|Year : 2020 | Volume
| Issue : 1 | Page : 1-4
COVID-19 pandemic: Only views, counter views, and reviews, no clear-cut answers yet
Editor-in-Chief, MGM Journal of Medical Sciences (MGMJMS), Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Navi Mumbai, Maharashtra, India
|Date of Submission||12-May-2020|
|Date of Acceptance||12-May-2020|
|Date of Web Publication||06-Jun-2020|
Dr. Sushil Kumar
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Navi Mumbai 410209, Maharashtra.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar S. COVID-19 pandemic: Only views, counter views, and reviews, no clear-cut answers yet. MGM J Med Sci 2020;7:1-4
|How to cite this URL:|
Kumar S. COVID-19 pandemic: Only views, counter views, and reviews, no clear-cut answers yet. MGM J Med Sci [serial online] 2020 [cited 2021 Dec 5];7:1-4. Available from: http://www.mgmjms.com/text.asp?2020/7/1/1/286111
At the time of writing this editorial, COVID-19 has spread almost all around the world, including India. Schools are closed, citizens are locked in their homes, no buses, no trains, no flights, and almost no economic activity. The virus has already infected over 3.7 million people around the world and killed over 250,000. India has fared a bit better, with approximately 60,000 infected and 2,000 killed to date. The tally is only going up. There is a common perception that it is one of the worst pandemics that has ever happened. Most people of my generation (the late 60s) and people younger than me have never experienced a pandemic of this magnitude. The question often asked is “whether the pandemic of this level had ever happened before.” This made me go through the history of pandemics. Before going through the history, let us have a look at “What is a pandemic?” To my surprise, there is no consensus on the definition. A simple definition could be a “large epidemic of infectious disease involving the globe.”
| History of pandemics|| |
Infectious diseases have plagued mankind probably since prehistoric days. However, with the community living, the spread of infection was quicker and it involved a larger population. International trade and increased interaction among people around the world were responsible for spreading the infection worldwide. There have been so many epidemics in the past, and it is difficult to mention all of them. To mention a few: The Justinian plague (541–542AD) killed 30–50 million people, the Japanese smallpox epidemic (735–737 ad) killed 1 million, cholera pandemic (1817–1923) killed more than one million people, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (1981-to-date) claimed approximately 25–35 million lives. More recent is the epidemic/pandemic related to the influenza virus. Influenza pandemics, if we consider its origin from Spanish flu, are now 100 years old and still going strong. The Spanish flu (H1N1) (from 1918 to 1920) claimed 50 million lives, Asian flu (H2N2) (1957–1958) claimed 1 million, and Swine flu (H1N1) (2009–10) claimed 0.2 million lives. It appears that the epidemics have always been there, and COVID-19 is no exception.
| How long will it (COVID-19) last?|| |
Past pandemics do not help in the prediction for COVID-19. Pandemics in the past lasted from a few months to a few years. However, let us compare COVID-19 with the last swine flu epidemic. WHO (World Health Organization) declared swine flu (H1N1) a pandemic on June 11, 2009. On October 5, 2009, United States started administering the newly approved H1N1 vaccine, and many other countries followed suit. The vaccine could have limited the number of people infected. However, globally 150,000–575,000 people died of H1N1 in the first year of the outbreak. WHO declared “The End” of swine flu (H1N1) pandemic on August 10, 2010. Therefore, it can be inferred that as the H1N1 pandemic lasted for a year, COVID-19 may also last for a year or so.
The statisticians have also produced data models, predicting the end of this pandemic: 97% by May 30, 2020, 99% by June 2020, and 100% by November 27, 2020. For India, the predictions are May 25, 2020, June 4, 2020, and August 1, 2020, respectively. However, some of the experts doubt these predictions due to poor data quality. Some astrologers are also in the fray, predicting the end of the disease by the end of May/June 2020. I can only say that it could be anybody’s guess. However, predictions of an early end to this pandemic may keep the citizens upbeat.
| Origin of the virus: Is it natural or from the lab?|| |
It is general consensus that the virus of COVID-19 jumped from animal to human. Increased interaction with animals through butchering for meat, wet markets, raising the animals for milk and eggs, and keeping animals as pets leads to the transmission of pathogens from animals to humans. It is now clear that the killing of nonhuman primates in Africa was responsible for the transmission of HIV from animals to humans. Severe acute respiratory syndrome (SARS) originated from bat, the intermediate host being animals in the wet market of China. In the last 100 years, approximately five influenza pandemics have occurred. Three of these pandemics had their origin from China. Why the “animal to human transmission” takes place more frequently from China? The answer lies probably in the eating habits of the Chinese and the wet market of China. On the contrary, many newspapers around the world claimed that the virus originated from the Wuhan Laboratory in China. Donald Trump, the US president, also made a similar statement. But the president changes his statement so often that we have to take his theory with a pinch of salt. Earlier, Luc Montagnier, a French Nobel Prize-winning scientist, claimed that SARS-CoV-2 virus originated from Wuhan Laboratory. The virus was genetically modified to make an anti-HIV vaccine. He further added that the presence of elements of HIV and malaria proves his theory that the virus was genetically modified. The name of another Nobel Prize winner, Tasuku Honjo, was also dragged into this controversy. However, he later denied that the virus originated from the Wuhan Laboratory. WHO also believes that the virus is of natural origin. The majority of the scientific community also rules out the possibility of man-made viruses.
