Clinical Study Report on - pankajakasthuri.in · ZingiVir-H in SARS-CoV-2 patients Confidential property of PHRF. Report on Primary endpoint efficacy analysis dated 23 July 2020 Page

ZingiVir-H in SARS-CoV-2 patients

Confidential property of PHRF. Report on Primary endpoint efficacy analysis dated 23 July 2020 Page 1

Clinical Study Report

on

Primary End Point Analysis

STUDY TITLE: RANDOMIZED CONTROLLED SINGLE BLINDED PROSPECTIVE

MULTI CENTRE CLINICAL TRIAL TO INVESTIGATE THE SAFETY AND

EFFICACY OF ZINGIVIR-H AS AN ADJUVANT THERAPY IN HOSPITALIZED

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

Protocol Number: PHRF 010-2020

Protocol Version: Version 1:1 dated 11 April 2020

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

Study Sponsor: Pankajakasthuri Herbal Research Foundation



TABLE OF CONTENTS

S.No Particulars Page Number

1 Clinical study design and Schematic Design of the study 03

2 Changes made in the Protocol or Study Procedures 05

3 Research Site Information 06

4 Start up Deliverables & Timelines 06

5 Information on patient screening 09

6 Eligibility Deviations 10

7 Baseline characteristics (pooled by treatment regimen) 10

8 Adherence to medication schedule (pooled by treatment

regimen)

11

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

10 Reporting delays for key events (pooled by treatment regimen) 12

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

regimen)

12

12 Statistical and Data modeling Assessments 12

13 Clinical Outcome assessments 23

14 Discussion 26



1. Overall Clinical Study Design

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



Study Procedures



2. Changes made in the Protocol or Study Procedures:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

on this behalf at study level.

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

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

laboratory for assessment as per recommended research protocols.

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



3. Research Site Information

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

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

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

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

Rajinder Nagar, New Delhi-110060

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

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

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

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

Maharashtra, India.

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

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

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

Z008 Dr. Sonali Nirali, Consultant, Life Point Hospital, Pune

4. Start up Deliverables & Timelines:

Start up Deliverables Comments

PI Qualifications All Principal Investigators have essential residency

qualifications in Modern Medicine and Experience to

Conduct Clinical Trials as per GCP and Regulatory

Guidelines.

Documents Obtained from

PI

Signed and dated

a) Non Disclosure Agreement

b) Financial Disclosure Form (FDA 3455)

c) Investigator Study Undertaking (FDA 1572)

d) Investigator consent on Protocol (PSP)

e) Filled in Feasibility forms

f) Signed CV and MRC



Research support &

Infrastructure at sites

Research activities of all Identified sites is managed by

Registered Site Management Organizations in Clinical

Research

Research Team As per AYUSH Guidelines in COVID trials.

Study Deliverables Comments

Site qualification

Assessments

A telephonic evaluation is made based on the project feasibility

submitted by the Investigator and team. Feasible sites with project

execution capabilities were selected.

Ethics Committee Documents submitted electronically to all ethics committee through

Investigators. Expedite review request was made as per ICMR

guidelines to Ethics Committee on COVID research studies

evaluation. Few Ethics Committee gave expedite approval and KIMS

hospital at Karad and Sir Ganga Ram hospital, NewDelhi are yet to

give the approval for the study conduct.

Site Training and

Initiation of the

Project

Once after Ethics Committee approval the sites and investigation

team is provided with telephonic training on Protocol, Study

procedures including consenting research subjects and

documentation, Study drug dispensing procedure, Laboratory

assessments, Blood sampling procedures, Handing AE/SAE’s in the

study, Data capturing requirements etcetera.

Study execution

and Safety

measures

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

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

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

research team as per the delegation of responsibilities by the Chief

Investigator.

Study Data

Collection

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

capture. The data points shall be captured in the CRF from the

corresponding Patient source data by the research staff at site. CRF

data will be 100% audited by the sponsor representative and will

retrieve the filled in CRF pages for data analysis. For the analysis the



available/ required data is collected through digital sources, without

auditing the source notes.

Safety data

Collection and

reporting

As per the clinical study protocol and applicable regulatory

guidelines, the participating sites were given training on

contemporary approaches in the collection, reporting of adverse

events (AEs) and Adverse Drug reactions (ADRs) in the present

study with a primary efficacy outcome. The sites are elaborated on

adverse events/ serious adverse events collection methods, steps to

reduce information loss on AE /ADR when analyzing at patient level,

assessment of severity and causality, reporting criteria, analysis

methods and presentation of AE data. AE data were collected (mode

of collection, timing) and defined (coding, attribution); how AEs

were assessed in terms of severity of the event or relatedness to the

medical intervention; AE analysis plan if any; how events were

selected for inclusion in the final analysis of data are explained. In the

present study no noticeable adverse events or serious adverse events

are reported till date. All unidentified adverse events will be captured

during site audits and if any will be reported in the final clinical study

report.

DMC / DSMB The data generated in the present clinical trial is controlled and

monitored by an independent FIVE member Peer review data

monitoring committee / Data Safety Monitoring board. Interim

analysis of the present study is reviewed and approved by the DMC

committee. The suggestions recommended in the DMC committee

were implemented further in the trial. The DMC proposed to meet

again to evaluate the final results before publication.



Project timelines

5. Information on patient screening:

S.No Patient Information Z001 Z004 Z006 Z008

1 Site Initiation dates 25-Apr-20 27-May-20 18-Jun-20 11- July-20

2 First patient in (FPI) 3-May-20 15 Jun 20 25 Jun 20 14- Jul-20

3 Total Patient Allocated 60 40 20 20

4 Total Patient Screened 60 40 18 12

5 Total Patient Randomized 60 40 18 12

6 Total Patient Withdrawal 0 0 3 1

The Primary end point analysis is performed with 116 evaluable patients out of the

randomized subjects. Three patient transferred from the primary hospital after withdrew from

the study participation on the second day. One patient withdraws the consent after signing the

consent form and after randomization. These four patients are recorded as withdrawn subjects

from the study. The patients were not interested to go for drawing blood to assess the safety.



However the patients were assessed by the Investigation team and found to have no study

related concerns. Their withdrawal are documented as appropriate in source notes.

6. Eligibility Deviations:

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

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

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

into account as eligibility for inclusion. These 7 patients’ data are excluded in the primary

efficacy endpoint analysis. However these patient data points shall be included in the “Per

Protocol Assessment Criteria” during the final analysis. There are protocol deviations

reported in the study in missing or delaying in the blood sampling procedures and visit day

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

deviation forms and kept for audit trial. All protocol deviations shall be documented and will

be reported to concerned ethics committee before the site closeout and such deviations shall

be tabulated in the final data analysis.

7. Baseline characteristics (pooled by treatment regimen)

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

randomization.

Demographics

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

surgeries/interventions prior to signing the informed consent).

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

mmHg, Respirations – breaths per

Concomitant medications (including medications, fluids and blood products administered

within the 7 days prior to randomization).

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

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

nonmedical treatment such as surgery or drainage).

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

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



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

(baseline dry weight).

Blood will be obtained for following laboratory tests:

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

with differential count) & ESR

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

Albumin, total bilirubin

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

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

randomization

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

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

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

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

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

their drug consumption.

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

Considering the administrative regulations in light of COVID pandemic and management

which are made in various districts in different manner, there are few lapses in the patient

visit to the hospital to complete study procedures as per the protocol. The study team

attempted to make home visit to reach out to few patients to perform the study procedure and

blood sampling. The missed visits and the data are captured as protocol deviations.

Corrective actions are recommended to make sure that all patients shall comply with the

study procedures. Few patients needed further counseling for blood withdrawal during day

06, 15 and 30. Few patients still denied giving away blood samples after study enrollment on

day 06, 15 & 30. Such patients are still considered in the study and performed vital

assessments and physical examinations and such data are captured in the source notes and

transcribed to CRF.



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

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

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

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

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

include such patients into the study.

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

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

patients completed the study without any safety issues. Few non-significant elevations above

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

12. Statistical / Data modeling assessments:

Survival Analysis

A total of 116 patient underwent randomization; 58 patient were assigned to ZingiVir-H group

and 58 to the Placebo group. The primary efficacy analysis was done on an intention-to-treat

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

patients had PCR negative; no clinical improvement or death was considered as right censored.

Time to clinical improvement was portrayed by Kaplan-Meier plot and compared with a log-rank

test. The HR and 95% CI for clinical improvement is calculated by Cox proportional hazards

model. Other analyses include subgroup analyses for those requiring medical care other than

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

(Ordinal Scale -6).

