Mumbai: The latest treatment protocol for COVID-19 issued by the Indian Council of Medical Research (ICMR) on April 22 includes many guidelines that were part of its protocol announced way back in March 2020. This raises some concerns--many doctors in India continue to prescribe medicines such as hydroxychloroquine, favipiravir and ivermectin in the early stages of the disease, which are not effective. The same is the case with plasma therapy, which does not have much scientific support globally.
Should we in India look at global inputs or suggestions at a time of crisis, or are our medical and clinical conditions fundamentally different and therefore, we should rely on our own clinical experience and knowledge? Most importantly, how do we avoid the panic situation that forces us to line up for medicines not supported by evidence elsewhere?
To discuss this, I am joined by two well-known doctors; Gunjan Chanchalani is a consulting intensivist at the Cumballa Hill Hospital and St Elizabeth Hospital in Mumbai; and Sumit Ray is head of the department of critical care at the Holy Family Hospital in New Delhi.
Dr Chanchalani, given that we are in the middle of a second wave, also with a far more infectious and deadly mutation, how do you view the new protocol?
GC: So, we are definitely in a second wave and the main problem that India has is the lack of resources. As you have already said, most of the medicines that we are prescribing are probably not indicated for COVID, which is a viral disease that the body itself learns to take care of. What we need to do is just give enough antipyretics to control the fever. It is only in the second week when there is a more inflammatory response or an immune response, [only then] do we need to intervene and give medications like maybe steroids and remdesivir… when people have a drop in [oxygen] saturation. Otherwise, there is no need to really go for any over-the-counter drugs or medicines that are ineffective against COVID.
Dr Ray, how are you seeing the initial responses?
SR: So, as Gunjan said, we don't need to give any antivirals. No antivirals in the early phase like Fabiflu etc. have been shown to work. There is no evidence to support it. We need antipyretics that reduce fever. But having said that, if high-grade fever persists and there is a more inflammatory response, we need to intervene.
As far as remdesivir goes, there's evidence to suggest it only reduces the length of stay in hospital. It is not a life-saving drug. It is important to tell everyone that and [explain] in which sub-group it has shown a reduction in the length of [hospital] stay. This subgroup is only of those who are on minimal amounts of oxygen. Those who are not on oxygen do not benefit [from] reduction in the length of stay in hospital. Those on high oxygen support or on ventilators--[for them] this is not a life-saving drug. So, do not run around trying to find it and waste your energy, time and money if your loved one is critically ill.
Remdesivir is [for] only those who require very low amounts of oxygen--2 to 4 litres maximum. There was an interesting article that said 'Remdesivir--a drug in search of a disease', because it failed against ebola, it failed against MERS, it failed against SARS. But unfortunately, even we are sometimes pushed to prescribe it because the pressure is so high. And if the patient is not doing well, the pressure is even more in spite of explaining to families, so we end up having to do it. Some families accept [medical advice] and some families say, give it my loved one [who] is very sick, please give it. And medicine, unfortunately, doesn't work like that but we are almost forced to do it.
If I were to go back to the Indiacovidsos.org, Dr Chanchalani, the treatments they say that are not routinely advised are ivermectin, hydroxychloroquine, convalescent plasma, vitamins C and D, itolizumab, lopinavir, ritonavir and favipiravir and so on. Whereas the ICMR, for instance, says for mild disease it recommends ivermectin 200 mcg once a day for three days, it also recommends hydroxychloroquine. Why this difference in approach? And are we fundamentally different?
GC: No, we are not fundamentally different. It is a misunderstanding, and as Dr Sumit Ray said, we are unfortunately doing all these things because we are under pressure to treat, under the pressure of lack of resources and poor healthcare in our country. So that is the reason we are using multiple drugs. Even today, when I get a consultation and when I do not really prescribe any antibiotic, I am actually questioned: "What was the consultation for?" But actually, what works in COVID is to decrease the inflammation in the first week, to keep the fever under control very tightly, keep the patient well-hydrated and only if he has an immune response in the second week do we need certain medicines--of them, the most important today is probably steroids and nothing else, and that too in the right dose, no overdose. So, ivermectin, doxycycline, HCQ, all these drugs have shown no benefit for COVID in any of the research.
Dr Ray, where does the problem then start? So patients put pressure on you because they either see something on WhatsApp groups or someone tells them. Doctors are also prescribing ivermectin and I know this from friends who have had COVID. When they look up the medicine online, they find that it is not being prescribed in other countries.
