-threatening suspected adverse 
reactions to the FDA no later than 7 days after initial receipt. UCSF will also report SAEs, 
findings suggesting significant human risk, and/or clinically important events that increase the 
rate of SAEs within 15 days after determining the information qualifies for reporting. UCSF 
must always cite the IND number 149526 on all correspondence. Additionally, UCSF will sumit 
an annual progress report within 60 days of the anniversary of the IND active date (4/18/2020).  
 
12 Protection of Human Subjects 
 
The research team will obtain formal ethical approval prior to the study start. Informed written 
consent will be collected from all participants electronically due to the remote nature of the 
study. A research team member will describe the study to participants in depth including 
information about the treatment and study activities. If, at any time, a participant wishes to 
withdraw from the study, they will be free to do so.  
 
A Data and Safety Monitoring Board (DSMB) will be empaneled to review patient data 
throughout the course of the study. The Board will meet to review and approve study procedures 
prior to trial commencement and will review reports of serious adverse events and interim safety 
and efficacy analyses. Members of the DSMB will have expertise in infectious disease, 
epidemiology, biostatistics, and randomized controlled trials. 
 
12.1 Institutional Review Board Approval  
 
UCSF Committee on Human Research 
UCSF’s Committee on Human Research will review the study protocol for ethical approval.  
 
12.2 Informed Consent  
 
As described in section 4.1.1, all participants will electronically sign an informed consent form. 
Consent scripts will be submitted to the UCSF Committee on Human Research prior to the study 
start for ethical approval. Young adults and children under 18 years of age, who cannot give 


Manual of Operations and Procedures v1.29 
33 
consent by law, will not be included in the study. Participants will be able to ask the research 
team questions about the study procedures and withdraw from the study at any time.  
 
12.3 Risks and Benefits of Study Procedures  
 
There are minimal risks to the participant during this trial. Participants may experience some 
mild or rare side effects as described in Chapter 7 due to the treatment. Adverse effects will be 
monitored. If any question on the questionnaire makes the participant uncomfortable, and they 
do not wish to answer, then they may skip the question. The patient may withdraw from the 
study at any time.  
 
The swabbing procedures present minimal risk to the study participants as well. The participants 
will self collect a nasal, saliva, and rectal swab. Temporary discomfort may occur. Adverse 
events such as nose bleeds are possible, but uncommon.  
 
13 Study Monitoring  
 
The project will be continuously monitored by the supervisory team, which will consist of 
members from UCSF. The supervisory team will run daily and weekly monitoring reports.  
 
The study analyst will daily update the list of eligible participants based on the REDCap 
screening form. The coordinator will then contact these eligible participants to explain the study 
in detail, collect informed consent, and obtain the participant’s place of residence. The analyst 
will also inform the coordinator of participants who are late in filling out their questionnaires so 
that the coordinator may follow-up with them.  
 
A weekly data quality report will be sent to the entire supervisory team, which will include 
enrollment counts, follow-up data, primary outcome data, and other study statistics.  
 
13.1 Protocol Violations  
 
A protocol violation occurs when the subject, investigator, or study staff fails to adhere to 
significant protocol requirements affecting the inclusion, exclusion, subject safety and primary 
endpoint criteria.  Protocol violations for this study include, but are not limited to, the following: 
• 
Failure to meet inclusion/exclusion criteria 
• 
Changes in the conduct of the research protocol without prior IRB approval  
• 
Any violation that has harmed, or posed significant risk of harm, to the research participant 
Failure to comply with Good Clinical Practice (GCP) guidelines will also result in a protocol 
violation. When a protocol violation occurs, it will be discussed with the investigator and a 
Protocol Violation Form detailing the violation will be generated. This form will be signed by a 
Sponsor representative and the Investigator. A copy of the form will be filed in the site’s 
regulatory binder and in the Sponsor’s files for FDA reporting purposes. Any protocol violation 
must be reported the UCSF IRB as well.  


Manual of Operations and Procedures v1.29 
34 
14 Data Collection, Management, and Security  
 
The project will be continuously monitored by the supervisory team, which will consist of 
members from the UCSF F.I. Proctor Foundation. The supervisory team will communicate with 
participants and monitor the data daily. This section discusses how the data are collected, entered 
into the database, stored, and transferred to the Data Coordinating Center under the supervision 
of Dr. Benjamin Arnold.  
 
14.1 Scope of the Data 
 
Mortality and morbidity data will be collected in this trial. Participant vital status will be 
collected at day 3, day 7, day 14 and 21 day follow-ups. Hospitalization and COVID-19 status 
will also be collected during follow-ups via an electronic questionnaire.  
 
14.2 Data Storage, Management, and Security 
 
Data will be recorded electronically using REDCap.  Data will be stored in a secure directory on 
Box, which maintains HIPAA-level compliance and encryption for UCSF accounts (details here: 
https://it.ucsf.edu/services/ucsf-box/additional/how-does-box-protect-your-data). Rapid transfer 
of electronically captured data will allow nearly real-time monitoring of activity at the study site. 
All handheld devices and data entry coordinating centers will be password protected, and all 
changes in data will be noted, including the date of the change, and the person who made the 
change. All information collected will adhere to HIPAA compliance rules.  
 
14.3 Electronic Data Collection Forms 
 
All forms for this study will be created electronically on REDCap. These forms will be tested by 
the UCSF investigators prior to using them for the study. All REDCap forms are electronic and 
should be completed in their online version. Paper copies will be available to be downloaded, 
printed, and completed by hand if necessary, but electronic data entry is preferred. Study 
personnel should communicate any clarifications or updates to the study forms to all participants.  
 
14.4 Data Review  
 
The study coordinator will review all REDCap forms for accuracy and completion prior to 
submitting them to the REDCap database. If issues are identified post-submission, the study 
coordinator will contact the appropriate person at the Coordinating Center to address the issue. 
Only the Coordinating Center is authorized to add missing data or make any changes to 
submitted data in REDCap. The Coordinating Center may conduct further investigations if 
certain fields are associated with a higher rate of form errors.   
 
14.5 Data Entry 
 


Manual of Operations and Procedures v1.29 
35 
Once the study coordinator has reviewed the completed REDCap forms, they will submit the 
electronic forms to the REDCap database. The data manager at the Coordinating Center will 
review the data for accuracy and completion.  
 
14.6 Data Transfer 
 
The Coordinating Center will access the data through a secure, online REDCap database system. 
The database manager will download the data sets and conduct checks for completeness and 
validity. Any queries generated will be communicated by secure encrypted email to the study 
coordinator for resolution.  
 
14.7 Data Entry Errors 
 
The data manager at the CC will assess study data using an automated program in REDCap (with 
a goal of completing within 2 days of data entry), searching for missing and contradicting data 
fields. Wherever there is a mismatch, an error file is generated with relevant data such as the 
form, field name, and data for which discrepancy is found. The data manager will then contact 
the study coordinator to verify the forms. Discrepancies and missing values will be assessed by 
the data manager, and resolved by queries sent to the study coordinator and appropriate 
observers (e.g., clinician). A logfile will preserve the date and time of any changes, together with 
who entered the changes.  
 
14.8 Data Consistency and Validity 
Through range checks, the data entry software helps prevent inconsistencies or invalid data. The 
database program will check for the following errors: (1) improper entry of the patient ID based 
on the checksum, (2) data fields that are out of range, (3) inconsistent or illogical entries, (4) 
incompleteness, and (5) numerical values that are far outside the range of those previously 
entered. The software will create an error file with relevant data such as the form identification, 
field names and the data. Automated checks will be made to ensure consistency and that each 
variable in the analysis set has in-range values (protecting against negative ages, spelling errors 
in categorical factors, and similar errors). The data manager will contact the study coordinator 
about any errors in order to resolve the inconsistencies.  
14.9 Data Preparation and Cleaning 
Datasets for analysis will be produced in comma separated values (.csv) files containing a single 
header line whose variable names match the REDCap database. Each analysis set will be in the 
form of a rectangular table in which each column corresponds to a single variable and each row 
to an observation. All missing values will be coded explicitly using the string “NA” (as used in 
the R software). Codes for categorical variables (such as 1 for male, and 2 for female) will be 
avoided in favor of self-documenting character strings or factor variables (such as Male, 
Female).  


Manual of Operations and Procedures v1.29 
36 
A detailed codebook will be prepared, containing for each variable, (a) the form from which the 
variable derived, (b) the text of the question, (c) all possible values for the variable, and (d) 
summary statistics for the variable. Note that all codes and character strings that represent 
categorical factors will be clearly defined in the codebook. Units for each continuous variable 
will be unambiguously indicated for each variable. Each release of the analysis set will be 
accompanied by the corresponding version of the codebook. Version numbering with dates will 
be strictly observed.  
14.10 Monitoring 
We will maintain a record of changes to the REDCap database. Database errors include (a) 
missing information, (b) erroneous information, and (c) errors arising from difficulties with the 
electronic forms themselves. Weekly quality assurance reports will summarize the number of 
each of these. Most importantly, we will closely monitor the time between the study visit date 
and submission of the electronic forms to REDCap to ensure that this time is less than 3 days. If 
entry times exceed 5 days, then this will trigger a response, which may include investigation 
and/or reassignment.  
14.11 Data Analysis 
Following data checks by the data analyst, the Data Analysis Committee will be responsible for 
analyzing the data from the REDCap database. It will merge the masked data with the 
randomization list, perform statistical analyses and prepare reports.  
Standard report-generation software included with the R statistical and data analysis package will 
be used to ensure consistency of the codebook and analysis set at all times.  
Data monitoring reports will be prepared based on analysis data sets. These will be prepared 
using report-generation software. Monitoring reports will include (a) recruitment reports for each 
center, (b) compliance reports, (c) retention reports, and (d) data quality reports. These will be 
reviewed by the Coordinating Center on a weekly basis.  
14.12 Data Storage and Security 
Electronic forms will be completed on an encrypted electronic device, requiring a passcode to 
unlock the device and additional separate login credentials to access the REDCap forms. Copies 
of the electronic forms will not be stored on the device itself but rather within the secured 
REDCap database.  
All electronic storage will be subject to standard security procedures in compliance with 
established enterprise information security standards. Each computer will be hardware-firewalled 
and will not be accessible outside the Local Area Network. Hard-disk encryption will be used for 
each machine, and the machine will not be accessible without a network account and password. 
Only study-specific personnel will have password access to the encrypted Box directory. 
Accounts will be immediately deactivated for data entry or other personnel who leave the study.  