The median age of study patients is 35 (Inter Quartile Range (IQR) 27-47), in which for the

treatment group the median age is 42 (IQR 30-50) and that of Placebo is 31.5 ( IQR 26 – 44.25).

Results from the 116 patients with data available after randomization indicated that those who

received ZingiVir-H had a median recovery time of 5 days (95% Confidence interval (CI) 5-5) as

compared with 6 days (95% CI 5-6) in those who received Placebo. Interestingly the Zingivir-

H treated arm shows significant recovery time in all treated patients between 3 and 6 days

whereas the placebo treated arm recovery time falls between 4 and 13 days, which shows



the significance of Zingivir-H as a potential antiviral drug against COVID-19 (P value

<0.0001).

The overall median recovery time is also evaluated and it is obtained as 5 days (95% CI 5-6).

The corresponding figure is provided below



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

and Placebo and it was resulted with a P value 0.000004 (<0.05) and lead to the conclusion

that ZingVir-H use was associated with a difference in time to clinical improvements in less

than 5 days compare to Placebo group which has recovery time upto 13 days. This means

that ZingiVir-H has a significantly less recovery time than that of a Placebo. The hazard ratio

obtained by the Cox proportional hazards model is 2.619 (95% CI 1.733 – 3.956), also supported

the above conclusion.

survdiff(formula = Surv(Days, Status) ~ Treat, data = trial) N Observed Expected (O-E)^2/E (O-E)^2/V Treat=Placebo 58 46 62.7 4.45 21.5 Treat=ZingiVir-H 58 58 41.3 6.76 21.5 Chisq= 21.5 on 1 degrees of freedom, p= 4e-06

Cox proportional hazards model

coxph(formula = Surv(Days, Status) ~ Treat, data = trial) n= 116, number of events= 104 coef exp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 0.9627 2.6188 0.2105 4.573 4.81e-06 *** --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 2.619 0.3819 1.733 3.956 Concordance= 0.645 (se = 0.029 ) Likelihood ratio test= 21.37 on 1 df, p=4e-06 Wald test = 20.91 on 1 df, p=5e-06 Score (logrank) test = 22.33 on 1 df, p=2e-06

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

performing the log-rank test (P Value = 0.44>0.05) (Schoenfeld Residual Test)

chisq df p Treat 0.59 1 0.44 GLOBAL 0.59 1 0.44 Cox proportional hazards model including age as a covariate

coxph(formula = Surv(Days, Status) ~ Treat + Age, data = trial) n= 116, number of events= 104 coef exp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 1.012337 2.752024 0.215402 4.700 2.6e-06 *** Age -0.009690 0.990357 0.008857 -1.094 0.274 --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1



exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 2.7520 0.3634 1.8043 4.198 Age 0.9904 1.0097 0.9733 1.008 Concordance= 0.663 (se = 0.037 ) Likelihood ratio test= 22.57 on 2 df, p=1e-05 Wald test = 22.1 on 2 df, p=2e-05 Score (logrank) test = 23.51 on 2 df, p=8e-06

The inclusion of Age in the model is not at all a significant (P value = 0.274>0.05) one, for the

improvement of the model.

Sub Group Analysis-1

These results are based on the criteria of inclusion (ordinal scale 5 and 6). In the case of ordinal

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

were 101 patients and under ordinal scale 6 (Hospitalized, not requiring supplemental oxygen-

not requiring ongoing medical care other than ZingiVir-H) is 15. The median age of group

corresponding to ordinal scale 5 is 36 (IQR 29 – 49) and that of group corresponding to 6 is 26

(IQR 24.5 – 32.5).

Ordinal Scale - 5



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

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

days (95% CI 5-5) and that of Placebo 6 days (95% CI 5-6). The Log-Rank test result

significance (P Value = 0.00006<0.05). This Means that, there is a significant difference is

existing in the recovery days and from the median value it is clear that ZingiVir-H requires

a lesser time 5 days) than that of Placebo (6 days).The hazard ratio obtained is 2.356 (95% CI

1.531 -3.624)

survdiff(formula = Surv(Days, Status) ~ Treat, data = trial) N Observed Expected (O-E)^2/E (O-E)^2/V Treat=Placebo 50 43 56.4 3.19 16.1 Treat=ZingiVir-H 51 51 37.6 4.78 16.1 Chisq= 16.1 on 1 degrees of freedom, p= 6e-05


coxph(formula = Surv(Days, Status) ~ Treat, data = trial) n= 101, number of events= 94 coef exp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 0.8568 2.3555 0.2198 3.898 9.69e-05 *** --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 2.356 0.4245 1.531 3.624



