The antibody cocktail is the best weapon to contain the spread of coronavirus currently and nearly 80 percent of the recipients of the drug might not need hospitalisation on contracting the disease, says Dr Naresh Trehan, one of India’s top doctors. The cocktail drug has also been tested in children above the age of 12 and found effective against the COVID-19, he said. Further, addressing the fears over third coronavirus wave affecting children more, he said while there is hope as vaccines are being tested for the children but at same time there is a realisation that in case kids do get infected, we do not have facilities in place.
In an exclusive interview to CNN-News18, Dr Trehan, Chairman Medanta, also speaks on Mucormycosis or the black fungus, indiscriminate use of steroid and possibility of herd immunity. Here are the excerpts from the interview:
Q. What is the reliable and viable treatment of COVID-19 available currently? We have seen plasma therapy being dropped from the protocol. Now questions are being raised over Remdesivir’s efficacy in reducing mortalities and hospitalisation. Where are we at as far as the COVID-19 treatment is concerned?
A. So, you know, it has been two days since we introduced the ‘antibody cocktail’, this has proved quite successful. You may have heard, former US President Donald Trump went to the Tesla hospital, where he was given this cocktail and he recovered and was back to the White House for work in two days. This is a concept which has proven to be very effective. So, these laboratories have made antibodies. There are two of them — Casirivimab and Imdevimab — that’s why its so effective. These two, when injected into the body, actually stop the virus. They’ll prevent the virus from entering the cells of the patients who got infected, so they don’t get any nutrition to multiply and the virus dies. It is the indication for the part that it must be given in the viral phase. The first seven days constitute the viral phase when the virus multiplies, goes into the throat, then lungs and multiplies. This cocktail of two antibodies is very effective in preventing the virus growth. So, your defense is in the first 7 days and after 7-10 days, the process finishes and it isn’t useful anymore.
Now, should everybody get it? Today, all the work done around the world says it will block replication of virus, but what has been approved include people at high risk, with comorbidities and the elderly. Even young with comorbidities can be given the drug because a large number of them passed away. This is applicable when someone tests RT-PCR positive. That’s the time to approach the facilities that give this cocktail. So, in Medanta we’ve done it a few days ago, we’ve already had 2 patients. We are getting many calls now because of the fact that it is very effective. The moment people get positive for RT-PCR, they should call our facility and enquire whether they are eligible for it. Get your RT-PCR test done whenever you think that you may have it. Not in facilities which takes 3 days to procure result, because by then you will waste 3 days. Today, it seems to us to be the best weapon to contain the virus immediately and hopefully 80% people who get sick and need hospitalisation won’t need hospitalisation.
Q. Interestingly, the drug which you are mentioning has also been approved for 12-18 years. Basically, teenagers and young adolescence, that is also encouraging.
A. Yes, the drug has been tested in children above 12 years of age but only, as long as, their body weight is 40 Kg and above. Minimum qualification is 40 Kg, above that is okay and it has been found effective. So, that’s what I am saying, this is very welcome. It is bad that it has taken so long to come when so many people have been infected. I wish it arrived few months ago. We would have actually saved many many many more lives. But, whoever is now going to get infected, should at least explore this option.
Q. There has been a lot of paranoia that the third wave is going to be extremely hard and lethal for children. Meanwhile, the doctors have been saying that children have already been affected by the virus, they had the exposure and have not seen serious bouts, also very limited. Sero-surveillance in the past indicated that the exposure children above 10 years have had is similar to adults. Yet, what can we do to ensure that we are more prepared as and when the third wave arrives?
A. So far, children who got infected have not got any serious side effects going forward. But, what is dangerous is that a very small percentage of them may get what we call multi-organ inflammation leading to multi-organ failure but most have recovered. There is a small number. Now, what is the fear? The fear is that as more and more get vaccinated and the third week comes, people who have had 2 doses and got infected had very mild symptoms. So it is very clear that there is definitely protection from vaccine. That’s one thing, more and more people are saying third wave may come 30-32 weeks later. Right now 7 – 8 months away, by the end of this year. What we need to know is how many of these people will be vaccinated. We are hoping by October we should have 60 Crore vaccinated with 2 doses.
