With input from Dr Monica Vasudev

1216: IMA-CMAAO Webinar on “COVID experience in Mumbai”

28^th November, 2020, 4-5pm

Participants: Dr KK Aggarwal, President CMAAO; Dr RK Datta; Dr Jayakrishnan Alapet; Dr Brijendra Prakash; Dr S Sharma

Faculty: Dr Rahul Pandit, Director Critical Care Medicine & ICU, Fortis Hospital, Mumbai

COVID Task Force Member, Maharashtra

Key points from the discussion

• Cases in Mumbai have reduced since November and are now 400-500 per day. In September, there were around 2000 cases every day.
• Children are protected due to a reasonable amount of immunity from the thymus gland, which is present in an active child up to 8-10 years of age.
• An exploratory trial was conducted with thymosin alfa in 15 patients to examine if it could activate CD4 and CD8 cells and increase lymphocyte count. Critically ill patients (as per ICMR criteria) were selected for the trial. Thymosin was started on Day 1 (3.2 mg TDS SC). Patients started showing improvement in CD4, CD8 and lymphocyte cell count by Day 4 and there was statistically significant improvement by Day 7. Cytokine markers also reduced (CRP, D-dimer); ferritin was not so robust. LDH did not change much. These findings need to be tested in a large trial.
• The average lymphocyte counts in these patients were in single digits when they were in ICU. The average TLC was 4100; the lymphocyte count was 9.2% (average). So if we act on moderate disease patients, perhaps we can stop progression to severe disease.
• Thymosin alfa has not been tried in HIV patients; no patient in the trial had co-existing HIV. It had no effect on monocytes and eosinophils. Neutrophil count reduced.
• Exploratory studies needed to study if these cases produced more antibody levels.
• Tocilizumab (single cytokine blocker) is losing its role in COVID-19. If supportive care and steroids are given in time in hypoxia, it is not needed. But in some patients where cytokine storm is just in place, it may have some role.
• Multiple cytokine inhibitors (Baricitinib) seem promising, but whether there is a need to use them is not clear.
• Oral baricitinib is available in India; it blocks inflammation in 72 hours, but not thrombosis. It is given in rheumatoid arthritis patients.
• Favipiravir and remdesivir should be given when the virus is replicating; they have no role if given after 7-9 days when replication is over; should be started on 3^rd-4^th
• There is less data on ivermectin and doxycycline in Mumbai; seem promising and a good RCT is needed.
• To prevent thrombosis, aspirin can be given; if the patient has developed a slightly higher microvascular state, LMWH, warfarin, acenocoumarol, dabigatran, rivaroxaban and apixaban. If these do not work, then thrombolysis can be done with streptokinase, tenecteplase.
• When we treat COVID-19, there are three options: Attack the virus within 48 hours; attack the inflammation (early diagnosis); attack the thrombosis and recover the damage (fibrosis) done.
• Up till now, mucosal vaccines have been only up to 60-70% effective. So re-dosing (multiple doses) is required.
• All nucleic acid vaccines are highly inflammatory and may cause inflammatory reactions.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA