Summary
Background
Casirivimab and imdevimab are non-competing monoclonal antibodies that bind to two different sites on the receptor binding domain of the SARS-CoV-2 spike glycoprotein, blocking viral entry into host cells. We aimed to evaluate the efficacy and safety of casirivimab and imdevimab administered in combination in patients admitted to hospital with COVID-19.
Methods
RECOVERY is a randomised, controlled, open-label platform trial comparing several possible treatments with usual care in patients admitted to hospital with COVID-19. 127 UK hospitals took part in the evaluation of casirivimab and imdevimab. Eligible participants were any patients aged at least 12 years admitted to hospital with clinically suspected or laboratory-confirmed SARS-CoV-2 infection. Participants were randomly assigned (1:1) to either usual standard of care alone or usual care plus casirivimab 4 g and imdevimab 4 g administered together in a single intravenous infusion. Investigators and data assessors were masked to analyses of the outcome data during the trial. The primary outcome was 28-day all-cause mortality assessed by intention to treat, first only in patients without detectable antibodies to SARS-CoV-2 infection at randomisation (ie, those who were seronegative) and then in the overall population. Safety was assessed in all participants who received casirivimab and imdevimab. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936).
Findings
Between Sept 18, 2020, and May 22, 2021, 9785 patients enrolled in RECOVERY were eligible for casirivimab and imdevimab, of which 4839 were randomly assigned to casirivimab and imdevimab plus usual care and 4946 to usual care alone. 3153 (32%) of 9785 patients were seronegative, 5272 (54%) were seropositive, and 1360 (14%) had unknown baseline antibody status. 812 (8%) patients were known to have received at least one dose of a SARS-CoV-2 vaccine. In the primary efficacy population of seronegative patients, 396 (24%) of 1633 patients allocated to casirivimab and imdevimab versus 452 (30%) of 1520 patients allocated to usual care died within 28 days (rate ratio [RR] 0·79, 95% CI 0·69–0·91; p=0·0009). In an analysis of all randomly assigned patients (regardless of baseline antibody status), 943 (19%) of 4839 patients allocated to casirivimab and imdevimab versus 1029 (21%) of 4946 patients allocated to usual care died within 28 days (RR 0·94, 95% CI 0·86–1·02; p=0·14). The proportional effect of casirivimab and imdevimab on mortality differed significantly between seropositive and seronegative patients (p value for heterogeneity=0·002). There were no deaths attributed to the treatment, or meaningful between-group differences in the pre-specified safety outcomes of cause-specific mortality, cardiac arrhythmia, thrombosis, or major bleeding events. Serious adverse reactions reported in seven (<1%) participants were believed by the local investigator to be related to treatment with casirivimab and imdevimab.
Interpretation
In patients admitted to hospital with COVID-19, the monoclonal antibody combination of casirivimab and imdevimab reduced 28-day mortality in patients who were seronegative (and therefore had not mounted their own humoral immune response) at baseline but not in those who were seropositive at baseline.
Funding
UK Research and Innovation (Medical Research Council) and National Institute of Health Research.
Introduction
Monoclonal antibodies are a set of identical antibodies that have high specificity and affinity for a single epitope. They have been shown to be safe and effective in selected viral diseases when used for prophylaxis (respiratory syncytial virus) or treatment (Ebola virus disease).1, 2, 3 The clinical efficacy of monoclonal antibodies in viral infections is thought to be mediated through direct binding to free virus particles and neutralisation of their ability to infect host cells. Monoclonal antibodies might also bind to viral antigens expressed on the surface of infected cells and stimulate antibody-dependent phagocytosis and cytotoxicity via the crystallisable fragment portion of the antibody.4
SARS-CoV-2 infection is initiated by binding of the viral transmembrane spike glycoprotein to angiotensin-converting enzyme 2 on the surface of host cells.5 The receptor-binding domain of the spike glycoprotein is, consequently, the main target for neutralising antibodies.6 Following the emergence of SARS-CoV-2, monoclonal antibodies targeting the spike receptor binding domain were rapidly isolated from humanised mice and from peripheral B cells of recovered patients.7, 8 Anti-SARS-CoV-2 spike protein neutralising monoclonal antibodies have shown in-vivo efficacy in both therapeutic and prophylactic settings in mouse models and non-human primates models, with decreases in viral load and lung pathology.9, 10, 11, 12
Research in context.
Evidence before this study
We searched MEDLINE, Embase, and medRxiv from Sept 1, 2019, up to Sept 9, 2021, for randomised trials or meta-analyses of trials evaluating the effects of antiviral monoclonal antibody therapy in patients admitted to hospital with COVID-19, using the search terms (“COVID-19”, “COVID”, “SARS-CoV-2”, “2019-nCoV”, or “Coronavirus”) and (“monoclonal”, “REGN-COV2”, “casirivimab”, “imdevimab”, or terms for other specific antiviral monoclonal antibodies identified from clinical trial registries [listed in appendix p 28]). We identified one relevant randomised trial comparing bamlanivimab with placebo in 314 patients admitted to hospital, which was assessed as being at low risk of bias. In the bamlanivimab group, nine of 163 patients died, compared with five of 151 patients in the placebo group (hazard ratio 2·00, 95% CI 0·67–5·99), and no significant difference was seen in the time to sustained recovery (rate ratio 1·06, 95% CI 0·77–1·47).
Added value of this study
The Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial is the largest randomised trial of antiviral monoclonal antibody therapy in patients admitted to hospital with COVID-19. We found that in 3153 COVID-19 patients admitted to hospital without detectable antibodies to SARS-CoV-2 at randomisation (ie, the seronegative group), the monoclonal antibody cocktail of casirivimab 4 g with imdevimab 4 g reduced 28-day mortality, increased the probability of being discharged alive within 28 days, and, among patients who were not receiving invasive mechanical ventilation at randomisation, reduced the probability of progression to the composite outcome of invasive mechanical ventilation or death. The benefits were consistent in all subgroups of seronegative patients. The effect of this treatment differed significantly between patients who were seronegative or seropositive at baseline, with benefit only observed in the seronegative study population.
Implications of all the available evidence
Our findings show that the combination of casirivimab 4 g and imdevimab 4 g given together as a single intravenous infusion improved survival and other clinical outcomes in patients admitted to hospital with COVID-19 who did not have detectable anti-SARS-CoV-2 antibodies (ie, had not yet mounted their own humoral immune response). We observed no clinical benefit in patients who did have detectable anti-SARS-CoV-2 antibodies at baseline.
Casirivimab and imdevimab are two non-competing, high-affinity human IgG1 anti-SARS-CoV-2 monoclonal antibodies, which bind specifically to the receptor binding domain of the spike glycoprotein of SARS-CoV-2, blocking viral entry into host cells.13 A combination of antibodies that bind to non-overlapping epitopes, rather than a single antibody, is intended to minimise the likelihood of loss of antiviral activity due to naturally circulating viral variants or development of escape mutants under drug pressure.14
In a clinical study in adult outpatients with SARS-CoV-2 infection and risk factors for severe COVID-19, the combination of casirivimab and imdevimab was well tolerated and, compared with placebo, reduced viral load in the upper airway, shortened the time to symptom resolution, and reduced the composite outcome of COVID-19-related admission to hospital or all-cause mortality.15, 16 The combination of casirivimab and imdevimab has also been shown to prevent SARS-CoV-2 infection in previously uninfected household contacts of infected individuals.17 Other anti-spike monoclonal antibody products have also shown an antiviral and clinical effect in adult outpatients with SARS-CoV-2 infection.18, 19 In the USA, Emergency Use Authorization has been given by the US Food and Drug Administration for the use of bamlanivimab with etesevimab, casirivimab and imdevimab, and sotrovimab in outpatients with mild to moderate COVID-19. The European Medicines Agency has authorised casirivimab and imdevimab combination for use in patients who are at high risk of progressing to severe COVID-19 but do not require supplemental oxygen. Interim results from a small trial20 of casirivimab and imdevimab in patients admitted to hospital with COVID-19 requiring low-flow oxygen was consistent with a clinical benefit in seronegative patients.
However, to date, no virus-directed therapy has been shown to reduce mortality in patients admitted to hospital with COVID-19, for whom the only treatments so far shown to reduce mortality have been those that modify the inflammatory response.21, 22, 23, 24 The only published trial of an anti-spike monoclonal antibody (bamlanivimab) in patients admitted to hospital was terminated for futility after 314 patients had been randomly assigned to treatment.25 Two other substudies of monoclonal antibody products (sotrovimab monotherapy, and BRII-196 with BRII-198 combination therapy) in patients admitted to hospital with COVID-19 were also terminated for futility with sample sizes of 344, and 343, respectively.26 On first principles, the clinical response to antibody-based therapies might be greatest in individuals early in disease or those who do not mount an effective immune response. This theory is supported by evidence of clinical benefit in early disease and evidence that baseline anti-SARS-CoV-2 antibody status might be an important predictor of the effect of anti-spike monoclonal antibodies on viral load.15, 16, 20, 27 A substantial proportion of COVID-19 patients admitted to hospital are seronegative on admission, and although a greater proportion already have detectable anti-SARS-CoV-2 antibodies, the quality of their immunological response might be poor since it has failed to prevent disease progression.28 As such, anti-spike monoclonal antibodies might have benefit even in later COVID-19 disease. Here we report the results of a large randomised controlled trial of casirivimab and imdevimab combination in patients admitted to hospital with COVID-19.
Methods
Study design and participants
The Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial is an investigator-initiated, individually randomised, controlled, open-label, platform trial designed to evaluate the effects of potential treatments in patients admitted to hospital with COVID-19. Details of the trial design and results for other possible treatments (dexamethasone, hydroxychloroquine, lopinavir-ritonavir, azithromycin, tocilizumab, convalescent plasma, colchicine, and aspirin) have been published previously.22, 23, 28, 29, 30, 31, 32, 33 The trial is underway at 177 hospital organisations in the UK supported by the National Institute for Health Research Clinical Research Network (appendix pp 3–27). Of these, 127 UK hospitals took part in the evaluation of casirivimab and imdevimab (Regeneron Pharmaceuticals, Tarrytown, NY, USA). The trial was coordinated by the Nuffield Department of Population Health at the University of Oxford (Oxford, UK), the trial sponsor. The trial is conducted in accordance with the principles of the International Conference on Harmonisation–Good Clinical Practice guidelines and approved by the UK Medicines and Healthcare products Regulatory Agency (MHRA) and the Cambridge East Research Ethics Committee (ref: 20/EE/0101). The protocol and statistical analysis plan are in the appendix (pp 69–150) with additional information available on the study website.
Patients admitted to hospital were eligible for the study if they had clinically suspected or laboratory-confirmed SARS-CoV-2 infection and no medical history that might, in the opinion of the attending clinician, put the patient at significant risk if they were to participate in the trial. Patients who had received intravenous immunoglobulin treatment during the current admission and children weighing <40 kg or aged <12 years were not eligible for randomisation to casirivimab and imdevimab. Pregnant and breastfeeding women were eligible for inclusion. Written informed consent was obtained from all patients, or a legal representative if they were too unwell or unable to provide consent.
Randomisation and masking
Baseline data were collected using a web-based case report form that included information on demographic characteristics, the level of respiratory support, major comorbidities, suitability of the study treatment for a particular patient, and treatment availability at the study site (appendix pp 34–36). Data on SARS-CoV-2 vaccination status was collected from Dec 22, 2020.
Baseline presence of anti-SARS-CoV-2 antibodies was determined for each participant using serum samples taken at the time of randomisation. Analysis was done at a central laboratory using the Oxford Immunoassay (University of Oxford, Oxford, UK), a validated 384-well plate indirect ELISA for anti-spike IgG (appendix p 28).34 Participants were categorised as seropositive or seronegative using a predefined assay threshold with a 99% or higher sensitivity and specificity in detecting individuals with SARS-CoV-2 infection at least 20 days previously.34 Post-hoc sensitivity analyses were done using commercially available immunoassays for total anti-spike and anti-nucleocapsid antibodies (Roche Diagnostics, Basel, Switzerland) with the seropositive thresholds defined as greater than 0·8 and greater than 0·1, respectively (appendix p 28).
Eligible and consenting patients were assigned (1:1:1) to either usual standard of care, usual standard of care plus casirivimab and imdevimab (antibody combination), or usual standard of care plus convalescent plasma (until Jan 15, 2021), using web-based simple (unstratified) randomisation with allocation concealed until after randomisation (appendix pp 32–34). The trial was not designed to directly compare convalescent plasma versus casirivimab and imdevimab, and the comparison of convalescent plasma versus usual care has been previously reported.28 For some patients, the antibody combination was unavailable at the hospital at the time of enrolment or was considered by the managing physician to be either definitely indicated or definitely contraindicated. These patients were excluded from the randomised comparison between casirivimab and imdevimab versus usual care.
As a platform trial, and in a factorial design, patients could be simultaneously randomly assigned to other treatment groups: azithromycin, colchicine, aspirin, or baricitinib versus usual care. Further details of when these factorial assignments were open is in the appendix (pp 32–34). Until Jan 24, 2021, the trial also allowed a subsequent random assignment for patients with progressive COVID-19 (evidence of hypoxia and a hyperinflammatory state) to tocilizumab versus usual care. Participants and local study staff were not masked to the allocated treatment. The trial steering committee, investigators, and all other individuals involved in the trial were masked to analyses of outcome data during the trial.
Procedures
Patients allocated to the antibody combination were to receive a single dose of casirivimab 4 g and imdevimab 4 g administered together in 250 ml 0·9% saline infused intravenously over 60 min (plus or minus 15 min) as soon as possible after randomisation. The dose of 4 g per antibody was chosen to maximise the probability of a therapeutic effect while ensuring patient safety, based on preliminary data from inpatient (NCT04426695) and outpatient (NCT04425629) studies of the safety, tolerability, and efficacy of casirivimab and imdevimab (unpublished data, Regeneron Pharmaceuticals).