SR: It is a bit of a chicken-and-egg situation. Because people are scared of COVID, they want some prescription. There are doctors, physicians who have given a long prescription and they feel that probably patients feel they will get better with this bunch of medicines. It is a kind of feeling of safety. As far as ivermectin is concerned, there is only one retrospective study from Bangladesh which has shown some benefits. So, the problem is the fear that the [patient] has to be hospitalised, that our healthcare system, as Gunjan said, is not good enough to handle [you] once you become sick or that you will not get a bed in a hospital--then one tends to expect more medications even pre-hospitalisation so that one don't end up in hospital. And because it's not a good public health system, there is over-privatisation of healthcare and a competitive edge to prescribing. This makes a complex and difficult situation even more complex.
You've had hundreds, if not thousands, of cases through the last year. What's your sense? Would you say many of these medicines that were prescribed, that you ideally would not have prescribed, have worked at all or made a difference? Maybe there's some chance they could have worked?
GC: I have actually prescribed these medicines in the initial wave and I have used it, I would not say I have not. In this wave, I don't prescribe it to anybody and honestly, it makes no difference. It makes no difference to the severity [of the disease] or the possibility of a patient worsening in the second week or the immune response that develops in a patient. It's just about gaining the confidence of your patient--[and saying] that you don't need that medicine. I do get calls back: 'Madam, you didn't write ivermectin, my neighbor was given that, my cousin was given that.' But it is just [about] gaining the confidence of your patient and telling them all these will not work and once they are confident they will follow you. And believe me, I have not seen any extra worsening after not giving these medicines. I have used Fabiflu as I said in the first phase [and] so many patients did complain of high uric acid; they had a lot of nausea, gastritis, and I think life was difficult for them. Now, all my patients are eating well and they do well.
So, in a way, you're saying their quality of recovery is better?
GC: Yes, the quality of recovery is better because we avoid the side-effects. Gastritis is the most common thing. Many people complain of vomiting, not being able to eat because of the gastritis. Some doctors are prescribing all of them together, whether it is ivermectin, fabiflu, everything. So, with that, your body definitely undergoes some change but here, when we just advise them some supplements and a good diet and maybe good hydration, they are quite happy. In fact, I feel it reduces the severity in the second wave.
SR: I have never used Fabiflu, never ever used Fabiflu even in the first wave. I never used ivermectin either in the first wave and multivitamins, etc. Ivermectin, to tell you honestly, I am prescribing once in a while because of the pressure. I am an intensivist as Gunjan is and we are under so much pressure in the ICU that sometimes patients or family and friends call and say, he has been prescribed ivermectin and I say okay, go ahead and take it. I really don't have the mind-space to argue. But not in the ICU, I have never prescribed [it] in the ICU. It's only earlier in the OPD phases--I don't have an OPD but on the phone [I say]: ivermectin, three days 12 mg, and I say look here, if you feel nauseous with this, stop it, it is probably not going to benefit you. But I don't think it benefits anyone. The evidence is very very weak for it and [for] Fabiflu, there is no evidence. There were two studies which were done which had very strong bias, very poor quality studies.
If you were to look back at all the patients you have treated in the last year, would you concur with Dr Chanchalani that in most cases, there is no impact or negative impact?
SR: No impact, I think. No impact at all of these drugs, absolutely.
Let me come to a slightly larger, maybe philosophical question. So maybe, in some of the Western countries, the healthcare response is different. If something goes wrong, you call 911, an ambulance arrives and you're taken care of. That's not the case in India and the trust in the system itself is weak. How do we then address this situation which pressurises us to over-medicate or over-prescribe?
SR: It obviously takes time. At a personal level, you can improve the trust by trying to take time and explain. In the previous surge I had more time because it was not so bad, I had more time to explain to people and that's why I never used any of these drugs. In this surge, Fabiflu--I say absolutely out and out, no. But [with] ivermectin it's almost like you're balancing things out but it's a personal aspect.
The other is how we deliver healthcare in a country--it is not just about prescribing practices but also about how healthcare is delivered. That depends on many other factors which are more important like triage--[with] which patient do we go up to which level of support? Even advanced healthcare systems like [in] Italy and [the UK's] NHS did that in spite of the equipment they have, the number of beds they have. You have to triage. In the Indian context, it is so difficult to explain triage, that if there is shortage of resources, a person who is younger, who has more [chances] of survival, has to be given preference over a person who is much more elderly with many comorbidities and has fewer chances [of survival]. It is difficult because people lack trust [in the system]--[they think] that this decision is being made because maybe I don't have the money or the resources or the contacts to get the best. In a good public health system like the NHS or the Italian system, the trust in the system is so high that people accept these things. They say okay, we understand. This lack of trust in the system is basically because of an over-privatised system. The best healthcare is delivered by good public health systems that serve everyone--the rich, not-so-rich and poor. Wherever there is good public health delivery, overall health delivery is better. Even if you take our country, the examples are very clear: Kerala and Tamil Nadu do much better on all indices because they have much better public health systems. The faith in the public healthcare system is also much higher there. You don't have to look [far] outside the country [for sound public healthcare systems], there is Sri Lanka in our neighbourhood.