| Social distancing and lockdown|| |
Communicable diseases can spread from person to person, therefore keeping the people isolated and away from each other could be a natural method of prevention of COVID-19. China has proved that this method was successful in Wuhan province. At the moment, there is no other method for preventing the spread of the disease. But for how long can we keep the people locked down in their homes? What will happen after the lockdown is over? There are no clear answers to these questions. Lockdown until an effective vaccine is available, may be the answer. But it may not be practical, as we do not know the time frame of vaccine development. The prolonged lockdown has its own adverse effects on the economy of a country and individuals. Millions around the world will be jobless. The poorest of the poor are the ones most affected. The migrant labor in the metro cities of India is an example. They have no job, no money, nothing to eat, and no place to stay. Some of them decided to walk on foot or cycle 1000–2000 km to reach their hometown as no bus, train, or air service was available.
I think gradual and watchful exit from lockdown may be the key. Lockdowns may be enforced again if conditions demand. This way, the hospitals may be able to cope with mild to moderate inflow of patients with COVID-19, and the health infrastructure will not collapse under the weight of a high influx of patients. Also, the gradual exit may improve the financial health of poor strata of the society. There is another radical opinion that allows social distancing only for older people who are >60 years. As the mortality in the younger generation is very low, let them socialize freely. This may lead to protective “herd immunity,” and the countries can be back to pre-COVID-19 days much faster.
| Shortage of personal protective equipment|| |
Prevention of infection protocols includes handwashing, personal protective equipment (PPE), and management of medical waste. The PPE consists of a mask, gown, gloves, hardcover, and boots. WHO has laid down the quality requirement of PPE with respect to highly contagious Ebola virus, which can be used for the patients with COVID-19, until new specifications are laid down. The problem is the shortage of PPE all over the world. This is because a pandemic of this level was never anticipated, and there are no reserve stockpiles of PPE with any of the countries affected. Governments repeatedly deny the shortages but the facts on the ground are that there are considerable shortages of quality PPE. Repeated uses of PPE are another controversial subject. Ideally, they should not be reused, but considering the resource crunch, a way to reuse PPE has to be found out. Besides complete PPE, there are shortages of N95 masks too. The masses in India are using cloth masks only. Cloth mask may provide some protection to the individual and to the public. I also would like to mention here that Jain monks in India have been using cloth masks in their day-to-day life since ancient times. It appears that this may become the norm in the future. “Masks or no masks for the general public” had its own controversy. Initial advice from WHO and many others was that the general public need not wear masks. They later changed their stance and advised masks for everybody.
| Effect on health workers and police personnel|| |
A considerable number of healthcare workers and police personnel lost their lives due to COVID-19. They paid the price for doing their duties. Others are also working under considerable mental strain. We can understand the fear among the families of these workers. They are also under tremendous tension. Not only the workers themselves, but their families are also vulnerable to infection. Governments, both central and state, are doing their best to raise the morale of these workers. Special pension schemes are also floated for healthcare workers. Some of the state governments have decided to double the pay for doctors working with patients of COVID-19. Those older than 60 years of age are exempt from duties. On the contrary, recently, a directive has been issued by the government of Maharashtra to all the private doctors to join the government hospitals that are taking care of patients with COVID-19. The directive has been resented by many.
| Use of traditional medicines, food items, and herbs for prevention or treatment|| |
The ministry of traditional medicine in India AYUSH (Ayurveda, Yoga, Naturopathy, Unani, Siddha, Homeopathy) has come out with certain formulation, which can help in the prevention and treatment of the disease. However, there is no concrete scientific evidence yet in traditional medicine, which helps in the treatment or prevention of COVID-19. The state of Kerala is also trying to get help with Ayurveda for the treatment of infected patients. Kerala has an ancient tradition of Ayurveda; therefore, it is possible that effective treatment may be found in this ancient branch of medicine. Among the food items and herbs, tea was found to be beneficial in China in the treatment of patients with COVID-19, probably due to its antioxidant activity. Others recommended steam inhalation alone or with ginger, turmeric, and holy basil (tulsi) leaves as beneficial.
