6 ms·

From the paper: "Interpretation: We were unable to confirm a benefit of hydroxychloroquine or chloroquine, when used alone or with a macrolide, on in-hospital

From the paper: "Interpretation: We were unable to confirm a benefit of hydroxychloroquine or chloroquine, when used alone or with a macrolide, on in-hospital outcomes for COVID-19. Each of these drug regimens was associated with decreased in-hospital survival and an increased frequency of ventricular arrhythmias when used for treatment of COVID-19."

huy-nguyen 6y ago
I guess that's the end of the road for hydroxychloroquine/chloroquine as a treatment for COVID-19.
- danans 6y ago
  Yes it's probably the end medically, but it's not the end of its use as a political wedge. To people who believe the current political rhetoric promoting hydroxychloroquine, a study in a medical journal doesn't change anything, as their interest in it was never based its medical efficacy, but rather as a symbol used to rally around their leader and their movement. Just look at the anti-vaccination movement, which continues despite being debunked for years. And we shouldn't so quickly dismiss this phenomenon. We underestimate the power of that kind of fictional narrative group-think to our peril. The only way to fight falsehood based narrative is truth based narrative. The dry statistical or scientifically derived truth that eggheads like most of us wish would prevail is largely powerless. Stories are what ultimately wins.
  - puranjay 6y ago
    It's been absurd that I have people on my Twitter feed attributing the low death rate in India to India's "widespread daily use of HCQ". 31 years in India and I've never even heard of it!
    - rsynnott 6y ago
      I suspect this was people thinking “chloroquine is a malaria drug and India has malaria, therefore it’s used in India”. Which sounds vaguely convincing at first glance, but malaria in India has been immune for decades.
      - puranjay 6y ago
        Don't even get me started on the people hoarding tonic water because it has quinine in it
    - rurban 6y ago
      Easy to explain. HCQ as treatment is questionable. Always was. Even the Chinese retracted their recommendation in End of February. But it is still recommended as prevention, and there is a Indian study confirming its suitability as prevention. That's how it always worked. India is also the sole manufacturer of it, for their malaria problem. It's still in widespread use there. Europeans were extra stupid to try it as treatment. If you read the early original Chinese reports they always mentioned that it worked as prevention, Lupus patients had an advantage. And those two disliked presidents always promoted its usage as prevention, not treatment. But reading is apparently a rare skill.
  - hn_throwaway_99 6y ago
    Exactly. What, you think these hucksters like Laura Ingraham are going to apologize for their dangerous bullshit (spoiler - no: https://www.thedailybeast.com/laura-ingraham-trashes-promising-coronavirus-treatment-remdesivir-to-promote-hydroxychloroquine https://www.thedailybeast.com/laura-ingraham-trashes-promisi... )? Of course not. Apologies are for losers, instead when the facts are against you, you just double down and demonize those who try to convince you with those facts as nefarious enemies. Those of us who live in the world of reality need to realize the only way to fight this "demon haunted world" is to make a scarier demon, not try to fight with facts.
  - eloff 6y ago
    It goes both ways. There are studies showing it is a statistically and clinically significant treatment [1]. Whether those results are reproducible or not remains to be seen. Most of these studies you never hear about because many people on the left want Trump to be wrong or have a knee jerk reaction to anything he says. It even has a name: Trump derangement syndrome. Irrational behavior in both directions is indefensible. [1] https://www.medrxiv.org/content/10.1101/2020.05.02.20080036v1 https://www.medrxiv.org/content/10.1101/2020.05.02.20080036v... [2] https://pubmed.ncbi.nlm.nih.gov/32335560/ https://pubmed.ncbi.nlm.nih.gov/32335560/
    - deleted 6y ago
      [deleted]
    - danans 6y ago
      > Irrational behavior in both directions is indefensible. Agreed that any political side is capable of false narratives, but that's hardly what's going on here. Nobody with the fundamental desire for a treatment for themselves and those they care about should they fall severely ill would want any proven effective treatment to be dismissed for political reasons, whether that is hydroxychloroquine or anything else. The problem is that what should have been left as an investigation into a medication with no political colors was turned into a political wedge by the US president who seemingly aspired to use it to regain relevance during this crisis. The same thing has also happened for the various promotions of very preliminary vaccines, or of a fictional nationally deployed testing website that was claimed by POTUS to be under development by Google. This follows the basic principle guiding this administration and its leader that there is no such thing as bad publicity. And to a certain extent, they might even be right. Time will tell.
