- COVID19 cases reached 10 million last Sunday but the situation is more hopeful
- Doctors say that they are more prepared now as more information has emerged
- Doctors treating corona say proning is more important than ventilators.
- As the blood thickens, blood thinning issues are being used early in treatment
- Hospitals are strategizing and making a whole unit to develop PPE
- Doctors dubious about hydroxychloroquine treatment, they think it’s best suited if given earlier in the disease, not in the critically ill stage
- Meanwhile, new treatment methods give them hope and they are developing new protocols of treatment.
- In the meantime, WHO has declared that AstraZeneca’s vaccine is ahead in race and has signed a 10-year manufacture deal
- WHO has urged AstraZeneca, Moderna and other vaccine makers to formulate a trial similar to that of their solidarity trial encompassing global audience
- WHO has set up a global COVID19 accelerator to establish a portfolio of medical research
- It might take 12-18 months to get a vaccine but it would be the fastest developed vaccine
According to a Reuters report, global coronavirus cases have exceeded 10 million on Sunday, marking a major milestone in the spread of the respiratory disease that has so far killed almost half a million people in seven months.
Resurgence As Lockdown Eases
The figure is roughly double the number of severe influenza illnesses recorded annually, according to the World Health Organisation.
- The milestone comes as many hard-hit countries are easing lockdowns while making extensive alterations to work and social life that could last for a year or more until a vaccine is available.
- Some countries are experiencing a resurgence in infections, leading authorities to partially reinstate lockdowns, in what experts say could be a recurring pattern in the coming months and into 2021.
- North America, Latin America and Europe each account for around 25% of cases, while Asia and the Middle East have around 11% and 9% respectively, according to the Reuters tally, which uses government reports.
- There have been more than 497,000 fatalities linked to the disease so far, roughly the same as the number of influenza deaths reported annually.
- Quotes of fear, defiance and hope as the coronavirus pandemic spans the globe
COVID19 New Phase
The pandemic has now entered a new phase, with India and Brazil battling outbreaks of over 10,000 cases a day, putting a major strain on resources.
- The two countries accounted for over a third of all new cases in the past week.
- Brazil reported a record 54,700 new cases on June 19.
- Some researchers said the death toll in Latin America could rise to over 380,000 by October, from around 100,000 this week.
- The total number of cases continued to increase at a rate of between 1-2% a day in the past week, down from rates above 10% in March.
Countries including China, New Zealand and Australia have seen new outbreaks in the past month, despite largely quashing local transmission.
In Beijing, where hundreds of new cases were linked to an agricultural market, testing capacity has been ramped up to 300,000 a day.
The United States, which has reported the most cases of any country at more than 2.5 million, managed to slow the spread of the virus in May, only to see it expand in recent weeks to rural areas and other places that were previously unaffected.
In some countries with limited testing capabilities, case numbers reflect a small proportion of total infections. Roughly half of reported infections are known to have recovered.
Doctors More Prepared, Finds Hope in New Treatment
Amidst this doctors are finding hope in new treatments that are showing good results, reports another Reuters article. Dr. Gopi Patel recalls how powerless she felt when New York’s Mount Sinai Hospital overflowed with COVID-19 patients in March.
Guidance on how to treat the disease was scant, and medical studies were being performed so hastily they couldn’t always be trusted.
“You felt very helpless,” said Patel, an infectious disease doctor at the hospital. “I’m standing in front of a patient, watching them struggle to breathe. What can I give them?”
While there is still no simple answer to that question, a lot has changed in the six months since an entirely new coronavirus began sweeping the globe.
Doctors say they’ve learned enough about the highly contagious virus to solve some key problems for many patients.
The changes could be translating into more saved lives, although there is little conclusive data.
Nearly 30 doctors around the world, from New Orleans to London to Dubai, told Reuters they feel more prepared should cases surge again in the fall.
“We are well-positioned for a second wave,” Patel said. “We know so much more.”
Doctors like Patel now have:
- A clearer grasp of the disease’s side effects, like blood clotting and kidney failure
- A better understanding of how to help patients struggling to breathe
- More information on which drugs work for which kinds of patients.
- They also have acquired new tools to aid in the battle, including:
- Widespread testing
- Promising new treatments like convalescent plasma, antiviral drugs and steroids
- An evolving spate of medical research and anecdotal evidence, which doctors share across institutions, and sometimes across oceans.
Despite a steady rise in COVID-19 cases, driven to some extent by wider testing, the daily death toll from the disease is falling in some countries, including the United States. Doctors say they are more confident in caring for patients than they were in the chaotic first weeks of the pandemic, when they operated on nothing but blind instinct.
- In June, an average of 4,599 people a day died from COVID-19 worldwide, down from 6,375 a day in April, according to Reuters data.
- New York’s Northwell Health reported a fatality rate of 21% for COVID-19 patients admitted to its hospitals in March.