| HYDROXYCHLOROQUINE for prevention/treatment|| |
Chloroquine and hydroxychloroquine are older drugs used effectively for the treatment of malaria. They are also used as an immunomodulator in cases of SLE (systemic lupus erythematosus). These drugs have been found effective against several viruses in vitro, including SARS-CoV-2. Workers from China have reported beneficial effects of hydroxychloroquine in 100 patients with SARS-CoV-2 pneumonitis. French physician Philipp Gauntlet et al. reported a significant reduction in viral load in patients treated with hydroxychloroquine compared to that in control. The team also reported significant clinical improvement in study group compared to that in control. Donald Trump, the US president, made a statement that this drug will be game changer for the treatment of COVID-19. As India is a major supplier of generic drugs, he requested India to supply a large quantity of the drugs on an emergency basis. India not only sent the drug to the US in large quantities but also supplied it to all the nations who requested the drug. There are skeptics too, who feel that there is more hype than the real value of the drug. Hydroxychloroquine has shown good results in in vitro studies, but clinically high-powered randomized control trials are yet to show the efficacy of the drug against viral infections. Also, the drug has significant cardiac toxicity. On the ground, the reality is that large numbers of physicians who are working in the high-risk areas are using the drug for the prevention of COVID-19.
| Antiviral drugs|| |
Several antiviral drugs have been used for viral infections in the past. Favipiravir has been used for influenza in Japan, remdesivir against Ebola, lopinavir–ritonavir against HIV, and ribavirin against Hepatitis C. Remdesivir, favipiravir, ribavirin, and lopinavir–ritonavir have been found effective against COVID-19 in vitro. However, their effectiveness against COVID-19 in humans is yet to be established. Favipiravir has been used in Japan and Indonesia with some success. Remdesivir, found effective in a preliminary trial, has been approved by the Food and Drug Administration (FDA) for use in the United States. Several clinical trials are ongoing for these drugs. These trials are likely to be completed by the end of 2020, only then we shall know the real value of the drugs against COVID-19.
| Use of nonsteroidal anti-inflammatory drug, angiotensin-converting enzyme inhibitor, and angiotensin receptor blocker|| |
On March 14, 2020, the French health minister made a statement that NSAIDs such as ibuprofen may aggravate the infection, and physicians should prefer paracetamol to nonsteroidal anti-inflammatory drugs (NSAIDs) while treating COVID-19. However, various reviews by eminent physicians doubted this claim due to a lack of evidence. The National Institute for Health and Care Excellence (NICE) revised their advice that the patient can take either paracetamol or ibuprofen for fever or headache due to COVID-19. “NICE” had earlier said that paracetamol should be used in preference to ibuprofen. A similar story is for angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blocker (ARB). COVID-19 enters the body through enzyme ACE 2, and both ACE inhibitors and ARB will increase the circulating ACE 2 levels, and therefore cause more susceptibility to the virus. This theory created panic in patients who were on ACE inhibitors or ARB. However, based on multiple studies, it is now suggested that those patients who are already on ACE inhibitors or ARB should continue taking these drugs.
| Vaccination|| |
Making a vaccine against viruses has always been a difficult task. Newer vaccines not adequately tried could be more harmful to humans than beneficial. However, many vaccines that were already in process for other viral infections are being tried for COVID-19. Also, there are vaccines that are specifically designed for COVID-19. At the moment, five vaccines are under phase 1 or phase 2 trial, and 71 are in the preclinical stage. The scientific community is extremely optimistic about finding an effective vaccine by the end of 2020. We are extremely hopeful that at least one of them will work.
| Bacillus Calmette–Guerin vaccination|| |
Bacillus Calmette–Guerin (BCG) vaccination is primarily used for the prevention of TB (tuberculosis) in children. However, it has been reported that it affects the immune system, and thus protects against respiratory infections. The COVID-19 virus is an ribonucleic acid (RNA) virus, and the BCG vaccine has been shown to reduce viraemia in viruses of similar structure. Therefore, it is presumed that BCG vaccination may reduce the severity of COVID-19. It has also been observed that the incidence of COVID-19 infections and deaths is much less in southeast Asian countries (India, Pakistan, Bangladesh, Sri Lanka, and Nepal) where the BCG vaccinations are still given to children compared to that in developed countries where BCG vaccination of children have been stopped. However, WHO does not recommend routine use of BCG vaccination as a part of the treatment or prevention of COVID-19. It is also feared that there is a remote chance that BCG vaccination may put the immune system in overdrive and harm the patient. At present, two high-powered randomized control trials are going on around the world. Their results will decide the use of BCG vaccination for the prevention or treatment of COVID-19 infections.
To conclude, I would say that like many of the past pandemics, the havoc caused by COVID-19 will be over in the coming months, and humanity will survive. COVID-19 is a new viral infection. Our understanding of the disease process and the treatment is just evolving. There is too much news on TV and print media. There are too many scientific papers published, some in reputed journals. There are new guidelines every day. At this moment, it is difficult to predict the outcome of this pandemic. Social distancing and hot steam inhalation were methods that were also prescribed 100 years back during the Spanish flu, and we are still prescribing them. There is no new effective therapy yet. Several new drugs and vaccines are on the horizon, we just have to wait for some more time. At the moment, the whole world is working toward finding an effective solution to this pandemic with a single-minded devotion and determination. With this commitment, nothing is impossible.
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