      - eloff 6y ago
        Every reference I've seen to Hydroxychloroquine in the media is quick to denounce it as a dangerous, discredited treatment. So I think this is not just irrationality on the part of the left, but an example of the gated institutional narrative suppressing ideas. Not to take away from the irrationality of blind faith in anything Trump says seen on the right. If you look at the experts, they're still designing studies to test it, and there are some papers suggesting it does work. The jury is very much still out on this subject.
- imglorp 6y ago
  The end of the science road perhaps, but there's still political obstacles to setting it aside. It's not obvious why Trump is pushing it so hard. https://www.vox.com/2020/4/7/21211872/trump-coronavirus-hydroxychloroquine-covid19-drugs-sanofi-owns https://www.vox.com/2020/4/7/21211872/trump-coronavirus-hydr...
- rsynnott 6y ago
  Unfortunately, probably not; the general public won’t read this, and some people won’t believe it when they see news media’s take on it. There was an article the other day that interviewed someone who’d been on long-term treatment with the drug (for lupus) they were shocked when they got covid, because they believed that the drug was a prophylactic. No reputable scientist ever claimed that, as far as I know; it was a popular myth encouraged by unscrupulous news outlets, which won’t go away just because of a study or two.
- eloff 6y ago
  Not necessarily. Some discussions[1] of potential mechanism focuses on hydroxychloroquine working as an ionophore to drive zinc into cells - so this potentially only works when given in conjunction with zinc. There are a few studies that suggest it is effective used that way. Whether those results hold up over time is an open question. [1] (video) https://fast.wistia.net/embed/medias/td0v8taipc https://fast.wistia.net/embed/medias/td0v8taipc
  - rurban 6y ago
    The effective use is applying it 3 weeks before the infection. Not two days after. That's not enough time to fill up the cells with zinc.
- throwablePie 6y ago
  "We included patients hospitalised between Dec 20, 2019, and April 14, 2020, with a positive laboratory finding for SARS-CoV-2" It may be the end of the road for hospitalized patients with heavy viral loads but, considering the fact that zinc is mentioned nowhere in the full text, it is not the end of the road for prophylaxis. Early action before hospitalization is necessary... see below. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31180-6/fulltext https://www.thelancet.com/journals/lancet/article/PIIS0140-6... Zinc does the hard work of inhibiting viral replication; HCQ is the zinc ionophore that lights the pathway. "First used in 1967, the term ionophore refers to the molecule’s ability to bind a metal ion and facilitate its transport across cellular membranes." In order to inhibit viral replication, zinc must enter the cell... HCQ and other zinc ionophores can facilitate this. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896753/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896753/ Pasting my previous comment below with slight modifications: Hydroxychloroquine is just one of several zinc ionophores that inhibit viral replication. "Zinc Ionophores Pyrithione Inhibits Herpes Simplex Virus Replication" https://pubmed.ncbi.nlm.nih.gov/23867132/ https://pubmed.ncbi.nlm.nih.gov/23867132/ "... the virus replicative cycle can be divided into 10 steps (Fig. 52-1): (1) adsorption, (2) penetration, (3) uncoating, (4) early transcription, (5) early translation, (6) replication of the viral genome, (7) late transcription, (8) late translation, (9) assembly, and (10) release of new virus particles." If using HCQ as a zinc ionophore which targets replication, "antiviral drug treatment should be started early, before irreversible tissue damage occurs. Such timely treatment is not possible without early and accurate diagnosis, which is difficult for many viral infections (such as infections of the respiratory tract)" https://www.ncbi.nlm.nih.gov/books/NBK8119/ https://www.ncbi.nlm.nih.gov/books/NBK8119/
macinjosh 6y ago
Does anyone know if zinc a macrolide? All the data I have seen on successful use of hydroxycholoroquine required the use of zinc along side. Also chloroquine is the drug that causes heart issues not hydroxychloroquine. The two are different. If zinc is not a `macrolide` I wouldn’t give this paper much credit as they didn’t test the treatment properly. Edit: Wow, how the HN community has fallen. Downvoting a simple, honest question into oblivion.
- deleted 6y ago
  [deleted]
