CORONA VACCINE: Who gets it first? Who pays?


CORONA VACCINE: Who gets it first? Who pays?

Most countries are involved in research into developing a vaccine against corona virus infection (causing COVID-19). The vaccine is likely to be available soon (in a few months from now). However, there are many logistical challenges that need to be considered and planning done well in advance to avoid chaos, as and when the vaccine becomes available.

1. Huge need: An effective vaccine is the most important method of winning over covid pandemic, in the absence of medicines that can cure this infection. So, everyone would need this vaccine. Depending on its efficacy, single or two doses per person could be needed. For India, this translates to 135 crores units of vaccine (270 crores if two doses per person are needed).

2. Huge amount of money needed: If the vaccine is priced at Rs 1000/ per unit, the total cost would be Rs 1,35,000 crores (Rs 2,70,000 crores if two doses per person are needed).

3. Who gets the vaccine first? In the initial phases, there would be scarcity of vaccine, as from day 1, we can not have the crores of vaccine doses that are needed. However, everyone would want to get vaccinated as early as possible. This could lead to ugly situations, such as black-marketing of vaccines, exorbitant pricing of vaccine by private parties, rich and mighty getting access to vaccine earlier, etc. It could be even lead to law & order issues.Therefore, we need to ensure that the high risk groups have the access to vaccines first. These could include: 1. Frontline workers- doctors, nurses, police, sanitisation workers, etc. 2. People who are more at risk of getting covid or dying from it- elderly, those with diabetes, heart disease, cancer, lung diseases, etc.

4. Everyone must get the vaccine: It is important to ensure complete immunisation of everyone to halt the pandemic. This is because even if a single person is left, he can be source of infections recurring in future.

Suggestions

1. Government should get involved along with private companies involved in developing vaccines. Sale and distribution should not be left to individual vaccine makers.

2. Vaccine should be sold at “no profit/no loss” basis or with minimal profits. This is not the time to look at profits. I hope the vaccine makers understand this.

3. Government should ensure a fair pricing of the vaccine so that it can be afforded by all. For those who can not afford, government can ensure free vaccination.

4. A priority list should be made regarding who gets the vaccine first. Obviously being rich and famous, or being a VIP should not be the criteria to get the vaccine first.It is time government swings into action now, rather than leaving things to the last moment. We have seen the chaos caused due to leaving things until the last moment (whether it was related to PPE kits, isolation or ICU beds, number of ventilators available, or testing capabilities). We were found lacking in all of these areas in the initial period of pandemic. I hope this chaos can be prevented when it comes to Corona vaccine.

Effective and universal vaccination against corona virus infection can ensure that we return to normalcy sooner, leading to better health as well as economic prosperity.

Dr Sudhir Kumar MD DM

drsudhirkumar@yahoo.com

20th August 2020

OFATUMUMAB is MORE effective than TERIFLUNOMIDE in MULTIPLE SCLEROSIS


OFATUMUMAB is MORE EFFECTIVE than TERIFLUNOMIDE in MULTIPLE SCLEROSIS

Multiple sclerosis (MS) is an autoimmune demyelinating disorder affecting optic nerves, brain and spinal cord.

Treatment includes disease modifying treatments (DMTs) to reduce the number of relapses. In a recent study, ofatumumab was compared with teriflunomide in patients with relapsing remitting multiple sclerosis.

Ofatumumab is an anti CD-20 monoclonal antibody. It is given as subcutaneous injections. 3 loading doses of 20 mg are given on days 1, 7 and 14. Maintenance dose is 20 mg every four weeks.

Teriflunomide, an oral inhibitor of pyrimidine synthesis, reduces B-cell and T-cell activation. It is given as 14 mg daily orally. The two drugs were compared in recently concluded study.

More than 900 patients were assigned to each drug and the median follow up was 1.6 years. The annualized relapse rate was significantly lower in the group receiving ofatumumab. The percentage with disability worsening at 3 and 6 months was also lower in ofatumumab group.

Ofatumumab was safe and well tolerated. No serious adverse effects were noted.

This study was published in NEJM (August 6, 2020)

Dr Sudhir Kumar MD DM

Apollo Hospitals, Hyderabad.

ANGIOEDEMA AFTER tissue PLASMINOGEN ACTIVATOR INFUSION


A 78-year old man presented with left hemiparesis of 90 minutes duration. A diagnosis of right MCA territory infarct was made and he was started on tissue plasminogen activator infusion for thrombolysis. 54 minutes after starting infusion, he developed swelling involving left side of tongue. t-PA infusion was stopped. A diagnosis of oro-lingual edema was made. Oro-lingual edema is a known adverse effect of t-PA.

