Thursday, September 16, 2021

Reliance



You might have asked your Local Government Units (LGU) or doctor if they are providing any Covid-19 treatment for outpatient individuals, and they answered "no". When I asked the LGU here they said all they gave was paracetamol. I thought this was insane. They just wait for people to get worse. This is the reason why when people have covid-19 symptoms, they will never tell the authorities, not even their doctors. Because apart from not getting treatment, you get punished: you are taken away into isolation for 14 days.

Physicians and local government authorities are following the Philippines unified algorithm and guidelines on Covid-19. This algorithm focuses on testing, contact tracing and isolation, and recommends only management of symptoms for outpatients, with no antibiotics or prophylaxis. Any investigational drugs for the treatment of Covid-19 are given only in the hospital setting. This means, you will have to be admitted to hospital to actually be treated for the disease. Understandably, this was the general case particularly in the early months of the pandemic because there were no known drugs or interventions for the treatment of of Covid-19 and all drugs and interventions considered may only be given in clinical trial settings.

The algorithm described above is probably what accounts for Covid-19 surge in hospitals and Covid-19 deaths. Consequently, under the algorithm, (1) you may need to be hospitalised if you cannot get early treatment at home; and (2) if you don't get early treatment at home you may get worse and receive treatment in hospital only when the disease is already in an advanced stage; and (3) hospitals are full due to (1) and (2), so patients are sent home without treatment.

To date, all drugs and interventions (including vaccines, with exception of Comirnaty by Pfizer recently approved by the FDA) remain investigational, approved for emergency use, allowed under compassionate use permits or experimental. In the meantime, a number of pharmaceutical companies are engaged in intensive research and testing to make available new drugs and interventions specifically made for the treatment of Covid-19. Some early known candidates are the oral Covid-19 drug PF-07321332 by Pfizer, molnupiravir for the prevention of Covid-19 by Merck, oral antiviral AT-527 by Roche and Atea Phrama, a DNA vaccine by Institut Pasteur, and ZyCoV-D a 3-dose needle-free DNA Vaccine from Zydus Cadila in India. At the same time, clinical trials are being undertaken to assess the efficacy of already existing drugs and interventions that may be repurposed for Covid-19 treatment.

With regard to FDA approved agents, there are no pre-exposure prophylaxis for Covid-19 at the moment. However, clinical trials are investigating several agents, including emtricitabine plus tenofovir alafenamide or tenofovir disoproxil fumarate, hydroxychloroquine, ivermectin, and supplements such as zinc, vitamin C, and vitamin D. Studies of monoclonal antibodies that target SARS-CoV-2 are in development.

You might ask, why not just get vaccinated? And I have been told many times, "the best way to get protected is to be vaccinated." The problem is there are individuals who cannot mount adequate responses to the vaccine. These include people who have immunocompromising conditions and those taking immunosuppressive medications. Also considered at risk for progression to severe Covid-19 infection are those who received the second vaccine dose in a two-dose series or a single-dose vaccine less than 2 weeks prior to Covid-19 exposure as well as those who may be fully vaccinated but the efficacy has waned over time. Pregnant and lactating individuals were not included in the initial vaccine trials, and clinical trials for some vaccines in younger age groups and clinical trials for other SARS-CoV-2 vaccine candidates are still currently ongoing. These circumstances exclude certain groups of individuals from vaccination. Vaccine availability in many developing countries is also very poor, and the long-term effects of new vaccines are yet unknown. Indeed, in Science, often the best answer is "I don't know."

Below is a small list of Covid-19 Treatment Guidelines and Protocols. It amazes me how little is known about these, particularly the fact that early outpatient treatment for Covid-19, despite their investigational status, are already allowed by pertinent official institutions. You will just need to find a compassionate and courageous physician to help administer the treatments.


