111 CMAAO CORONA FACTS and
MYTH BUSTER: Treatment Protocols
Dr K K Aggarwal
President CMAAO
935: Minutes of
Virtual Meeting of CMAAO NMAs
Treatment protocols
in different countries and their experience with remdesivir
30th
May, 2020, Saturday
9.30am-10.30am
Participants
Member
NMAs
Dr
KK Aggarwal, President CMAAO
Dr
Yeh Woei Chong, Singapore Chair CMAAO
Dr
Ravi Naidu, Past President CMAAO, Malaysia
Dr
N Gnanabaskaran, President Malaysian Medical Association
Dr
Thirunavukarasu Rajoo, Hon. General Secretary, Malaysian Medical Association
Dr
Ashok Philip, Malaysia
Dr
Alvin Yee-Shing Chan, Hong Kong
Dr
Marie Uzawa Urabe, Japan
Dr
Md Jamaluddin Chowdhary, Bangladesh
Invitees
Dr
Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr
Sanchita Sharma, Editor IJCP Group
- There is a
discrepancy in the number of deaths. To get the actual number of deaths,
multiply the number of deaths with 2. This will cover the false negatives,
sudden deaths etc.
- China conducted
6.5 million tests for coronavirus, where 6 new cases were detected two
weeks ago; 200 cases were found, mostly people who showed no symptoms. The
ratio of undocumented cases for each documented case in Wuhan is 1:33 i.e.
there were 33 asymptomatic cases for every one new infection. This is a
reliable study as the total population was studied and not a sample
population.
- This ratio in
New York City is 1:10 i.e., there were 10 asymptomatic patients, for every
positive patient. New York conducted an antibody testing study, while
Wuhan did antigen test. The reliability of antibody test is unknown.
- Treatment
for mild/pre-symptomatic/pauci-symptomatic /asymptomatic cases (Pauci-symptomatic patients have
transient symptoms e.g. mild fever or sore throat for 1-2 days): Paracetamol
(for fever and myalgia), hydroxychloroquine (HCQ), azithromycin (this may
have cardiac toxicity, so alternative is doxycycline), famotidine,
ivermectin, ritonavir+lopinavir, nafamostat (anticoagulant), remdesivir
- India is trying
to make a biosimilar of remdesivir to reduce the cost; it should be
recommended to the respective governments that Asian countries should be
allowed to make biosmilars in this time of a pandemic.
Malaysia protocol
- Management of
Covid-19 is entirely in government hospitals by order of the government;
no private hospital treats Covid patients.
- Treatment:
Symptomatic treatment, combination of doxycycline and azithromycin,
anti-HIV drug combination.
- The govt. had
earlier stated that they would be participating in remdesivir trial, but
there are no results of the trial
- The cost of
remdesivir is likely to be high in Malaysia.
Singapore protocol
- Remdesivir has been
used by NCID only in clinical trial with NIH, not otherwise.
- Kaletra
(lopinavir+ritonavir) and beta-interferon have been used. Following a
feedback from NICD about their relative lack of usefulness, Kaletra and
beta-interferon are not used now for treatment of patients.
- Basic supportive
care is still paramount.
- HCQ has not been
used at all, not even in clinical trials.
- A study has
found that on Day 11, there is minimal viral load, it is non infectious.
Singapore has moved to time-based discharge i.e., after Day 14, patient is
deemed to be free of Covid and can go to work after Day 21.
Hong Kong protocol
- Combination of
ritonavir+lopinavir has been mainly used.
- Supportive is
still the mainstay of treatment, for mild cases. All new cases are in
people who have returned from overseas, they are mild or asymptomatic. No
local cases for few weeks.
- Management of
comorbid conditions such as diabetes is very important.
- Not tried
remdesivir or HCQ
Bangladesh protocol
- Bangladesh has
been using HCQ and azithromycin; but has recently temporarily stopped use
of HCQ after a directive from technical committee in line with the WHO
guidelines on this and an analysis published in The Lancet.
- Plasma therapy
is being used.
- Production of
remdesivir has started but not come to the market yet.
Patient-specific
treatment
Covid-19
has the following presentations. We should be able to differentiate patients
according to their manifestations. All patients do not show all manifestations.
Hypothesis:
If we choose the right patient for the drug, the results would be very
different.
- It is a viral
disorder and is self-limiting in 90% patients. Earlier you give antivirals
(within 48 hours), better it is. In India, Tamiflu (oseltamivir) is
given on Day 1 before test results are available.
- The virus
behaves like HIV in some patients; if lymphopenia or reduced CD4 cell
count, give anti-HIV drugs
- It produces
hyperimmune inflammation, so if there are signs of hyperinflammation such
as high ESR, CRP and ferritin, anti-inflammatory drugs such as HCQ,
indomethacin become important.
- It behaves like
bacteria, so azithromycin can be given; azithromycin may cause
cardiotoxicity, so doxycycline may be given, which also covers atypical
bacteria.
- It produces
thrombo-inflammation; fibrinogen and d-dimer levels are raised; such
patients have moderate/ severe illness. Give anticoagulant – heparin,
nafamostat
- It produces
silent hypoxia; oxygen supplementation with high flow nasal cannula, BiPAP
(if required) and ventilator (last resort).
- Cytokine storm
and ARDS: this is terminal illness and managed as per protocol for ARDS.
Hyperimmune
inflammation is mainly seen in Europe and the US and not much seen in Asian
countries including India. Most CMAAO countries have not reported Kawasaki-like
cases. There may be few scattered cases.
Use
Remdesivir early as studies with Tamiflu have shown that if used very early,
the difference in morbidity is significant. Start antivirals when symptoms are
primarily due to the viral infection. Don’t wait for symptoms due to body’s
immune response.
The
minimum space requirement for working in office, according to WHO, is 100 sq ft
per person. In India, the standard is 75 sq ft per person for living. In
countries with high population density, social distancing may not be possible.
So masks should be compulsorily used at all places, at least for the next 3
months.
Take
same precautions at home as followed outside the home.
Recommendations for
re-opening of schools
- Individual
countries can form their rules about use of masks by children as they do
not sit facing each other.
- No
cafeteria/canteens in schools
- No mixing of
classes
- Not more than
20-25 students in one class
- Break between
classes will be divided
- India recommends
starting from 9th class onwards, while Europe recommends
starting primary school first
- E-classes in
high risk areas and for disabled
- Only soap and
water to wash hands; use of sanitizer must be done only under supervision
- Teachers and
staff to wear masks
- Every school
should have a written policy on how to handle the first positive case in
their school to avoid any kneejerk reaction and/or media circus
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