Salient features of oro-lingual edema due to tissue plasminogen activator

  1. The swelling can be asymmetric at onset, and it commonly develops contralateral to the ischemic side of brain,
  2. It is more common with infarcts in insula region,
  3. It is more common in patients who have received treatment with ACE inhibitors.
  4. Treatment involves intravenous antihistamine and glucocorticoids.

Source: NEJM, June 18, 2020

Best Chance Against Corona is by Not Getting This Infection


Best Chance Against Corona is by Not Getting This Infection

Dr Sudhir Kumar MD DM

Corona Virus Disease- 2019 (COVID-19) is caused by a corona virus, named SARS CoV2. It started in China in late 2019 and has rapidly spread all over the world, including India.

COVID-19 is highly contagious

It is highly contagious and spreads from person-to-person through aerosols (generated from the infected persons while sneezing or talking) or fomites (that contaminate various surfaces such as tables, door handles, etc).

There is no vaccine against COVID-19

Research is being done in many parts of the world to find a vaccine to prevent it or medicine to cure it. On vaccine front, there has been no success till date. There is no vaccine to prevent COVID-19.

There is no effective treatment for COVID-19

Regarding treatments, multiple drugs have been claimed to offer, “cure”, however, no drug, offers cure in most or all patients. HCQ works only in mild cases of COVID-19 and there is no benefit in severely affected cases. Remdesivir also has partial efficacy, and moreover, it is not yet available in India. Dexamethasone, which was widely reported recently, also has limited role to play. In helps only in the most severe cases of COVID-19, which require mechanical ventilation. It may prevent only 1 in 8 deaths in patients on mechanical ventilator, and only 1 in 25 deaths in patients requiring oxygen treatment.

There is severe shortage of manpower, hospital beds and ICU rooms

Despite ramping up healthcare infrastructure, there is severe shortage of doctors and nurses. Hospital and ICU beds are also inadequate, especially in larger cities. So, there is a possibility that a patient may not get a bed, or if he gets a bed, ICU room or a ventilator may not be available. Also, if wards and ICUs run with full occupancy, the quality of care may not be the best.

So, preventing corona remains the best bet

Prevention of the COVID-19 is in our hands, as it can spread from one human to another. There are no known animal reservoirs for this virus. The virus can enter through nose, mouth or eyes.

What steps can be taken to prevent COVID-19

1. Avoid socialising- strict NO: to parties, gossiping in groups, public gathering, eating out in restaurants, watching movies in movie theaters, contact sports, classroom education, etc.
2. Do not step out of home, unless essential,
3. At workplace- avoid coffee breaks in groups, avoid having lunches in groups, avoid physical meetings as much as possible, maintain adequate distancing between desks,
4. Avoid public transport as much as possible,
5. Cover face with mask or cloth, when in public,
6. Wash hands frequently, when outdoors (with sanitizer or soap/water)
7. If you develop fever, cough, breathing difficulty, loss of taste/smell, etc, self-isolate yourself and consult a doctor.

drsudhirkumar@yahoo.com 18.06.2020

BE CAUTIOUS WHILE USING HCQ FOR TREATING COVID-19 IN MYASTHENIA GRAVIS


BE CAUTIOUS WHILE USING HCQ FOR TREATING COVID-19 IN MYASTHENIA GRAVIS

Hydroxychloroquine (HCQ) is anti-malarial drug, which is commonly used for treating rheumatological disorders such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).

HCQ has been recommended for prophylaxis as well as treatment of COVID-19 infection.

Myasthenia gravis (MG) is an autoimmune disorder resulting in neuromuscular weakness. Patients with MG have symptoms such as double vision, difficulty in swallowing and speaking and breathing difficulty. Severe cases of MG require mechanical ventilation.

HCQ treatment can cause myasthenic symptoms, and can worsen the severity of symptoms in a patient suffering from MG. It is possible that a patient with COVID-19 who has breathing difficulty, may worsen after receiving HCQ treatment. HCQ treatment may increase the risk of respiratory failure in a COVID-19 patient with comorbid myasthenia gravis.

CONCLUSIONS

1. Avoid HCQ treatment in COVID-19 patients with myasthenia gravis.

2. COIVD-19 patients with neuro-muscular disorders who are receiving HCQ should be carefully monitored in an ICU, as the risk of respiratory failure is higher.

