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 While there is still no simple answer to that question, a lot has
changed in the six months since an entirely new coronavirus began
sweeping the globe.
Doctors say they’ve learned enough about the highly contagious virus
to solve some key problems for many patients. The changes could be
translating into more saved lives, although there is little
conclusive data.
Nearly 30 doctors around the world, from New Orleans to London to
Dubai, told Reuters they feel more prepared should cases surge again
in the fall.
“We are well-positioned for a second wave,” Patel said. “We know so
much more.”
Doctors like Patel now have:
*A clearer grasp of the disease’s side effects, like blood clotting
and kidney failure
*A better understanding of how to help patients struggling to
breathe
*More information on which drugs work for which kinds of patients.
They also have acquired new tools to aid in the battle, including:
*Widespread testing
*Promising new treatments like convalescent plasma, antiviral drugs
and steroids *An evolving spate of medical research and anecdotal
evidence, which doctors share across institutions, and sometimes
across oceans.
Despite a steady rise in COVID-19 cases, driven to some extent by
wider testing, the daily death toll from the disease is falling in
some countries, including the United States. Doctors say they are
more confident in caring for patients than they were in the chaotic
first weeks of the pandemic, when they operated on nothing but blind
instinct.
In June, an average of 4,599 people a day died from COVID-19
worldwide, down from 6,375 a day in April, according to Reuters
data.
New York's Northwell Health reported a fatality rate of 21% for
COVID-19 patients admitted to its hospitals in March. That rate is
now closer to 10%, due to a combination of earlier treatment and
improved patient management, Dr. Thomas McGinn, director of
Northwell's Feinstein Institutes for Medical Research, told Reuters.
"I think everybody is seeing that," he said. "I think people are
coming in sooner, there is better use of blood thinners, and a lot
of small things are adding up."
Even nuts-and-bolts issues, like how to re-organize hospital space
to handle a surge of COVID-19 patients and secure personal
protective equipment (PPE) for medical workers, are not the
time-consuming, mad scrambles they were before.
“The hysteria of who’d take care of (hospital staff) is not there
anymore,” said Dr. Andra Blomkalns, head of emergency medicine at
Stanford Health Care, a California hospital affiliated with Stanford
University. “We have an entire team whose only job is getting PPE.”
To be sure, the world is far from safe from a virus that continues
to rage. It is expected to reach two grim milestones in the next
several days: 10 million confirmed global infections and 500,000
deaths. As of Thursday evening, more than 9.5 million people had
tested positive for the coronavirus, and more than 483,000 had died,
according to Reuters data. The United States remains the epicenter
of the pandemic, and cases are rising at an alarming pace in states
like Arizona, Florida and Texas.
There is still no surefire treatment for COVID-19, the disease
caused by the new virus, which often starts as a respiratory illness
but can spread to attack organs including the heart, liver, kidneys
or central nervous system. Scientists are at least months away from
a working vaccine.
And while medical knowledge has improved, doctors continue to
emphasize that the best way for people to survive is to avoid
infection in the first place through good hygiene, face coverings
and limited group interaction.
Dr. Ramanathan Venkiteswaran, medical director of Aster Hospitals in
the United Arab Emirates, said COVID-19 will likely result in
permanent changes in medicine and for the general public on “basic
things like social distancing, wearing of masks and hand washing.”
LEARNING ON THE FLY
In the medical field, change can be slow, with years-long studies
often needed before recommendations are altered. But protocols for
COVID-19 have evolved at lightning speed.
In Brazil, São Paulo-based Hospital Israelita Albert Einstein, one
of the country’s leading private hospital networks, has updated its
internal guidelines for treating coronavirus patients some 50 times
since the outbreak began earlier this year, according to Dr. Moacyr
Silva Junior, an infectious disease specialist at the center. Those
guidelines govern questions such as which patients are eligible for
which drugs, how to handle patients with breathing problems, and the
use of PPE like masks, gowns and gloves.
“In only three months, a resounding amount of scientific work on
COVID-19 has been published,” he said.
At Stanford Health Care, treatment guidelines changed almost daily
in the early weeks of the pandemic, Blomkalns said. She described a
patchwork approach that began by following guidelines established by
the U.S. Centers for Disease Control and Prevention, then modifying
them to reflect a shortage of resources, and finally adding new
measures not addressed by the CDC, such as how to handle pregnant
healthcare workers.
The new coronavirus has been particularly vexing for doctors because
of the many and often unpredictable ways it can manifest. Most
people infected experience only mild flu-like symptoms, but some can
develop severe pneumonia, stroke and neurological disease. Doctors
say the biggest advance so far has been understanding how the
disease can put patients at much higher risk for blood clots. Most
recently, doctors have discovered that blood type might influence
how the body reacts to the virus.