- That rate is now closer to 10%, due to a combination of earlier treatment and improved patient management, Dr. Thomas McGinn, director of Northwell’s Feinstein Institutes for Medical Research, told Reuters.
“I think everybody is seeing that,” he said. “I think people are coming in sooner, there is better use of blood thinners, and a lot of small things are adding up.”
Even nuts-and-bolts issues, like how to re-organize hospital space to handle a surge of COVID-19 patients and secure personal protective equipment (PPE) for medical workers, are not the time-consuming, mad scrambles they were before.
“The hysteria of who’d take care of (hospital staff) is not there anymore,” said Dr. Andra Blomkalns, head of emergency medicine at Stanford Health Care, a California hospital affiliated with Stanford University.
“We have an entire team whose only job is getting PPE.”
The Road Ahead
To be sure, the world is far from safe from a virus that continues to rage.
It is expected to reach two grim milestones in the next several days: 10 million confirmed global infections and 500,000 deaths.
- As of Thursday evening, more than 9.5 million people had tested positive for the coronavirus, and more than 483,000 had died, according to Reuters data.
- The United States remains the epicenter of the pandemic, and cases are rising at an alarming pace in states like Arizona, Florida and Texas.
Vaccine Still Months Away
There is still no surefire treatment for COVID-19, the disease caused by the new virus, which often starts as a respiratory illness but can spread to attack organs including the heart, liver, kidneys or central nervous system. Scientists are at least months away from a working vaccine.
Permanent Change
And while medical knowledge has improved, doctors continue to emphasize that the best way for people to survive is to avoid infection in the first place through good hygiene, face coverings and limited group interaction.
Dr. Ramanathan Venkiteswaran, medical director of Aster Hospitals in the United Arab Emirates, said COVID-19 will likely result in permanent changes in medicine and for the general public on
“basic things like social distancing, wearing of masks and hand washing.”
In the medical field, change can be slow, with years-long studies often needed before recommendations are altered. But protocols for COVID-19 have evolved at lightning speed.
In Brazil, São Paulo-based Hospital Israelita Albert Einstein, one of the country’s leading private hospital networks, has updated its internal guidelines for treating coronavirus patients some 50 times since the outbreak began earlier this year, according to Dr. Moacyr Silva Junior, an infectious disease specialist at the center. Those guidelines govern questions such as which patients are eligible for which drugs, how to handle patients with breathing problems, and the use of PPE like masks, gowns and gloves.
“In only three months, a resounding amount of scientific work on COVID-19 has been published,” he said.
At Stanford Health Care, treatment guidelines changed almost daily in the early weeks of the pandemic, Blomkalns said. She described a patchwork approach that began by following guidelines established by the U.S. Centers for Disease Control and Prevention, then modifying them to reflect a shortage of resources, and finally adding new measures not addressed by the CDC, such as how to handle pregnant healthcare workers.
New Discoveries and New Protocols
The new coronavirus has been particularly vexing for doctors because of the many and often unpredictable ways it can manifest. Most people infected experience only mild flu-like symptoms, but some can develop severe pneumonia, stroke and neurological disease.
Doctors say the biggest advance so far has been understanding how the disease can put patients at much higher risk for blood clots.
Most recently, doctors have discovered that blood type might influence how the body reacts to the virus.
“We developed specific protocols, such as when to start blood thinners, that are different from what would be done for typical ICU patients,” said Dr. Jeremy Falk, pulmonary critical care specialist at Cedars-Sinai Medical Center in Los Angeles.
- Around 15% of COVID-19 patients are at risk of becoming sick enough to require hospitalization.
- Scientists have estimated that the fatality rate could be as high as 5%, but most put the number well below 1%.
- People with the highest risk of severe disease include older adults and those with underlying health conditions like heart disease, diabetes and obesity.
While rates of COVID-19 infection have recently been rising in many parts of the United States, the total number of U.S. patients hospitalized with COVID-19 has been steadily falling since a peak in late April, according to the CDC.
Many hospitals report success with guidelines for “proning” patients – positioning them on their stomachs to relieve pressure on the lungs,
and hopefully stave off the need for mechanical ventilation, which many doctors said has done more harm than good.
“At first, we had no idea how to treat severely ill patients when we (ventilate),” said Dr. Satoru Hashimoto, who directs the intensive care division at Kyoto Prefectural University of Medicine in Japan. “We treated them in the fashion we treated influenza,” only to see those patients suffer serious kidney, digestive and other problems, he said.
Hospitals say increased coronavirus testing – and faster turnaround times to get results – are also making a difference.
“What has really helped us triage patients is the availability of rapid testing that came on about six weeks ago,” said Falk of Cedars-Sinai. “Initially, we had to wait two, three or even four days to get a test back. That really clogged up the COVID areas of the hospital.”