Dr Sudhir Kumar MD DM

YOGA AS ADD ON THERAPY IS SUPERIOR TO MEDICAL THERAPY ALONE IN MIGRAINE


Yoga as ADD-ON Therapy is Superior to Medical Therapy alone in Patients Suffering from Migraine

Dr Sudhir Kumar MD DM

Migraine is the commonest cause of headache, especially affecting young people, more common in women. Migraine leads to disability and is a leading cause of absence from work. The mainstay of migraine treatment is medical treatment. Various medicines such as propranolol, flunarizine, amitriptyline, divalproex and topiramate are used to reduce severity and frequency of headaches in migraine patients. These medications at best help about 65% people. Many either have no or partial relief from headaches with medical treatment alone.

In a recent research conducted at AIIMS, New Delhi, the effect of yoga on migraine was studied. Patients aged 18-50 years were divided into two groups- one group received only medical treatment, and the other group practised yoga in addition to taking their medical treatment. They were followed up for three months. Patients who practised add-on yoga had lower headache frequency and severity. They also had lesser migraine-related disability and required lesser number of pain-killer pills.

Conclusion

Yoga as an add-on therapy in migraine is superior to medical therapy alone. It may be useful to integrate a cost-effective and safe intervention like yoga into the management of migraine.

(Source: Neurology, May 6, 2020)

UNEXPECTED AND UNINTENDED BENEFITS OF LOCKDOWN


“UNEXPECTED & UNINTENDED BENEFITS” OF LOCKDOWN

Dr Sudhir Kumar MD DM

Apollo Hospitals, Hyderabad

25th May 2020

COVID-19 caused by SARS CoV2 virus is a pandemic that started from China and rapidly spread to about 200 countries worldwide. In the absence of a vaccine, strict lockdown was imposed in March 2020 to prevent a sudden surge in COVID-19 cases. In India, lockdown has been in force for more than two months, though, a number of relaxations have been given in the past couple of weeks. Lockdown has served its primary purpose of preventing an exponential growth in the number of people with COVID-19 infections. However, lockdown has brought with it, a number of hardships and miseries too. Some of these include- migrant labour crisis, loss of jobs and incomes for a large number of people, a number of people getting stranded away from their homes and families, difficulty in getting access to items of daily needs, and so on. You are well aware of these through media reports. However, the current article’s aim is to highlight the “unexpected benefits” of lockdown.

  1. Reduction in the number of road traffic accidents (RTA) and deaths– Lockdown has resulted in significantly reduced traffic movements on roads. So, a reduction in RTA and accident-related deaths was expected. The reduction in fatalities due to road accidents has been in the range of 30-50% (as compared to the same period last year).
  2. Cleaner and healthier air: Reduction in vehicular traffic and closure of industrial establishments during lockdown has resulted in cleaner air. Reduction in air pollution over the past month has resulted in 11,000 fewer deaths from pollution in UK and Europe. Reduction in death was due to lower incidence of heart failure, chronic obstructive lung diseases, strokes, cancer, infections and diabetes. In the same period, 6000 fewer children developed asthma. Levels of nitrogen dioxide have fallen by 40% and tiny particulate matter (PM2.5) is down by 10% (as compared to same period last year). These two forms of air pollution weaken heart and respiratory system, and are responsible for 4,70,000 deaths in Europe per year.
  3. Reduction in crime rates: Lockdown has had another unintended gain- drastic fall in the crime rates. As per a top police officer in Kerala, there has been a 70% fall in rape cases and 40% fall in cases of murder during lockdown. There has been 100% fall in cases of violence against women and children. Suicides have dropped by 60% and unnatural deaths by 40%. As per Mumbai police, there has been not a single case of chain snatching or dacoity during entire month of April. Cases of thefts and robberies too have significantly declined.
  4. Reduction in hospitalizations due to heart attacks and strokes: Significantly lesser number of hospitalizations from acute myocardial infarction (heart attacks) has been reported during lockdown from many countries. In a recent study from California, admissions due to heart attacks reduced by 48% during COVID-19 period (March-April 2020). In an earlier study from Italy, similar reduction was noted. The daily admission rates of heart attacks reduced from 19 per day (in Feb-Mar 2019) to 13 per day (in Feb-Mar 2020). The admissions due to stroke have also come down by about 50% during the Covid-19 period. Rates of thrombolysis and mechanical thrombectomy (treatments that significantly reduce stroke-related disability) have also halved during the Covid-19 period.