Early safety outcomes were recorded by site staff using an online form 72 h after randomisation (appendix pp 37–41). An online follow-up form was completed by site staff when patients were discharged, had died, or at 28 days after randomisation, whichever occurred first (appendix pp 42–48). Information was recorded on adherence to allocated trial treatment, receipt of other COVID-19 treatments, duration of admission, receipt of respiratory or renal support, and vital status (including cause of death). In addition, routinely collected health-care and registry data were obtained, including information on vital status at day 28 (with date and cause of death), discharge from hospital, and receipt of respiratory support or renal replacement therapy.
Outcomes
Outcomes were assessed at 28 days after randomisation, with further analyses specified at 6 months. The primary outcome was 28-day all-cause mortality. Secondary outcomes were time to discharge from hospital, and, in patients not on invasive mechanical ventilation at randomisation, the composite outcome of invasive mechanical ventilation (including extra-corporeal membrane oxygenation) or death. Pre-specified subsidiary clinical outcomes were use of invasive or non-invasive ventilation among patients not on any ventilation at randomisation, time to successful cessation of invasive mechanical ventilation (defined as cessation of invasive mechanical ventilation within, and survival to, 28 days), and use of renal replacement therapy (dialysis or haemofiltration). Information on suspected serious adverse reactions was collected in an expedited way to comply with regulatory requirements. Details of the methods used to ascertain and derive outcomes are in the appendix (pp 151–71).
Pre-specified safety outcomes were cause-specific mortality, major cardiac arrhythmia, and thrombotic and major bleeding events (only collected since Nov 6, 2021). Information on early safety outcomes at 72 h after randomisation (worsening respiratory status, severe allergic reactions, fever, sudden hypotension, clinical haemolysis, and thrombotic events) ceased on Feb 19, 2021, on the advice of the study's data monitoring committee and in accordance with the protocol.
Statistical analysis
For all outcomes, we did intention-to-treat analyses comparing patients randomly assigned to casirivimab and imdevimab with patients who were randomly assigned to usual care but for whom the antibody combination was both available and suitable as a treatment. For the primary outcome of 28-day mortality, the log-rank observed minus expected statistic and its variance were used to both test the null hypothesis of equal survival curves (ie, the log-rank test) and to calculate the one-step estimate of the average mortality rate ratio (RR). We constructed Kaplan-Meier survival curves to display cumulative mortality over the 28-day period. We used the same method to analyse time to hospital discharge and successful cessation of invasive mechanical ventilation, with patients who died in hospital censored on day 29. Median time to discharge was derived from Kaplan-Meier estimates. For the pre-specified composite secondary outcome of progression to invasive mechanical ventilation or death within 28 days (in those not receiving invasive mechanical ventilation at randomisation), and the subsidiary clinical outcomes of receipt of ventilation and use of haemodialysis or haemofiltration, the precise dates were not available and so the risk ratio was estimated instead. Estimates of rate and risk ratios are shown with 95% CI.
In the light of new evidence that became available during the trial, it was hypothesised that any beneficial effect of casirivimab and imdevimab would be larger among seronegative participants (and might be negligible in seropositive participants).20, 35 Consequently, before any unmasking of results, the trial steering committee specified that hypothesis-testing of the effect of allocation to casirivimab and imdevimab on the primary outcome of 28-day mortality (and secondary outcomes) would first be done only in seronegative participants (ie, those without detectable antibodies to SARS-CoV-2 infection; appendix pp 144–46). Hypothesis testing of the primary outcome in all randomly assigned patients was then only to be done if a reduction in mortality in seronegative patients was noted with a two-sided p value of less than 0·05. A prespecified comparison of the effects of allocation to casirivimab and imdevimab on 28-day mortality in seronegative versus seropositive participants was done by performing a test for heterogeneity. Tests for heterogeneity or trend according to other baseline characteristics (age, sex, ethnicity, level of respiratory support, days since symptom onset, and use of corticosteroids; appendix pp 135–36) were also pre-specified.
The full database is held by the study team, which collected the data from study sites and performed the analyses at the Nuffield Department of Population Health, University of Oxford (Oxford, UK).
As stated in the protocol, appropriate sample sizes could not be estimated when the trial was being planned at the start of the COVID-19 pandemic. On April 27, 2021, the trial steering committee, whose members were unaware of the results of the trial comparisons, determined that, with more than 9700 patients recruited to the casirivimab and imdevimab comparison and average daily recruitment of four patients, further recruitment was unlikely to increase the reliability of the results materially and so should discontinue (appendix p 34). The statistical analysis plan was finalised and published on May 21, 2021 (without any knowledge of the study results; appendix pp 114–50) and recruitment to the casirivimab and imdevimab comparison was closed on May 22, 2021. The trial steering committee and all other individuals involved in the trial were masked to outcome data until after the close of recruitment (appendix p 49). Analyses were performed using SAS version 9.4 and R version 4.0.3. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936).
Role of the funding source
The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. Regeneron Pharmaceuticals supported the study through supply of casirivimab and imdevimab and DMW provided comments on the manuscript as a member of the writing committee.
Results
Between Sept 18, 2020, and May 22, 2021, 11 464 (47%) of 24 343 patients enrolled into the RECOVERY trial at one of the 127 participating sites were eligible to be randomly assigned to casirivimab and imdevimab (ie, the treatment was available in the hospital at the time and the attending clinician was of the opinion that the patient had no known indication for or contraindication to it; figure 1). Of these patients, 4839 were randomly assigned to casirivimab and imdevimab combination and 4946 were randomly assigned to usual care. The mean age of study participants in this comparison was 61·9 years (SD 14·5) and the median time since symptom onset was 9 days (IQR 6–12; appendix p 52).
Figure 1.
Trial profile
Casirivimab and imdevimab unavailable and casirivimab and imdevimab unsuitable groups are not mutually exclusive. *Number recruited overall during the period that adult participants could be recruited into the casirivimab and imdevimab comparison. †Includes patients allocated to tocilizumab. Until Jan 24, 2021, tocilizumab was allocated via the second randomisation to 185 (4%) of 4839 patients allocated casirivimab and imdevimab and to 271 (5%) of 4946 patients allocated to usual care.
The characteristics of patients considered unsuitable for this comparison are in the appendix (p 51). At randomisation, 5272 (54%) were seropositive at baseline, 3153 (32%) were seronegative, and serostatus was unknown for 1360 (14%). Other baseline characteristics including receipt of corticosteroids and SARS-CoV-2 PCR test results are in table 1 and the appendix (p 52). 812 (8%) were known to have received at least one dose of a SARS-CoV-2 vaccine.
Table 1.
Baseline characteristics of the study population
|
Seronegative patients |
All patients |
||||
|---|---|---|---|---|---|
| Casirivimab and imdevimab (n=1633) | Usual care (n=1520) | Casirivimab and imdevimab (n=4839) | Usual care (n=4946) | ||
| Age, years | 63·2 (15·5) | 64·0 (15·2) | 61·9 (14·6) | 61·9 (14·4) | |
| <70* | 1054 (65%) | 943 (62%) | 3389 (70%) | 3454 (70%) | |
| 70–79 | 348 (21%) | 344 (23%) | 936 (19%) | 962 (19%) | |
| ≥80 | 231 (14%) | 233 (15%) | 514 (11%) | 530 (11%) | |
| Sex | |||||
| Men | 995 (61%) | 879 (58%) | 3033 (63%) | 3095 (63%) | |
| Women† | 638 (39%) | 641 (42%) | 1806 (37%) | 1851 (37%) | |
| Ethnicity | |||||
| White | 1325 (81%) | 1254 (83%) | 3779 (78%) | 3822 (77%) | |
| Black, Asian, and minority ethnic | 151 (9%) | 136 (9%) | 596 (12%) | 697 (14%) | |
| Unknown | 157 (10%) | 130 (9%) | 464 (10%) | 427 (9%) | |
| Number of days since symptom onset | 7 (4–10) | 7 (5–9) | 9 (6–12) | 9 (6–12) | |
| Number of days since admission to hospital | 1 (1–2) | 1 (1–3) | 2 (1–3) | 2 (1–3) | |
| Respiratory support received | |||||
| No oxygen received | 182 (11%) | 148 (10%) | 332 (7%) | 309 (6%) | |
| Simple oxygen | 1085 (66%) | 995 (65%) | 2980 (62%) | 3016 (61%) | |
| Non-invasive ventilation | 332 (20%) | 341 (22%) | 1244 (26%) | 1317 (27%) | |
| Invasive mechanical ventilation | 34 (2%) | 36 (2%) | 283 (6%) | 304 (6%) | |
| Previous diseases | |||||
| Diabetes | 403 (25%) | 407 (27%) | 1240 (26%) | 1337 (27%) | |
| Heart disease | 407 (25%) | 398 (26%) | 1038 (21%) | 1061 (21%) | |
| Chronic lung disease | 455 (28%) | 458 (30%) | 1085 (22%) | 1159 (23%) | |
| Tuberculosis | 7 (<1%) | 5 (<1%) | 18 (<1%) | 16 (<1%) | |
| HIV | 7 (<1%) | 4 (<1%) | 24 (<1%) | 22 (<1%) | |
| Severe liver disease‡ | 28 (2%) | 17 (1%) | 69 (1%) | 70 (1%) | |
| Severe kidney impairment§ | 114 (7%) | 114 (8%) | 266 (5%) | 242 (5%) | |
| Any of the above previous diseases | 935 (57%) | 913 (60%) | 2557 (53%) | 2662 (54%) | |
| SARS-CoV-2 PCR test result | |||||
| Positive | 1587 (97%) | 1476 (97%) | 4702 (97%) | 4813 (97%) | |
| Negative | 19 (1%) | 16 (1%) | 42 (1%) | 56 (1%) | |
| Unknown | 27 (2%) | 28 (2%) | 95 (2%) | 77 (2%) | |
| SARS-CoV-2 antibody test result | |||||
| Positive | 0 | 0 | 2636 (54%) | 2636 (53%) | |
| Negative | 1633 (100%) | 1520 (100%) | 1633 (34%) | 1520 (31%) | |
| Missing | 0 | 0 | 570 (12%) | 790 (16%) | |
| Received a COVID-19 vaccine | 128 (8%) | 117 (8%) | 394 (8%) | 418 (8%) | |
| Corticosteroids received | |||||
| Yes | 1481 (91%) | 1399 (92%) | 4530 (94%) | 4639 (94%) | |
| No | 152 (9%) | 118 (8%) | 308 (6%) | 299 (6%) | |
| Not recorded | 0 | 3 (<1%) | 1 (<1%) | 8 (<1%) | |
| Other randomly assigned treatments | |||||
| Azithromycin | 38 (2%) | 43 (3%) | 124 (3%) | 124 (3%) | |
| Colchicine | 364 (22%) | 350 (23%) | 1085 (22%) | 1139 (23%) | |
| Aspirin | 405 (25%) | 372 (24%) | 1339 (28%) | 1389 (28%) | |
| Baricitinib | 139 (9%) | 138 (9%) | 440 (9%) | 422 (9%) | |
Data are mean (SD), n (%), or median (IQR).
Includes 11 children (aged <18 years).
Includes 26 pregnant women.
Defined as requiring ongoing specialist care.
Defined as estimated glomerular filtration rate lower than 30 mL/min per 1·73 m2.
The follow-up form was completed for 4790 (99%) of 4839 patients in the casirivimab and imdevimab group and 4916 (99%) of 4946 patients in the usual care group. Among patients with a completed follow-up form, 90% assigned to casirivimab and imdevimab received casirivimab and imdevimab; no patients assigned to usual care received casirivimab and imdevimab (figure 1; appendix p 53). Use of other treatments for COVID-19 was similar among patients allocated casirivimab and imdevimab and among those allocated usual care, with about 25% receiving remdesivir and about 15% receiving tocilizumab or sarilumab (appendix p 53).
Primary and secondary outcome data are known for more than 99% of randomly assigned patients. In patients who were known to be seronegative at baseline, allocation to casirivimab and imdevimab was associated with a significant reduction in the primary outcome of 28-day mortality compared with usual care alone: 396 (24%) of 1633 patients in the casirivimab and imdevimab group died versus 452 (30%) of 1520 patients in the usual care group (RR 0·79, 95% CI 0·69–0·91; p=0·0009; table 2, figure 2, figure 3). The proportional effect of casirivimab and imdevimab on mortality differed significantly between seropositive and seronegative patients (test for heterogeneity p=0·002; figure 3). Among all randomly assigned patients (including those with negative, positive, or unknown baseline antibody status), there was no significant difference in the primary outcome of 28-day mortality between the casirivimab and imdevimab versus the usual care groups: 943 (19%) of 4839 patients in the casirivimab and imdevimab group died versus 1029 (21%) of 4946 patients in the usual care group (RR 0·94, 95% CI 0·86–1·02; p=0·14; figure 2, figure 3, appendix p 54). Similar results were noted in post-hoc sensitivity analyses using a commercial immunoassay to define either anti-S or anti-N serostatus (appendix pp 62–63).
Table 2.