Faster, wider testing also helps conserve PPE by identifying the negative patients around whom doctors don’t have to wear as much gear, said Dr. Saj Patel, who treats non-critical patients at the University of California San Francisco Medical Center. “You can imagine how much PPE we burned through” waiting for test results, he said.
Hospitals around the world acted early to restructure operations, including floor layouts, to isolate coronavirus patients and reduce exposure to others. It wasn’t always smooth, but doctors say they’re figuring out how to do it more efficiently.
“Our hospital infrastructure, and the way that we … manage people coming through the door is a lot slicker than it was earlier in the epidemic,” said Dr. Tom Wingfield, a clinical lecturer at the Liverpool School of Tropical Medicine in Liverpool, England.
‘THE PRESIDENT’S DRUG’
Hospitals said some of their early hunches about best treatments for COVID-19 patients ended up being wrong. Case in point: use of the anti-malaria pill hydroxychloroquine.
It gained attention in March, when U.S. President Donald Trump began publicly touting it. Early reports showed the drug could have some benefit, and hospitals, desperate for solutions, started giving it to critically sick patients. But subsequent trial data have told a different story, suggesting the drug is not effective for treatment or prevention, and might even cause harm. Other clinical trials of the drug are still underway.
Dr. Mangala Narasimhan, regional director of critical care at Northwell Hospital in New York, recalled the uncertainty around hydroxychloroquine. The hospital used it early on, but stopped after the negative studies were published. “That was one of our mainstays of treatment in the beginning,” Narasimhan said. “We didn’t have anything else.”
Trump’s loud support for the drug turned the medical debate into a political one. That happened in Brazil, too, when far-right President Jair Bolsonaro fiercely supported hydroxychloroquine. Hospital Sírio-Libanês, in São Paulo, is one of the many hospitals around the globe that have now abandoned it.
Some patients at Sírio-Libanês refused to be part of clinical trials involving what they called the “president’s drug,” said Dr. Mirian Dal Ben, an epidemiologist there, while others demanded to be treated with it.
The lingering questions about use of hydroxychloroquine highlight the hazards of quickly moving science. Hospitals normally rely on fully vetted research published by prominent medical journals like the Lancet and the New England Journal of Medicine to flag important medical findings. But as the pandemic built, so did the number of so-called “pre-print” studies that have not been peer-reviewed.
The Montpellier University Hospital in southern France used hydroxychloroquine on severely ill patients until the government banned the substance in May.
“I have no major regrets when looking back on the decisions that we took,” said Dr. Jacques Reynes, head of infectious and tropical diseases. “But I would say that, at the beginning, we were somewhat in a fog.”
USING WHAT’S AT HAND
But even if hydroxychloroquine looks unlikely as an effective COVID-19 treatment, hospitals continue to try new medications – both by repurposing older drugs and exploring novel therapies. Patients are being enrolled in hundreds of coronavirus clinical trials launched in the past three months.
Many hospitals said they are seeing success with the use of plasma donated by survivors of COVID-19 to treat newly infected patients.
People who survive an infectious disease like COVID-19 are generally left with blood containing antibodies, which are proteins made by the body’s immune system to fight off a virus. The blood component that carries the antibodies, known as convalescent plasma, can be collected and given to new patients.
Early results from a study at New York’s Mount Sinai Hospital found that patients with severe COVID-19 who were given convalescent plasma were more likely to stabilize or need less oxygen support than other similar hospital patients. But results from other studies have been mixed, and doctors still await findings from a rigorously-designed trial. And availability of plasma varies between regions.
At Henry Ford Hospital in Detroit, Michigan, “anecdotally everyone can provide stories” of the benefits of plasma, said Dr. John Deledda, the hospital’s chief medical officer.
But in rural New Mexico, hospitals that care for largely underserved populations struggle to find it. “There’s a limited number of blood centers” that can provide plasma, said Valory Wangler, chief medical officer at Rehoboth McKinley Christian Health Care Services, in Gallup, New Mexico. Until trial data is more conclusive, plasma is “not something we’re pursuing actively,” she said.
Dr Abdullatif al-Khal, head of infectious diseases at Qatar’s Hamad Medical Corporation and a co-chair of the country’s pandemic preparedness team, said he saw patients improve after he started using donated plasma early in the course of COVID-19 before the patients deteriorated.
Qatar is also assessing a steroid known as dexamethasone to treat COVID-19. But Khal says he wants to wait for publication of clinical data behind a recent UK study suggesting that the steroid reduced death rates by around a third among the most severely ill COVID-19 patients.
In patients with severe COVID-19, the immune system can overreact, triggering a potentially harmful cascade. Steroids are an older class of drugs that suppress that inflammatory response. But they can also make it easier for other viral or bacterial infections to take hold – making doctors leery of their use in a hospital setting or in patients with early-stage COVID-19.
