Dr. Edsel Maurice T. Salvana
Emergency rooms are full, and clusters of COVID-19 are sprouting in workplaces and homes with alarming frequency. It is a year later and the whole world is still seeing surges in COVID-19 cases. The more transmissible variants may contribute to the surges, but the existence of variants is just one among several reasons for the increase in cases.
The proportion of variants of concern in our country remains relatively low. Other reasons for the surge are more mundane but no less important. Pandemic fatigue leads to carelessness with minimum health standards. Increased mobility from opening the economy also increased opportunities for the virus to transfer. The WHO has also stated that misplaced overconfidence as vaccines arrived may have contributed to relaxation of prevention measures.
The most important objective remains prevention of deaths from COVID-19. Minimizing new infections is important but ultimately it is saving lives that will matter most. Decreasing the number of deaths requires keeping the healthcare system open to accommodate severe COVID-19 cases. Treatment of COVID-19 has improved dramatically, but the mechanism to treat must be available. There must be available hospital beds, a steady supply of life-saving medications, and enough healthcare workers to take care of sick patients.
With so much misinformation on COVID-19 prevention and treatment, it is worthwhile to review what works and what doesn’t work.
What works:
Vaccination
The Israel experience has shown that vaccination will bring down cases and deaths very fast. Israel has more overall COVID-19 cases than the Philippines, but only half the deaths. They continued vaccinating despite an increase in cases that heralded a second wave. There is no reason to delay vaccination even during a surge, especially for the most vulnerable. The more people get vaccinated at the soonest time, the more people will survive.
There is no proven link between vaccination and the emergence of variants. The variants began emerging before widespread vaccination. Emergence of variants is a natural phenomenon with viruses. Other factors are more likely to encourage emergence of variants. For example, surreptitious use of unapproved treatments with partial activity against the virus may hasten the emergence of mutations. This is well-described in the HIV field. Haphazard use of antiretroviral medications typically results in signature drug-resistance mutations. Partially or minimally active medications, just like using antibiotics haphazardly, can lead to unforeseen consequences which may include more transmissible and deadly variants.
Remdesivir, dexamethasone, and tocilizumab
These three drugs have good phase 3 randomized placebo-controlled trial (RCT) data that they work to either decrease deaths or hasten recovery. Dexamethasone decreases deaths by up to one-third in critically ill patients, while tocilizumab further decreases deaths in patients already on dexamethasone.
Remdesivir doesn’t seem to affect deaths significantly, but it decreases recovery time by five days (from 15 days to 10 days) in patients with moderate to severe COVID-19 disease. This significantly decreases hospitalization costs and decongests hospitals.
Most of these drugs are only useful for moderate to severe COVID-19 disease. Asymptomatic and mild COVID-19 are generally self-limited and do not need medicines. Dexamethasone in particular is a steroid and can increase the risk for infection if used inappropriately. Drugs should only be used when prescribed by a physician.
Face mask, face shield, physical distancing
Face masks are 60 to 85 percent effective in decreasing the risk for COVID-19. Eye protection in the form of a face shield is 60 to 78 percent effective at decreasing infection rates. When combined with proper physical distancing, these three interventions decrease the risk of acquiring COVID-19 by over 90 percent.
Face shields work not just for eye protection but also sharply decrease the risk of acquiring COVID-19 when combined with masks. A study among community healthcare workers going house to house to look for COVID-19 patients showed that infection rates dropped to zero after they started using face shields with masks.
Avoiding crowds of more than 10 people, staying at home
At the height of the Wuhan COVID-19 outbreak in China, the only intervention that drastically cut transmission was staying home. There are now less drastic interventions that work and are more targeted. When infections are high, however, nothing works better than sheltering in place for two weeks. This finding is the rationale for the current heightened restrictions.
What does not work/is not yet proven:
Hydroxychlorquine/chloroquine
No other medications have been so polarized as hydroxychloroquine and chloroquine. Initially touted as the first drugs with potential activity against SARS-CoV-2, RCT after RCT quickly showed they were not very useful and could potentially harm patients. Even the people who are now pushing ivermectin have already abandoned hydroxychloroquine despite swearing by it in the past. There was a group of doctors who were so enamored with hydroxychloroquine that they removed their masks during an event in a foolhardy demonstration of their faith in this discredited drug. As a final warning, there is some evidence that hydroxychloroquine can attenuate the immune response and decrease the efficacy of vaccines.
Ivermectin
This is the medicine du jour occupying headlines. The scientific evidence on its efficacy is mixed, but just like hydroxychloroquine the early data looked promising. Better quality studies, however, are showing very little effect. The majority of properly peer-reviewed publications does not support its use for treatment or prophylaxis.
Brazil has one of the highest ivermectin usage rates. Brazil is yet on another surge with over 2,000 deaths per day. They have more deaths in one week than the Philippines has had in its entire pandemic. Ivermectin did not appear to have much of an effect on COVID-19 deaths or cases in Brazil.
There are over 70 ongoing trials using ivermectin, so it is best to wait for the trial results. Haphazard use may also drive the emergence of mutations, assuming the proper human formulations are being used. Unapproved and unproven drugs should be avoided. Ivermectin trials are still ongoing and the best evidence at this time is that it does not work. If it did work, infectious disease specialists the world over would be using it, The preponderance of evidence for ivermectin for now shows, however, that it is not useful for either the prevention or treatment of COVID-19.
The original drug manufacturer Merck does not recommend the use of ivermectin for COVID-19 or any viral infection. This should give people pause when even the company that is in a position to profit the most from it does not recommend its use.
Other unregistered COVID-19 medications
There are many other unproven remedies being offered in the marketplace against COVID-19, some of which are potentially more harmful than others. These are uncertain times and people will cling to whatever seems to offer some efficacy. Some of the more dangerous treatments are those that can affect the immune system and paradoxically increase the risk of severe COVID-19 or some other infection.
It is unfortunate that some healthcare workers who should know better are promoting unsafe and harmful advice against COVID-19. They may mean well, but the harm these unproven treatments can cause is real.
Delaying vaccination for the most vulnerable groups is going to cause a lot of harm as well. Getting people vaccinated as soon as possible with properly approved vaccines will save lives. There are well-studied, safe and effective medicines used among the sickest COVID-19 patients. There is no reason to experiment with unproven remedies that can harm or give a false sense of security. Pseudoscience and fake news may prove to be as deadly as the SARS-CoV-2 and listening to properly vetted scientific sources is the best medicine against these dangerous scams.