Effect of allocation to casirivimab and imdevimab on key study outcomes in seronegative participants
| Casirivimab and imdevimab (n=1633) | Usual care (n=1520) | RR (95% CI) | |
|---|---|---|---|
| Primary outcome | |||
| Mortality at 28 days | 396 (24%) | 452 (30%) | 0·79 (0·69–0·91) |
| Secondary outcomes | |||
| Median duration of hospitalisation, days | 13 (7 to >28) | 17 (7 to >28) | .. |
| Discharged from hospital within 28 days | 1049 (64%) | 878 (58%) | 1·19 (1·09–1·31) |
| Invasive mechanical ventilation or death* | 488/1599 (31%) | 544/1484 (37%) | 0·83 (0·75–0·92) |
| Invasive mechanical ventilation | 190/1599 (12%) | 202/1484 (14%) | 0·87 (0·73–1·05) |
| Death | 383/1599 (24%) | 435/1484 (29%) | 0·82 (0·73–0·92) |
| Subsidiary outcomes | |||
| Use of ventilation† | 360/1267 (28%) | 373/1143 (33%) | 0·87 (0·77–0·98) |
| Non-invasive ventilation | 348/1267 (27%) | 362/1143 (32%) | 0·87 (0·77–0·98) |
| Invasive mechanical ventilation | 90/1267 (7%) | 120/1143 (10%) | 0·68 (0·52–0·88) |
| Successful cessation of invasive mechanical ventilation‡ | 10/34 (29%) | 10/36 (28%) | 1·19 (0·49–2·88) |
| Renal replacement therapy§ | 67/1614 (4%) | 65/1498 (4%) | 0·96 (0·69–1·34) |
Data are n (%), median (IQR), or n/N (%). RR=rate ratios for the outcomes of 28-day mortality, hospital discharge, and successful cessation of invasive mechanical ventilation, and risk ratios for other outcomes.
Excluding patients receiving invasive mechanical ventilation at randomisation.
Excluding patients receiving invasive or non-invasive ventilation at randomisation.
Excluding patients not receiving invasive mechanical ventilation at randomisation.
Excluding patients receiving renal replacement therapy at randomisation.
Figure 2.
Effect of allocation to casirivimab and imdevimab on 28-day mortality in (A) seronegative patients versus seropositive patients and (B) all participants overall
RR=rate ratio.
Figure 3.
Primary and secondary outcomes, overall and by baseline antibody status
Subgroup-specific RR estimates are represented by squares (with areas of the squares proportional to the amount of statistical information) and the lines through them correspond to the 95% CIs. Open squares represent participants with unknown status, solid squares represent participants with known status. The tests for heterogeneity (ie, χ21) compare the log RRs in the seronegative versus seropositive subgroups (ie, excluding those with unknown antibody status). Excluded participantsare included in the overall summary diamonds. RR=risk ratio for the composite outcome of invasive mechanical ventilation or death, and rate ratio for the other outcomes.
In seronegative patients, the proportional effects of casirivimab and imdevimab on mortality were consistent across all other pre-specified subgroups (figure 4), including by the level of respiratory support received at randomisation (test for trend p=0·55; figure 4) and, in a post-hoc exploratory analysis, by use of remdesivir at baseline (test for heterogeneity p=0·36; appendix p 64), and by baseline C-reactive protein concentration divided into thirds (test for trend p=0·22). Likewise, among all randomly assigned patients combined (ie, irrespective of serostatus), there was similar consistency across subgroups (appendix p 65). Results were also similar when restricted to participants with a positive SARS-CoV-2 PCR test (appendix p 55). In a sensitivity analysis using a Cox model adjusted for all pre-specified subgroups, allocation to casirivimab and imdevimab was associated with a mortality RR of 0·85 (95% CI 0·74–0·97) in seronegative patients (appendix p 55). In all participants, there was no evidence that the effect of casirivimab and imdevimab on mortality varied depending on concurrent randomised allocation to azithromycin, colchicine, or aspirin (all interaction p values >0·11).
Figure 4.
Effect of allocation to casirivimab and imdevimab on 28-day mortality by baseline characteristics in seronegative patients
Subgroup-specific RR estimates are represented by squares (with areas of the squares proportional to the amount of statistical information) and the lines through them correspond to the 95% CIs. The ethnicity, days since onset, and use of corticosteroids subgroups exclude patients with missing data, but these patients are included in the overall summary diamond. RR=rate ratio. χ21=test for heterogeneity or trend.
In seronegative patients, discharge alive within 28 days was more common for those assigned to casirivimab and imdevimab than those assigned to usual care (table 2, figure 3, appendix p 66). However, there was no meaningful between-group difference in the overall study population for this outcome (median 10 days [IQR 6 to >28] vs 10 days [5 to >28]; figure 3, appendix p 54).
In seronegative patients not on invasive mechanical ventilation at baseline, casirivimab and imdevimab was associated with a lower risk of progressing to the composite secondary outcome of invasive mechanical ventilation or death (table 2, figure 3). However, there was no between-group difference in the overall study population (figure 3, appendix p 54).
The proportional effects of casirivimab and imdevimab on the secondary outcomes of discharge alive from hospital and invasive mechanical ventilation or death differed significantly between seropositive and seronegative patients (p value for heterogeneity for both <0·001; figure 3). In all participants (irrespective of baseline serostatus), there was no evidence of differences in secondary outcomes in prespecified subgroups of patients (appendix pp 67–68).
In patients who were not on ventilation at baseline, casirivimab and imdevimab was associated with less frequent progression to use of ventilation than usual care in those who were seronegative (table 2) but not in the overall study population (appendix p 54). There were no meaningful differences in progression to renal replacement therapy, non-COVID mortality, cardiac arrhythmia, thrombosis, or major bleeding either in the seronegative or overall study populations (table 2, appendix pp 56–58).
Information on potential infusion reactions occurring within the first 72 h after randomisation was collected for 1792 patients in the casirivimab and imdevimab group and 1715 patients in the usual care group (before collection of these data stopped on Feb 19, 2021). In the overall study population, the reported frequency of fever (in 79 [4%] of 1792 vs 52 [3%] of 1715), sudden hypotension (66 [4%] vs 39 [2%]), and thrombotic events (31 [2%] vs 24 [1%]) was numerically higher in the casirivimab and imdevimab group versus the usual care group, and the frequency of sudden worsening in respiratory status (369 [21%] vs 372 [22%]) and clinical haemolysis (26 [1%] vs 31 [2%]) was numerically lower (appendix p 59). There were seven reports (<1% of particpants) of a serious adverse reaction believed to be related to treatment with the combination of casirivimab and imdevimab (three allergic reactions, two seizures, one acute desaturation, and one transient loss of consciousness; appendix p 60), and no deaths attributed to the treatment.
Discussion
In this large, randomised trial, casirivimab and imdevimab antibody combination in patients who were anti-SARS-CoV-2 antibody negative (ie, had not yet mounted their own humoral immune response) significantly reduced 28-day mortality by about one-fifth compared with usual care, an absolute benefit of six fewer deaths per 100 patients allocated the treatment. In addition, casirivimab and imdevimab was associated with an increased rate of discharge alive from hospital within the first 28 days and a reduced rate of progression to invasive mechanical ventilation or death in these patients. By contrast, no such benefits were seen for patients who were anti-SARS-CoV-2 antibody positive at randomisation. Consequently, when all patients were considered together (including those with unknown antibody status), casirivimab and imdevimab was associated with non-significant differences in clinical outcomes. Randomised clinical trials of three neutralising monoclonal antibody preparations (LY-CoV555, sotrovimab, and BRII-196 with BRII-198) in patients admitted to hospital for COVID-19 were all terminated early based on interim futility analyses.25, 26 Although there was some evidence of potential heterogeneity of effect of BRII-196 with BRII-198 by baseline serostatus, none of these three evaluations were powered to detect moderate treatment effects in subgroups defined by baseline serostatus. The total number of patients enrolled in these three evaluations was 860, less than 10% of the number enrolled in the RECOVERY evaluation of casirivimab and imdevimab.
Based on our findings, any therapeutic use of casirivimab and imdevimab combination in the hospital setting would be best restricted to seronegative patients, as has now been implemented in the UK based on our results.36 This approach requires serological testing before drug administration. High-performance, laboratory-based commercial assays for anti-SARS-CoV-2 antibodies are available and used in high-income health-care settings. For example, we noted similar results when analyses of the primary and secondary outcomes were repeated using a commercially available assay for either anti-spike or anti-nucleocapsid antibodies. However, serology assays are not widely available in lower-income settings.37 Point-of-care lateral-flow immunoassays have been developed but some have suboptimal performance and their suitability for guiding therapeutic decisions, as opposed to sero-epidemiological studies, requires further evaluation.34, 38, 39 Assays with lower costs and technological requirements than commercial bench-top systems and better performance than lateral-flow immunoassays have been developed and might offer more scalable and affordable options for serostatus evaluation but these also require further evaluation before clinical use.40
This study was conducted predominantly at a time before the widespread use of SARS-CoV-2 vaccines, when serostatus (the presence of antibodies to the viral spike protein) was reflective of acute response to infection. Now, however, seropositive status might additionally reflect the response to previous SARS-CoV-2 vaccination rather than acute infection. The vaccine-induced antibody response might be quantitatively and qualitatively different to the virus-induced antibody response. Although serological testing strategies, such as testing for antibodies against both spike and nucleocapsid proteins, might help to distinguish between vaccine-induced versus acute virus-induced antibody responses, it is not known if casirivimab and imdevimab treatment would be beneficial in vaccinated patients with COVID-19 who are S-antibody positive but N-antibody negative. The reliability of seropositive status as a predictor of therapeutic non-response to monoclonal antibodies is further complicated by the emergence of the B.1.1.529 variant (omicron) that can evade antibodies raised against earlier SARS-CoV-2 variants. Going forward, antigen status might be a more meaningful biomarker of potential therapeutic response to monoclonal antibodies than antibody status.26
In October, 2020, the independent data monitoring committee of an industry-sponsored trial41 of casirivimab and imdevimab in patients with COVID-19 admitted to hospital recommended that recruitment of patients on high-flow oxygen or mechanical ventilation be suspended because of a potential safety signal, while an interim analysis of the same trial in December, 2020, suggested a possible benefit in patients on low-flow oxygen.20 However, we did not observe any evidence that the proportional effect of casirivimab and imdevimab on mortality varied by level of respiratory support received at randomisation, either when assessed in all participants or when assessed only in the subgroup of seronegative participants.
Monoclonal antibodies are susceptible to the evolution of viral resistance if substitutions in the targeted epitope reduce or abrogate antibody binding, and a US Emergency Use Authorisation for monotherapy with the monoclonal antibody LY-CoV555 was revoked because of resistance in several major virus variants.42 This risk can be reduced by using a combination of monoclonal antibodies that bind to non-overlapping epitopes.14 Although we did not study the emergence of resistance variants in this trial, the major variants circulating in the UK throughout the trial, including the B.1.1.7 (alpha) variant that was the dominant variant in the UK from December, 2020, to April, 2021, remained sensitive to casirivimab and imdevimab.43, 44, 45, 46 Although spike glycoprotein mutations at residue E484 of the spike glycoprotein in some variants (eg, B.1.351 [beta, E484K], and B.1.617.1 [kappa, E484Q]) are associated with a marked reduction of neutralisation activity of casirivimab, the combination of casirivimab with imdevimab retains potency against these variants because of the inhibitory activity of imdevimab.43, 44, 45, 47 Although the B.1.617.2 (delta) variant is associated with markedly reduced neutralisation activity of imdevimab, the neutralising activity of casirivimab is retained, such that the combination likely retains clinical effectiveness against the delta variant.46, 48 In late 2021, after this study of casirivimab and imdevimab was completed, the omicron variant of SARS-CoV-2 emerged. With numerous amino acid substitutions in the spike glycoprotein, omicron is able to evade neutralisation by some naturally occurring, vaccine-induced and monoclonal antibodies. Both casirivimab and imdevimab have markedly reduced ability to neutralise omicron in vitro and, therefore, are unlikely to retain clinical effectiveness against the omicron variant. However, this study is proof of principle that monoclonal antibody therapy can have clinical benefit in hospitalised patients with COVID-19. The emergence of the omicron variant highlights the importance of continued monitoring of resistance, the ongoing development and evaluation of monoclonal antibody preparations that are not sensitive to common and newly arising substitutions, and the exploration of antiviral combination therapies with different mechanisms of action.49
The strengths of this trial included that it was randomised, had a large sample size, broad eligibility criteria, and more than 99% of patients were followed up for the primary outcome. The study has some limitations: information on virological outcomes was not collected, nor was information on radiological or physiological outcomes. Although this randomised trial is open label (ie, participants and local hospital staff are aware of the assigned treatment), the outcomes are unambiguous and were ascertained without bias through linkage to routine health records. The dose of casirivimab and imdevimab used in this study was high compared to those used in outpatient studies; understanding the effects of lower doses would require additional evidence from a randomised controlled trial.16
In summary, this large, randomised trial provides the first evidence that an antiviral therapy can reduce mortality in patients admitted to hospital with COVID-19. The results support the use of the monoclonal neutralising antibody combination of casirivimab and imdevimab in seronegative patients admitted to hospital with COVID-19 caused by SARS-CoV-2 variants that are sensitive to these antibodies.
Data sharing
The protocol, consent form, statistical analysis plan, definition and derivation of clinical characteristics and outcomes, training materials, regulatory documents, and other relevant study materials are available online. As described in the protocol, the trial steering committee will facilitate the use of the study data and approval will not be unreasonably withheld. Deidentified participant data will be made available to researchers registered with an appropriate institution within 3 months of publication. However, the steering committee will need to be satisfied that any proposed publication is of high quality, honours the commitments made to the study participants in the consent documentation and ethical approvals, and is compliant with relevant legal and regulatory requirements (eg, relating to data protection and privacy). The steering committee will have the right to review and comment on any draft manuscripts before publication. Data will be made available in line with the policy and procedures described at: https://www.ndph.ox.ac.uk/data-access. Individuals wishing to request access should complete the form at https://www.ndph.ox.ac.uk/files/about/data_access_enquiry_form_13_6_2019.docx and e-mail to: data.access@ndph.ox.ac.uk.
Declaration of interests
DMW is an employee of Regeneron Pharmaceuticals and holds shares or share options in the company. All other authors declare no competing interests or financial relationships relevant to the submitted work. No form of payment was given to anyone to produce the manuscript. The Nuffield Department of Population Health at the University of Oxford has a staff policy of not accepting honoraria or consultancy fees directly or indirectly from industry (see https://www.ndph.ox.ac.uk/files/about/ndph-independence-of-research-policy-jun-20.pdf).