Some countries, including Bahrain and the United Arab Emirates, reported using HIV drugs lopinavir and ritonavir with some success. Clinical trials, though, have suggested little benefit, and they aren’t widely used in the United States.
Doctors Bulllish on Remdesivir
Many of the doctors who spoke with Reuters were bullish on the use of remdesivir, the only drug so far shown to be effective against the coronavirus in a rigorous clinical trial. The antiviral developed by California-based Gilead Sciences Inc (GILD.O) was shown to reduce the length of hospital stays for COVID-19 patients by about a third, but hasn’t been proven to boost survival.
Remdesivir is designed to disable the mechanism by which certain viruses, including the new coronavirus, make copies of themselves and potentially overwhelm their host’s immune system.
It is available under emergency approvals in several countries, including the United States. But Gilead’s donated supplies are limited, and distribution and availability are uneven.
Dr. Andrew Staricco, chief medical officer at McLaren Health Care, which operates 11 hospitals across Michigan, recalls the urgency to obtain remdesivir early on. He got an email from Michigan’s health department on May 9, a week after the U.S. Food & Drug Administration authorized the drug for use in treating COVID-19. The health department said it had received a small batch from the federal government, and planned to dole it out to local hospitals based on need. Staricco wrote back, saying he had 15 to 18 critically ill patients, but was given enough to treat just four.
The drug was so precious, he said, that state police troopers were responsible for transporting it to the hospital – which they did, dropping it off around 1 a.m. the next morning.
Health officials originally directed remdesivir for use on the most critically ill patients.
But doctors later found they got the best results administering it earlier.
“We started finding that, actually, the sooner you get treated with it, the better,” Staricco said. “We’ve revisited our criteria for giving it to patients three different times.”
Data on the drug, he said, is still scarce. But his anecdotal observations on the benefits of early treatment were echoed by several U.S. doctors.
‘COPY-CATTING’
Gilead on Monday said it aims to manufacture another 2 million courses of remdesivir this year, but did not comment on how it plans to distribute, or sell, those supplies for use by hospitals. The company has licensed the antiviral to several generic drugmakers, who will be allowed to sell the medication in over 100 low-income nations.
Although much about the coronavirus remains unknown, a key reason hospitals say they now are more prepared owes to teamwork.
Many doctors described a kind of unofficial network of information sharing.
In hard-hit Italy, Dr. Lorenzo Dagna of the IRCCS San Raffaele Scientific Institute in Milan, organized conference calls with institutions in the United States and elsewhere to share experiences and anecdotes treating COVID-19 patients.
McLaren’s Staricco said the Michigan hospital chain adopted its policy on use of blood thinners by looking at peers at Detroit Medical Center and Vanderbilt University Medical Center.
As more institutions put their guidelines online, he said, there was “lots of copy-catting going on.”
Leading Vaccine Candidate
Meanwhile,the World Health Organization’s (WHO) chief scientist declared on Friday,
that AstraZeneca’s experimental COVID-19 vaccine is probably the world’s leading candidate and most advanced in terms of development
The British drugmaker has already begun large-scale, mid-stage human trials of the vaccine, which was developed by researchers at University of Oxford.
This week, AstraZeneca signed its tenth supply-and-manufacturing deal.
“Certainly in terms of how advanced they are, the stage at which they are, they are I think probably the leading candidate,” WHO chief scientist Soumya Swaminathan told a news conference.
“So it’s possible they will have results quite early.”
Swaminathan said Moderna’s COVID-19 vaccine candidate was “not far behind” AstraZeneca’s, among more than 200 candidates, 15 of which have entered clinical trials.
“We do know that Moderna’s vaccine is also going to go into phase three clinical trials, probably from the middle of July, and so that vaccine candidate is not far behind,” she said.
“But I think AstraZeneca certainly has a more global scope at the moment in terms of where they are doing and planning their vaccine trials.”
The WHO is in talks with multiple Chinese manufacturers, including Sinovac, on potential vaccines, as well as with Indian researchers, Swaminathan said.
She called for drugmakers to consider collaborating on COVID-19 vaccine trials, similar to the WHO’s ongoing Solidarity trial for drugs.
Portfolio of COVID19 Research Efforts
A WHO-led coalition fighting the pandemic on Friday asked government and private sector donors to help raise $31.3 billion in the next 12 months to develop and deliver tests, treatments and vaccines for the disease. The initiative is called the ACT-Accelerator.
Andrew Witty, Special Envoy for the ACT-Accelerator, said it was important to consider a “portfolio of research efforts” for vaccines.
“It’s still very early days in this journey, we may be super lucky – which would be terrific – and have an early win,” Witty said.
“Even if it takes 12 to 18 months that would be without precedent, the world’s fast development of vaccine.”
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Source: Reuters