Concordance= 0.637 (se = 0.033 ) Likelihood ratio test= 15.4 on 1 df, p=9e-05 Wald test = 15.2 on 1 df, p=1e-04 Score (logrank) test = 16.01 on 1 df, p=6e-05

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

chisq df p Treat 0.21 1 0.65 GLOBAL 0.21 1 0.65

Cox proportional hazards model including age as a covariate

coxph(formula = Surv(Days, Status) ~ Treat + Age, data = trial) n= 101, number of events= 94 coef exp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 0.951164 2.588722 0.227053 4.189 2.8e-05 *** Age -0.015653 0.984468 0.009353 -1.674 0.0942 . --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 2.5887 0.3863 1.6589 4.040 Age 0.9845 1.0158 0.9666 1.003 Concordance= 0.669 (se = 0.04 ) Likelihood ratio test= 18.22 on 2 df, p=1e-04 Wald test = 17.93 on 2 df, p=1e-04 Score (logrank) test = 18.73 on 2 df, p=9e-05

Ordinal Scale – 6



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

time is 6 days ( 95% Lower CI is 6). Corresponding to ZingiVir-H had a median recovery time

of 6 (maximum) days and that of Placebo more than 6 days. The Log-Rank test resulted a

significance difference P Value 0.0075<0.05) in the number of days. Here it can be observed

that the median recovery days for ZingiVir-H is less than that of Placebo Group, when the

treatment group is receiving only ZingiVir-H and it is also statistically significant (P Value

0.00075<0.05).The hazard ratio obtained is 5.899 (95% CI 1.446-24.07).

survdiff(formula = Surv(Days, Status) ~ Treat, data = trial) N Observed Expected (O-E)^2/E (O-E)^2/V Treat=Placebo 8 3 6.03 1.52 7.15 Treat=ZingiVir-H 7 7 3.97 2.31 7.15 Chisq= 7.1 on 1 degrees of freedom, p= 0.008


coxph(formula = Surv(Days, Status) ~ Treat, data = trial) n= 15, number of events= 10 coef exp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 1.7749 5.8995 0.7174 2.474 0.0134 * --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 5.899 0.1695 1.446 24.07 Concordance= 0.806 (se = 0.036 ) Likelihood ratio test= 6.89 on 1 df, p=0.009 Wald test = 6.12 on 1 df, p=0.01 Score (logrank) test = 7.55 on 1 df, p=0.006



PH Verification for Log Rank Test (Schoenfeld Residual Test)

chisq df p Treat 0.43 1 0.51 GLOBAL 0.43 1 0.51

Cox proportional hazards model including age as a covariate

coxph(formula = Surv(Days, Status) ~ Treat + Age, data = trial) n= 15, number of events= 10 coef exp(coef) se(coef) z Pr(>|z|) TreatZingiVir-H 1.91402 6.78028 0.73217 2.614 0.00894 ** Age -0.05413 0.94731 0.04696 -1.153 0.24903 --- Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1 exp(coef) exp(-coef) lower .95 upper .95 TreatZingiVir-H 6.7803 0.1475 1.614 28.475 Age 0.9473 1.0556 0.864 1.039 Concordance= 0.896 (se = 0.061 ) Likelihood ratio test= 8.42 on 2 df, p=0.01 Wald test = 7.29 on 2 df, p=0.03 Score (logrank) test = 8.67 on 2 df, p=0.01

Analysis of Temperature of the Patients

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

primary endpoint analysis we have obtained these values of 104 patients only. A brief summary

Statistics of this is given below.

Summary statistics-Whole

mean sd n

Day1 98.33077 0.6315456 104

Day3 98.21923 0.5215877 104

Day5 98.20577 0.4542842 104

Summary statistics – Corresponding to Treatment

Variable: Day1 mean sd n Placebo 98.23725 0.6131756 51 ZingirVir-H 98.42075 0.6416201 53 Variable: Day3 mean sd n Placebo 98.17255 0.5532010 51 ZingirVir-H 98.26415 0.4903273 53 Variable: Day5



mean sd n Placebo 98.16078 0.4968213 51 ZingirVir-H 98.24906 0.4093253 53 The graph of reduction in the temperature of all patients considered for the trial is given below

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

graph



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

three days (Day 1 - P Value 0.02058<0.05, Day 2 - P Value 0.006794<0.05, Day 1 - P Value

0.000077<0.05). So the corresponding non-Parametric analogue Friedmanns test is performed.