Manual of Operations and Procedures v1.29 
37 
15 Data and Safety Monitoring Committee Charter 
 
This charter is for the Data and Safety Monitoring Committee (DSMC) for the Azithromycin for 
COVID-19 Treatment in Outpatients Nationwide (ACTION) Trial.  
 
The Charter will define the primary responsibilities of the DSMC, its relationship with other trial 
components, its membership, and the purpose and timing of its meetings. The Charter will also 
provide the procedures for ensuring confidentiality and communication, statistical monitoring 
guidelines to be implemented by the DSMC, and an outline of the content of the Open and 
Closed Reports that will be provided to the DSMC. 
 
The DSMC will be advisory to the trial leadership group, hereafter referred to as the Steering 
Committee (SC). The SC will be responsible for promptly reviewing the DSMC 
recommendations and determining, whether to continue or terminate the trial, and to determine 
whether amendments to the protocol are required. If needed, the DSMC may seek the advice of a 
content expert outside of the committee.  
 
15.1 DSMC Membership 
The DSMC is an independent multidisciplinary group consisting of epidemiologists, 
biostatisticians, bioethicists, and clinicians that collectively has experience in the management of 
infectious diseases and in the conduct and monitoring of randomized clinical trials. 
 
The DSMC membership has been restricted to individuals free of apparent conflicts of interest. 
The source of these conflicts may be financial, scientific, or regulatory. Thus, neither study 
investigators nor individuals employed by the sponsor, nor individuals who might have 
regulatory responsibilities for the trial products, are members of the DSMC. 
 
15.2 Conflicts of Interest 
The DSMC members will disclose to fellow members any consulting agreements or financial 
interests they have with the sponsor of the trial, with the contract research organizations (CRO) , 
or with other sponsors having products that are being evaluated or that are competitive with 
those in the trial. The DSMC will be responsible for deciding whether these consulting 
agreements or financial interests materially impact their objectivity.  
 
The DSMC members will be responsible for advising fellow members of any changes in any of 
the membership requirements that occur during the course of the trial. It may be appropriate for 
DSMC members who develop significant conflicts of interest resign from the DSMC.  
 
DSMC membership is to be for the full duration of the trial. If any members leave the DSMC, 
the SC, in consultation with the DSMC, will promptly appoint a replacement.   
 
15.3 Timing and Purpose of the DSMC Meetings 
 
Organizational Meeting 


Manual of Operations and Procedures v1.29 
38 
The initial meeting of the DSMC will be an Organizational Meeting. This is during the final 
stages of protocol development and the purpose is to provide advisory review of scientific and 
ethical issues relating to study design to discuss the standard operating procedures and to discuss 
the format and content of the Open and Closed Reports that will be used to present trial results. 
 
The Organizational Meeting will be attended by all DSMC members, lead trial investigators, and 
the trial biostatistician. 
 
Formal Interim Analysis Meetings 
One or more ‘Formal Interim Analysis’ meetings will be held to review data relating to treatment 
safety and efficacy, and quality of trial conduct. 
 
15.4 Procedures to Ensure Confidentiality and Proper Communication 
To enhance the integrity and credibility of the trial, procedures will be implemented to ensure the 
DSMC has access to all emerging information from the trial regarding comparative results of 
efficacy and safety, aggregated by treatment arm.  
 
Closed Sessions 
Sessions involving only DSMC members and, where appropriate, those unmasked trial 
investigators (on the Data Coordinating Committee) who generate the Closed Reports (called 
Closed Sessions) will be held to allow discussion of confidential data from the trial, including 
information about the relative efficacy and safety of interventions.  
 
At a final Closed Session, the DSMC will develop a consensus on its list of recommendations, 
including that relating to whether the trial should continue. 
 
Open Session  
In order for the DSMC to have access to information provided, by study investigators, or 
members of regulatory authorities, a joint session between these individuals and DSMC 
members will be held between the Closed Sessions.  
 
Open and Closed Reports 
For each DSMC meeting, Open and Closed Reports will be provided. Open Reports, will include 
data on recruitment and baseline characteristics, pooled data on eligibility violations, and 
completeness of follow-up and compliance. The study statistician (TCP) will prepare these Open 
Reports.  
 
Closed reports, available only to those attending the Closed Sessions of the meeting, will include 
analyses of primary and secondary efficacy endpoints, including subgroup and adjusted analyses, 
AEs and symptom severity, and Open Report analyses that are displayed by intervention group. 
These Closed Reports will be prepared by the study biostatistician.  
 
The Open and Closed Reports should provide information that is accurate, with follow-up that is 
complete to within two months of the date of the DSMC meeting. The Reports should be 
provided to DSMC members approximately three days prior to the date of the meeting. 
 


Manual of Operations and Procedures v1.29 
39 
Minutes of the DSMC Meeting 
The research team will prepare minutes for the open portion of the meeting, including the 
DSMC’s recommendations. 
 
Recommendations to the Steering Committee (SC) 
At each meeting of the DSMC during the trial, the committee will make a recommendation to the 
Steering Committee to continue or terminate. This recommendation will be based primarily on 
safety and efficacy considerations and will be guided by statistical monitoring guidelines defined 
in this Charter. 
 
Recommendations to amend the protocol or conduct of the study made by the DSMC will be 
considered and accepted or rejected by the SC. The SC will be responsible for deciding whether 
to continue or to stop the trial based on the DSMC recommendations.  
 
The DSMC will be notified of all changes to the protocol or to study conduct. The DSMC 
concurrence will be sought on all substantive recommendations or changes to the protocol or 
study conduct prior to implementation.  
 
The SC may communicate information in the Open Report to the sponsor and may inform them 
of the DSMC recommended alterations to study conduct or early trial termination in instances in 
which the SC has reached a final decision agreeing with the recommendation. The SC will 
maintain confidentiality of all information it receives other than that contained in the Open 
Reports until after the trial is completed or until a decision for early termination has been made. 
 
15.5 Statistical Monitoring Guidelines 
 
The SC will propose statistical rules for a futility stopping rule (requested by the sponsor) and an 
efficacy stopping rule at the first DSMC meeting.  
 
15.6 DSMC Contact Information 
 
Art Reingold: reingold@berkeley.edu 
Dave Glidden: david.glidden@ucsf.edu 
Emily Gower: egower@email.unc.edu 
 
 
 
 
 
 
 
 
 


Manual of Operations and Procedures v1.29 
40 
APPENDIX 
 
Appendix 1: Original manual of procedures 
 
REVISION HISTORY 
 
4/9/2020: Addition of 21 day follow up timepoint, added additional details to the Study Methods 
Chapter.  
4/10/2020: Addition of Pfizer information to Medication Chapter, addition of Chapter 12 Study 
Monitoring.  
4/19/2020: New eligibility criteria added (QT prolongation + chloroquine over 55). 
4/20/2020: Chapter 5 and 6: addition of a sub-study where 100 patients per arm are asked to 
collect nasal, saliva, and rectal swabs at days 3, 7, 14. Addition of chapter 8: Staff 
responsibilities.  
4/21/2020: Addition of adverse events and SAE information per request of Pfizer.  
4/24/2020: Addition of Pfizer SAE reporting requirements. 
4/27/2020: Addition of section 3.3 Sub-Studies. Addition of Death as a secondary endpoint. 
Addition of eligibility criteria (not currently taking nelfinavir or warfarin). Section 5.10 change 
of patient ID number to REDCap based.  
4/28/2020: Addition of figure 1 in 3.3. Change in main study swabs from first 300 participants to 
all participants will be asked to collect rectal swab at day 3.  
5/4/2020: Specification that we will exclude pregnant women. Addition of FDA reporting 
criteria to SAE section.  
5/5/2020. Addition of protocol violation section, drug storage section, concurrent medications 
section 
5/6/2020: Specification of cardiovascular related events for reportable serious adverse events to 
Pfizer 
5/12/2020: Removal of rectal swab in group 1 & group 2 in swab sub-study section.  
5/26/2020: Addition of Dr. Seitzman and Dr. Redd to the protocol. Addition of color-coded 
sticker scheme for kits to section 5.10. Addition of lot numbers from drug to 10.4.  
6/3/2020: Addition of online social media ad campaign under recruitment.  
6/8/2020: Expansion of eligibility criteria “positive test within past 3 days” to “positive test 
within past 7 days”. Specified that participant can fill out questionnaires via email or over the 
phone in eligibility criteria.  
7/8/2020: Addition of unmasking protocol to 3.6.1.  
8/24/2020: Addition of protocol for short form method of consent.  
9/23/20: Addition of Rhode Island Open Door Health as recruitment site. Addition of EDDM to 
recruitment methods. Addition of random drawing lottery.  
11/13/20: Addition of WebMD to recruiting methods. Addition of language for obtaining 
informed consent from computer illiterate participants.  
12/7/20: Change primary outcome. Moved hospitalization to secondary outcome.  
• 
The investigators edited the primary outcome to a symptom based outcome. Instead of a 
hospitalization at Day 14 post enrollment, the primary outcome will be a binary 
assessment of whether the participant is symptom free at Day 14 (yes or no) post 
enrollment. This change was made because the trial will not have enough statistical 
power for the original hospitalization outcome. The event “hospitalization” is much rarer 


Manual of Operations and Procedures v1.29 
41 
in the study population than anticipated and enrollment is slower than planned. This 
change was approved by the trial’s Data Safety Monitoring Committee and Institutional 
Review Board.  
 