Acknowledgments
Acknowledgments
The RECOVERY trial is supported by grants to the University of Oxford (Oxford, UK) from UK Research and Innovation (UKRI; Medical Research Council) and the National Institute of Health Research (NIHR; MC_PC_19056), the Wellcome Trust (222406/Z/20/Z) through the COVID-19 Therapeutics Accelerator, and by core funding provided by the NIHR Oxford Biomedical Research Centre, the Wellcome Trust, the Bill and Melinda Gates Foundation, the Foreign, Commonwealth and Development Office, Health Data Research UK, the Medical Research Council Population Health Research Unit, the NIHR Health Protection Unit in Emerging and Zoonotic Infections, and NIHR Clinical Trials Unit Support Funding. TJ is supported by a grant from UK Medical Research Council (MC_UU_00002/14) and an NIHR Senior Research Fellowship (NIHR-SRF-2015-08-001). WSL is supported by core funding provided by NIHR Nottingham Biomedical Research Centre. Tocilizumab was provided free of charge for this trial by Roche Products. Regeneron Pharmaceuticals supported the trial through provision of casirivimab and imdevimab. The views expressed in this publication are those of the authors and not necessarily those of the UK National Health Service, the NIHR, the Department of Health and Social Care, or Regeneron Pharmaceuticals. We would like to thank the thousands of patients who participated in this trial. We would also like to thank the many doctors, nurses, pharmacists, other allied health professionals, and research administrators at 177 NHS hospital organisations across the whole of the UK, supported by staff at the NIHR Clinical Research Network, NHS DigiTrials, Public Health England, Department of Health & Social Care, the Intensive Care National Audit & Research Centre, Public Health Scotland, National Records Service of Scotland, the Secure Anonymised Information Linkage at University of Swansea, NHS Blood & Transplant and the NHS in England, Scotland, Wales, and Northern Ireland.
Writing committee (on behalf of the RECOVERY Collaborative Group)
Peter W Horby*, Marion Mafham*, Leon Peto, Mark Campbell, Guilherme Pessoa-Amorim, Enti Spata, Natalie Staplin, Jonathan R Emberson, Benjamin Prudon, Paul Hine, Thomas Brown, Christopher A Green, Rahuldeb Sarkar, Purav Desai, Bryan Yates, Tom Bewick, Simon Tiberi, Tim Felton, J Kenneth Baillie, Maya H Buch, Lucy C Chappell, Saul N Faust, Thomas Jaki, Katie Jeffery, Edmund Juszczak, Wei Shen Lim, Alan Montgomery, Andrew Mumford, Kathryn Rowan, David M Weinreich, Richard Haynes†, Martin J Landray†.
*PWH and MM contributed equally. †RH and MJL contributed equally.
Data monitoring committee
Peter Sandercock, Janet Darbyshire, David DeMets, Robert Fowler, David Lalloo, Mohammed Munavvar (from January, 2021), Ian Roberts (until December, 2020), Adilia Warris (from March, 2021), and Janet Wittes.
Contributors
This manuscript was initially drafted by PWH and MJL, further developed by the Writing Committee, and approved by all members of the trial steering committee. PWH and MJL approved the data and analyses, and vouch for the fidelity of this report to the study protocol and data analysis plan. PWH, MM, JKB, MHB, LCC, JD, SNF, TJ, EJ, KJ, WSL, AMo, AMu, KR, RH, and MJL designed the trial and study protocol. MM, LP, MC, GP-A, BP, PH, TBr, CAG, RS, PD, BY, TBe, ST, TF, and the Data Linkage team at the RECOVERY Coordinating Centre, and the Health Records and Local Clinical Centre staff listed in the appendix collected the data. ES, NS, and JRE did the statistical analysis. All authors contributed to data interpretation, and critical review and revision of the manuscript. PWH and MJL (the corresponding authors) had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Contributor Information
RECOVERY Collaborative Group:
Obbina Abani, Ali Abbas, Fatima Abbas, Mustafa Abbas, Sadia Abbasi, Hakam Abbass, Alfie Abbott, Nabeel Abdallah, Ashraf Abdelaziz, Mohamed Abdelfattah, Bushra Abdelqader, Basir Abdul, Althaf Abdul Rasheed, Ajibode Abdulakeem, Rezan Abdul-Kadir, Abdullah Abdullah, Abdulfatahi Abdulmumeen, Rasheed Abdul-Raheem, Niyaz Abdulshukkoor, Kula Abdusamad, Yazeed Abed El Khaleq, Mai Abedalla, Abeer Ul-Amna, Katrina Abernethy, Adebanke Aboaba, Hani Abo-Leyah, Ahmed Abou-Haggar, Mahmoud Abouibrahim, Miriam Abraham, Tizzy Abraham, Abraheem Abraheem, Judith Abrams, Hyacinth-John Abu, Ahmed Abu-Arafeh, Syed M Abubacker, Akata Abung, Yaa Aceampong, Amaka Achara, Devikumar Acharya, Sarah Acheampong, Janet Acheson, Andres Acosta, Catherine Acton, Jacqueline Adabie-Ankrah, Fiona Adam, Matthew Adam, Huzaifa Adamali, Carol Adams, Charlotte Adams, Kate Adams, Richard Adams, Tim Adams, Krishma Adatia, Kirsty Adcock, Ade Adebiyi, Ken Adegoke, Vicki Adell, Sherna Adenwalla, Oluwasegun A Adesemoye, Emmanuel O Adewunmi, Joyce Adeyemi, Binay Adhikari, Rina Adhikary, Gabrielle Adkins, Adnan Adnan, John Aeron-Thomas, Debbie Affleck, Carmel Afnan, Muhammad Afridi, Zainab A Aftab, Meenakshi Agarwal, Rachel Agbeko, Chris Agbo, Sunil Aggarwal, Arameh Aghababaie, Shafana Ahamed Sadiq, Mohamed H Ahammed Nazeer, Mohammad Ahmad, Syed Ahmad, Asim Ahmed, Bilal Ahmed, Forizuddin Ahmed, Hamze Ahmed, Irshad Ahmed, Khaled Ahmed, Liban Ahmed, Mahin Ahmed, Maria C Ahmed, Muhammad S Ahmed, Naseer Ahmed, Nausheen Ahmed, Osama Ahmed, Rajia A Ahmed, Rizwan Ahmed, Saif Ahmed, Sammiya Ahmed, Syed Ahmed, Syed Haris Ahmed, Roa Ahmed Ali, Sana Ahmed, Sana Ahmer, Dhiraj Ail, Mark Ainsworth, Myriam Aissa, Lindianne Aitken, Bini Ajay, Abdulakeem Ajibode, Ayesha Ajmi, Nasim Akhtar, Nauman Akhtar, Suha Akili, Oludoyinsola Akindolie, Yinka Akinfenwa, Olugbenga Akinkugbe, Ibrahim Akinpelu, Olugbenro Aktinade, Ahmad S A R Al Aaraj, Asma Al Balushi, Majd Al Dakhola, Aladdin Al Swaifi, Eslam Al-Abadi, Narendra Aladangady, Ayaz Alam, Sajid Alam, Abbas Al-Asadi, Kyriaki Alatzoglou, Paul Albert, Lorraine Albon, Gemma Alcorn, Stephen Alcorn, Aggie Aldana, David Alderdice, Rayan Aldouri, Jonathan Aldridge, Nicolas Aldridge, Ana Alegria, Alison Alexander, John Alexander, Peter D G Alexander, Julyan Al-Fori, Laith Alghazawi, Bahij Al-Hakim, Shams Al-Hity, Ali Ali, Asad Ali, Fawzia R Ali, Jawad Ali, Mariam Ali, Mohammad Ali, Nayab Ali, Oudai Ali, Sakina Ali, Syed Ali, Abid Alina, Fine Aliyuda, Katrin Alizadeh, Maithem Al-Jibury, Saba Al-Juboori, Majid Al-Khalil, Moutaz Alkhusheh, Fiona Allan, Alison Allanson, Robert Allcock, Eireann Allen, Kerry Allen, Louise Allen, Poppy Allen, Rebecca Allen, Sam Allen, Sharon Allen, Simon Allen, Kathryn Allison, Bethan Allman, Lynne Allsop, Hassan Al-Moasseb, Magda Al-Obaidi, Lina Alomari, Akram Al-Rabahi, Bahar Al-Ramadhani, Zayneb Al-Saadi, Inji Alshaer, Rustam Al-Shahi Salman, Warkaq Al-Shamkhani, Bashar Al-Sheklly, Sara Altaf, Mary Alvarez, Maysaa Alzetani, Susan Amamou, Noor Amar, Sakkarai Ambalavanan, Robert Ambrogetti, Chris Ambrose, Amir Ameen, Maria R Amezaga, Allison Amin, Amina Amin, Kanish Amin, Syed Amin, Tara Amin, Amjad Amjad, Neelma Amjad, Victoria Amosun, Khaled Amsha, Pugh Amy, Atul Anand, Samantha Anandappa, Julie Anderson, Laura Anderson, Michelle Anderson, Nicola Anderson, Rachel Anderson, Rory Anderson, Wendy Anderson, Prematie Andreou, Angela Andrews, Antonette Andrews, Jill Andrews, Kanayochukwu Aneke, Andrew Ang, Wan Wei Ang, Tammy Angel, Aramburo Angela, Paola Angelini, Lazarus Anguvaa, Oleg Anichtchik, Millicent Anim-Somuah, Krishnan Aniruddhan, Jessica Annett, Louise Anning, Patrick J Anstey, Rebekah Anstey, Alpha Anthony, Aaron Anthony-Pillai, Philip Antill, Zhelyazkova Antonina, Varghese Anu, Muhammad Anwar, Aristeidis Apostolopoulos, Sarah Appleby, Diane Appleyard, Maia Far Aquino, Bianca Araba, Samuel Aransiola, Mariana Araujo, Ann Archer, Denise Archer, Simon Archer, Christian Ardley, Ana-Maria Arias, Ryoki Arimoto, Charlotte Arkley, Charlotte Armah, Ilianna Armata, Adam Armitage, Ceri Armstrong, Maureen Armstrong, Sonia Armstrong, Philippa Armtrong, Heike Arndt, Clare Arnison-Newgass, David Arnold, Rachael Arnold, Dhawal Arora, Kavan Arora, Pardeep Arora, Rishi Arora, Arslam Arter, Ayush Arya, Rita Arya, Denisa Asandei, Adeeba Asghar, Catherine Ashbrook-Raby, Helen Ashby, Jan Ashcroft, John Ashcroft, Samuel Ashcroft, Georgia Asher, Ayesha Ashfaq, Abdul Ashish, Sally Ashman-Flavell, Sundar Ashok, Abd-El-Aziz Ashour, Muhammad Z Ashraf, Saima Ashraf, Mohammad B Ashraq, Deborah Ashton, Susan Ashton, Andrew Ashworth, Rebecca Ashworth, Arshia Aslam, Harshini Asogan, Atif Asrar, Omar Assaf, Raine Astin-Chamberlain, Deborah Athorne, Billie Atkins, Christopher Atkins, Stacey Atkins, John Atkinson, Vicki Atkinson, Brygitta Atraskiewicz, Abdul A Attia, Paula Aubrey, Avinash Aujayeb, Aye CT Aung, Hnin Aung, Kyaw T Aung, Yin Aung, Zaw M Aung, Emily Austin, Karen Austin, Abdusshakur Auwal, Miriam Avery, Nicholas Aveyard, Joanne Avis, Georgina Aviss, Cristina Avram, Paula Avram, Gabriel Awadzi, Atia Awan, Aszad Aya, Eman Ayaz, Amanda Ayers, Jawwad Azam, Mohammed Azharuddin, Ghazala Aziz, N Aziz, Ali Azkoul, Ashaari Azman Shah, Giada Azzopardi, Hocine Azzoug, Fiyinfoluwa Babatunde, Melvin Babi, Babiker Babiker, Gayna Babington, Matthew Babirecki, Marta Babores, Adetona O Babs-Osibodu, Sammy Bacciarelli, Roudi Bachar, Gina Bacon, Jenny Bacon, Bibi Badal, Gurpreet R Badhan, Shreya Badhrinarayanan, Joseph P Bae, Alice Baggaley, Amy Baggott, Graham Bagley, Dinesh Bagmane, Lynsey Bagshaw, Kasra Bahadori, James Bailey, Katie Bailey, Lindsey Bailey, Liz Bailey, Morgan Bailey, Pippa Bailey, Sarah Bailey, Hamish Baillie, J Kenneth Baillie, Jennifer Bain, Vikram Bains, David Baird, Kevin Baird, Susan Baird, Tracy Baird, Yolanda Baird, Aiysha Bajandouh, Evelyn Baker, Johanne Baker, Josephine Baker, Kenneth Baker, Rebecca Baker, Terri-Anne Baker, Victoria Baker, Hugh Bakere, Nawar Bakerly, Michelle Baker-Moffatt, Nauman Bakhtiar, Panos Bakoulas, Niranjan Balachandran, Andrea Balan, Theodosios Balaskas, Madhu Balasubramaniam, Alison Balcombe, Alexander Baldwin, Ashley Baldwin, Caron Baldwin, Danielle Baldwin, Rebekah Baldwin-Jones, James Balfour, Matthew Ball, K Ballard, Ismael Balluz, Craig Balmforth, Emese Balogh, Amir Baluwala, Gabby Bambridge, Alasdair Bamford, Amy Bamford, Peter Bamford, Adefunke Bamgboye, Elizabeth