Research continues into effective treatments for COVID-19, as observers highlight that global funding in pursuit of vaccines has significantly dwarfed funding necessary to conduct broad-based clinical drug trials.
With COVID-19 deaths continuing to mount, infections and hospitalizations in the capital showing no sign of flattening, and the country’s healthcare system said to be on the brink of collapse, many Bahamians question why precious little is discussed about treatment strategies that can prevent or reduce incidences of infection and acute illness.
Since COVID-19 is highly contagious and will be with us even if a vaccine is produced, according to infectious disease experts worldwide, calls for treatment options loom.
Perspective spoke with infectious disease specialist Dr. Nikkiah Forbes, integrative medicine consultant Dr. Kevin Bethel, cardiovascular surgeon Dr. Duane Sands and infectious disease specialist Dr. Charlyon Bonimy on this subject, which continues to spark debate and
investigation within the scientific and medical community.
Treatment of COVID-19 in The Bahamas is “largely supportive care”, according to Forbes, who explained that standard of care is based on best practice expert guidelines in The Bahamas which include the World Health Organization (WHO) guidelines and their acute critical management of COVID-19, and the Infectious Diseases Society of America (IDSA).
Considerations for COVID-19 treatment must be evidence-based, Forbes explained, pointing to the IDSA’s recommendations on the use of the corticosteroid dexamethasone for those requiring supplemental oxygen, which is in use in The Bahamas.
She added, “And then by and large the rest of the care is supportive — oxygen, fever reducers, pain reducers, supplemental IV fluids, antibiotics where needed, if persons have blood clots we treat those blood clots and we give medications to prevent blood clots for those persons who are at risk.”
Bonimy noted, “In the initial wave we have used experimental agents, we have used hydroxychloroquine; we have been using corticosteroids which is now a known, proven therapeutic option; we have used convalescent plasma; and have used monochromal antibodies.
“We have actually done some pretty extreme measures to try to save lives, as a matter of fact.”
Those measures include extracorporeal membrane oxygenation (ECMO) — a critical care therapy where blood is pumped outside the body to a heart-lung machine that removes carbon dioxide, and sends oxygen-filled blood back to tissues in the body.
Sands, who operates on most of the country’s ECMO patients, informed us that the country’s first ECMO survivor was discharged last Friday, after being hospitalized for between seven and eight weeks.
As local physicians work with the established standard of care for COVID-19 cases requiring hospitalization, the question on the minds of many is how to manage asymptomatic carriers to minimize their risk of deteriorating to the point of needing advanced care.
Scientists in Cuba recently reported on findings of the country’s use of the drugs Interferon alfa 2b and Heberferon in the treatment of both asymptomatic and symptomatic COVID-19 patients.
Director of Biomedical Research at the Center for Genetic Engineering and Biotechnology Dr. Gerardo Guillén is quoted in The Caribbean Council publication as stating Interferon alfa 2b was introduced very early in Cuban treatment protocols, due to the evidence of its antiviral and immune-enhancing capacity.
Cuban studies, according to Guillén, revealed that patients who were treated with Interferon alfa 2b tested negative for COVID-19 after five days, and when combined with Heberferon, 50 percent of patients took only three days to test negative.
When asked whether The Bahamas has considered looking into the use of either drug, Forbes pointed out neither is recommended in standard of care guidelines.
Bonimy acknowledged, “There is a huge gap in knowledge with regards to the mild, non-hospitalized COVID cases. Should we give treatment, should we not give treatment, will they continue to do well, or will they go downhill?
“To do a randomized, robust clinical trial in somebody who has no symptoms or is mildly symptomatic is very difficult to do, and the truth of the matter is we don’t know.”
According to Bethel, a consultant physician at Family Wellness Center on Grand Bahama who has been vocal since the start of the country’s outbreak about medicinal, vitamin and mineral preventatives, there is much within the scientific literature that aids physicians in developing the answers to how to manage asymptomatic or mildly symptomatic cases before they reach the point of requiring hospitalization.
‘Dangerous to send patients home without treatment’
Bethel insisted, “Sending patients home when they are first diagnosed without treatment is a gamble; it is dangerous for the patient and dangerous for every single person that patient comes in contact with.
“We have to talk about strategies that are actually affordable for The Bahamas, and equally if not more effective and safer than drugs like remdesivir.”
Bethel disclosed that when he sees a patient, he asks about the number of people in his or her household and persons with whom extensive contact was had within the previous week, and asks them all to start a regimen of vitamin D, zinc and quercetin.
Quercetin, a widely used herbal available over the counter and registered as possibly safe for most users short term, acts with the same mechanism as does hydroxychloroquine in helping zinc to pass through cell walls where it can halt viral replication.
The role of both vitamin D and zinc in immunity and antiviral activity is well documented in scientific literature, and their specific role in the pathogenesis and treatment of COVID-19 are both the subject of ongoing research.
The Journal of Clinical Medicine in London states that vitamin D deficiency, “is associated with an increase in thrombotic episodes, which are frequently observed in COVID-19. Vitamin D deficiency has been found to occur more frequently in patients with obesity and diabetes. These conditions are reported to carry a higher mortality in COVID-19.”
A pilot randomized, double-blind clinical trial conducted on hospitalized patients in Spain and published this month in the Journal of Steroid Biochemistry and Molecular Biology, found that administration of high-dose calcifediol (a D vitamin), “significantly reduced the need for ICU treatment of patients requiring hospitalization due to proven COVID-19”.