12/18/20: Updated objective and sample size.  
4/5/21: Addition of section 5.12 Emergency Room Follow-Up.  
 
REFERENCES  
 
1. Schogler A, Kopf BS, Edwards MR, Johnston SL, Casaulta C, Kieninger E, Jung A, Moeller 
A, Geiser T, Regamey N, Alves MP: Novel antiviral properties of azithromycin in cystic fibrosis 
airway epithelial cells. Eur Respir J 2015, 45:428-39. 
 
2.  Retallack H, Di Lullo E, Arias C, Knopp KA, Laurie MT, Sandoval-Espinosa C, Mancia 
Leon WR, Krencik R, Ullian EM, Spatazza J, Pollen AA, Mandel-Brehm C, Nowakowski TJ, 
Kriegstein AR, DeRisi JL: Zika virus cell tropism in the developing human brain and inhibition 
by azithromycin. Proceedings of the National Academy of Sciences of the United States of 
America 2016, 113:14408-13. 
 
3. Li C, Zu S, Deng YQ, Li D, Parvatiyar K, Quanquin N, Shang J, Sun N, Su J, Liu Z, Wang M, 
Aliyari SR, Li XF, Wu A, Ma F, Shi Y, Nielsevn-Saines K, Jung JU, Qin FX, Qin CF, Cheng G: 
Azithromycin Protects against Zika virus Infection by Upregulating virus-induced Type I and III 
Interferon Responses. Antimicrobial agents and chemotherapy 2019. 
 
4. Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L, Mailhe M, Doudier B, Courjon J, 
Giordanengo V, Vieira VE, Dupont HT, Honore S, Colson P, Chabriere E, La Scola B, Rolain 
JM, Brouqui P, Raoult D: Hydroxychloroquine and azithromycin as a treatment of COVID-19: 
results of an open-label non-randomized clinical trial. Int J Antimicrob Agents 2020:105949. 
 
5. Philippe Gautret J-CL, Philippe Parola, Van Thuan Hoang , Line Meddeb , Jacques Sevestre, 
Morgane Mailhe, Barbara Doudier, Camille Aubry, Sophie Amrane, Piseth Seng, Marie 
Hocquart , Julie Finance, Vera Esteves Vieira, Hervé Tissot Dupont, Stéphane Honoré, Andreas 
Stein, Matthieu Million, Philippe Colson, Bernard La Scola, Véronique Veit, Alexis Jacquier, 
Jean-Claude Deharo, Michel Drancourt, Pierre Edouard Fournier, Jean-Marc Rolain, Philippe 
Brouqui, Didier Raoult Clinical and microbiological effect of a combination of 
hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow 
up: an observational study Available at: https://wwwmediterranee-infectioncom/wp-
content/uploads/2020/03/COVID-IHU-2-1pdf 2020. 
 
6. Gautret P, Lagier J, Parola P, Doudier B, Courjon J, Scola B La, et al. Hydroxychloroquine 
and azithromycin as treatment of COVID-19: results of an open-label non-randomized clinical 
trial. Int J Antimicrob Agents. 2020;Epub ahead. doi:10.1016/j.ijantimicag.2020.105949. 
 
7. Oldenburg CE, Arzika AM, Maliki R, Kane S, Lebas E, Ray KJ, et al. Safety of azithromycin 
in infants under six months of age in Niger: A community randomized trial. PLoS Negl Trop 
Dis. 2018;12:e0006950. 


Manual of Operations and Procedures v1.29 
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8. Keenan JD, Bailey RL, West SK, Arzika A, Hart J, Weaver J, et al. Azithromycin to Reduce 
Childhood Mortality in Sub-Saharan Africa. N Engl J Med. 2018;378:1583–92. 
papers3://publication/uuid/94889A59-49DD-4FAD-BDC0-E1A6B125E22C. 
 
9. Astale T, Sata E, Zerihun M, Nute AW, Stewart AEP, Chanyalew M, et al. Self-Reported Side 
Effects following Mass Administration of Azithromycin to Eliminate Trachoma in Amhara, 
Ethiopia: Results from a Region-Wide Population-Based Survey. Am J Trop Med Hyg. 
2019;100:696–9. 
 
10. Ayele B, Gebre T, House JI, Zhou Z, McCulloch CE, Emerson PM, et al. Adverse Events 
after Mass Azithromycin Treatments for Trachoma in Ethiopia. Am J Trop Med Hyg. 
2011;85:291–4. http://www.ajtmh.org/content/journals/10.4269/ajtmh.2011.11-0056. 
 
 
  
 
 
 

SAP_001.pdf: 
ACTION trial Statistical Analysis Plan 
Version 6, 2020-5-29 
 
1 
Azithromycin for COVID-19 
Treatment In Outpatients 
Nationwide (ACTION) 
 
 
Statistical Analysis Plan 
 
1.  Administrative Information 
 
Trial registration:   
ClinicalTrials.gov NCT04332107 
Funder: 
Bill & Melinda Gates Foundation (grant # INV-017026) 
SAP Version: 
Version 6, Updated 2020-5-29 
A revision history for this document is included at the end. 
Protocol Version: 
Refers to Protocol Version 1.29 
Contributors: 
Statisticians responsible:  
 
Benjamin F. Arnold 1 , Travis C. Porco 1 
Principal Investigators:  
 
Catherine E. Oldenburg 1, Thuy Doan1 
 
1 Francis I. Proctor Foundation for Research in Ophthalmology, 
University of California, San Francisco, USA 
 
 
 
 
 


ACTION trial Statistical Analysis Plan 
Version 6, 2020-5-29 
 
2 
SAP Table of Contents 
1.  ADMINISTRATIVE INFORMATION ........................................................................................................... 1 
2.  INTRODUCTION .......................................................................................................................................... 3 
2.1. BACKGROUND AND RATIONALE ......................................................................................................................... 3 
2.2. OBJECTIVES ...................................................................................................................................................... 3 
3.  STUDY METHODS ...................................................................................................................................... 3 
3.1. TRIAL DESIGN .................................................................................................................................................... 3 
3.2. RANDOMIZATION ................................................................................................................................................ 3 
3.3. SAMPLE SIZE ..................................................................................................................................................... 3 
3.4. STATISTICAL FRAMEWORK ................................................................................................................................ 4 
3.5. STATISTICAL INTERIM ANALYSES AND STOPPING GUIDANCE ............................................................................ 4 
3.6. TIMING OF THE FINAL ANALYSIS ........................................................................................................................ 5 
3.7. TIMING OF OUTCOME ASSESSMENTS ................................................................................................................ 5 
4.  STATISTICAL PRINCIPLES ....................................................................................................................... 6 
4.1. CONFIDENCE INTERVALS AND P-VALUES .......................................................................................................... 6 
4.2. PROTOCOL DEVIATIONS .................................................................................................................................... 6 
5.  TRIAL POPULATION .................................................................................................................................. 6 
5.1. SCREENING DATA .............................................................................................................................................. 6 
5.2. ELIGIBILITY ........................................................................................................................................................ 6 
5.3. RECRUITMENT ................................................................................................................................................... 6 
5.4. WITHDRAWAL/FOLLOW-UP ................................................................................................................................ 6 
5.5. BASELINE PATIENT CHARACTERISTICS .............................................................................................................. 6 
6.  ANALYSIS .................................................................................................................................................... 7 
6.1. OUTCOME DEFINITIONS ..................................................................................................................................... 7 
6.2. ANALYSIS METHODS .......................................................................................................................................... 7 
6.3. MISSING DATA ................................................................................................................................................... 9 
6.4. ADDITIONAL ANALYSES ...................................................................................................................................... 9 
6.5. HARMS ............................................................................................................................................................. 10 
6.6. STATISTICAL SOFTWARE ................................................................................................................................. 10 
7.  REFERENCES ........................................................................................................................................... 10 
8.  REVISION HISTORY ................................................................................................................................. 11 
9. APPENDIX……………………………………………………………………………………………………….12 
 
The content of this Statistical Analysis Plan meets the requirements stated by the US Food and 
Drug Administration and conforms to the American Statistical Association’s Ethical Guidelines. 
This SAP was organized following guidelines proposed in:  
 
Gamble C, Krishan A, Stocken D, Lewis S, Juszczak E, Doré C, et al. Guidelines for the 
Content of Statistical Analysis Plans in Clinical Trials. JAMA. 2017;318: 2337–2343. PMID: 
29260229 [1] 
 
The companion computational notebook with underlying sample size calculations presented 
herein is entitled: ACTION-sample-size-power-symptom-free.Rmd / .html; it is saved in the 
same directory as this document. 
 
 


ACTION trial Statistical Analysis Plan 
Version 6, 2020-5-29 
 
3 
2.  Introduction 
2.1. Background and rationale 
Identification of a safe, effective treatment for individuals with mild or moderate COVID-19 that 
prevents disease progression and reduces hospitalization would reduce the burden on the 
health system. High dose hydroxychloroquine is being evaluated for SARS-CoV-2 prevention 
and COVID-19 disease treatment, but has a high risk of a number of potentially severe adverse 
events. Recent evidence has indicated that the broad-spectrum macrolide azithromycin may 
have some activity against coronaviruses. A large community randomized trial in Niger 
demonstrated reduced viral load among children with commensal coronaviruses (prior to the 
emergence of SARS-CoV-2) in communities receiving biannual mass azithromycin distribution 
compared to placebo (submitted). In SARS-CoV-2 patients in France, the addition of 
azithromycin to a hydroxychloroquine regimen appeared to decrease SARS-CoV-2 positivity by 
PCR compared to hydroxychloroquine-only and control patients. Azithromycin is generally well-
tolerated and may be an attractive option for treating patients with mild disease. 
2.2. Objectives 
1: To determine if a single oral dose of azithromycin is effective for reducing progression to 
hospitalization in patients with a positive SARS-CoV-2 PCR test with mild or moderate disease.  
3.  Study Methods 
3.1. Trial design 
The trial will be a scalable, telemedicine-based parallel group simple trial to evaluate the 
efficacy of azithromycin for the prevention of COVID-19 disease progression and hospitalization.  
 