Bancroft, Hollie Bancroft, Joyce Banda, Krishna Bandaru, Srini Bandi, Nageswar Bandla, Somaditya Bandyopadhyam, Amit Banerjee, Ritwik Banerjee, Harrison Banks, Luke Banks, Paul Banks, Oliver Bannister, Laura Banton, Tran Bao, Mariamma Baptist, Tanya Baqai, Ananya M Baral, Desislava Baramova, Russel Barber, Emma Barbon, Miriam Barbosa, Monica Barbosa, Jamie Barbour, Alexander Barclay, Claire Barclay, George Bardsley, Stephanie Bareford, Shahedal Bari, Morris Barimbing, Amy Barker, Debbie Barker, Helen Barker, Joseph Barker, Leon Barker, Oliver Barker, Kerry Barker-Williams, Sinha Barkha, Juliana Barla, Gavin Barlow, Richard Barlow, Valerie Barlow, James Barnacle, Alex Barnard, Debi Barnes, Nicky Barnes, Theresa Barnes, Calum Barnetson, Amy Barnett, Ashton Barnett-Vanes, William Barnsley, Andrew Barr, David Barr, Shaney Barratt, Manuella Barrera, Amy Barrett, Fiona Barrett, Jessica Barrett, Jazz Bartholomew, Claire Bartlett, Georgina Bartlett, Greg Barton, Jill Barton, Lorna Barton, Rachael Barton, Rosaleen Baruah, Sonia Baryschpolec, Archana Bashyal, Betsy Basker, Buddha Basnyat, Ayten Basoglu, John Bassett, G Bassett, Chris Bassford, Bengisu Bassoy, Victoria Bastion, Anup Bastola, Anupam Basumatary, Tristan Bate, Harry J Bateman, Kathryn Bateman, Vhairi Bateman, Eleanor Bates, Hayley Bates, Michelle Bates, Simon Bates, Sally Batham, Ana Batista, Amit Batla, Dushyant Batra, Harry Batty, Thomas Batty, Miranda Baum, Rachel Baumber, Carina Bautista, Fareha Bawa, Fatima S Bawani, Simon Bax, Matt Baxter, Nicola Baxter, Zachary Baxter, Hannah Bayes, Farid Bazari, Rohit Bazaz, Ahmad Bazli, Laura Beacham, Wendy Beadles, Philip Beak, Andy Beale, Jack Bearpark, Karen Beaumont, Dawn Beaumont-Jewell, Theresa Beaver, Sarah Beavis, Christy Beazley, Sarah Beck, Virginia Beckett, Rosie Beckitt, Heidi Beddall, Seonaid Beddows, Deborah Beeby, Gail Beech, Michelle Beecroft, Sally Beer, Jane Beety, Gabriela Bega, Alison Begg, Susan Begg, Sara Beghini, Ayesha Begum, Salman Begum, Selina Begum, Teresa Behan, Roya Behrouzi, Jon Beishon, Claire Beith, James Belcher, Holly Belfield, Katherine Belfield, Ajay Belgaumkar, Dina Bell, Gareth Bell, Gillian Bell, Lauren Bell, Louise Bell, Nicholas Bell, Pippa Bell, Stephanie Bell, Jennifer L Bell, Jennifer Bellamu, Mary Bellamy, Arianna Bellini, Amanda Bellis, Fionn Bellis, Lesley Bendall, Naveena Benesh, Nicola Benetti, Leonie Benham, Guy Benison-Horner, Ann Bennett, Caroline Bennett, Gillian Bennett, Kristopher Bennett, Lorraine Bennett, Sara Bennett, Karen Bennion, Vivienne Benson, Andrew Bentley, James Bentley, Ian Benton, Eva Beranova, Matthew Beresford, Colin Bergin, Malin Bergstrom, Jolanta Bernatoniene, Thomas Berriman, Zoe Berry, Kimberley Best, Ans-Mari Bester, Yvonne Beuvink, Emily Bevan, Sarah Bevins, Tom Bewick, Andrew Bexley, Sonay Beyatli, Fenella Beynon, Arjun Bhadi, Sanjay Bhagani, Shiv Bhakta, Rekha Bhalla, Khushpreet Bhandal, Kulbinder Bhandal, Ashwin Bhandari, Sangam Bhandari, Aashutosh Bhanot, Ravina Bhanot, Prashanth Bhat, Rahul Bhatnagar, Karan Bhatt, Janki Bhayani, Deepika Bhojwani, Salimuzzaman Bhuiyan, Anna Bibby, Fatima Bibi, Naheeda Bibi, Salma Bibi, Tihana Bicanic, Sarah Bidgood, Julie Bigg, Sarah Biggs, Alphonsa Biju, Andras Bikov, Sophie Billingham, Jessica Billings, Alice Binns, Muhammad BinRofaie, Oliver Bintcliffe, Catherine Birch, Jenny Birch, Katherine Birchall, Sam Bird, Sumedha Bird, Mark Birt, Kilanalei Bishop, Linda Bishop, Lisa Bishop, Karen Bisnauthsing, Nibedan Biswas, Sahar Biuk, Karen Blachford, Ethel Black, Helen Black, Karen Black, Mairead Black, Polly Black, Hayley Blackgrove, Bethan Blackledge, Joanne Blackler, Samantha Blackley, Helen Blackman, Caroline Blackstock, Francesca Blakemore, Helen Blamey, Alison Bland, Sujata Blane, Simon Blankley, Parry Blaxill, Katie Blaylock, Jane Blazeby, Natalie Blencowe, Ben Bloom, Jack Bloomfield, Angela Bloss, Hannah Bloxham, Louise Blundell, Andrew Blunsum, Mark Blunt, Ian Blyth, Kevin Blyth, Andrew Blythe, Karen Blythe, Marilyn Boampoaa, Boniface Bobie, Karen Bobruk, Pritesh N Bodalia, Neena Bodasing, Tanya Bodenham, Gabriele Boehmer, Marta Boffito, Kristyna Bohmova, Niamh Bohnacker, Sumit Bokhandi, Maria Bokhar, Saba Bokhari, Sakina Bokhari, Syed O Bokhari, Ambrose Boles, Charlotte Bond, Helena Bond, Stuart Bond, Thomas Bond, Alice Bone, Georgia Boniface, Lizzy Bonney, Sarah Boot, Joanne Borbone, Naomi Borman, Mamu Boshir, Fiona Bottrill, Laura Bough, Hayley Boughton, Zoe Boult, Miriam Bourke, Stephen Bourke, Michelle Bourne, Rachel Bousfield, Lucy Boustred, Alexandra Bowes, Amy Bowes, Philip Bowker, Louise Bowman, Simon Bowman, Rachel Bowmer, Angie Bowring, Helen Bowyer, Aileen Boyd, Jenny Boyd, Laura Boyd, Namoi Boyle, Pauline Boyle, Rosalind Boyle, Louise Boyles, Leanna Brace, Jodie Bradder, Clare J Bradley, Pamela Bradley, Patrick Bradley, Paul Bradley, Joanne Bradley-Potts, Lynne Bradshaw, Zena Bradshaw, Rebecca Brady, Shirin Brady, Denise Braganza, Marie Branch, Thomas Brankin-Frisby, Jamie Brannigan, Sophie Brattan, Fiona Bray, Nancy Bray, Manny Brazil, Lucy Brear, Tracy Brear, Stephen Brearey, Laura Bremner, Morwenna Brend, Giovanna Bretland, Chris Brewer, Gavin Bridgwood, Sara Brigham, John Bright, Chris Brightling, Lutece Brimfield, Elaine Brinkworth, Robin Brittain-Long, Vianne Britten, Lauren Broad, Sarah Broad, Rosie Broadhurst, Andrew Broadley, Marie Broadway, Christopher Brockelsby, Megan Brocken, Tomos Brockley, Mary Brodsky, Fiona Brogan, Liz Brohan, Felicity Brokke, Jacob Brolly, David Bromley, Hannah Brooke-Ball, Verity Brooker, Matthew Brookes, Deirdre Brooking, Alison Brooks, Karen Brooks, Nicole Brooks, Philip Brooks, Rachel Brooks, Sophie Brooks, Tim Brooks, Natalie Broomhead, Chloe Broughton, Nathaniel Broughton, Matt Brouns, Alison Brown, Ammani Brown, Carly Brown, Catrin Brown, Ellen Brown, Heather Brown, Janet Brown, Louise Brown, Niall Brown, Pauline Brown, Rachel Brown, Richard Brown, Robert Brown, Steven Brown, Thomas Brown, Tom Brown, Bria Browne, Charlotte Browne, Duncan Browne, Mitchell Browne, Stephen Brownlee, Alba Brraka, Johanna Bruce, Michelle Bruce, Wojciech Brudlo, Nigel Brunskill, Alan Brunton, Margaret Brunton, Meera Bryant, April Buazon, Maya H Buch, Ruaridh Buchan, Ruaridh Buchanan, Danielle Buche, Amanda Buck, Matthew Buckland, Laura Buckley, Philip Buckley, Sarah Buckley, Carol Buckman, George Bugg, Ramadan Bujazia, Marwan Bukhari, Shanze Bukhari, Richard Bulbulia, Alex Bull, Damian Bull, Rhian Bull, Thomas Bull, Naomi Bulteel, Kasun Bumunarachchi, Roneleeh Bungue-Tuble, Caroline Burchett, Dorota Burda, Christy Burden, Thomas G Burden, Mika Burgess, Richard Burgess, Sophia Burgess, Adrian Burman, Sara Burnard, Caroline Burnett, Amy Burns, Collette Burns, James Burns, Karen Burns, Daniel Burrage, Kate Burrows, Claire Burston, Ben Burton, Fiona Burton, Matthew Burton, Deborah Butcher, Aaron Butler, Jessica Butler, Joanne Butler, Joshua Butler, Peter Butler, Susan Butler, Al-Tahoor Butt, Mohammad M Butt, Caryl Butterworth, Nicola Butterworth-Cowin, Robert Buttery, Tom Buttle, Heather Button, Daniel Buttress, Jane Byrne, Wendy Byrne, Victoria Byrne-Watts, Amanda Cabandugama, Ruth Cade, Anthony Cadwgan, Ajeng Cahyareny, Donna Cairney, James Calderwood, Darren Caldow, Giorgio Calisti, Debbie Callaghan, Jennifer Callaghan, Claire Callens, Donaldson Callum, Caroline Calver, Melissa Cambell-Kelly, Tracey Camburn, David R Cameron, Eleanor Cameron, Fraser Cameron, Sarah Cameron, Sheena Cameron, Christian Camm, Renee F D Cammack, Alison Campbell, Amy Campbell, Barbara Campbell, Bridget Campbell, Debbie Campbell, Helen Campbell, Hilary Campbell, Jonathan Campbell, Mark Campbell, Robyn Campbell, Wynny Campbell, Quentin Campbell Hewson, Julie Camsooksai, Lisa Canclini, Shaula M Candido, Janie Candlish, Cielito Caneja, Alexandra Cann, Johnathon Cann, Ruby Cannan, Emma Cannon, Michael Cannon, Petra Cannon, Vivienne Cannons, Jane Cantliff, Ben Caplin, Santino Capocci, Noemi Caponi, Angelika Capp, Thomas Capstick, Mary Cardwell, Rachel Carey, Simon Carley, Tammy Carlin, Samantha Carmichael, Mandy Carnahan, Charlotte Caroline, Jodi Carpenter, Sharon Carr, Anna Carrasco, Zoe Carrington, Amy Carroll, Paul Carroll, Jonathan Carter, Michael Carter, Paul Carter, Penny Carter, Douglas Cartwright, Jo-Anne Cartwright, Claire Carty, Jaime Carungcong, Susan Casey, Annie Cassells, Teresa Castiello, Gail Castle, Bridget Castles, Melanie Caswell, Ana Maria Catana, Heidi Cate, Susanne Cathcart, Katrina Cathie, Christine Catley, Laura Catlow, Matthew Caudwell, Anna Cavazza, Luke Cave, Simon Cavinato, Frianne Cawa, Kathryn Cawley, Chloe Caws, Hankins Cendl, Hannah Century, Jeva Cernova, Mansur Cesay, Ed Cetti, Stephanie Chabane, Manish Chablani, Cathleen Chabo, David Chadwick, Julie Chadwick, Robert Chadwick, Ela Chakkarapani, Arup Chakraborty, Mallinath Chakraborty, Mollika Chakravorty, Bimal Chalise, James Chalmers, Richard Chalmers, Georgina Chamberlain, Sarah Chamberlain, Emma Chambers, Jonathan Chambers, Lucy Chambers, Naomi Chambers, Alex Chan, Carmen Chan, Cheuk Chan, Evelyn Chan, Kayen Chan, Kimberley Chan, Ping Chan, Rebekah (Pui-Ching) Chan, Xin Hui S Chan, Chris Chandler, Heidi Chandler, Kim J Chandler, Stuart Chandler, Zoe Chandler, Sumit Chandra, Navin Chandran, Badrinathan Chandrasekaran, Yvonne Chang, Josephine Chaplin, Graeme Chapman, John Chapman, Katie Chapman, Laura Chapman, Lianne Chapman, Polly Chapman, Timothy Chapman, Lucy C Chappell, Lucy Chappell, Amanda Charalambou, Bethan Charles, Dianne Charlton, Kevin Chatar, Calvin Chatha, Ritesh Chaube, Muhammad Y N Chaudhary, Iram Chaudhry, Nazia Chaudhuri, Muhammad Chaudhury, Anoop Chauhan, Ruchi Singh Chauhan, Nicola Chavasse, Vipal Chawla, Lindsay Cheater, James Cheaveau, Charlotte Cheeld, Michelle Cheeseman, Fang Chen, Hui Min Chen, Terence Chen, Floria Cheng, Lok Yin Cheng, Zhihang Cheng, Helen Chenoweth, Chun How Cheong, Shiney Cherian, Mary Cherrie, Helen Cheshire, Chee Kay Cheung, Elaine Cheung, Michelle Cheung, Claire Cheyne, Swati Chhabra, Wei Ling Chia, Eric Chiang, Angela Chiapparino, Rosavic Chicano, Zviedzo A Chikwanha, Sam Chilcott, Phillipa Chimbo, KokWai Chin, Wen Jie Chin, Rumbidzai Chineka, Amol Chingale, Heather