“We developed specific protocols, such as when to start blood
thinners, that are different from what would be done for typical ICU
patients,” said Dr. Jeremy Falk, pulmonary critical care specialist
at Cedars-Sinai Medical Center in Los Angeles.
Around 15% of COVID-19 patients are at risk of becoming sick enough
to require hospitalization. Scientists have estimated that the
fatality rate could be as high as 5%, but most put the number well
below 1%. People with the highest risk of severe disease include
older adults and those with underlying health conditions like heart
disease, diabetes and obesity.
While rates of COVID-19 infection have recently been rising in many
parts of the United States, the total number of U.S. patients
hospitalized with COVID-19 has been steadily falling since a peak in
late April, according to the CDC.
Many hospitals report success with guidelines for "proning" patients
- positioning them on their stomachs to relieve pressure on the
lungs, and hopefully stave off the need for mechanical ventilation,
which many doctors said has done more harm than good.
“At first, we had no idea how to treat severely ill patients when we
(ventilate),” said Dr. Satoru Hashimoto, who directs the intensive
care division at Kyoto Prefectural University of Medicine in Japan.
“We treated them in the fashion we treated influenza,” only to see
those patients suffer serious kidney, digestive and other problems,
he said.
Hospitals say increased coronavirus testing - and faster turnaround
times to get results - are also making a difference.
"What has really helped us triage patients is the availability of
rapid testing that came on about six weeks ago," said Falk of
Cedars-Sinai. "Initially, we had to wait two, three or even four
days to get a test back. That really clogged up the COVID areas of
the hospital."
Faster, wider testing also helps conserve PPE by identifying the
negative patients around whom doctors don’t have to wear as much
gear, said Dr. Saj Patel, who treats non-critical patients at the
University of California San Francisco Medical Center. “You can
imagine how much PPE we burned through” waiting for test results, he
said.
Hospitals around the world acted early to restructure operations,
including floor layouts, to isolate coronavirus patients and reduce
exposure to others. It wasn’t always smooth, but doctors say they’re
figuring out how to do it more efficiently.
“Our hospital infrastructure, and the way that we ... manage people
coming through the door is a lot slicker than it was earlier in the
epidemic," said Dr. Tom Wingfield, a clinical lecturer at the
Liverpool School of Tropical Medicine in Liverpool, England.
‘THE PRESIDENT’S DRUG’
Hospitals said some of their early hunches about best treatments for
COVID-19 patients ended up being wrong. Case in point: use of the
anti-malaria pill hydroxychloroquine.
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It gained attention in March, when U.S. President Donald Trump began publicly
touting it. Early reports showed the drug could have some benefit, and
hospitals, desperate for solutions, started giving it to critically sick
patients. But subsequent trial data have told a different story, suggesting the
drug is not effective for treatment or prevention, and might even cause harm.
Other clinical trials of the drug are still underway.
Dr. Mangala Narasimhan, regional director of critical care at Northwell Hospital
in New York, recalled the uncertainty around hydroxychloroquine. The hospital
used it early on, but stopped after the negative studies were published. “That
was one of our mainstays of treatment in the beginning,” Narasimhan said. “We
didn’t have anything else.”
Trump’s loud support for the drug turned the medical debate into a political
one. That happened in Brazil, too, when far-right President Jair Bolsonaro
fiercely supported hydroxychloroquine. Hospital Sírio-Libanês, in São Paulo, is
one of the many hospitals around the globe that have now abandoned it.
Some patients at Sírio-Libanês refused to be part of clinical trials involving
what they called the “president’s drug,” said Dr. Mirian Dal Ben, an
epidemiologist there, while others demanded to be treated with it.
The lingering questions about use of hydroxychloroquine highlight the hazards of
quickly moving science. Hospitals normally rely on fully vetted research
published by prominent medical journals like the Lancet and the New England
Journal of Medicine to flag important medical findings. But as the pandemic
built, so did the number of so-called "pre-print" studies that have not been
peer-reviewed.
The Montpellier University Hospital in southern France used hydroxychloroquine
on severely ill patients until the government banned the substance in May.
“I have no major regrets when looking back on the decisions that we took,” said
Dr. Jacques Reynes, head of infectious and tropical diseases. “But I would say
that, at the beginning, we were somewhat in a fog.”
USING WHAT'S AT HAND
But even if hydroxychloroquine looks unlikely as an effective COVID-19
treatment, hospitals continue to try new medications - both by repurposing older
drugs and exploring novel therapies. Patients are being enrolled in hundreds of
coronavirus clinical trials launched in the past three months.
Many hospitals said they are seeing success with the use of plasma donated by
survivors of COVID-19 to treat newly infected patients.
People who survive an infectious disease like COVID-19 are generally left with
blood containing antibodies, which are proteins made by the body’s immune system
to fight off a virus. The blood component that carries the antibodies, known as
convalescent plasma, can be collected and given to new patients.