- meheleventyone 6y ago
  I’d suggest it’s the other way around and those that suggest Zinc is important need to actually demonstrate that. I’d also suggest a dose of humility if you’re promoting it particularly if you aren’t able to quickly find out what a macrolide is and whether Zinc would be one.
  - macinjosh 6y ago
    I am programmer not a medical professional, how do you expect me to find that out for myself? Not sure how ask a simple question about something I am not an expert at means I need more humility. Nice projection though.
    - meheleventyone 6y ago
      It’s not the question that requires humility (although tbf this is a pretty easily Googlable one if you combine it with a high school level of chemistry) but the conclusion you drew that the study “doesn’t deserve much credit” as you baselessly claim Zinc is important.
      - macinjosh 6y ago
        I based my conclusion to not give the study much credit because it didn’t involve the inclusion of zinc or use of the therapy as a prophylactic. Which, from my understanding, is the actual claim that started the HCQ discussion in the first place. I am sure this paper is accurate in regards to the data they did look at. I am just saying I think it is the wrong data to look at to answer this question.
Natsu 6y ago
It's important to keep in mind the study's limitations section, too: "Our study has several limitations. The association of decreased survival with hydroxychloroquine or chloro-quine treatment regimens should be interpreted cautiously. Due to the observational study design, we cannot exclude the possibility of unmeasured con-founding factors, although we have reassuringly noted consistency between the primary analysis and the propensity score matched analyses. Nevertheless, a cause-and-effect relationship between drug therapy and survival should not be inferred. These data do not apply to the use of any treatment regimen used in the ambulatory, out-of-hospital setting. Randomised clinical trials will be required before any conclusion can be reached regarding benefit or harm of these agents in COVID-19 patients. We also note that although we evaluated the relationship of the drug treatment regimens with the occurrence of ventricular arrhyth-mias, we did not measure QT intervals, nor did we stratify the arrhythmia pattern (such as torsade de pointes). We also did not establish if the association of increased risk of in-hospital death with use of the drug regimens is linked directly to their cardiovascular risk, nor did we conduct a drug dose-response analysis of the observed risks. Even if these limitations suggest a conservative interpretation of the findings, we believe that the absence of any observed benefit could still represent a reasonable explanation.In summary, this multinational, observational, real-world study of patients with COVID-19 requiring hospitalisation found that the use of a regimen con-taining hydroxychloroquine or chloroquine (with or without a macrolide) was associated with no evidence of benefit, but instead was associated with an increase in the risk of ventricular arrhythmias and a greater hazard for in-hospital death with COVID-19. These findings suggest that these drug regimens should not be used outside of clinical trials and urgent confirmation from randomised clinical trials is needed." Has anyone seen good randomized clinical trials yet?
throwablePie 6y ago
Hydroxychloroquine is a zinc ionophore. It provides an ion channel that permits zinc to enter the cell and inhibit viral replication. In order to be effective, the zinc + ionophore antiviral should be administered early. Hospitalized ICU patients on ventilators are far from ideal candidates. Chinese (successful) studies used Zinc and Hydroxychloroquine; never Hydroxychloroquine without zinc. Improving the efficacy of Chloroquine and Hydroxychloroquine against SARS-CoV-2 may require Zinc additives - A better synergy for future COVID-19 clinical trials https://digitalcommons.mtu.edu/michigantech-p/1795/ https://digitalcommons.mtu.edu/michigantech-p/1795/ Zn2+ Inhibits Coronavirus and Arterivirus RNA Polymerase Activity In Vitro and Zinc Ionophores Block the Replication of These Viruses in Cell Culture https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2973827/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2973827/ Does Zinc Supplementation Enhance the Clinical Efficacy of Chloroquine/Hydroxychloroquine to Win Todays Battle Against COVID-19? https://www.preprints.org/manuscript/202004.0124/v1 https://www.preprints.org/manuscript/202004.0124/v1] https://en.wikipedia.org/wiki/Ionophore https://en.wikipedia.org/wiki/Ionophore Zinc ionophores have been shown to inhibit replication of various viruses in vitro: Coxsackievirus Equine viral arteritis Hepatitis C virus Herpes simplex virus Human coronavirus Human Immunodeficiency Virus Mengovirus MERS coronavirus Rhinovirus SARS coronavirus Zika virus