Chisem, Claire Chisenga, Ben Chisnall, Carolyn Chiswick, Sunder Chita, Nihil Chitalia, Matthew Chiu, Brenda Chivima, Catherine Chmiel, Soha Choi, Willy Choon Kon Yune, Vandana Choudhary, Sarah Choudhury, Bing-Lun Chow, Mahibbur Chowdhury, Shahid Chowdhury, Victoria Christenssen, Peter Christian, Alexander Christides, Fiona Christie, Daniel Christmas, Thereza Christopherson, Mark Christy, Paris Chrysostomou, Yunli Chua, Dip Chudgar, Richard Chudleigh, Srikanth Chukkambotla, Michael Eze Chukwu, Izu Chukwulobelu, Chi Yee Chung, Elaine Church, Sara R Church, David Churchill, Nicole Cianci, Nick Ciccone, Paola Cicconi, Paola Cinardo, Zdenka Cipinova, Bessie Cipriano, Sarah Clamp, Melanie Clapham, Edel Clare, Sarbjit Clare, Andrew Clark, Charlotte Clark, Diane Clark, Felicity Clark, Gabrielle Clark, James Clark, Katherine Clark, Kaylea Clark, Louise Clark, Lucy Clark, Matthew Clark, Patricia Clark, Richard Clark, Thomas Clark, Zoe Clark, Andrea Clarke, Paul Clarke, Robert Clarke, Roseanne Clarke, Samantha Clarke, Sheron Clarke, Alleyna Claxton, Kate Clay, Elizabeth Clayton, Olivia Clayton, Jill Clayton-Smith, Chris Cleaver, Carlota Clemente de la Torre, Jayne Clements, Suzanne Clements, Francesca Clemons, Rachael Clifford, Sarah Clifford, Amelia Clive, Jonathan Clouston, Samantha Clueit, Andrea Clyne, Michelle 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Rhiannon Conway, Jo-Anna Conyngham, Colette Cook, Eloise Cook, Gemma Cook, Helen Cook, Julie Cook, Danielle Cooke, Graham Cooke, Katrina Cooke, Tim Cooke, Adele Cooper, Chris Cooper, David Cooper, Helen Cooper, Jamie Cooper, Lauren Cooper, Nick Cooper, Rowena Cooper, Thomas Cope, Sinead Corbet, Carolyn Corbett, John Corcoran, Chris Cordell, Jessica Cordle, Alasdair Corfield, John Corless, Alison Corlett, Joe Cornwell, Michael Cornwell, Diana Corogeanu, Mirella Corredera, Ruth Corrigan, P Corry, Rita Corser, Denise Cosgrove, Tracey Cosier, Patricia Costa, Charlie Coston, Susannah Cotgrove, Zoe Coton, Lisa-Jayne Cottam, Rhiannon Cotter, Donna Cotterill, Caroline Cotton, Andrew Coull, James Coulson, David Counsell, David Counter, Cherry Coupland, Ellie Courtney, Julia Courtney, Rebecca Cousins, Alexander Cowan, Elena Cowan, Richard Cowell, Louise Cowen, Steve Cowman, Amanda Cowton, Ellie Cox, Giles Cox, Karina Cox, Miriam Cox, Karen Coy, Andrea Cradduck-Bamford, Victoria Craig, Felicity 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Patrycja Czylok, Silvia D'Arcangelo, Joana da Rocha, Andrew Dagens, Helen Daggett, Jacqui Daglish, Sandeep Dahiya, Anne Dale, Katie Dale, Michaela Dale, Sam Dale, Jolyon Dales, Helen Dalgleish, Helen Dallow, Dermot Dalton, Zoe Daly, Eleanor Damm, Akila Danga, Amelia Daniel, Priya Daniel, Allison Daniels, Adela Dann, Sandra Danso-Bamfo, Alex Darbyshire, Janet Darbyshire, Paul Dargan, Paul Dark, Kate Darlington, Sarah Darnell, Tom Darton, Guledew Darylile, Manjusha Das, Sukamal Das, Martin Daschel, Joanne Dasgin, Dibyendu Datta, Anna Daunt, Vaishali Dave, Emily Davenport, Mark Davey, Miriam Davey, Molly Davey, Mini David, Alexander Davidson, Laura Davidson, Neil Davidson, Richard Davidson, Albert Davies, Amanda Davies, Amy Davies, Angela Davies, Carolyn Davies, Catrin Davies, Drew Davies, Elaine Davies, Ffyon Davies, Helen Davies, Jim Davies, Karen Davies, Kelly Davies, Kim Davies, Louisa Davies, Matthew Davies, Michelle Davies, Nina Davies, Owen Davies, Patrick Davies, Rachel Davies, Rhys Davies, Ruth Davies, Sarah Davies, Simon Davies, Alison Davis, Gwyneth Davis, Illinos Davis, Julie-Ann Davis, Katherine Davis, Peter Davis, Alexander Davison, Christine Dawe, H Dawe, Mark Dawkins, Danielle Dawson, Elizabeth Dawson, Joy Dawson, Susan Dawson, Tom Dawson, Andrew Daxter, Andrew Day, Jacob Day, Jeremy N Day, Jamie D'Costa, Parijat De, Duneesha de Fonseka, Toni de Freitas, Frederico De Santana Miranda, Eleanor de Sausmarez, Shanika de Silva, Thushan de Silva, Jessica De Sousa, Paulo De Sousa, James de Souza, Anthony De Soyza, Natasha de Vere, Johannes de Vos, Bethan Deacon, Sharon Dealing, Anna Dean, Julie Dean, Katrina Dean, Stephen Dean, Tessa Dean, Jill Deane, James Dear, Effie Dearden, Alison Deary, Catherine Deas, Samuel Debbie, Gabor Debreceni, Vashist Deelchand, Matthew Deeley, Joanne Deery, Emmanuel Defever, Manuela Del Forno, Arnold Dela Rosa, Amanda Dell, Carrie Demetriou, David DeMets, Jane Democratis, Jacqueline Denham, Emmanuelle Denis, Laura Denley, Craig Denmade, Kathy Dent, Martin Dent, Elise Denton, Tom Denwood, Nishigandh Deole, Darshita Depala, Maria Depante, Susan Dermody, Amisha Desai, Asmita Desai, Purav Desai, Sanjeev Deshpande, Vai Deshpande, Sirjana Devkota, Usha Devkota, Prakash Dey, Vishal Dey, Rogin Deylami, Kevin Dhaliwal, Sundip Dhani, Amandeep Dhanoa, Mili Dhar, Devesh Dhasmana, Ekanjali Dhillon, Reiss Dhillon, Meghnath Dhimal, Priya Dias, Stephanie Diaz, Kayleigh Diaz-Pratt, Debbie Dickerson, Pamela Dicks, Stuart Dickson, J Digby, Sean Dillane, Sarah Diment, Paul Dimitri, Thai Ha Dinh, Alex Dipper, Laura Dirmantaite, Lisa Ditchfield, Sarah Diver, Lavanya Diwakar, Caroline Dixon, Giles Dixon, Brice Djeugam, Petr Dlouhy, Andrea D'Mello, Paul Dmitri, Laurence Dobbie, Marinela Dobranszky Oroian, Charlotte Dobson, Lee Dobson, Marie Docherty, David Dockrell, James Dodd, Jackie Dodds, Rebecca Dodds, Steve Dodds, Richi Dogra, Erin Doherty, Warren Doherty, Yumiko Doi, Iain Doig, Eleanor Doke, Daniel Dolan, Mark Dolman, Rozzie 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Stephanie Dundas, Alessia Dunn, Charlotte Dunn, Damian Dunn, Laura Dunn, Paul Dunn, Charlene Dunne, Karen Dunne, Fiona Dunning, Aidan Dunphy, Venkat Duraiswamy, Beatriz Duran, Ingrid DuRand, Natalie Duric, Alison Durie, Emily Durie, Hannah Durrington, Haris Duvnjak, Akshay Dwarakanath, Laasya Dwarakanath, Ellen Dwyer, Claudia Dyball, Kristyn Dyer, Harvey Dymond, Tom Dymond, Chris Eades, Laura Eagles, Joanne Early, Melissa Earwaker, Nicholas Easom, Clare East, Amy Easthope, Fraser Easton, Ruth Eatough, Oluwadamilola Ebigbola, Daniel Ebner, Martin Ebon, Sinan Eccles, Chloe Eddings, Michael Eddleston, Maureen Edgar, Katharine Edgerley, Nicholas Edmond, Mary Edmondson, Tracy Edmunds, Alexandra Edwards, Catherine Edwards, Joy Edwards, Kennedy Edwards, Mandy Edwards, Jenny Eedle, Dawn Egginton, Loveth Ehiorobo, Sarah Eisen, Ugochukwu Ekeowa, Mohamed Ekoi, Ayomide Ekunola, Soha El Behery, Mohamed Elbeshy, Kate El-Bouzidi, Jennifer Elder, Mohammed El-Din, Diana Eleanor, Ibrahim Eletu, Eman Elfar, Mayy M Elgamal, Amr Elgohary, Stellios Elia, Jennifer Elias, Tania Elias, Nadia Elkaram, Andrew V Elkins, Julie Ellam, Nikki Ellard, Laura N Ellerton, Lucy Elliot, Amy Elliott, Fiona Elliott, Kerry Elliott, Scott Elliott, Annie Ellis, Christine Ellis, Kaytie Ellis, Tak-Yan Ellis, Yvette Ellis, Rahma Elmahdi, Einas Elmahi, Hannah-May Elmasry, Najla Elndari, Omer Elneima, Mohamed Elokl, Ahmed Elradi, Mohamed Elsaadany, Sally El-Sayeh, Hana El-Sbahi, Tarek Elsefi, Karim El-Shakankery, Hosni El-Taweel, Sarah Elyoussfi, Jonathan Emberey, Jonathan R Emberson, John Emberton, Julian Emmanuel, Ingrid Emmerson, Michael Emms, Florence Emond, Marieke Emonts, Nicu Enachi, Angila Engden, Katy English, Emma Entwistle, Hene Enyi, Marios Erotocritou, Peter Eskander, Hanif Esmail, Lise Estcourt, Brynach Evans, Chris Evans, Debra Evans, Gail Evans, Gareth Evans, Jennifer Evans, Jolanta Evans, Lisa Evans, Lynn Evans, Mim Evans, Morgan Evans, Ranoromanana Evans, Teriann Evans, Terry J Evans, Caroline Everden, Serenydd Everden, Hayley Evison, Lynsey Evison, David Eyre, Jacqueline Faccenda, Leila Fahel, Youstina Fahmay, Sara Fairbairn, Terry Fairbairn, Andy Fairclough, Louise Fairlie, Mark Fairweather, Anne Fajardo, Naomi Falcone, Euan Falconer, John Fallon, Andrea Fallow, David Faluyi, Victoria Fancois, Qayyum Farah, Nowin Z Fard, Leila Fares, Amr Farg, Adam Farmer, Katie Farmer, Toni Farmery, Samantha Farnworth, Faiyaz Farook, Hadia Farooq, Sidrah Farooq, Fiona Farquhar, Aaron Farrell, Barbara Farrell, James Farthing, Syeda Farzana, Rahmatu Fasina, Azam Fatemi, Mina Fatemi, Nibah Fatimah, Maria Faulkner, Saul N Faust, Joe Fawke, Sinmidele Fawohunre, Abul Fazal, Simon Fearby, Alex Feben, Federico Fedel, Daria Fedorova, Christopher Fegan, Mae Felongco, Lynsey Felton, Tim Felton, Kate Fenlon, Andrea Fenn, Isabelle Fenner, Ciara Fenton, Melisa Fenton, Cameron Ferguson, Jenny Ferguson, Kathryn Ferguson, Katie Ferguson, Susan Ferguson, Susie Ferguson, Victoria Ferguson, Denzil Fernandes, Candida Fernandez, Eduardo Fernandez, Maria Fernandez, Sonia Fernandez Lopez, Callum J Fernando, Ahmed Feroz, Pietro Ferranti, Thais Ferrari, Eleanor Ferrelly, Alexandra Ferrera, Emma Ferriman, Nicholas Fethers, Ben Field, Janet Field, Rebecca Field, Karen Fielder, Lindsey Fieldhouse, Andra Fielding, Julie Fielding, Sarah Fielding, Asma Fikree, Sarah A Filson, Sarah Finbow, Debbie Finch, Joanne Finch, Laurie Finch, Natalie Fineman, Lauren Finlayson, Adam Finn, Joanne Finn, Clare Finney, Sofia Fiouni, Jo Fiquet, James Fisher, Neil Fisher, Daniel Fishman, Krystofer Fishwick, Fiona Fitzgerald, Chloe Fitzpatrick-Creamer, Jan Flaherty, Michael Flanagan, Charles Flanders, Julie Fleming, Lucy Fleming, Paul Fleming, William Flesher, Alison Fletcher, Jonathan Fletcher, Lucy Fletcher, Simon Fletcher, Sophie Fletcher, Karen Flewitt, Christopher Flood, Ian Floodgate, Vincent Florence, Sharon Floyd, Rachel Flynn, Claire Foden, Adama Fofana, Georgina Fogarty, Claire Foley, Paul Foley, Linda Folkes, Daniela M Font, Aiwyne Foo, Jane Foo, Andrew Foot, Jayne Foot, Jane Forbes, Jamie Ford, Jennifer Foreman, Caroline Fornolles, Adam Forrest, Ellie Forsey, Miranda Forsey, Thomas Forshall, Elliot Forster, Julian Forton, Emily Foster, Joseph Foster, Rachel A Foster, Tracy Foster, Angela Foulds, Ian Foulds, Folakemi Fowe, Emily Fowler, Robert Fowler, Stephen Fowler, Claire Fox, Heather Fox, Jonathan Fox, Lauren Fox, Natalie Fox, Olivia Fox, Simon Fox, Sarah-Jane Foxton, Rebecca Frake, Alex Francioni, Olesya Francis, Rebecca Francis, Sarah Francis, Sasha Francis, Theodora Francis-Bacon, Helen Frankland, Jessica Franklin, Catherine Fraser, Sharon Frayling, Martyn Fredlund, Carol Freeman, Elaine Freeman, Hannah Freeman, Nicola