The test rests that, the Temperature was not significantly different at the different time points

during the trial, X2(2) = 3.7236, p = 0.1554. The Median temperature for each days is given by

Day1 Day3 Day5

98.40 98.25 98.20

Effect of Treatment on Temperature

In order to verify the effect of treatment, two Kruskal-Wallis test is performed for an adjusted P

value. Because the variables does not follow the normality assumption in two cases.

Normality assumption

Treat time variable statistic p "ZingiVir-H " Day1 score 0.970 0.207 "ZingiVir-H " Day3 score 0.968 0.167 "ZingiVir-H " Day5 score 0.939 0.010 "Placebo" Day1 score 0.960 0.084 "Placebo" Day3 score 0.956 0.058 "Placebo" Day5 score 0.921 0.002

The Kruskall-Wallis test for the comparison of means of temperatures of three time points

corresponding to Placebo resulted with a P-Value 0.683 >0.0033 (Adjusted P-Value). This

concluded that the temperatures are not differing across Day1, Day 2 and Day3. The following is

the corresponding Box plot of these measures



The Kruskall-Wallis test for the comparison of means of temperatures of three time points

corresponding to ZingiVir-H resulted with a P-Value 0.248>0.0033 (Adjusted P-Value). This

concluded that the temperatures are not differing across Day1, Day 2 and Day3. The following is

the corresponding Box plot of these measures



13. Clinical Outcome

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

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

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

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

characteristics, so that different methodological standards for their construction and

utilization are required.

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

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

samples were obtained on day 5 in most of the cases, on completion of 4 days of study drug

consumption (either Zingivir-H or its Placebo) and on after day 5 based on investigator

discretion until patient became COVID Negative. These N/T swab samples were obtained

for all evaluable patients who were still active at every time point. Laboratory samples

were assessed for the patients before the start of the drug on Day 01, Day 06 or the date of

discharge whichever comes earlier, Day 15 End of treatment day for safety analysis and in

Day 30 for safety analysis. The available data for Day 01 and day 07 of all accessing

patients are taken into consideration for the assessments. Clinical and laboratory data were

recorded on patient specific source documents and the data modeling information shall be

transcribed to study specific logs and paper case record forms and then Entered into an

electronic database and statistically validated by trial staff.

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

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

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

category ordinal scale consisted of the following categories:

1. Death

2. Hospitalized & on invasive mechanical ventilation or Extracorporeal Membrane

Oxygenation (ECMO)

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

4. Hospitalized, requiring low flow supplemental oxygen

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

(Coronavirus (COVID-19) related or otherwise)



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

(other than per protocol ZingiVir-H administration)

7. Discharge from hospital.

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

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

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

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

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

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

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

analysis.

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

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

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

other than study drug after enrolment into the study. Those patients are categorized as if they

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

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

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

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

Safety outcomes

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

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

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

patients until 23 July 2020. It is anticipated that few AE information might be missed

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

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

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

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

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

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



Primary efficacy analysis

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

who had undergone randomization. However in the present primary endpoint analysis the

sample size is determined as per protocol. The time to clinical improvement was assessed

after all patients who had tested for RT-PCR after consumption of study drug (Either

Zingivir-H or Placebo) for duration of minimum Three days.

Of the 116 patients who are assessed for primary endpoint efficacy analysis (100%)

underwent randomization, 58 patients were assigned to receive Zingivir-H and Standard of

care and 58 patients to Placebo and standard care alone. All the 116 patients assigned to

receive study drug received standard of care treatment as per hospital and COVID protocol.

Few Patients who have mild symptoms were not treated at all and considered as criteria 6

in the ordinal scale. All the patients assessed till date are complied on study drug

consumption after randomization.