huy-nguyen 6y ago

I guess that's the end of the road for hydroxychloroquine/chloroquine as a treatment for COVID-19.

danans 6y ago
Yes it's probably the end medically, but it's not the end of its use as a political wedge. To people who believe the current political rhetoric promoting hydroxychloroquine, a study in a medical journal doesn't change anything, as their interest in it was never based its medical efficacy, but rather as a symbol used to rally around their leader and their movement. Just look at the anti-vaccination movement, which continues despite being debunked for years. And we shouldn't so quickly dismiss this phenomenon. We underestimate the power of that kind of fictional narrative group-think to our peril. The only way to fight falsehood based narrative is truth based narrative. The dry statistical or scientifically derived truth that eggheads like most of us wish would prevail is largely powerless. Stories are what ultimately wins.
- puranjay 6y ago
  It's been absurd that I have people on my Twitter feed attributing the low death rate in India to India's "widespread daily use of HCQ". 31 years in India and I've never even heard of it!
  - rsynnott 6y ago
    I suspect this was people thinking “chloroquine is a malaria drug and India has malaria, therefore it’s used in India”. Which sounds vaguely convincing at first glance, but malaria in India has been immune for decades.
    - puranjay 6y ago
      Don't even get me started on the people hoarding tonic water because it has quinine in it
  - rurban 6y ago
    Easy to explain. HCQ as treatment is questionable. Always was. Even the Chinese retracted their recommendation in End of February. But it is still recommended as prevention, and there is a Indian study confirming its suitability as prevention. That's how it always worked. India is also the sole manufacturer of it, for their malaria problem. It's still in widespread use there. Europeans were extra stupid to try it as treatment. If you read the early original Chinese reports they always mentioned that it worked as prevention, Lupus patients had an advantage. And those two disliked presidents always promoted its usage as prevention, not treatment. But reading is apparently a rare skill.
- hn_throwaway_99 6y ago
  Exactly. What, you think these hucksters like Laura Ingraham are going to apologize for their dangerous bullshit (spoiler - no: https://www.thedailybeast.com/laura-ingraham-trashes-promising-coronavirus-treatment-remdesivir-to-promote-hydroxychloroquine https://www.thedailybeast.com/laura-ingraham-trashes-promisi... )? Of course not. Apologies are for losers, instead when the facts are against you, you just double down and demonize those who try to convince you with those facts as nefarious enemies. Those of us who live in the world of reality need to realize the only way to fight this "demon haunted world" is to make a scarier demon, not try to fight with facts.
- eloff 6y ago
  It goes both ways. There are studies showing it is a statistically and clinically significant treatment [1]. Whether those results are reproducible or not remains to be seen. Most of these studies you never hear about because many people on the left want Trump to be wrong or have a knee jerk reaction to anything he says. It even has a name: Trump derangement syndrome. Irrational behavior in both directions is indefensible. [1] https://www.medrxiv.org/content/10.1101/2020.05.02.20080036v1 https://www.medrxiv.org/content/10.1101/2020.05.02.20080036v... [2] https://pubmed.ncbi.nlm.nih.gov/32335560/ https://pubmed.ncbi.nlm.nih.gov/32335560/
  - deleted 6y ago
    [deleted]
  - danans 6y ago
    > Irrational behavior in both directions is indefensible. Agreed that any political side is capable of false narratives, but that's hardly what's going on here. Nobody with the fundamental desire for a treatment for themselves and those they care about should they fall severely ill would want any proven effective treatment to be dismissed for political reasons, whether that is hydroxychloroquine or anything else. The problem is that what should have been left as an investigation into a medication with no political colors was turned into a political wedge by the US president who seemingly aspired to use it to regain relevance during this crisis. The same thing has also happened for the various promotions of very preliminary vaccines, or of a fictional nationally deployed testing website that was claimed by POTUS to be under development by Google. This follows the basic principle guiding this administration and its leader that there is no such thing as bad publicity. And to a certain extent, they might even be right. Time will tell.