3.2. Randomization 
Participants will be randomized 2:1 to either receive a dose of oral azithromycin or oral placebo. 
Patients will be twice as likely to receive azithromycin than placebo. The randomization will not 
be stratified or blocked in any way. We found that even with permuted block sizes and ≥6 labels 
(4 azithromycin, 2 placebo), a 2:1 allocation could lead to unmasking through longer runs of 
active treatment labels. 
 
3.3. Sample size 
The trial’s revised target enrollment is 455 participants, which will be sufficient to detect an 
increase in the proportion of patients who are symptom free 50% to 65% (15 percentage point 
increase) at 14 days from enrollment.  
 
With 455 participants, the trial will have 80% power to detect an increase of 15 percentage 
points in the percentage of patients who are symptom free at 14-d under the following 
assumptions: 
 
• 
2:1 allocation ratio of azithromycin : placebo  
• 
50% symptom-free under placebo at the 14-day measurement (binomial outcome)  
• 
20% loss to follow-up 
• 
2-sided alpha of 0.05, power = 0.8. 


ACTION trial Statistical Analysis Plan 
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4 
• 
A single interim analysis with 50% of primary outcomes collected with stopping guideline 
determined using the Lan-DeMets spending function approach with an O’Brien and 
Fleming boundary. 
 
The table below shows sample sizes under several effect size scenarios, assuming 
azithromycin increases the proportion of patients who are symptom free by 0.1 to 0.2 compared 
to placebo. 
 
 
 
3.4. Statistical framework 
The ACTION trial will use a superiority testing framework, with the active treatment arm 
(azithromycin) compared against placebo.  
 
The analysis will account for interim analyses using a group-sequential testing framework using 
the Lan-DeMets spending function approach with an O’Brien and Fleming boundary [2].  
 
3.5. Statistical interim analyses and stopping guidance 
Due to uncertainty in the possible effects of treatment and the urgency of identifying effective 
therapies for COVID-19, sequential randomized controlled trials with interim monitoring are 
expected to provide robust results faster than standard fixed parallel trials without interim 
monitoring [3]. In the absence of a significant difference between randomized arms, the study 
team believes that there is value in continuing the randomized comparison of Azithromycin 
versus placebo to full enrollment (i.e., 455 participants) in order to obtain as much precision as 
possible and to provide maximal information to inform the field. We therefore have not 
recommended interim analyses for futility.   
 
Interim analyses for efficacy 
We have assumed 1 interim analysis at 50% of participants with 14-day endpoints measured 
using a Lan-DeMets spending approach with an O’brien-Fleming boundary.  The actual alpha 
spending will be updated according to the actual interim analysis schedule, should trial 
investigators change the schedule in coordination with the trial’s DSMC.  
 


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5 
A summary of the interim analysis and nominal P-values is below, created by the R package 
gsDesign. We have also included a summary of standardized treatment effects along the 
efficacy bound, For additional details see this SAP’s companion computational notebook: 
ACTION-sample-size-power-symptom-free.Rmd / .html .   
 
## One-sided group sequential design with 
## 80 % power and 2.5 % Type I Error. 
##                
##   Analysis  N   Z   Nominal p  Spend 
##          1 228 2.96    0.0015 0.0015 
##          2 456 1.97    0.0245 0.0235 
##      Total                    0.0250  
##  
## ++ alpha spending: 
##  Lan-DeMets O'Brien-Fleming approximation spending function with none = 1. 
##  
## Boundary crossing probabilities and expected sample size 
## assume any cross stops the trial 
##  
## Upper boundary (power or Type I Error) 
##           Analysis 
##    Theta      1      2 Total  E{N} 
##   0.0000 0.0015 0.0235 0.025 454.8 
##   0.1316 0.1641 0.6359 0.800 417.9 
 
We note the pre-specification of a flexible alpha spending function permits interim analysis at 
the discretion of the DSMC. We will update the efficacy bound according to the trial’s actual 
interim analysis schedule. 
 
The DSMC will review interim analyses and will make a recommendation to stop the trial for 
efficacy after each review. Early stopping for any reason will mandate final analysis at alpha of 
the full final prespecified value based on all available data (incorporating any alpha spending, as 
needed). In considering possible modifications to the study or termination of the study, the 
DSMC may consider other outcome measures than the composite hospitalization/death 
outcome measure.  For example, the DSMC might make recommendations based on a high 
level of evidence for a difference between randomized arms in the proportion dying. A “high 
level of evidence” might be based on application of the O’Brien and Fleming stopping guideline 
to the death outcome.   
 
 
3.6. Timing of the final analysis 
The final analysis will take place when 14-day outcomes have been measured on all 
participants. If the trial is stopped for efficacy or for any other reason before the full sample, the 
final analysis will include all outcomes among patients who have been enrolled at the time the 
trial is stopped. 
 
3.7. Timing of outcome assessments 
Primary outcomes will be measured 14-days after enrollment. Additional visits will take place at 
3, 7, and 21 days after enrollment. Protocol section 3.2 includes details about the trial profile. 
 


ACTION trial Statistical Analysis Plan 
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6 
4.  Statistical Principles 
4.1. Confidence intervals and P-values 
 
The trial will report 95% confidence intervals and permutation P-values estimated from the 
primary analysis. The level of statistical significance will depend on the alpha spending function 
that accounts for the group sequential design (see section 3.5 for details). 
 
4.2. Protocol deviations 
The analysis population will be intention to treat, and will include all participants enrolled and 
randomized.  Adherence to protocol will be determined during the 14-day assessment based on 
patient report of whether they took the medication delivered by the trial. At that time, the trial will 
assess whether patients have taken other medication during the study period, including 
azithromycin or other macrolides not provided by the trial.  Patients who take azithromycin or 
other macrolide not provided by the study will be considered protocol deviations but will be 
included according to randomized group in the intention-to-treat analysis.  
 
5.  Trial Population 
5.1. Screening data 
We will report the number of patients screened and characteristics to the extent they are 
available to assess representativeness of the enrolled study population. 
 
5.2. Eligibility 
See Section 4 of the trial protocol for eligibility criteria. 
 
5.3. Recruitment  
See section 5.1 of the study protocol. We will report the number of participants screened, 
enrolled, randomized, and measured at the primary endpoint, along with reasons for exclusion 
at each step following CONSORT guidelines. 
 
5.4. Withdrawal/follow-up  
We will report the proportion of patients in both study arms who withdraw from the trial, along 
with reasons. We will report this information in the trial’s CONSORT flow chart.  The analysis 
will be intention-to-treat: patients will be analyzed according to the arm they are randomized. 
 
5.5. Baseline patient characteristics  
We will summarize patient characteristics by arm, including: age, sex, location (to level of US 
state), and clinical symptoms at the time of enrollment. 
 


ACTION trial Statistical Analysis Plan 
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7 
6.  Analysis 
6.1. Outcome definitions 
 
Primary Outcome: 
The primary outcome will be free of symptoms at 14 days after the electronic enrollment 
assessment. Symptoms include: cough, fever, myalgia, anosmia, shortness of breath (and 
related abilities such as ability to walk across a room or up a flight of stairs), fatigue, 
conjunctivitis, and orthostatic symptoms. 
 
Secondary Outcomes: 
• 
Hospitalization and/or death by 14 days after the electronic enrollment assessment. 
• 
Hospitalization/death by 21 days: we will extend follow-up beyond the primary 
endpoint to capture any hospitalizations or death that progress more slowly and are not 
detected by 14 days. 
• 
Adverse events: we will conduct an adverse event survey at Day 3 after treatment, 
including gastrointestinal side effects (nausea, vomiting, diarrhea, abdominal pain) and 
rash. We note that some COVID-19 patients report gastrointestinal symptoms, and this 
survey will provide data on whether azithromycin causes additional gastrointestinal 
effects beyond those symptoms. 
• 
Prevalence of positive swabs: we will compare the prevalence of SARS-CoV-2 
positive swabs at Day 3 after treatment in self-collected nasal, saliva, and rectal swabs 
in azithromycin compared to placebo-treated participants. 
• 
Viral load: we will assess viral load by RT-PCR in self-collected nasal, saliva, and rectal 
swabs at Day 3 after treatment. 
• 
Mortality: we will collect emergency contact/next of kin information during the baseline 
questionnaire. We will follow-up with the emergency contact if participants are lost to 
follow-up at the Day 14 and Day 21 questionnaires to assess mortality and 
hospitalization outcomes. 
• 
Genetic macrolide resistance determinants: We will evaluate the prevalence of 
genetic macrolide resistance determinants ermB, mefA/E, and mphA by targeted PCR in 
rectal samples collected at Day 3 after treatment. 
• 
COVID-19 symptoms at 21 days: we will ask patients about COVID-19 symptomology 
during each online questionnaire, including cough, fever, myalgia, anosmia, shortness of 
breath (and related abilities such as ability to walk across a room or up a flight of stairs), 
fatigue, conjunctivitis, and orthostatic symptoms. 
• 
Number of emergency room visits: during each online questionnaire we will survey 
patients about any emergency room visits (with stays <24 hours) that occurred since 
their last survey. 
• 
Number of household members with COVID-19 (confirmed or symptomatic): during 
each online questionnaire we will ask participants how many of their household 
members have symptoms of COVID-19 or confirmed disease. 
 