The statistical analysis of this data reported that, ZingiVir-H has a median recovery time of 5

days and that of Placebo is 6. In the case of patients require medical care along with medicine,

has the Median recovery time 5 days for ZingiVir-H and 6 days for Placebo group. Similarly, in

the case of patients requiring only medicine, has the median recovery time 6 for ZingiVir-H and

more than 6 days for placebo. The Log-Rank test lead to a conclusion that the median recovery

time is significantly different among ZingiVir-H group and Placebo group and specifically it is

less for the ZingiVir-H group. It is also proved that the age is not contributing any significant

information in the model improvement. The temperature analysis does not show any significant

difference across three time points (Day1, Day 2 and Day 3). Separate analysis of temperature

corresponding to Placebo group and ZingiVir-H group also leads to the same conclusion.

The Log-Rank test leads to the conclusion that the median recovery time is significantly

different among the ZingiVir-H group and Placebo group and specifically it is less for the

ZingiVir-H group. It is also proved that age is not contributing any significant information in

the model improvement. A total of 58 patients (50 %) of evaluated patients who had a

diagnostic respiratory tract sample that was positive on RT-PCR had a negative RT-PCR

result on the throat swab taken after a median recovery time of five days of Zingivir-H

treatment P value 0.000004 (<0.05) which is highly significant.



The primary end point analysis elaborately assessed the clinical recovery time in detail

between the treatment groups. Log-Rank test is performed to verify the significance of

recovery time over ZingiVir-H and Placebo and it was resulted with a P value 0.000004

(<0.05) and lead to the conclusion that ZingVir-H use was associated with a difference in

time to clinical improvements in less than 5 days compare to Placebo group which has

recovery time upto 13 days.

14. Discussion

The primary end point data analysis of this randomized trial found that Zingivir-H

treatment added to standard supportive care is clearly associated with clinical improvement

or mortality in mild to moderately ill patients with Covid-19 from placebo arm that

associated with standard care alone. No mortality or serious adverse events reported in the

subjects participated in this trial which indicates that the patients enrolled are

asymptomatic, mild and moderate population.

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

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

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

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

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

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

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

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

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

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

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

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

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

complications in Covid-19 patients.

The present analysis did not discuss in this primary endpoint efficacy analysis report that

adding Zingivir-H treatment shall reduce the viral RNA loads as compared with standard

supportive care alone. As we will be assessing Interferon alpha quantification test results as



the indirect marker for viral load analysis only in the final analysis to ensure the immuno

marker expression pattern in any such viral clearance events in both the arms. The reasons

for the antiviral effect of Zingivir-H molecule could be as predicted in our earlier studies

and as per the known significant effect of active ingredients in the Zingivir-H molecule.

RTPCR NP Swab were taken intermittently (on days 5,6, 8, 11, 14 and until the results

become negative) in most of the study patients. Since we are not keen to understand the

viral load clearance on daily basis we avoid taking more frequent sampling in the first 5

days which could have provided more detailed characterization of viral load kinetics in the

two groups over this critical period.

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

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

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

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

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

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

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

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

performed in the trials to understand the immunomodulatory and hematological variations

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

important hematological parameters including CRP, ESR, IL6, IgG and IgM already

reveals the potential immunomodulatory role of Zingivir-H drug which was discussed in

the interim analysis. The full analysis of hematological and immunological parameters will

be in the scope of final analysis.

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

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

concurrent pharmacologic interventions in this present analysis.

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

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

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

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

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



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

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

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

creative solutions to overcome these challenges to the maximum.

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

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

moderate Covid-19 patients with or without any comorbidities. These primary endpoint

efficacy analysis data in 100% sample size of randomized populations in the study shall

reveal positive signs to consider the molecule in COVID treatment protocol.

Disclaimer:

Considering the study as Single blinded and the product is already got license for human use

the present report reveals the significant data points which validate the primary endpoint in

the trial. Considering the pandemic and a possible hope on therapeutic front, the present

report is notified to AYUSH department and appropriate authorities for further assessments

and data validation. However the full analysis Clinical Study Report (CSR) shall be made

available to the regulatory agencies. The finding shall also be published in peer reviewed

scientific journals.

Report Prepared by Dr. K.P.Srinivasakumar

Steering Committee (SC) Member, Zingivir-H study

Statistical analysis & Data

Modeling

Dr. Jerin Paul-

DM & Statistics, External Consultant

Primary endpoint efficacy

analysis Report Sign off

Name/ Designation and Date

Dr.J.Hareendran Nair

SC Chairman and Sponsor Representative

Zingivir-H Study

Signature: ----------------------------------

Date: 23 JULY 2020