    - eloff 6y ago
      Every reference I've seen to Hydroxychloroquine in the media is quick to denounce it as a dangerous, discredited treatment. So I think this is not just irrationality on the part of the left, but an example of the gated institutional narrative suppressing ideas. Not to take away from the irrationality of blind faith in anything Trump says seen on the right. If you look at the experts, they're still designing studies to test it, and there are some papers suggesting it does work. The jury is very much still out on this subject.
imglorp 6y ago
The end of the science road perhaps, but there's still political obstacles to setting it aside. It's not obvious why Trump is pushing it so hard. https://www.vox.com/2020/4/7/21211872/trump-coronavirus-hydroxychloroquine-covid19-drugs-sanofi-owns https://www.vox.com/2020/4/7/21211872/trump-coronavirus-hydr...
rsynnott 6y ago
Unfortunately, probably not; the general public won’t read this, and some people won’t believe it when they see news media’s take on it. There was an article the other day that interviewed someone who’d been on long-term treatment with the drug (for lupus) they were shocked when they got covid, because they believed that the drug was a prophylactic. No reputable scientist ever claimed that, as far as I know; it was a popular myth encouraged by unscrupulous news outlets, which won’t go away just because of a study or two.
eloff 6y ago
Not necessarily. Some discussions[1] of potential mechanism focuses on hydroxychloroquine working as an ionophore to drive zinc into cells - so this potentially only works when given in conjunction with zinc. There are a few studies that suggest it is effective used that way. Whether those results hold up over time is an open question. [1] (video) https://fast.wistia.net/embed/medias/td0v8taipc https://fast.wistia.net/embed/medias/td0v8taipc
- rurban 6y ago
  The effective use is applying it 3 weeks before the infection. Not two days after. That's not enough time to fill up the cells with zinc.
throwablePie 6y ago
"We included patients hospitalised between Dec 20, 2019, and April 14, 2020, with a positive laboratory finding for SARS-CoV-2" It may be the end of the road for hospitalized patients with heavy viral loads but, considering the fact that zinc is mentioned nowhere in the full text, it is not the end of the road for prophylaxis. Early action before hospitalization is necessary... see below. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31180-6/fulltext https://www.thelancet.com/journals/lancet/article/PIIS0140-6... Zinc does the hard work of inhibiting viral replication; HCQ is the zinc ionophore that lights the pathway. "First used in 1967, the term ionophore refers to the molecule’s ability to bind a metal ion and facilitate its transport across cellular membranes." In order to inhibit viral replication, zinc must enter the cell... HCQ and other zinc ionophores can facilitate this. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896753/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896753/ Pasting my previous comment below with slight modifications: Hydroxychloroquine is just one of several zinc ionophores that inhibit viral replication. "Zinc Ionophores Pyrithione Inhibits Herpes Simplex Virus Replication" https://pubmed.ncbi.nlm.nih.gov/23867132/ https://pubmed.ncbi.nlm.nih.gov/23867132/ "... the virus replicative cycle can be divided into 10 steps (Fig. 52-1): (1) adsorption, (2) penetration, (3) uncoating, (4) early transcription, (5) early translation, (6) replication of the viral genome, (7) late transcription, (8) late translation, (9) assembly, and (10) release of new virus particles." If using HCQ as a zinc ionophore which targets replication, "antiviral drug treatment should be started early, before irreversible tissue damage occurs. Such timely treatment is not possible without early and accurate diagnosis, which is difficult for many viral infections (such as infections of the respiratory tract)" https://www.ncbi.nlm.nih.gov/books/NBK8119/ https://www.ncbi.nlm.nih.gov/books/NBK8119/