6.2. Analysis methods 
 
Primary Outcome: 
The primary analysis will estimate the risk difference (RD) comparing the proportion of patients 
who are symptom-free at 14 days in the azithromycin versus placebo arms. We will compute P-


ACTION trial Statistical Analysis Plan 
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8 
values for differences between arms using a permutation test with the prevalence difference 
between arms as the test statistic and 10,000 iterations. We will additionally estimate and report 
the prevalence ratio. 
 
Determination of statistical significance for the primary and secondary analyses will follow the 
final alpha-spending function determined by the interim analyses (see section 3.5). 
 
 
Secondary Outcomes: 
 
• 
Hospitalization/death by 21 days: We will use a Kaplan-Meier approach to account for 
losses to follow-up. We will use Greenwood’s formula to estimate the standard error of 
the log proportion in each arm will be used to determine the variance of the risk 
difference at 21 days. 
• 
Mortality by 21 days: we will collect emergency contact/next of kin information during 
the baseline questionnaire. We will follow-up with the emergency contact if participants 
are lost to follow-up at the Day 14 and Day 21 questionnaires to assess mortality and 
hospitalization outcomes. 
• 
COVID-19 symptoms at 21 days: we will ask patients about COVID-19 symptomology 
during each online questionnaire, including cough, fever, myalgia, anosmia, shortness of 
breath (and related abilities such as ability to walk across a room or up a flight of stairs), 
fatigue, conjunctivitis, and orthostatic symptoms. 
• 
COVID-19 (confirmed or symptomatic) among household members of enrolled 
patients: during each online questionnaire we will ask participants how many of their 
household members have symptoms of COVID-19 or confirmed disease. This analysis 
will be conducted on an expanded dataset that includes an observation for each 
household member. To account for outcome correlation among individuals within 
households, we will estimate 95% confidence intervals for the risk difference and risk 
ratio with a clustered, non-parametric bootstrap that resamples households with 
replacement (10,000 iterations).  
 
Outcomes with a prevalent measure at Day 3: 
 
We will estimate the difference in prevalence between arms and the 95% confidence interval for 
the difference. We will compute P-values for differences between arms using a permutation test 
with the prevalence difference between arms as the test statistic and 10,000 iterations. 
 
• 
Prevalence of positive swabs: we will compare the prevalence of SARS-CoV-2 
positive swabs at Day 3 after treatment in self-collected nasal, saliva, and rectal swabs 
in azithromycin compared to placebo-treated participants. 
• 
Genetic macrolide resistance determinants: We will evaluate the prevalence of 
genetic macrolide resistance determinants ermB, mefA/E, and mphA by targeted PCR in 
rectal samples collected at Day 3 after treatment. 
• 
Adverse events: we will conduct an adverse event survey at Day 3 after treatment, 
including gastrointestinal side effects (nausea, vomiting, diarrhea, abdominal pain) and 
rash. We note that some COVID-19 patients report gastrointestinal symptoms, and this 
survey will provide data on whether azithromycin causes additional gastrointestinal 
effects beyond those symptoms. We also note that adverse events will be cumulative 
through Day 3 and measure cumulative incidence (risk) not prevalence.  
 


ACTION trial Statistical Analysis Plan 
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9 
Outcomes with a continuous measure at Day 3: 
 
We will compare log transformed values of relative read and number of reads using a t-test. We 
will compute P-values for differences between arms using a permutation test with the difference 
between arms as the test statistic and 10,000 iterations. 
 
• 
Viral load: we will assess viral load by RT-PCR in self-collected nasal, saliva, and rectal 
swabs at Day 3 after treatment.  
 
Count outcomes:  
 
• 
Number of emergency room visits: during each online questionnaire we will survey 
patients about any emergency room visits (with stays <24 hours) that occurred since 
their last survey. We will model the total number of emergency room visits for each 
participant through 14 days as a count outcome using a negative binomial regression 
model with a single indicator for treatment arm and an offset for the number of days of 
follow-up completed by each participant. The exponentiated coefficient on the indicator 
will estimate the incidence rate ratio. We will compute a P-value for difference between 
arms using a permutation test with the coefficient from the model as the test statistic and 
10,000 iterations.    
 
 
6.3. Missing data 
 
If outcome data are missing for >15% of participants we will report results from sensitivity 
analyses for missing data [4,5]. We selected 15% missing because trials with >20% missing 
values are thought to be a concern for bias [6]. The primary analysis will account for censoring 
but will assume outcomes are missing completely at random. We will relax this assumption 
slightly, assuming that outcomes are missing at random (MAR) with an inverse-probability 
weighted (IPW) estimator using cumulative incidence through 14 days as the binary endpoint. 
We will model the probability of censoring as a function of baseline patient characteristics with a 
logistic regression model, and will use the inverse of the predicted probabilities from the model 
to re-weight the analysis population to reflect the full study population at the time of enrollment, 
using a doubly-robust targeted maximum likelihood estimator that also includes an outcome 
model using the same covariates [7]. Baseline characteristics used in the censoring model will 
include age, sex, race/ethnicity, zip code, comorbidities, concomitant medications, symptoms at 
enrollment, insurance status, alcohol use, tobacco/e-cigarette/marijuana use, and household 
composition. We will additionally consider a range of scenarios assuming the outcomes are 
missing not at random (MNAR), i.e. systematically, using a pattern mixture model approach 
described by Little et al. [4], whereby we model cumulative incidence through 14 days with a 
linear probability model as a function of covariates listed for the IPW estimator; missing 
outcomes will then be imputed using the model fit to predict , adding a shift parameter Δ that we 
vary across a range of values.   
 
6.4. Additional analyses 
 
Pre-specified Subgroup Analyses 
 


ACTION trial Statistical Analysis Plan 
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10 
In secondary analyses, we will estimate differences separately by the following subgroups: 
• 
Age >60 versus ≤ 60 
• 
“High risk” versus low risk patients, with “high risk” defined as Age >60 and reported 
hypertension, cardiovascular disease, diabetes, or obstructive or restrictive lung disease 
at enrollment. 
• 
Presence of COVID-19 symptoms at enrollment versus asymptomatic at enrollment. 
 
6.5. Harms 
 
Section 10 of the trial protocol includes details of adverse event monitoring and reporting. All 
serious adverse events including deaths will be recorded for the period between the date the 
first dose of azithromycin or placebo and the date of the primary endpoint, 14 days later, and 
through the final follow-up at 21 days.  
 
6.6. Statistical software 
Analyses will be conducted using R version 4.0 or later. We will strive to make all replication 
files publicly available along with the trial results through the Proctor Foundation’s GitHub page 
and other public repositories such as the Open Science Framework and Zenodo. 
 
7.  References 
1.  Gamble C, Krishan A, Stocken D, Lewis S, Juszczak E, Doré C, et al. Guidelines for the 
Content of Statistical Analysis Plans in Clinical Trials. JAMA. 2017;318: 2337–2343. 
doi:10.1001/jama.2017.18556 
2.  DeMets DL, Lan KK. Interim analysis: the alpha spending function approach. Stat Med. 
1994;13: 1341–1352; discussion 1353-1356. doi:10.1002/sim.4780131308 
3.  Cooper BS, Boni MF, Pan-ngum W, Day NPJ, Horby PW, Olliaro P, et al. Evaluating clinical 
trial designs for investigational treatments of Ebola virus disease. PLoS Med. 2015;12: 
e1001815. doi:10.1371/journal.pmed.1001815 
4.  National Research Council (U.S.), National Research Council (U.S.), National Academies 
Press (U.S.), editors. The prevention and treatment of missing data in clinical trials. 
Washington, D.C: National Academies Press; 2010.  
5.  Little RJ, D’Agostino R, Cohen ML, Dickersin K, Emerson SS, Farrar JT, et al. The 
prevention and treatment of missing data in clinical trials. N Engl J Med. 2012;367: 1355–
1360. doi:10.1056/NEJMsr1203730 
6.  Schulz KF, Grimes DA. Sample size slippages in randomised trials: exclusions and the lost 
and wayward. Lancet. 2002;359: 781–785. doi:10.1016/S0140-6736(02)07882-0 
7.  Gruber S, van der Laan M. tmle: An R Package for Targeted Maximum Likelihood 
Estimation. J Stat Softw. 2012;51: 1–35.  
 
 


ACTION trial Statistical Analysis Plan 
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11 
8.  Revision history 
 
Version 
Date 
Summary of Changes, Justification, and Timing vis-à-vis key 
trial events (enrollment completion, interim analyses, 
unmasking, etc) 
1 
2020-03-28 
 
• 
First draft 
2 
2020-03-28 
 
• 
Updated administrative information 
3 
2020-04-03 
• 
Provided additional detail in the interim monitoring section. 
4 
2020-05-05 
• 
Update to reflect discussions during the trial’s first DSMC 
meeting on April 8, 2020, as well as input from the FDA 
through the IND approval process, including: 
• 
Add secondary outcomes beyond viral load at day 3, including 
analysis details for each 
• 
Add pre-specified subgroup analysis (previously none) 
• 
Remove the futility bound for interim analyses 
• 
Update the interim analysis alpha spending function to Lan-
DeMets (harmonization with other COVID-19 therapeutic 
trials) 
• 
Update the primary analysis to be based on a Kaplan-Meier 
estimator rather than cumulative proportions to explicitly 
account for censoring. 
• 
Add language regarding a possible expansion of sample size 
to target a smaller detectable effect (RR = 0.8 rather than RR 
= 0.6) if large-scale enrollment is possible.  
• 
Made risk difference the primary comparison with risk ratio 
(RR) an additional contrast we plan to report. 
• 
Include details of masked sample-size re-assessment 
committee, and specific timing for masked sample size re-
assessment. 
• 
Add details of possible sensitivity analyses for missing 
outcomes under MAR and MNAR 
5 
2020-05-29 
• 
Revised the interim sample size evaluation process and 
group who will be involved in the decision making process. 
(version 5 included in the Appendix) 
6 
2020-12-15 
• 
Changed the trial’s primary outcome from 
hospitalization/death by 14-d to symptom free at 14-d 
• 
Updated the sample size calculation for the new outcome, 
revising the trial’s planned enrollment to N=455. 
• 
Updated the interim analysis plan to propose a single interim 
efficacy analysis when 50% of participants have reached the 
primary endpoint. 
• 
Simplified the missing data section with demotion of 
hospitalization/death to a secondary outcome, since the 
interim analyses will no longer include that outcome. 
 