Freeman, Clare Freer, Eleanor French, Matthew Frise, Renate Fromson, Adam Frosh, John Frost, Victoria Frost, Oliver Froud, Rachel Frowd, Arun Fryatt, Bridget Fuller, Liz Fuller, Tracy Fuller, Duncan Fullerton, Carrie Fung, Gayle Fung, Sarah Funnell, John Furness, Andrew Fyfe, Nytianandan G, Elizabeth Gabbitas, Claire Gabriel, Zoë Gabriel, Hadiza Gachi, Joshua Gahir, Sarveen Gajebasia, Katarzyna Gajewska-Knapik, Christopher Gale, Hugo Gale, Rebecca Gale, Swetha Gali, Bernadette Gallagher, Jude Gallagher, Rosie Gallagher, William Gallagher, Joanne Galliford, Catherine Galloway, Chris Galloway, Emma Galloway, Jacqui Galloway, James Galloway, Laura Gamble, Liz Gamble, Brian Gammon, Jaikumar Ganapathi, Ramesh Ganapathy, Kaminiben Gandhi, Sarah Gandhi, Usha Ganesh, Abrar Gani, Emma-James Garden, Antoni D Gardener, Emma Gardiner, Michael Gardiner, Phil Gardiner, Siobhan Gardiner, Caroline Gardiner-Hill, Jonathan Gardner, Mark Garfield, Atul Garg, Nathan Garlick, Justin Garner, Lucie Garner, Zoe Garner, Rosaline Garr, Florence Garty, Rachel Gascoyne, Hyeriju Gashau, Aoife Gatenby, Erin Gaughan, Alok Gaurav, Mariana Gavrila, Jane Gaylard, Emma Gaywood, Catherine Geddie, Ian Gedge, Sarah Gee, Minerva Gellamucho, Karzan Gelly, Leila Gelmon, Sandra Gelves-Zapata, Gemma Genato, Susan Gent, Natalie Geoghegan, Sam George, Tina George, Simon Georges, Domonique Georgiou, Peter Gerard, Leigh Gerdes, Louise Germain, Helen Gerrish, Abel Getachew, Louise Gethin, Hisham Ghanayem, Anca Gherman, Alison Ghosh, Justin Ghosh, Sudhamay Ghosh, Sarra Giannopoulou, Malick Gibani, Ben Gibbison, Kerry Gibbons, Alex Gibson, Bethan Gibson, Kimberley Gibson, Kirsty Gibson, Sian Gibson, Cat Gilbert, Jeanette Gilbert, Kayleigh Gilbert, Benjamin Giles, Mandy Gill, Lynne Gill, Paul Gillen, Annelies Gillesen, Katherine Gillespie, Elizabeth Gillham, Andrew Gillian, Deborah Gilliland, Robert Gillott, Danielle Gilmour, Kate Gilmour, Franciscus Ginting, Theodora Giokanini-Royal, Anna Gipson, Joanna Girling, Rhian Gisby, Angelena Gkioni, Aikaterini Gkoritsa, Effrossyni Gkrania-Klotsas, Amy Gladwell, James Glanville, Jessica Glasgow, Susannah Glasgow, Jon Glass, Lynn Glass, Sharon Glaysher, Lisa Gledhill, Ana Glennon, John Glover, Kyle Glover, Jan Glover Bengtsson, Deborah Glowski, Chevanthy Gnanalingam, Julie Goddard, Wendy Goddard, Emily Godden, Jo Godden, Emma Godson, Sukanya Gogoi, Aiky Goh, Rebeca Goiriz, Sriya Gokaraju, Raphael Goldacre, Arthur Goldsmith, Portia Goldsmith, Darren Gomersall, Lucia Gomez, Raquel Gomez-Marcos, Ali Gondal, Celia Gonzalez, Jack Goodall, Bob Goodenough, Laura Goodfellow, James Goodlife, Camelia Goodwin, Elizabeth Goodwin, Jayne Goodwin, Paula Goodyear, Rajiv Gooentilleke, Michelle Goonasekara, Sheila Gooseman, Shameer Gopal, Sally Gordon, Robin Gore, Hugh Gorick, Caitlin Gorman, Claire Gorman, Stuart Gormely, Diana Gorog, Michelle Gorst, Thomas Gorsuch, Jayshreebahen Gosai, Rebecca Gosling, Sally Gosling, Georgina Gosney, Vanessa Goss, Dzintars Gotham, Naomi Gott, Elizabeth Goudie, Susan Gould, Lysander Gourbault, Abha Govind, Sharon Gowans, Girish Gowda, Rohit Gowda, Hannah Gower, Pankaj Goyal, Sunil Goyal, Sushant Goyal, Clive Graham, Jonathan Graham, Justin Graham, Libby Graham, Sharon Graham, Matthew Graham-Brown, Julia Grahamslaw, Gianluca Grana, Tracyanne Grandison, Louis Grandjean, Alison Grant, Ann Grant, David Grant, Matthew Grant, Pauleen Grant, Rhys Gravell, Jenny Graves, Alasdair Gray, Catherine Gray, Georgina Gray, Jackie Gray, Karen Gray, Nicola Gray, Sebastian Gray, Alan Grayson, Fiona Greaves, Paul Greaves, Alastair Green, Charlotte Green, Christopher A Green, David Green, Frederick Green, Joel Green, Marie Green, Nicola Green, Stacey Green, Diarra Greene, Philippa Greenfield, Alan Greenhalgh, Daniel Greenwood, Sandra Greer, James Gregory, Jane Gregory, Katie Gregory, Tamsin Gregory, Jill Greig, Julia Greig, Rebecca Grenfell, Teena Grenier, Susan Grevatt, Glaxy Grey, Andrew Gribbin, Amy Gribble, Natasha Grieg, Douglas Grieve, Ben Griffin, Denise Griffin, Mel Griffin, Sian Griffith, Andrew Griffiths, Daniel Griffiths, David Griffiths, Donna Griffiths, Isabel Griffiths, Mark Griffiths, Nicola Griffiths, Oliver Griffiths, Sarah Griffiths, Yvonne Griffiths, Sofia Grigoriadou, Steph Grigsby, Evelina Grobovaite, Clarissa Grondin, Rachel Groome, Liliana Grosu, Jenny Grounds, Margaret Grout, Helen Grover, Helen Grover, Jayne Groves, Neil Grubb, Julie Grundy, Francesca Guarino, Sharada Gudur, Sharazeq Guettari, Shivang Gulati, Vikas Gulia, Pumali Gunasekera, Malin Gunawardena, Kirun Gunganah, Jessica Gunn, Emma Gunter, Alok Gupta, Atul Gupta, Rajeev Gupta, Richa Gupta, Rishi Gupta, Tarun Gupta, Vineet Gupta, Ankur Gupta-Wright, Victoria Guratsky, Alvyda Gureviciute, Sambasivarao Gurram, Anju Gurung, Bhawana Gurung, Shraddha Gurung, Hazel Guth, Pradip Gyanwali, Ruth Habibi, Berkin Hack, Pamela Hackney, Christian Hacon, Aiman Haddad, Denise Hadfield, Michalis Hadjiandreou, Nikolaos Hadjisavvas, Anna Haestier, Nauman Hafiz, Rana Hafiz-Ur-Rehman, Javed Hafsa, Samantha Hagan, Jack W Hague, Rosemary Hague, Kate Haigh, Christina Haines, Scott Hainey, Morton Hair, Brigid Hairsine, Juraj Hajnik, Anne Haldeos, Writaja Halder, Jennie Hale, Carmel Halevy, Paul 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Edward Harlock, Paula Harman, Tracy Harman, Mark Harmer, Muhammad A Haroon, Charlie Harper, Heather Harper, Peter Harper, Rosemary Harper, Sarah Harrhy, Sian Harrington, Yasmin Harrington-Davies, Jade Harris, Jess Harris, John Harris, Laura Harris, Marie-Clare Harris, Nichola Harris, Sophie Harris, David Harrison, Laura Harrison, Melanie Harrison, Rowan Harrison, Susie Harrison, Thomas Harrison, Wendy Harrison, Elizabeth Harrod, Ciaran Hart, Dominic Hart, Lisa Hartley, Rosemary Hartley, Ruth Hartley, Tom Hartley, William Hartrey, Phillipa Hartridge, Stuart Hartshorn, Heli Harvala, Alice Harvey, Angela Harvey, Max Harvey, Catherine Harwood, Helen Harwood, Brigitte Haselden, K Hashem, Mohammed Hashimm, Tadaaki Hashimoto, Imranullah Hashmi, Zena Haslam, Adil Hassan, Ali Hassan, Sapna Hassasing, Jane Hassell, Philip Hassell, Alex Hastings, Bethany Hastings, Janice Hastings, Stephanie Hatch, Jonathan Hatton, May Havinden-Williams, Stefan Havlik, Daniel B Hawcutt, Kadean Hawes, Liz Hawes, 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Val Irvine, Robert Irving, Mina Ishak, Erica Isherwood, Aminul Islam, Samsul Islam, Abdurrahman Islim, Ali Ismail, Omar Ismail, Caroline Ison, M'hamedi Israa, Sharon Isralls, Monica Ivan, Chineze Ivenso, Ashleigh Ivy, Sophie Iwanikiw, Karen Ixer, Menaka Iyer, Mia Iyer, Calum Jack, Amanda Jackson, Ben Jackson, Beth Jackson, Ella Jackson, Helen Jackson, Lauren Jackson, Melanie Jackson, Nicola Jackson, Shane Jackson, Patricia Jacob, Reni Jacob, Nicola Jacques, Anisa Jafar, Daniel Jafferji, Ali Jaffery, Chandrashekar Jagadish, Vijay Jagannathan, Mandeep Jagpal, Fernandez R Jaime, Neemisha Jain, Seema Jain, Susan Jain, Sanjay Jaiswal, Danyal Jajbhay, Thomas Jaki, Bintou Jallow, Yusuf Jaly, Sabine Jamal, Zeba Jamal, Yasmin Jameel, Albie James, Christie James, Kate James, Lee James, Linda James, Mark James, Nicholas James, Olivia James, Rebecca James, Ruth James, Tracy James, Jack Jameson, Aaron Jamison, Phoebe Jane, Azara Janmohamed, Deepa Japp, Victor Jardim, Catherine Jardine, Emma 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Mark Johnson, Nelsonseelan Johnson, Oliver Johnson, Claire Johnston, Janet Johnston, Susan Johnston, Victoria Johnston, Dawn Johnstone, Ed Johnstone, Janet Johnstone, Manohar Joishy, Adam Jones, Alistair Jones, Annabel Jones, Ben Jones, Bryony Jones, Carys Jones, Ceri Jones, Charlotte Jones, Christine E Jones, Debra Jones, Emily Jones, Gareth Jones, Geraldine Jones, Jac Jones, James Jones, Jonathon Jones, Julie Jones, Kate E Jones, Laura Jones, Laura M Jones, Louise Jones, Mathew Jones, Nicola Jones, Paul Jones, Rhianna Jones, Ruth E Jones, Samantha Jones, Sophie Jones, Stefanie Jones, Steve Jones, Taya Jones, Tim Jones, Tracey Jones, Ramya Jonnalagadda, Rebecca Jordache, Sanal Jose, Anna Joseph, P Aiden Joseph, Rosane Joseph, Sibet Joseph, Dhaara Joshi, Mehul Joshi, Pratichi Joshi, Benz Josiah, Tiffany Joyce, Adriel Ju Wen Kwek, Edward Jude, Parminder Judge, Jessica Juhl, Sirisha Jujjavarapu, Mark Juniper, Edmund Juszczak, Deepthi Jyothish, Kasamu Kabiru Dawa, Mark Kacar, Nikhil 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Laura Korcierz, James Korolewicz, George Koshy, Chris Kosmidis, Jalpa Kotecha, Easwari Kothandaraman, Leonidas Koukouflis, Koushan Kouranloo, Rukhsana Kousar, Margarita Kousteni, Maja Kovac, Alex Kozak Eskenazia, Kestutis Krasauskas, Raghu Krishnamurthy, Vinodh Krishnamurthy, Manju Krishnan, Hari Krishnan, Suzanne Krizak, Sean Krupej, Agnieszka Kubisz-Pudelko, Soren Kudsk-Iversen, Aurimas Kudzinskas, Chirag Kukadiya, Nainesha Kulkarni, Aditi Kumar, Mayur Kumar, Ramesh Kumar, Ravi Kumar, Rita Kumar, Rupa Kumar, Satish Kumar, Vimal Kumar, Arun Kundu, Heinke Kunst, Amit Kurani, Mohammed Kurdy, Rincy Kurian, Vimal Kurmars, Cameron Kuronen-Stewart, Ranganai S Kusangaya, Vlad Kushakovsky, Apexa Kuverji, Amma Kyei-Mensah, Thyra Kyere-Diabour, Moe Kyi, Nyan May Kyi, Laura Kyle, Karali-Tsilimpari Kyriaki, Julius Labao, Louise Lacey, Nikki Lack, Emma Ladlow, Heather Lafferty, Shondipon Laha, Sushil Lahane, Clement Lai, James Lai, Robert Laing, Inez Laing-Faiers, Emily Laity, Nicki Lakeman, David 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McSorland, Gini McTaggart, Jacqueline McTaggart, Joanna Mead, Emma Meadows, Olivia Meakin, Ben Mearns, Claire Mearns, Kim Mears, William Mears, Manjula Meda, Ayren Mediana, Ross Medine, Thomas Medveczky, Sharon Meehan, Emily Meeks, Abbi Megan, Nevan Meghani, Salim Meghjee, Amina Mehar, Rohan Mehra, James Meiring, Rayane Mejri, Sabina Melander, Adriana-Stefania Melinte, Francesca Mellor, Samantha Mellor, Zoe Mellor, Katrina Mellows, Vladimir Melnic, Alice Melville, Julie Melville, Helen Membrey, Mark Mencias, Cheryl Mendonca, Alexander Mentzer, Dan Menzies, Sue Mepham, Oliver Mercer, Pauline Mercer, Arwa Merchant, Fatema Merchant, Mihaela Mercioniu, Megan Meredith, Marta Merida Morillas, Blair