It is possible that the reduction may not be real and just that patients are not reaching hospital- a) Difficulty in transportation facilities, b) Patients may be fearful of contracting Covid-19 and avoiding hospitals, c) Patients may be trying home remedies or self-medication for minor symptoms, d) Patients may be consulting general or family physicians, or taking remote advice via tele-medicine. However, the reduction could be real too on account of following factors- a) Lesser work and travel-related stress, b) Improved sleep quality and duration, c) Regular exercises, d) Better compliance with medicines for diabetes and hypertension, e) Reduction in “eating out” in restaurants, which are often rich in oil and salt. A proper study is needed to confirm these hypotheses.

Lessons learnt from lockdown

More than 2-month lockdown was tough on a majority of Indians leading to unprecedented hardships for them. It would be a great dis-service if we do not gather a few useful insights from it.

  1. Reducing fossil fuel use and stricter pollution control for industries can significantly reduce air pollution, leading to better health and lesser deaths.
  2. Road traffic accidents and crimes can be reduced too.
  3. Reduction in stress, good quality sleep, avoiding outside food and regular exercise can lead to reduction in heart attacks and strokes.
  4. The biggest lesson off course is that a lot still needs to be done for the poor including migrant workers so that our country- India as well as Bharat- can have a bright future.

Olfactory Bulb Edema in a Patient with Loss of Smell due to COVID-19 infection


Loss of smell (anosmia) and loss of taste (dysgeusia) have been commonly noted in people with COVID-19 infection, including those without any other symptoms such as fever, cough or breathing difficulty.

In a recent case, anosmia developed on day 7 of infection. MRI showed edema (swelling) and increased signal of olfactory bulbs and tracts. Patient recovered on day 24 and the repeat MRI showed normal findings.

Conclusion

1. Loss of smell and taste can occur in patients with COVID-19 infection, even in the absence of other symptoms.
2. Loss of smell is reversible and patients usually recover their sense of smell and taste within 4 weeks.
3. The underlying basis of anosmia seems to be involvement of olfactory nervous system (olfactory bulbs and tracts by the virus through trans-nasal spread.

(Source: Neurology, May 22, 2020)

FACIAL PARALYSIS AS A NEUROLOGICAL MANIFESTATION OF COVID-19 INFECTION


About a third of COVID-19 patients have neurological manifestations. These include headache, dizziness, loss of smell, delirium, stroke, Guillain-Barre syndrome, meningitis and encephalopathy.

Recently a case of facial paralysis was reported from Singapore (with a travel history from Spain). 27-year old man was admitted with myalgia, cough, headache and fever for 4 days. RT PCR test for SARS CoV-2 was positive. On day 6 of illness, he developed a lower motor neuron type of facial palsy on the left side. MRI of brain showed enhancement of left facial nerve. CSF PCR for SARS CoV-2 and other viruses were negative. He was treated with prednisolone, valacyclovir, ropinavir-ritonavir combination. SARS-CoV2 viral load rapidly diminished with treatment.

Conclusion

1. Facial palsy (Bell’s palsy) can be seen as a neurological manifestation of COVID-19 infection.

2. The mechanism seems to be inflammatory effects, rather than direct spread of SARS CoV2 virus.

(Source: Neurology, May 21, 2020)

SMOKING REDUCES THE RISK OF PARKINSON’S DISEASE (PD)


Smoking is a risk factor for many non-communicable diseases, such as heart attacks, strokes, cancers, chronic obstructive lung diseases, liver disease, diabetes and pneumonia. It is expected to cause 1 billion deaths in 21st century.

However, it has one benefit. In a long term study, smokers were found to have lower occurrence of Parkinson’s disease (PD). Death rates due to PD were also lower in smokers.

30,000 male doctors were followed up from 1951 to 1998 (about five decades). The crude rates of PD death were lower in current smokers than in never smokers at baseline (30 vs 46/100,000 persons-years). Current smokers at baseline had a 30% lower risk of PD. Continuing smokers had a 40% lower risk of PD.

The reason for protective effects of smoking on PD are not well known.

Conclusions

1. Smoking reduces the occurrence of Parkinson’s disease.

2. Deaths due to PD are lower in current smokers as compared to never smokers.

The study was published in Neurology (May 6, 2020 issue) and can be accessed at the following link:https://n.neurology.org/content/94/20/e2132

Dr Sudhir Kumar MD DM
Apollo Hospitals, Hyderabad