 
 


ACTION trial Statistical Analysis Plan 
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12 
9. Appendix 
Azithromycin for COVID-19 
Treatment In Outpatients 
Nationwide (ACTION) 
 
 
Statistical Analysis Plan 
 
1.  Administrative Information 
 
Trial registration:   
ClinicalTrials.gov NCT04332107 
Funder: 
Bill & Melinda Gates Foundation (grant # INV-017026) 
SAP Version: 
Version 5, Updated 2020-05-29 
A revision history for this document is included at the end. 
Protocol Version: 
Refers to Protocol Version 1.17 
Contributors: 
Statisticians responsible:  
 
Benjamin F. Arnold 1 , Travis C. Porco 1 
Principal Investigators:  
 
Catherine E. Oldenburg 1, Thuy Doan1 
 
1 Francis I. Proctor Foundation for Research in Ophthalmology, 
University of California, San Francisco, USA 
 
 
 
 
 


ACTION trial Statistical Analysis Plan 
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13 
SAP Table of Contents 
1.  ADMINISTRATIVE INFORMATION ......................................................................................................... 12 
2.  INTRODUCTION ........................................................................................................................................ 14 
2.1. BACKGROUND AND RATIONALE ....................................................................................................................... 14 
2.2. OBJECTIVES .................................................................................................................................................... 14 
3.  STUDY METHODS .................................................................................................................................... 14 
3.1. TRIAL DESIGN .................................................................................................................................................. 14 
3.2. RANDOMIZATION .............................................................................................................................................. 14 
3.3. SAMPLE SIZE ................................................................................................................................................... 14 
3.4. STATISTICAL FRAMEWORK .............................................................................................................................. 16 
3.5. STATISTICAL INTERIM ANALYSES AND STOPPING GUIDANCE .......................................................................... 16 
3.6. TIMING OF THE FINAL ANALYSIS ...................................................................................................................... 18 
3.7. TIMING OF OUTCOME ASSESSMENTS .............................................................................................................. 18 
4.  STATISTICAL PRINCIPLES ..................................................................................................................... 18 
4.1. CONFIDENCE INTERVALS AND P-VALUES ........................................................................................................ 18 
4.2. PROTOCOL DEVIATIONS .................................................................................................................................. 18 
5.  TRIAL POPULATION ................................................................................................................................ 18 
5.1. SCREENING DATA ............................................................................................................................................ 18 
5.2. ELIGIBILITY ...................................................................................................................................................... 19 
5.3. RECRUITMENT ................................................................................................................................................. 19 
5.4. WITHDRAWAL/FOLLOW-UP .............................................................................................................................. 19 
5.5. BASELINE PATIENT CHARACTERISTICS ............................................................................................................ 19 
6.  ANALYSIS .................................................................................................................................................. 19 
6.1. OUTCOME DEFINITIONS ................................................................................................................................... 19 
6.2. ANALYSIS METHODS ........................................................................................................................................ 20 
6.3. MISSING DATA ................................................................................................................................................. 22 
6.4. ADDITIONAL ANALYSES .................................................................................................................................... 22 
6.5. HARMS ............................................................................................................................................................. 22 
6.6. STATISTICAL SOFTWARE ................................................................................................................................. 23 
7.  REFERENCES ........................................................................................................................................... 23 
8.  REVISION HISTORY ................................................................................................................................. 24 
 
The content of this Statistical Analysis Plan meets the requirements stated by the US Food and 
Drug Administration and conforms to the American Statistical Association’s Ethical Guidelines. 
This SAP was organized following guidelines proposed in:  
 
Gamble C, Krishan A, Stocken D, Lewis S, Juszczak E, Doré C, et al. Guidelines for the 
Content of Statistical Analysis Plans in Clinical Trials. JAMA. 2017;318: 2337–2343. PMID: 
29260229 [1] 
 
The companion computational notebook with underlying sample size and group sequential 
design calculations presented herein is entitled: ACTION-sample-size-power.Rmd / .html; it 
is saved in the same directory as this document. 
 
 


ACTION trial Statistical Analysis Plan 
Version 6, 2020-5-29 
 
14 
2.  Introduction 
2.1. Background and rationale 
Identification of a safe, effective treatment for individuals with mild or moderate COVID-19 that 
prevents disease progression and reduces hospitalization would reduce the burden on the 
health system. High dose hydroxychloroquine is being evaluated for SARS-CoV-2 prevention 
and COVID-19 disease treatment, but has a high risk of a number of potentially severe adverse 
events. Recent evidence has indicated that the broad-spectrum macrolide azithromycin may 
have some activity against coronaviruses. A large community randomized trial in Niger 
demonstrated reduced viral load among children with commensal coronaviruses (prior to the 
emergence of SARS-CoV-2) in communities receiving biannual mass azithromycin distribution 
compared to placebo (submitted). In SARS-CoV-2 patients in France, the addition of 
azithromycin to a hydroxychloroquine regimen appeared to decrease SARS-CoV-2 positivity by 
PCR compared to hydroxychloroquine-only and control patients. Azithromycin is generally well-
tolerated and may be an attractive option for treating patients with mild disease. 
2.2. Objectives 
1: To determine if a single oral dose of azithromycin is effective for reducing progression to 
hospitalization in patients with a positive SARS-CoV-2 PCR test with mild or moderate disease.  
3.  Study Methods 
3.1. Trial design 
The trial will be a scalable, telemedicine-based parallel group simple trial to evaluate the 
efficacy of azithromycin for the prevention of COVID-19 disease progression and hospitalization.  
 
3.2. Randomization 
Participants will be randomized 2:1 to either receive a dose of oral azithromycin or oral placebo. 
Patients will be twice as likely to receive azithromycin than placebo. The randomization will not 
be stratified or blocked in any way. We found that even with permuted block sizes and ≥6 labels 
(4 azithromycin, 2 placebo), a 2:1 allocation could lead to unmasking through longer runs of 
active treatment labels. 
 
3.3. Sample size 
The trial’s initial target enrollment will be on the order of 2,300 participants, which will be 
sufficient to detect a reduction of proportion of patients who are hospitalized from 10% to 6% (4 
percentage point reduction) allowing for 7 interim analyses (details below). The trial’s final 
enrollment could be as high as 10,000 participants, depending on how the trial evolves. 
 
Due to unknown true incidence, probability of hospitalization, and enrollment potential, we 
propose an adaptive sample size that is re-evaluated at pre-specified junctures by a masked 
group of investigators that will include a masked statistician (TC Porco), only provided incidence 
and enrollment data (masked to study arm) for sample size re-estimation, along with study PIs 
(Drs. Oldenburg, Doan) and Dr. Lietman. The sample size evaluation will be based on primary 
outcome rates estimated across all three arms (pooled), and will be completed after 30% 
(n=690) and 50% (n=1,150) of participants reach the primary endpoint. The masked investigator 


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15 
group will consider recommending change to sample size based not only on statistical 
considerations but also on logistical considerations such as the pace of enrollment and the 
course of the epidemic. The masked investigators will make a final recommendation to the trial’s 
Data and Safety Monitoring Committee and institutional review board. Masked interim sample 
size re-estimation is not thought to strongly influence Type I error [2]. 
 
With 2,268 participants, the trial will have 80% power to detect a relative reduction of 40% in 
hospitalization or death under the following assumptions: 
 
• 
2:1 allocation ratio of azithromycin : placebo  
• 
10% hospitalization under placebo over 14-day period (binomial outcome, 14-d 
cumulative incidence)  
• 
10% of patients seek azithromycin therapy outside of the trial.  
o 
This non-compliance will attenuate the ITT estimates slightly by making the 
outcome rate more similar between the two groups. For example, if we assume 
10% hospitalization in the control arm and that treatment reduces the percentage 
to 6% (a risk difference of 4%), then this non-compliance means that the actual 
outcome prevalence in the placebo arm will be (0.9)(10%)+(0.10)(6%)=9.6% 
• 
15% loss to follow-up 
• 
2-sided alpha of 0.05, power = 0.8. 
• 
Seven interim analyses at 30%, 40%, …, 90% of outcomes collected with stopping 
guideline determined using the Lan-DeMets spending function approach with an O’Brien 
and Fleming boundary. 
 
The table below shows sample sizes under five effect size scenarios, assuming azithromycin 
reduces hospitalization or death by between 1% (RR = 0.9) and 5% (RR = 0.5) compared to 
placebo. 
 
 
 
Note, these estimates do not account for interim analyses in a group-sequential analysis. 
Sequential randomized controlled trials have been demonstrated to result in overall better 
patient outcomes during fast-moving epidemics because they reach answers for efficacy more 
quickly than a trial without interim analyses [3]. 
 
Using the scenario of a 4% reduction in hospitalization due to placebo, we estimated the 
maximum sample size under a group-sequential design. Under the assumptions in Section 3.5 


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(below), the maximum sample size would be 2,268, a 3.5% increase over a design with no 
interim monitoring due to alpha spending at 7 interim analyses.  
 