  1. USA, Covid-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (Covid-19) Treatment Guidelines. National Institutes of Health. Available at https://www.covid19treatmentguidelines.nih.gov/ and https://files.covid19treatmentguidelines.nih.gov/guidelines/covid19treatmentguidelines.pdf (Full Guideline)
  2. USA, Front Line Covid-19 Critical Care Alliance Prophylaxis & Treatment Protocols for Covid-19 (USA). Available at http://www.flccc.net/ and https://covid19criticalcare.com/covid-19-protocols/
  3. Philippines, Healthcare Professionals Alliance Against Covid-19 (HPAAC) Philippine Covid-19 Living Recommendations. Available at https://www.psmid.org/philippine-Covid-19-living-recommendations/ (Note: This Philippine guideline offers no Prophylaxis or Early Treatment Protocols. The inpatient dosing regimen provided are for Remdesivir, Favipiravir, Dexamethasone, Interferon Beta -1a and Tocilizumab)
  4. Philippines, iProtect version 2 Covid-19 Prophylaxis or Early Treatment Protocols, Concerned Doctors and Citizens of the Philippines (https://cdcph.org/) available at https://img1.wsimg.com/blobby/go/37e9c191-8ed4-4d2c-a2b2-4e81a5039d79/downloads/I-Protect%20Protocol%20v2.pdf?ver=1629182479152 (Note: This updated protocol includes contraindications for Ivermectin. Regimen includes Doxycycline, Inhaled Budesonide, Ivermectin, oral steroids Methylprednisolone or Dexamethasone depending on severity).
  5. Philippines, Dr. Allan Landrito (https://drlandrito.com/) Prophylaxis, Early Treatment, Post Covid Exposure and Late Treatment Protocols available at https://drlandrito.com/dosing-of-ivermectin/ (Updated August 2021)
  6. China, "Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia" https://www.chinadaily.com.cn/pdf/2020/1.Clinical.Protocols.for.the.Diagnosis.and.Treatment.of.Covid-19.V7.pdf (Trial Version 7 March 2020) https://covid19.alliancebrh.com/covid19en/c100036/202008/12b9b42813a94755bbf442008fe86f63/files/b0ae9b6c1d9a47bf81d7dc1f5e7ddda5.pdf (Trial Version 8 August 2020) (Note: There is no outpatient Prophylaxis or Early Treatment Protocol. However, the treatment includes a section on Traditional Chinese Medicine which may be done inpatient through all stages of the disease. Since Lianhua has become popular in the Philippines since the pandemic, this document recommends Lianhua Qingwen only for fatigue and fever during medical observation and not for confirmed Covid-19 patients. TCM Protocols are for Mild to Critical.)
  7. India, "Covid-19 Treatment Guidelines for Kerala State version 3 April 2021" Available at https://dhs.kerala.gov.in/wp-content/uploads/2021/04/Guidelines-Treatment-Protocol-April-2021-merged.pdf (Note: Interesting that they base their categories on symptomatology (A-B-C) and Mild-Moderate-Severe for Clinical Severity with the corresponding aforementioned categories, and Respiratory Rate used for severity categories for treatment purposes. This usefully represents the stages/phases of Covid-19 disease alongside treatment. The Kerala protocol for outpatient includes Oseltamivir (Tamiflu, prior to a testing), Ivermectin and Inhalational budesonide. Protocols and guidelines for children and diabetics included).
  8. USA, Multifaceted highly targeted sequential multidrug treatment of early ambulatory high-risk SARS-CoV-2 infection (COVID-19) by AAPS - Association of American Physicians and Surgeons. Available https://aapsonline.org/stem-the-tide-of-covid-hospitalizations-deaths/
  9. South Africa, Outpatient Alternative Management of COVID-19 - Perspectives from South Africa with Dr Shandara Chetty (Note: The mainstay of Dr Chetty's treatment is promethazine, an antipsychothic alternatively used as antihistamine. Dr Chetty serves a majority rural community with no access to tertiary healthcare, this is a very interesting case of inpatient treatment with very scarce resources). https://web.facebook.com/watch/live/?v=211929946998128

List of Covid-19 Clinical Trials https://clinicaltrials.gov/ct2/results?cond=COVID-19


Still, the best prophylaxis is good immune health (and not excessive hygiene; ever wonder why those families living out on the streets of Metro Manila are not dropping like flies from covid-19?) AND - if you believe in God, there's prayer. But still, as the Hadith on Reliance goes: Trust in Allah, but tie your camel!