International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases · 2026
SARS-CoV-2 viral shedding and vaccination‑modified effects of oral antivirals in older COVID-19 patients: A retrospective cohort study in Hong Kong.
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Lin Yun, Wu Peng, Lau Eric H Y, Blais Joseph, Wong Jessica Y, Tsang Tim K, Hung Ivan Fan Ngai, Cowling Benjamin J
Аннотация
OBJECTIVES: To evaluate how oral antivirals (molnupiravir and nirmatrelvir-ritonavir) and COVID-19 vaccination affect SARS-CoV-2 viral kinetics in adults aged ≥60 years with symptomatic COVID-19 hospitalized in Hong Kong.
METHODS: We analyzed viral burden using cycle threshold (Ct) values from patients admitted between May 23, 2022 and Jan 23, 2023 when Omicron subvariants predominated. Viral trajectories were modelled with log-polynomial random-effects framework to estimate daily Ct values and duration of potentially infectious shedding (time to Ct ≥30). We then examined how antiviral timing and vaccination history modified these virological outcomes.
RESULTS: Among 3759 symptomatic COVID-19 patients included, 1318 received molnupiravir, 1613 received nirmatrelvir-ritonavir. Compared with no treatment, nirmatrelvir-ritonavir was associated with shorter shedding (mean difference -2.4 days, 95% CIs: -2.7, -2.2), especially with earlier initiation, whereas molnupiravir had a smaller effect (-0.6 days, 95% CIs: -0.9, -0.3). The virologic effect of nirmatrelvir-ritonavir was greater in unvaccinated than vaccinated patients, while the effect of molnupiravir did not differ notably by vaccination status.
CONCLUSION: Early nirmatrelvir-ritonavir substantially shortens SARS-CoV-2 shedding in older adults, especially if unvaccinated. These findings support timely antiviral use and consideration of vaccination history when optimizing treatment for high-risk populations.
METHODS: We analyzed viral burden using cycle threshold (Ct) values from patients admitted between May 23, 2022 and Jan 23, 2023 when Omicron subvariants predominated. Viral trajectories were modelled with log-polynomial random-effects framework to estimate daily Ct values and duration of potentially infectious shedding (time to Ct ≥30). We then examined how antiviral timing and vaccination history modified these virological outcomes.
RESULTS: Among 3759 symptomatic COVID-19 patients included, 1318 received molnupiravir, 1613 received nirmatrelvir-ritonavir. Compared with no treatment, nirmatrelvir-ritonavir was associated with shorter shedding (mean difference -2.4 days, 95% CIs: -2.7, -2.2), especially with earlier initiation, whereas molnupiravir had a smaller effect (-0.6 days, 95% CIs: -0.9, -0.3). The virologic effect of nirmatrelvir-ritonavir was greater in unvaccinated than vaccinated patients, while the effect of molnupiravir did not differ notably by vaccination status.
CONCLUSION: Early nirmatrelvir-ritonavir substantially shortens SARS-CoV-2 shedding in older adults, especially if unvaccinated. These findings support timely antiviral use and consideration of vaccination history when optimizing treatment for high-risk populations.