Let me get a quick sum-up from both of you. Dr Chanchalani, you are in Mumbai where things have steadied a little bit. What would you advise patients who are contracting COVID-19--the numbers of cases here are still high--what should they do or not do?
GC: Mumbai's situation is comparatively better: We are not in as much of a crisis as other states. Our task force has managed it quite well and the lockdown has definitely helped. The only thing that I can say to all patients is that, please don't panic when you're detected positive, follow your doctor, monitor yourself, monitor your own oxygen, monitor your oxygen on exertion which is a six-minute walk test. And only when the oxygen drops, report to your doctor and get admitted or take oral medications which are required. Panic is the worst thing [in the situation]. Have faith in your doctor--that is the most important thing. People are using all these over-the-counter medicines or comparing [their medication] with others because they are panicking.
COVID, in more than 95% of people, does not even require [hospital] admission. It can be managed at home, managed quite well and a good number of people get well at home. So, avoid panic and [all the] talk about how much someone worsened because the numbers are so high. We have [seen] much more worsening, and a worsened healthcare system during the dengue epidemic which arrives every monsoon though we didn't see it last year. It does not cause much panic because we are so used to it now. This is so new and the panic is what is driving everybody crazy. So just calm down, follow your doctor and report to him on a regular basis. It should not be that I'm checking my oxygen today and then I'm checking it after 8-9 days. So, every day monitor yourself, eat well, drink well and you'll be fine.
SR: One thing is monitoring oneself, monitoring oneself with the lab tests that the doctor prescribes. And tracking the course of illness. The problem with COVID is also the infodemic. People do not understand the particular physiology of a disease process so well because it's complex, it takes years of training. What has happened with COVID is that there is certain information [about it] which makes them panic because they cannot analyse and contextualise it. We used to call it the third-year syndrome in our medical school. We started reading about clinical conditions the first time when we were third-year medical students. And we used to feel that we have all the diseases described. That's what's happening to a lot of people. So, 90% of cases, as Gunjan said, will not worsen. [Upto] 8- 10% will get hospitalised and the patterns of the disease process is different in different people. That's why tracking the disease in each individual with the help of the doctor is important and for most people, it will improve on its own with some nutrition, fluids and some supplements, vitamins etc. And for others, if you track it, well, [there could be] early hospitalisation in that subset. But just because some test number is high [it] is not an indication to be admitted. As Gunjan said, your oxygen levels, if they start dipping, you get breathless and you have a persistent cough and high-grade fever, yes, you have to track it with your doctor--do you need hospitalisation or not. [But] 90% will not require [it].
Dr Ray, you are in Delhi where there clearly seems to be a huge strain in the system. Would these general rules apply there too?SR: So, the general rules apply, but what is happening now is that the numbers are overwhelming. If there were 10,000 cases, then if you say 10% get hospitalised, only 1,000 per day would get hospitalised. Now with 25,000-30,000 [cases a day], 2500 a day [get hospitalised]. And those who get admitted stay an average length of about seven days. So the system has got choked and blocked. Patients who go into the ICU don't move out for almost three weeks. So, at every level, the system is blocked and choked. That is why the panic of not getting beds and the only way to reduce that is logistical improvement, surge capacity build-up, increasing the number of hospital beds. Actually, to tell you honestly, there are not enough hospital beds. What we have to do is look at it as a disaster at this point. One end is to say, do not panic, but yes, people will panic in this condition when beds are not available. How do you improve that? As a government they have to build like in an earthquake--you bring in prefabricated hospitals with staff, machines, ventilators and start. And also, reduce the numbers at the backend with lockdowns, etc. So only will this level of panic reduce. And then better sense will prevail among doctors and patients. Even doctors are panicking, they don't want their patients to end up in hospitals searching for a hospital bed. If they ended in hospitals, it is okay, but they are searching for hospital beds and dying outside hospitals or in casualties because there are no beds available. That adds to the panic. So, it is very easy for somebody to say that we should not panic but it is understandable that is happening. The only way to stop it is to stop the surge on one hand and build surge capacity [on the other].