Merrick, Jack Merritt, Simon Merritt, Ekta Merwaha, Simon Message, Gabriel Metcalf-Cuenca, Benjamin Metcalfe, Kneale Metcalfe, Stella Metherell, Alexsandra Metryka, Louise Mew, Simon Meyrick, Nhlanhla Mguni, Atiqa Miah, Jagrul Miah, Nahima Miah, Gabriela Mic, Dariush Micallef, Alice Michael, Angiy 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Abdelrahman Mohamed, Arez Mohamed, Osab Mohamed, Waheed Mohammad, Aliabdulla Mohammed, Omer Mohammed, Yaser N S Mohammed, Bilal A Mohamud, Amr Moharram, Hoi-Ping Mok, Jonathan Mok, Christine Moller-Christensen, Mateus Mollet, Malid Molloholli, Aoife Molloy, Linda Molloy, Andrew Molyneux, Tasnim Momoniat, Holly Monaghan, Krista Monaghan, Shiva Mongolu, Tesha Monika, Katelyn Monsell, Mahmoud Montasser, Alan Montgomery, Hugh Montgomery, Prebashan Moodley, Margaret Moody, Nick Moody, Angela Moon, James Moon, Ji-Hye Moon, Maria Moon, May Moonan, Parvez Moondi, Alex Moore, Christopher Moore, David A J Moore, Faye Moore, Judith Moore, Laura Moore, Sally Moore, Sonia Moore, Rachel Moores, Ed Morab, Jose Morales, Nuria Moramorell, Louise Moran, Grishma Moray, Jeronimo Moreno-Cuesta, Amy Morgan, Caitlin Morgan, Christine Morgan, Colin Morgan, Lauren Morgan, Leila Morgan, Matthew Morgan, Patrick Morgan, Katie Morgan-Jones, Emily Morgan-Smith, Anna Morley, Thomas Morley, Wendy Morley, Anna Morris, 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McDonald Mupudzi, Arshid Murad, Oluwatosin H Muraina, Koteshwara Muralidhara, Mhairi Murdoch, Jennifer Murira, Alison Murphy, Carl Murphy, Gail Murphy, Peter Murphy, Sheenagh Murphy, Simon Murphy, Clare Murray, David Murray, Eleanor Murray, Katie Murray, Kenneth Murray, Lisa Murray, Lorna Murray, Tracey Murray, Eoin Murtagh, Mithun Murthy, Catherine Murton, Rosie Murton, Neeka Muru, Rosemary Musanhu, Maimuna Mushabe, Omaisa Mushtaq, Ahmed M M Mustafa, Elhaytham Mustafa, Mustafa Mustafa, Ibrahim Mustapha, Zhain Mustufvi, Callum Mutch, Eric Mutema, Balakumar Muthukrishnan, Sheree Mutton, Natasha Muzengi, Memory Mwadeyi, Bettina Mwale, Esther Mwaura, Raji Myagerimath, Alice Myers, Sam Myers, Khin Swe Myint, Yadee Myint, Libor Myslivecek, Evelyn Nadar, Iftikhar Nadeem, Moosa Nadheem, Asma Naeem, Hassan Naeem, Salman Naeem, Samraiz Nafees, Mohamed Nafei, Thapas Nagarajan, Imrun Nagra, Deepak Nagra, Mina Naguib, Kirushthiga Naguleswaran, K Shonit Nagumantry, Kevin Naicker, Sarveshni Naidoo, Gireesha Naik, Rishi Naik, Samir Naik, Devu S Nair, Rajiv Nair, Tanushree Nair, Jay Naisbitt, Kerry Naismith, Sri Nallapareddy, Soum Nallapeta, Arumugan Nallasivan, Uttam Nanda, Aarti Nandani, Ali Raza Naqvi, Asadullah Naqvi, Sara Naqvi, Sophia Nasa, Dominic Nash, Nader Nasheed, Abdul Nasimudeen, Umer Nasir, Tahir Nasser, Anuja Natarajan, Geetha Natarajan, Nalin Natarajan, Nikhila Natarajan, Rajkumar Natarajan, Noel Nathaniel, Mala Nathvani, Priyan Nathwani, George Nava, Neena Navaneetham, Jeya Navaratnam, Helen Navarra, Sadaf Naveed, John Navin, Khuteja Nawaz, Sarfaraz Nawaz, Shasta Nawaz, Bonilla Nayar, Suzanne Naylor, Moez Nayyar, Farrah Naz, Mobeena Naz, Babak Nazari, S Nazir, Sehar Nazir, Dumisani Ncomanzi, Onyine Ndefo, Alan Neal, Elaine Neary, Mostafa Negmeldin, Paula Neill, Hector E Neils, Avideah Nejad, Louise Nel, Marie Nelson, Richard Nelson, Scott Nelson, Erni Nelwan, Rajesh Nemane, Samiksha Nepal, Daniel Nethercott, Kimberley Netherton, Kimberley Nettleton, Alison Newby, Angela Newby, David Newby, Tracy Newcombe, Diana Newman, Julie Newman, Oscar Newman, Tabitha Newman, Thomas Newman, Rachel Newport, Maria Newton, Anthony Y K C Ng, Ka Wing Ng, Maxine Ng, Sarah Ng, Wee Jin Ng, Thomas Ngan, Gabriel CE Ngui, Alice Ngumo, Caoimhe Nic Fhogartaigh, Nathalie Nicholas, Philip Nicholas, Donna Nicholls, Lisa Nicholls, Alice Nicholson, Anne Nicholson, Annette Nicholson, Ian Nickson, Eileen Nicol, Elizabeth Nicol, Rebecca Nicol, Pantelis Nicola, Antony Nicoll, Pantzaris Nikolaos, Georgii Nikonovich, Annette Nilsson, Kofi Nimako, Louise Nimako, Camus Nimmo, Preethy Ninan, Mahesh Nirmalan, Muhammad Nisar, Toby Nisbett, Aksinya Nisha James, Sabaahat Nishat, Tomoko Nishiyama, Sara Nix, Jennifer Nixon, Maxine Nixon, Khwaja Nizam Ud Din, Maria Nizami, Lyrics Noba, Harriet Noble, Hsu M Noe, Jerry Nolan, Zahid Noor, Zaid Noori, Louis Norman, Rachel Norman, Karen Norris, Lillian Norris, Sally Ann Nortcliffe, Fiona North, Julie North, Thomas North, John Northfield, Samantha 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Gabiel Wallis, Gabriel Wallis, Louise Wallis, Donna Walsh, Elizabeth Walsh, Livia Walsh, Deborah Walstow, Daniel Walter, Alex Walters, Holt Walters, James Walters, Jocelyn Walters, Eileen Walton, Lucy Walton, Olivia Walton, Sharon Walton, Susan Walton, Mandy Wan, Thin Wan, Junita Wanda, Mary Wands, Rachel Wane, Frank Wang, Nick Wang, Ran Wang, Deborah Warbrick, Samantha Warburton, Deborah Ward, Emma Ward, Joanna Ward, Luke Ward, Nicola Ward, Rachael Ward, Thomas Ward, Tom Ward, Scott A Warden, Steve Wardle, Hassan Wardy, Scott Waring, Jenny Warmington, Ben Warner, Christian Warner, Lewis Warnock, Sarah Warran, Jade Warren, Lisa Warren, Yolanda Warren, Hannah Warren-Miell, Adilia Warris, Gill Warwick, Hazel J Watchorn, Holly Waterfall, Abby Waters, Donald Waters, Mark Waterstone, Catherine Watkins, Catrin Watkins, Eleanor Watkins, Karen Watkins, Lynn Watkins, Abigail Watson, Adam J R Watson, Ekaterina Watson, Eleanor Watson, J G R Watson, Paul Watson, Rebecca Watson, Robert Watson, Malcolm Watters, Donna Watterson, Daniel Watts, John Watts, Merlin Watts, Victoria Waugh, Emma Wayman, Akhlaq Wazir, Mark Weatherhead, Nick Weatherly, Hayley Webb, Kathryn Webb, Kylie Webb, Stephen Webb, Cheryl Websdale, Deborah Webster, Ian Webster, Tim Webster, Ling Wee, Rebecca Weerakoon, Thanuja Weerasinghe, Janaka Weeratunga, Maria Weetman, Shuying Wei, Immo Weichert, David M Weinreich, Hugh Welch, James Welch, Leanne Welch, Steven Welch, A Welford, Samantha Weller, Lucy Wellings, Brian Wells, Susan Wellstead, Berni Welsh, Richard Welsh, Ingeborg Welters, Rachael Welton, Lauren Wentworth, Kate Wesseldine, Magdelena West, Raha West, Ruth West, Sophie West, Luke Western, Ruth Westhead, Heather Weston, Alice Westwood, Bill Wetherill, Sharon Wheaver, Helen Wheeler, Ben Whelan, Matthew Whelband, Amanda Whileman, Alison Whitcher, Andrew White, Benjamin White, Christopher White, Duncan White, Hannah White, James White, Jonathan White, Katie White, Marie White, Nick White, Sarah White, 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Steven Wishart, Eric Witele, Nicholas Withers, Janet Wittes, Donna Wixted, Therese Wodehouse, Will Wolf, Nicola Wolff, Kirsten Wolffsohn, Rebecca Wolf-Roberts, Magda Wolna, Elena Wolodimeroff, Adam Wolstencroft, Alan Wong, Charlotte Wong, Chi-Hung Wong, Chi-Man Wong, Edwin Wong, Jessica Sue Yi Wong, Kit Y Wong, Mei Yin Wong, Nick Wong, Sam Wong, Amanda Wood, Caroline Wood, Dianne Wood, Fiona Wood, Hannah Wood, Jennifer Wood, Joe Wood, Lisa Wood, Louise Wood, Stephen Wood, Tracy Wood, Katharine Woodall, Rebecca Woodfield, Christopher Woodford, Elizabeth Woodford, Jill Woodford, Louise Woodhead, Timothy Woodhead, Philip Woodland, Marc Woodman, Jane Woods, Katherine Woods, Sarah Woods, Zoe Woodward, Megan Woolcock, Gemma Wooldridge, Rebecca Woolf, Chris Woollard, Christopher Woollard, Louisa Woollen, Emma Woolley, Jade Woolley, Daniel Woosey, Dan Wootton, Joanne Wootton, Daniel Worley, Stephy Worton, Jonathan Wraight, Maria Wray, Kim Wren, Lynn Wren, Caroline Wrey Brown, Catherine Wright, Demi Wright, Francesca Wright, Imogen Wright, Lianne Wright, Rachel Wright, Stephanie Wright, Tim Wright, Caroline Wroe, Hannah Wroe, Henry Wu, Peishan Wu, Pensee Wu, Jonathan Wubetu, Fitria Wulandari, Retno Wulandari, Craig Wyatt, Frederick Wyn-Griffiths, Inez Wynter, Bindhu Xavier, Arnold Xhikola, Zhongyang Xia, Huiyuan Xiao, Masseh Yakubi, May Yan, Freda Yang, Yingjia Yang, Michael Yanney, Woei Lin Yap, Nabil Yaqoob, Salima Yasmin, Bryan Yates, David Yates, Edward Yates, Helen Yates, Thomas Yates, Mark Yates, Charlotte Yearwood Martin, Khin Yein, Fiona Yelnoorkar, Peter Yew, Laura Ylquimiche, Laura Ylquimiche Melly, Inez Ynter, H Yong, Jemma Yorke, Jasmine Youens, Abdel Younes Ibrahim, Eoin Young, Gail Young, Louise Young, Asfand Yousafzar, Sajeda Youssouf, Ahmed Yousuf, Chrissie Yu, Bernard Yung, Daniel Yusef, Said Yusef, Intekhab Yusuf, Anna-Sophia Zafar, Silvia Zagalo, Su Zaher, Aqsa Zahoor, Kareem Zaki, Nabhan Zakir, Kasia Zalewska, Ane Zamalloa, Mohsin Zaman, Shakir Zaman, Julie Zamikula, Louise Zammit, Marie Zammit-Mangion, Esther Zebracki, Daniel Zehnder, Lisa Zeidan, Xiaobei Zhao, Dongling Zheng, Doreen Zhu, Madiha Zia, Omar Zibdeh, Rabia Zill-E-Huma, Ei Thankt Zin, Eleanor Zinkin, Vivian Zinyemba, Christos Zipitis, Arkadiusz Zmierczak, Azam Zubir, Naz Zuhra, Rasha Zulaikha, Sabrina Zulfikar, Carol Zullo, Ana Zuriaga-Alvaro, and Sheba Zyengi
Supplementary Material
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The protocol, consent form, statistical analysis plan, definition and derivation of clinical characteristics and outcomes, training materials, regulatory documents, and other relevant study materials are available online. As described in the protocol, the trial steering committee will facilitate the use of the study data and approval will not be unreasonably withheld. Deidentified participant data will be made available to researchers registered with an appropriate institution within 3 months of publication. However, the steering committee will need to be satisfied that any proposed publication is of high quality, honours the commitments made to the study participants in the consent documentation and ethical approvals, and is compliant with relevant legal and regulatory requirements (eg, relating to data protection and privacy). The steering committee will have the right to review and comment on any draft manuscripts before publication. Data will be made available in line with the policy and procedures described at: https://www.ndph.ox.ac.uk/data-access. Individuals wishing to request access should complete the form at https://www.ndph.ox.ac.uk/files/about/data_access_enquiry_form_13_6_2019.docx and e-mail to: data.access@ndph.ox.ac.uk.