We note that ACTION is designed as a scalable trial. If pre-specified, interim sample size 
calculations or external factors suggest that increasing the sample size would be desirable, then 
the masked investigator group that evaluates interim sample size assessments at 30% and 50% 
enrollment will make a recommendation to the trial’s Data and Safety Monitoring Committee, 
which together will decide if such expansion is desirable. An expansion to approximately 10,000 
participants would allow for the detection of smaller but still clinically relevant effects (RR=0.8) 
given the severity of hospitalization or death. 
 
3.4. Statistical framework 
The ACTION trial will use a superiority testing framework, with the active treatment arm 
(azithromycin) compared against placebo.  
 
The analysis will account for interim analyses using a group-sequential testing framework using 
the Lan-DeMets spending function approach with an O’Brien and Fleming boundary [4].  
 
3.5. Statistical interim analyses and stopping guidance 
Due to uncertainty in the possible effects of treatment and the urgency of identifying effective 
therapies for COVID-19, sequential randomized controlled trials with interim monitoring are 
expected to provide robust results faster than standard fixed parallel trials without interim 
monitoring [3]. In the absence of a significant difference between randomized arms, the study 
team believes that there is value in continuing the randomized comparison of Azithromycin 
versus placebo to full enrollment (i.e., 2300 participants) in order to obtain as much precision as 
possible and to provide maximal information to inform the field. We therefore have not 
recommended interim analyses for futility.   
 
Interim analyses for efficacy 
The efficacy bound was derived using a Lan-DeMets spending approach with an O’brien-
Fleming boundary. At this time, we have assumed 7 interim analyses at 30%, 40%, …, 90% of 
participants with 14-day endpoints measured.  This is an approximation as the trial is currently 
considering weekly interim analyses. The actual alpha spending will be updated according to 
the actual interim analysis schedule.  
 
A summary of the interim analyses and nominal P-values is below, created by the R package 
gsDesign. We have also included a summary of standardized treatment effects along the 
efficacy bound, For additional details see this SAP’s companion computational notebook: 
ACTION-sample-size-power.Rmd / .html .   
 
 
 


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## One-sided group sequential design with 
## 80 % power and 2.5 % Type I Error. 
##                 
##   Analysis   N   Z   Nominal p  Spend 
##          1  681 3.93    0.00004 0.00004 
##          2  907 3.37    0.0004  0.0004 
##          3 1134 2.99    0.0014  0.0011 
##          4 1361 2.71    0.0033  0.0023 
##          5 1587 2.50    0.0061  0.0036 
##          6 1814 2.34    0.0098  0.0048 
##          7 2041 2.20    0.0140  0.0059 
##          8 2268 2.08    0.0187  0.0069 
##      Total                      0.0250  
##  
## ++ alpha spending: 
##  Lan-DeMets O'brien-Fleming approximation spending function. 
##  
## Boundary crossing probabilities and expected sample size 
## assume any cross stops the trial 
##  
## Upper boundary (power or Type I Error) 
##           Analysis 
##    Theta     1      2      3      4      5      6      7      8 Total   E{N} 
##   0.0000 0.000 0.0004 0.0011 0.0023 0.0036 0.0048 0.0059 0.0069 0.025 2257.1 
##   0.0599 0.009 0.0509 0.1099 0.1471 0.1524 0.1359 0.1104 0.0844 0.800 1735.2  
 
The figure below shows the difference in the proportion of patients hospitalized (placebo minus 
azithromycin) at each of the interim analyses along the efficacy bound based on the alpha 
spending function above. It shows, for example, that with 681 patients enrolled at the first 
interim analysis, hospitalization would need to be 9 percentage points higher among patients in 
the placebo arm compared with the azithromycin arm to stop the trial for efficacy. 
 
 
We note the pre-specification of a flexible alpha spending function permits interim analysis at 
the discretion of the DSMC. We will update the efficacy bound according to the trial’s actual 
interim analysis schedule. 
 
The DSMC will review interim analyses and will make a recommendation to stop the trial for 
efficacy after each review. Early stopping for any reason will mandate final analysis at alpha of 
the full final prespecified value based on all available data (incorporating any alpha spending, as 


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needed). In considering possible modifications to the study or termination of the study, the 
DSMC may consider other outcome measures than the composite hospitalization/death 
outcome measure.  For example, the DSMC might make recommendations based on a high 
level of evidence for a difference between randomized arms in the proportion dying. A “high 
level of evidence” might be based on application of the O’Brien and Fleming stopping guideline 
to the death outcome.   
 
 
3.6. Timing of the final analysis 
The final analysis will take place when 14-day outcomes have been measured on all 
participants. If the trial is stopped for efficacy or futility before the full sample, the final analysis 
will include all outcomes among patients who have been enrolled at the time the trial is stopped. 
 
3.7. Timing of outcome assessments 
Primary outcomes will be measured 14-days after enrollment. Additional visits will take place at 
3, 7, and 21 days after enrollment. Protocol section 3.2 includes details about the trial profile. 
 
4.  Statistical Principles 
4.1. Confidence intervals and P-values 
 
The trial will report 95% confidence intervals and permutation P-values estimated from the 
primary analysis. The level of statistical significance will depend on the alpha spending function 
that accounts for the group sequential design (see section 3.5 for details). 
 
4.2. Protocol deviations 
The analysis population will be intention to treat, and will include all participants enrolled and 
randomized.  Adherence to protocol will be determined during the 14-day assessment based on 
patient report of whether they took the medication delivered by the trial. At that time, the trial will 
assess whether patients have taken other medication during the study period, including 
azithromycin or other macrolides not provided by the trial.  Patients who take azithromycin or 
other macrolide not provided by the study will be considered protocol deviations but will be 
included according to randomized group in the intention-to-treat analysis.  
 
5.  Trial Population 
5.1. Screening data 
We will report the number of patients screened and characteristics to the extent they are 
available to assess representativeness of the enrolled study population. 
 


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5.2. Eligibility 
See Section 4 of the trial protocol for eligibility criteria. 
 
5.3. Recruitment  
See section 5.1 of the study protocol. We will report the number of participants screened, 
enrolled, randomized, and measured at the primary endpoint, along with reasons for exclusion 
at each step following CONSORT guidelines. 
 
5.4. Withdrawal/follow-up  
We will report the proportion of patients in both study arms who withdraw from the trial, along 
with reasons. We will report this information in the trial’s CONSORT flow chart.  The analysis 
will be intention-to-treat: patients will be analyzed according to the arm they are randomized. 
 
5.5. Baseline patient characteristics  
We will summarize patient characteristics by arm, including: age, sex, location (to level of US 
state), and clinical symptoms at the time of enrollment. 
 
6.  Analysis 
6.1. Outcome definitions 
 
Primary Outcome: 
The primary outcome will be hospitalization and/or death at 14 days after the electronic 
enrollment assessment.  
 
Secondary Outcomes: 
• 
Hospitalization/death by 21 days: we will extend follow-up beyond the primary 
endpoint to capture any hospitalizations or death that progress more slowly and are not 
detected by 14 days. 
• 
Adverse events: we will conduct an adverse event survey at Day 3 after treatment, 
including gastrointestinal side effects (nausea, vomiting, diarrhea, abdominal pain) and 
rash. We note that some COVID-19 patients report gastrointestinal symptoms, and this 
survey will provide data on whether azithromycin causes additional gastrointestinal 
effects beyond those symptoms. 
• 
Prevalence of positive swabs: we will compare the prevalence of SARS-CoV-2 
positive swabs at Day 3 after treatment in self-collected nasal, saliva, and rectal swabs 
in azithromycin compared to placebo-treated participants. 
• 
Viral load: we will assess viral load by RT-PCR in self-collected nasal, saliva, and rectal 
swabs at Day 3 after treatment. 
• 
Mortality: we will collect emergency contact/next of kin information during the baseline 
questionnaire. We will follow-up with the emergency contact if participants are lost to 
follow-up at the Day 14 and Day 21 questionnaires to assess mortality and 
hospitalization outcomes. 


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• 
Genetic macrolide resistance determinants: We will evaluate the prevalence of 
genetic macrolide resistance determinants ermB, mefA/E, and mphA by targeted PCR in 
rectal samples collected at Day 3 after treatment. 
• 
COVID-19 symptoms: we will ask patients about COVID-19 symptomology during each 
online questionnaire, including cough, fever, myalgia, anosmia, shortness of breath (and 
related abilities such as ability to walk across a room or up a flight of stairs), fatigue, 
conjunctivitis, and orthostatic symptoms. 
• 
Number of emergency room visits: during each online questionnaire we will survey 
patients about any emergency room visits (with stays <24 hours) that occurred since 
their last survey. 
• 
Number of household members with COVID-19 (confirmed or symptomatic): during 
each online questionnaire we will ask participants how many of their household 
members have symptoms of COVID-19 or confirmed disease. 
 
6.2. Analysis methods 
 
Primary Outcome: 
The primary analysis will estimate the risk difference (RD) comparing cumulative incidence of 
hospitalization or death by 14 days in the azithromycin versus placebo arms. Kaplan-Meier 
approach to account for losses to follow-up. We will use Greenwood’s formula to estimate the 
standard error of the log proportion in each arm will be used to determine the variance of the 
risk difference, and will report 95% confidence intervals adjusted for interim analyses. We will 
compute P-values for differences between arms using a permutation test with the risk difference 
between arms as the test statistic and 10,000 iterations. We will additionally estimate and report 
the risk ratio. 
 
Determination of statistical significance for the primary and secondary analyses will follow the 
final alpha-spending function determined by the group sequential design (see section 3.5). 
 
 
Secondary Outcomes: 
 
Outcomes with analyses that follow the same approach as the primary outcome: 
 
Analyses for the following secondary endpoints will follow the same analysis methods as the for 
the primary outcome, a Kaplan-Meier analysis to estimate cumulative incidence, and P-values 
for differences between arms using a permutation test with the risk difference between arms as 
the test statistic and 10,000 iterations.  
 