Early results from a study at New York's Mount Sinai Hospital found that
patients with severe COVID-19 who were given convalescent plasma were more
likely to stabilize or need less oxygen support than other similar hospital
patients. But results from other studies have been mixed, and doctors still
await findings from a rigorously-designed trial. And availability of plasma
varies between regions.
At Henry Ford Hospital in Detroit, Michigan, “anecdotally everyone can provide
stories” of the benefits of plasma, said Dr. John Deledda, the hospital’s chief
medical officer.
But in rural New Mexico, hospitals that care for largely underserved populations
struggle to find it. “There’s a limited number of blood centers” that can
provide plasma, said Valory Wangler, chief medical officer at Rehoboth McKinley
Christian Health Care Services, in Gallup, New Mexico. Until trial data is more
conclusive, plasma is “not something we’re pursuing actively,” she said.
Dr Abdullatif al-Khal, head of infectious diseases at Qatar’s Hamad Medical
Corporation and a co-chair of the country’s pandemic preparedness team, said he
saw patients improve after he started using donated plasma early in the course
of COVID-19 before the patients deteriorated.
Qatar is also assessing a steroid known as dexamethasone to treat COVID-19. But
Khal says he wants to wait for publication of clinical data behind a recent UK
study suggesting that the steroid reduced death rates by around a third among
the most severely ill COVID-19 patients.
In patients with severe COVID-19, the immune system can overreact, triggering a
potentially harmful cascade. Steroids are an older class of drugs that suppress
that inflammatory response. But they can also make it easier for other viral or
bacterial infections to take hold - making doctors leery of their use in a
hospital setting or in patients with early-stage COVID-19.
Some countries, including Bahrain and the United Arab Emirates, reported using
HIV drugs lopinavir and ritonavir with some success. Clinical trials, though,
have suggested little benefit, and they aren’t widely used in the United States.
MIDNIGHT DELIVERY
Many of the doctors who spoke with Reuters were bullish on the use of remdesivir,
the only drug so far shown to be effective against the coronavirus in a rigorous
clinical trial. The antiviral developed by California-based Gilead Sciences Inc
<GILD.O> was shown to reduce the length of hospital stays for COVID-19 patients
by about a third, but hasn’t been proven to boost survival.
Remdesivir is designed to disable the mechanism by which certain viruses,
including the new coronavirus, make copies of themselves and potentially
overwhelm their host’s immune system.
It is available under emergency approvals in several countries, including the
United States. But Gilead's donated supplies are limited, and distribution and
availability are uneven. Dr. Andrew Staricco, chief medical officer at McLaren
Health Care, which operates 11 hospitals across Michigan, recalls the urgency to
obtain remdesivir early on. He got an email from Michigan’s health department on
May 9, a week after the U.S. Food & Drug Administration authorized the drug for
use in treating COVID-19. The health department said it had received a small
batch from the federal government, and planned to dole it out to local hospitals
based on need. Staricco wrote back, saying he had 15 to 18 critically ill
patients, but was given enough to treat just four. The drug was so precious, he
said, that state police troopers were responsible for transporting it to the
hospital - which they did, dropping it off around 1 a.m. the next morning.
Health officials originally directed remdesivir for use on the most critically
ill patients. But doctors later found they got the best results administering it
earlier. “We started finding that, actually, the sooner you get treated with it,
the better,” Staricco said. “We’ve revisited our criteria for giving it to
patients three different times." Data on the drug, he said, is still scarce. But
his anecdotal observations on the benefits of early treatment were echoed by
several U.S. doctors.
‘COPY-CATTING’
Gilead on Monday said it aims to manufacture another 2 million courses of
remdesivir this year, but did not comment on how it plans to distribute, or
sell, those supplies for use by hospitals. The company has licensed the
antiviral to several generic drugmakers, who will be allowed to sell the
medication in over 100 low-income nations. Although much about the coronavirus
remains unknown, a key reason hospitals say they now are more prepared owes to
teamwork. Many doctors described a kind of unofficial network of information
sharing. In hard-hit Italy, Dr. Lorenzo Dagna of the IRCCS San Raffaele
Scientific Institute in Milan, organized conference calls with institutions in
the United States and elsewhere to share experiences and anecdotes treating
COVID-19 patients. McLaren’s Staricco said the Michigan hospital chain adopted
its policy on use of blood thinners by looking at peers at Detroit Medical
Center and Vanderbilt University Medical Center.
As more institutions put their guidelines online, he said, there was “lots of
copy-catting going on.”
(Reporting by Nick Brown in New York, Deena Beasley in Los Angeles, Gabriela
Mello in São Paulo and Alexander Cornwell in Dubai.; Additional reporting By
Alistair Smout in London, Matthias Blamont in Paris, Emilio Parodi in Milan,
Lisa Barrington in Dubai, Rocky Swift in Tokyo and Sangmi Cha in Seoul.; Editing
by Michele Gershberg and Marla Dickerson)
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