Bethel said, “My findings have been that every single patient responds with basically 50 percent improvement in symptoms per 24 hours, and it stops the spread of the disease when you treat the whole family.”
Those findings, he noted, include the use of various prescription medications, depending on a patient’s clinical presentation, including bromhexine, prednisone and ivermectin.
“When you intervene correctly, this virus is very manageable,” Bethel maintained, adding that the subject of treating COVID-19 must be viewed in the context of what is best for each stage of the infection.
With regard to the use of the popular and controversial drug hydroxychloroquine, Bethel advised that he does prescribe it, but only to patients he is able to examine in-person to determine factors including their current medications, and whether they suffer from G6PD deficiency, a genetic disorder that would render the patient unable to metabolize the drug.
Focusing on prescribing treatment regimens early in the course of one’s infection so as to disrupt the viral replication phase of COVID-19 infection, Bethel argued, “We cannot afford to send people home, roll the dice and pray that they are not going to end up back in the hospital or in the ICU. I have treated over 200 patients and their family members. No patients have required hospitalization.”
We questioned the Grand Bahama physician on whether he has documented his findings, and whether he has pursued research with respect to his treatment protocols tailored for the progressive stages of COVID-19 infection.
Bethel said he has started the process of research but claimed, “it is very difficult to get the Medical Association to cooperate”.
The issue of research in The Bahamas is one we also raised with Sands, who opined that The Bahamas has both the clinical volume and the expertise to become “thought leaders” in finding effective treatments for COVID-19.
‘We have been too passive’
Regarding current COVID-19 research findings and recommendations on standard of care, Sands said, “It is important that you pay attention to the evidence, however the evidence is being created, and I have a problem with us only accepting evidence created elsewhere.
“In The Bahamas, we are using European and Chinese trial-based evidence, and I think it is very important for us to get aggressive and look to see, given the fact that this a brand new disease, why can’t we be proactive and contribute to the generation of knowledge on the diagnosis, the treatment, the management of COVID in the same way we have contributed to HIV, sickle cell and other diseases.
“I think we have been too passive, and there are possibly some therapies that may be right in front of our eyes, and we need to go and look for them.”
The country’s unfortunate volume of COVID-19 cases per million, which is two to three times the international average, provides The Bahamas with the “clinical volume” that can enable it “to be thought leaders, or at least key influence leaders in the management of COVID”, Sands insisted.
The former health minister pointed out that the country’s limited number of medical experts are so busy with the country’s volume of cases, that they do not have the downtime to “cerebrate, plan and study”, adding that submitting to the peer review process requires significant legwork and documentation that would take a team of knowledgeable support staffers to undertake.
“All of which takes time,” Sands explained, “so what ends up happening is you have a clinical experience that guides your management that you incorporate into your understanding of the disease, and had you written it up you would have been among the first in the world to report.
“We are still too heavily service-oriented, and less research and publication-oriented, and that means that a lot of the institutional knowledge is not lost, but is hidden from the rest of the world.
“You accumulate a tremendous amount of clinical acumen, which translated, can add significantly to the world’s understanding of the management of this problem, but because we don’t publish anywhere near as much as we should, we end up adopting evidence from programs which may indeed be lower volume and possibly even lower expertise than us.”
Sands pointed to the country’s first ECMO survivor, who weighed in excess of 400 pounds with a body mass index of 58, and who he said would have been denied the therapy anywhere else in the world because all current protocols exclude him as being “too big”.
“But in The Bahamas, we have people who are 3x and 4x and that is normal,” he pointed out. “Extrapolation of data from people who don’t look like you, who don’t have your genetic makeup, is dangerous.
“If you now start taking care of black people on the basis of data that you have gathered from Chinese men, for instance, you may get it wrong.”
The World Health Organization (WHO) released its interim report on its Solidarity Trial which enrolled more than 11,000 patients in 400 hospitals around the globe, finding that drugs, including remdesivir and interferon-beta, did not lower mortality rates in COVID-19 patients or delay the point at which they required ventilation.
The Bahamas applied to be a part of the Solidarity Trial, and Forbes disclosed that the country was still awaiting the arrival of remdesivir as part of that trial.
Some scientists have questioned whether the findings are impacted by when the drugs are administered, raising the point that the drugs might be given to COVID-19 patients too late in their course of infection to positively impact rates of mortality.
Bethel argued that late administration of these drugs, including hydroxychloroquine, which he said must be dosed with zinc to be effective, is the likely cause of such findings.
We asked Sands his opinion on the ongoing debate. He noted, “Well it is a selection bias because when people show up is when you treat them, so if you had a national program that involved regular testing, then you could probably intervene sooner.
“The problem is we are selecting out the sickest patients, and the sickest patients of a group with preexisting conditions, and so your data is going to be skewed in the wrong direction.”
As for local clinicians and scientists who believe they have found effective COVID-19 treatments, Sands stressed that they would have to present their findings in a format that the scientific community would accept as a well-conducted study, because medical advancement involves scrutiny.
“We have to move the conversation forward even when people are reluctant to move the conversation; it is time for disruptive thought,” he asserted.
“One of my issues as a practicing clinician has been the constantly bandied-about idea that nothing good could come out of a program in a country of 400,000 people, because we don’t have enough cases compared to a city of millions.
“In an environment like this, you can still contribute to the world’s understanding, but you have to be brash, bold and confident, and that does not happen often enough.”
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source https://thenassauguardian.com/treating-covid-19-2/
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