The fear is that maybe the children will not get infected more than what has happened in the second wave, but, proportionally instead of 400K, if there were 100K, children will be a larger proportion. The other part is that there is enough scientific investigation going on where vaccines have been tested for children from 12-18 years already. The studies are far along, even there is an Indian company Zydus Cadila studying this. They are saying they are quite comfortable with the results, the efficacy has to be established over a period of time. They are applying for emergency clearance. Pfizer has already done it. We’ll get it soon given their capacity. The External Affairs Minister is trying to get more vaccines for India from US. There is hope, but at same time the realisation is that in case kids do get infected, we don’t have facilities in place. We should prepare, make doctors aware, prepare an army of paramedics who know how to take care of children. One thing, it is important not to spread panic, but, make people aware and children should be tested and treated properly.
Q. During the treatment of COVID-19, we seen a very lethal side effect of the steroid emerging, in the form of Mucormycosis. We know those who have used steroids for long period and are diabetic are more at risk. So, what can we do to deal with this challenge at this stage?
A. When you first look at the fungus itself, mucormycetes, it is present everywhere specially in large quantity in soil. It is an opportunistic fungus. Means, if the resistance form body is strong then fungus can not grow. But, in people who got COVID-19 and in addition to that who got severe COVID-19 and diabetes, who were given steroids, those are the people who became vulnerable to mucormycosis, which otherwise does not attack the people because the resitance is very low. Those people then experience mucormycosis which is now commonly known as black fungus because it produces black spots. It starts from nose, it gets blocked, then it enters sinuses. So people may feel face pain, pain in cheeks and swelling in the eye. These are the common symptoms for black fungus, people may get lose teeth and raw patches in the mouth. That’s what we want to make people aware of, that long use of steroids, diabetes and comorbidities, immune compromise in cancer patients or people who have been on chemotherapy or on any other arthritis drugs which are supposed to weaken your immune system, they are the ones who are vulnerable to it. If they experience any of this which I just described, immediately rush to a physician. Specially if it’s in their mouth or nose, they should see a physician because most doctors might now know what this may be. It needs specialised treatment.
Q. Speaking of the aftermath of mucormycosis or the aftermath of steroid use, do you think there has been irrational use or indiscriminate use of some COVID medication for treatment. Do you think even for the medical community it has been a steep learning to understand what works and what doesn’t?
A. It is very true, because there is no experience of COVID-19. There is experience of influenza virus and all that, but this covid or what we called SARS-Cov-2 is very notorious. Initially, it was thought that it affects the lungs and people people die because it. Then along the line 50 autopsies were done by doctors in Italy because WHO said do not do autopsies on Covid patients. Despite the warnings, these doctors went ahead and did the autopsies and discovered how people die. When the virus comes, the body reacts by citrosine release. If the citrosine release is excessive, it affects the whole body. The mechanism of death is not because of so much lung tissue is destroyed but the fact is due to complications exchange of oxygen couldn’t happen properly. Similarly, steroids was used after a study from UK came out saying steroid helps reduce the inflation. But, it is the severity of the disease and underlying comorbidities that lead to prolong use of steroids, so its not indiscriminate. The point is that, yes, the doctors were not fully aware of it. Most people learn how to use the right doses over the period of time. But, patients who are very very sick, they were not recovering despite of all the treatment. So, you are right that the people thought it was a silver bullet. Medical professionals never said Remdesivir is a silver bullet.
Q. The medical community is grappling to deal with COVID-19 because its changing and it is also very new. What people want to know is whether we will have to deal with COVID as a seasonal flu in future? Do you think that situation will arise?
A. You know, nobody knows that is the truth, like we didn’t know in the very beginning if it will coming back or it will die a natural death. Speculation is that it may convert itself like H1N1 and it becomes as a seasonal thing and it may come once or twice in a year. I don’t know and without knowing we should not sound like experts. We need to be conscious of the fact that all this could happen. Now that the vaccine is made, it is possible that we will have to change the vaccine every year like we do it in influenza vaccine. People may have to take it every year for a long time to come, specially the vulnerable people like the elderly, people with lung problem, one who have their immunity compromised. This will happen as time comes and whatever is the need for the period.
Q. There have been doubts about achieving herd immunity even though large sections of the population is believed to be infected or immunised. But, can herd immunity be achieved, can it be a lasting immunity?
A. Yes, history tells us that when 60 to 70 percent of population is either infected or immunised or a combination of both, those people are mainly protected. Although, there is no full-proof protection. If you can get it once, you can get it again. But there are far and few between the number of people who will get it like that post vaccine, post getting the infection. But, there won’t be enough people to generally infect, the one’s who never got infected or never took the vaccines. That is called herd immunity and herd immunity is called natural shield. When a country or community achieves 70 percent immunity then you can have idea that very few infections will occur after that.
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