macinjosh 6y ago

Does anyone know if zinc a macrolide? All the data I have seen on successful use of hydroxycholoroquine required the use of zinc along side. Also chloroquine is the drug that causes heart issues not hydroxychloroquine. The two are different. If zinc is not a `macrolide` I wouldn’t give this paper much credit as they didn’t test the treatment properly. Edit: Wow, how the HN community has fallen. Downvoting a simple, honest question into oblivion.

deleted 6y ago
[deleted]
meheleventyone 6y ago
I’d suggest it’s the other way around and those that suggest Zinc is important need to actually demonstrate that. I’d also suggest a dose of humility if you’re promoting it particularly if you aren’t able to quickly find out what a macrolide is and whether Zinc would be one.
- macinjosh 6y ago
  I am programmer not a medical professional, how do you expect me to find that out for myself? Not sure how ask a simple question about something I am not an expert at means I need more humility. Nice projection though.
  - meheleventyone 6y ago
    It’s not the question that requires humility (although tbf this is a pretty easily Googlable one if you combine it with a high school level of chemistry) but the conclusion you drew that the study “doesn’t deserve much credit” as you baselessly claim Zinc is important.
    - macinjosh 6y ago
      I based my conclusion to not give the study much credit because it didn’t involve the inclusion of zinc or use of the therapy as a prophylactic. Which, from my understanding, is the actual claim that started the HCQ discussion in the first place. I am sure this paper is accurate in regards to the data they did look at. I am just saying I think it is the wrong data to look at to answer this question.

Natsu 6y ago

It's important to keep in mind the study's limitations section, too: "Our study has several limitations. The association of decreased survival with hydroxychloroquine or chloro-quine treatment regimens should be interpreted cautiously. Due to the observational study design, we cannot exclude the possibility of unmeasured con-founding factors, although we have reassuringly noted consistency between the primary analysis and the propensity score matched analyses. Nevertheless, a cause-and-effect relationship between drug therapy and survival should not be inferred. These data do not apply to the use of any treatment regimen used in the ambulatory, out-of-hospital setting. Randomised clinical trials will be required before any conclusion can be reached regarding benefit or harm of these agents in COVID-19 patients. We also note that although we evaluated the relationship of the drug treatment regimens with the occurrence of ventricular arrhyth-mias, we did not measure QT intervals, nor did we stratify the arrhythmia pattern (such as torsade de pointes). We also did not establish if the association of increased risk of in-hospital death with use of the drug regimens is linked directly to their cardiovascular risk, nor did we conduct a drug dose-response analysis of the observed risks. Even if these limitations suggest a conservative interpretation of the findings, we believe that the absence of any observed benefit could still represent a reasonable explanation.In summary, this multinational, observational, real-world study of patients with COVID-19 requiring hospitalisation found that the use of a regimen con-taining hydroxychloroquine or chloroquine (with or without a macrolide) was associated with no evidence of benefit, but instead was associated with an increase in the risk of ventricular arrhythmias and a greater hazard for in-hospital death with COVID-19. These findings suggest that these drug regimens should not be used outside of clinical trials and urgent confirmation from randomised clinical trials is needed." Has anyone seen good randomized clinical trials yet?

throwablePie 6y ago

Hydroxychloroquine is a zinc ionophore. It provides an ion channel that permits zinc to enter the cell and inhibit viral replication. In order to be effective, the zinc + ionophore antiviral should be administered early. Hospitalized ICU patients on ventilators are far from ideal candidates. Chinese (successful) studies used Zinc and Hydroxychloroquine; never Hydroxychloroquine without zinc. Improving the efficacy of Chloroquine and Hydroxychloroquine against SARS-CoV-2 may require Zinc additives - A better synergy for future COVID-19 clinical trials https://digitalcommons.mtu.edu/michigantech-p/1795/ https://digitalcommons.mtu.edu/michigantech-p/1795/ Zn2+ Inhibits Coronavirus and Arterivirus RNA Polymerase Activity In Vitro and Zinc Ionophores Block the Replication of These Viruses in Cell Culture https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2973827/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2973827/ Does Zinc Supplementation Enhance the Clinical Efficacy of Chloroquine/Hydroxychloroquine to Win Todays Battle Against COVID-19? https://www.preprints.org/manuscript/202004.0124/v1 https://www.preprints.org/manuscript/202004.0124/v1] https://en.wikipedia.org/wiki/Ionophore https://en.wikipedia.org/wiki/Ionophore Zinc ionophores have been shown to inhibit replication of various viruses in vitro: Coxsackievirus Equine viral arteritis Hepatitis C virus Herpes simplex virus Human coronavirus Human Immunodeficiency Virus Mengovirus MERS coronavirus Rhinovirus SARS coronavirus Zika virus