• 
Hospitalization/death by 21 days: we will extend follow-up beyond the primary 
endpoint to capture any hospitalizations or death that progress more slowly and are not 
detected by 14 days. 
• 
Mortality by 14 and 21 days: we will collect emergency contact/next of kin information 
during the baseline questionnaire. We will follow-up with the emergency contact if 
participants are lost to follow-up at the Day 14 and Day 21 questionnaires to assess 
mortality and hospitalization outcomes. 
• 
COVID-19 symptoms: we will ask patients about COVID-19 symptomology during each 
online questionnaire, including cough, fever, myalgia, anosmia, shortness of breath (and 


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related abilities such as ability to walk across a room or up a flight of stairs), fatigue, 
conjunctivitis, and orthostatic symptoms. 
• 
COVID-19 (confirmed or symptomatic) among household members of enrolled 
patients: during each online questionnaire we will ask participants how many of their 
household members have symptoms of COVID-19 or confirmed disease. This analysis 
will be conducted on an expanded dataset that includes an observation for each 
household member. To account for outcome correlation among individuals within 
households, we will estimate 95% confidence intervals for the risk difference and risk 
ratio with a clustered, non-parametric bootstrap that resamples households with 
replacement (10,000 iterations).  
 
Outcomes with a prevalent measure at Day 3: 
 
We will estimate the difference in prevalence between arms and the 95% confidence interval for 
the difference. We will compute P-values for differences between arms using a permutation test 
with the prevalence difference between arms as the test statistic and 10,000 iterations. 
 
• 
Prevalence of positive swabs: we will compare the prevalence of SARS-CoV-2 
positive swabs at Day 3 after treatment in self-collected nasal, saliva, and rectal swabs 
in azithromycin compared to placebo-treated participants. 
• 
Genetic macrolide resistance determinants: We will evaluate the prevalence of 
genetic macrolide resistance determinants ermB, mefA/E, and mphA by targeted PCR in 
rectal samples collected at Day 3 after treatment. 
• 
Adverse events: we will conduct an adverse event survey at Day 3 after treatment, 
including gastrointestinal side effects (nausea, vomiting, diarrhea, abdominal pain) and 
rash. We note that some COVID-19 patients report gastrointestinal symptoms, and this 
survey will provide data on whether azithromycin causes additional gastrointestinal 
effects beyond those symptoms. We also note that adverse events will be cumulative 
through Day 3 and measure cumulative incidence (risk) not prevalence.  
 
Outcomes with a continuous measure at Day 3: 
 
We will compare log transformed values of relative read and number of reads using a t-test. We 
will compute P-values for differences between arms using a permutation test with the difference 
between arms as the test statistic and 10,000 iterations. 
 
• 
Viral load: we will assess viral load by RT-PCR in self-collected nasal, saliva, and rectal 
swabs at Day 3 after treatment.  
 
Count outcomes:  
 
• 
Number of emergency room visits: during each online questionnaire we will survey 
patients about any emergency room visits (with stays <24 hours) that occurred since 
their last survey. We will model the total number of emergency room visits for each 
participant through 14 days as a count outcome using a negative binomial regression 
model with a single indicator for treatment arm and an offset for the number of days of 
follow-up completed by each participant. The exponentiated coefficient on the indicator 
will estimate the incidence rate ratio. We will compute a P-value for difference between 
arms using a permutation test with the coefficient from the model as the test statistic and 
10,000 iterations.    


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6.3. Missing data 
 
If we find there is significant delay in ascertainment of the primary outcome during the trial, it 
could bias interim analyses. If, in the conduct of the trial, we find that outcome ascertainment is 
delayed for a significant number of participants, then we will consider adjusting our interim 
analysis Kaplan-Meier estimator using an inverse probability of censoring weighted approach, 
which weights the failure distribution by a Kaplan-Meier estimate of the censoring distribution 
[5]. 
 
If outcome data are missing for >15% of participants we will report results from sensitivity 
analyses for missing data [6,7]. We selected 15% missing because trials with >20% missing 
values are thought to be a concern for bias [8]. The primary analysis will account for censoring 
but will assume outcomes are missing completely at random. We will relax this assumption 
slightly, assuming that outcomes are missing at random (MAR) with an inverse-probability 
weighted (IPW) estimator using cumulative incidence through 14 days as the binary endpoint. 
We will model the probability of censoring as a function of baseline patient characteristics with a 
logistic regression model, and will use the inverse of the predicted probabilities from the model 
to re-weight the analysis population to reflect the full study population at the time of enrollment, 
using a doubly-robust targeted maximum likelihood estimator that also includes an outcome 
model using the same covariates [9]. Baseline characteristics used in the censoring model will 
include age, sex, race/ethnicity, zip code, comorbidities, concomitant medications, symptoms at 
enrollment, insurance status, alcohol use, tobacco/e-cigarette/marijuana use, and household 
composition. We will additionally consider a range of scenarios assuming the outcomes are 
missing not at random (MNAR), i.e. systematically, using a pattern mixture model approach 
described by Little et al. [6], whereby we model cumulative incidence through 14 days with a 
linear probability model as a function of covariates listed for the IPW estimator; missing 
outcomes will then be imputed using the model fit to predict , adding a shift parameter Δ that we 
vary across a range of values.   
 
6.4. Additional analyses 
 
Pre-specified Subgroup Analyses 
 
In secondary analyses, we will estimate differences separately by the following subgroups: 
• 
Age >60 versus ≤ 60 
• 
“High risk” versus low risk patients, with “high risk” defined as Age >60 and reported 
hypertension, cardiovascular disease, diabetes, or obstructive or restrictive lung disease 
at enrollment. 
• 
Presence of COVID-19 symptoms at enrollment versus asymptomatic at enrollment. 
 
6.5. Harms 
 
Section 10 of the trial protocol includes details of adverse event monitoring and reporting. All 
serious adverse events including deaths will be recorded for the period between the date the 


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first dose of azithromycin or placebo and the date of the primary endpoint, 14 days later, and 
through the final follow-up at 21 days.  
 
6.6. Statistical software 
Analyses will be conducted using R version 3.6 or later. We will strive to make all replication 
files publicly available along with the trial results through the Proctor Foundation’s GitHub page 
and other public repositories such as the Open Science Framework and Zenodo. 
 
7.  References 
1.  Gamble C, Krishan A, Stocken D, Lewis S, Juszczak E, Doré C, et al. Guidelines for the 
Content of Statistical Analysis Plans in Clinical Trials. JAMA. 2017;318: 2337–2343. 
doi:10.1001/jama.2017.18556 
2.  Jennison C, Turnbull BW. Group sequential methods with applications to clinical trials. Boca 
Raton: Chapman & Hall/CRC; 2000.  
3.  Cooper BS, Boni MF, Pan-ngum W, Day NPJ, Horby PW, Olliaro P, et al. Evaluating clinical 
trial designs for investigational treatments of Ebola virus disease. PLoS Med. 2015;12: 
e1001815. doi:10.1371/journal.pmed.1001815 
4.  DeMets DL, Lan KK. Interim analysis: the alpha spending function approach. Stat Med. 
1994;13: 1341–1352; discussion 1353-1356. doi:10.1002/sim.4780131308 
5.  Zhao H, Tsiatis A. A consistent estimator for the distribution of quality adjusted survival time. 
Biometrika. 1997;84: 339–348. doi:10.1093/biomet/84.2.339 
6.  National Research Council (U.S.), National Research Council (U.S.), National Academies 
Press (U.S.), editors. The prevention and treatment of missing data in clinical trials. 
Washington, D.C: National Academies Press; 2010.  
7.  Little RJ, D’Agostino R, Cohen ML, Dickersin K, Emerson SS, Farrar JT, et al. The 
prevention and treatment of missing data in clinical trials. N Engl J Med. 2012;367: 1355–
1360. doi:10.1056/NEJMsr1203730 
8.  Schulz KF, Grimes DA. Sample size slippages in randomised trials: exclusions and the lost 
and wayward. Lancet. 2002;359: 781–785. doi:10.1016/S0140-6736(02)07882-0 
9.  Gruber S, van der Laan M. tmle: An R Package for Targeted Maximum Likelihood 
Estimation. J Stat Softw. 2012;51: 1–35.  
 
 
 


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8.  Revision history 
 
Version 
Date 
Summary of Changes, Justification, and Timing vis-à-vis key 
trial events (enrollment completion, interim analyses, 
unmasking, etc) 
1 
2020-03-28 
 
• 
First draft 
2 
2020-03-28 
 
• 
Updated administrative information 
3 
2020-04-03 
• 
Provided additional detail in the interim monitoring section. 
4 
2020-05-05 
• 
Update to reflect discussions during the trial’s first DSMC 
meeting on April 8, 2020, as well as input from the FDA 
through the IND approval process, including: 
• 
Add secondary outcomes beyond viral load at day 3, including 
analysis details for each 
• 
Add pre-specified subgroup analysis (previously none) 
• 
Remove the futility bound for interim analyses 
• 
Update the interim analysis alpha spending function to Lan-
DeMets (harmonization with other COVID-19 therapeutic 
trials) 
• 
Update the primary analysis to be based on a Kaplan-Meier 
estimator rather than cumulative proportions to explicitly 
account for censoring. 
• 
Add language regarding a possible expansion of sample size 
to target a smaller detectable effect (RR = 0.8 rather than RR 
= 0.6) if large-scale enrollment is possible.  
• 
Made risk difference the primary comparison with risk ratio 
(RR) an additional contrast we plan to report. 
• 
Include details of masked sample-size re-assessment 
committee, and specific timing for masked sample size re-
assessment. 
• 
Add details of possible sensitivity analyses for missing 
outcomes under MAR and MNAR 
5 
2020-05-29 
• 
Revised the interim sample size evaluation process and 
group who will be involved in the decision making process.