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FAST CoViD19 antiviral mass intervention and evidence gathering

Hi, I joined here after I saw this study-a-thon video https://www.youtube.com/watch?v=VDsZiSzfgqM. I had introduced myself here: Welcome to OHDSI! - Please introduce yourself. But now I was able to look around here in the forum a little more and I am wondering if this is indeed the right place. I think it can be. But I don’t see my topics discussed.

I am not here because of biomedical informatics stuff. I do that professionally, and I have my share of merits in the area. I am not that much interested in data models or vocabulary, all that I do in peace time. But right now, this is war and I feel there is other stuff that needs to be pushed.

We have an urgent need to devise a complete “nuking” strategy of this pandemic. I don’t even care much about the latest life-saving ICU treatment, anti-IL-6, cytokine adsorption columns, whatever. What I think needs to be done urgently is to stop the pandemic. And we cannot wait for a vaccine, we don’t even know if there will be a good one at all. And this social distancing is killing the world economy, that not just the stock market and money, it is is people’s very livelihoods. Every day of delay counts. And I am annoyed with all that time that has already been lost! We knew that hydroxychloroquine (HCQ) was active in vitro against SARS-CoV-1 and yet it took 4 freaking months of the raging epidemic to have some feeble results? And we have all sorts of places, including NYC+FDA beat their chest about starting a trial, that was two (2) weeks ago, and there are no preliminary results? You gotta be kidding me!

HCQ+azithromycin (HCQ+Azm) in all trials is dosed too low, it should at least be starting up the way the malaria treatment is dosed as per label: 800 mg once, 400 mg after 6 hours, then 400 mg after 18 hours. then again after 24 hours, and it could probably go on for a few more days. But ideally dosed even higher in the early phase. Because if you don’t do that, you just end up with the highest dose at the end of the treatment, which makes no sense! Some docs see this, and would want to do a quick trial, but to set it up can be daunting. The whole IRB stuff is completely crazy right now. If I am a doc, I can decide how I want to treat patients, and it is my duty as a scientist to keep records and to learn from my experience. To impede docs from gathering evidence while treating patients is absolutely crazy. We need to facilitate practice trials that do not require a hassle and delay of IRBs.

HCQ is also in a world shortage. We would need 92 tons (and counting) to nuke the disease now, if we knew it works. And we should know by now if NYC didn’t delay the release of the evidence. I don’t know WTH these people think they are doing! Anyway, the world doesn’t have 92 tons and Governments sit on stockpiles and there is just not enough to go around. Synthesis of HCQ is difficult. If you have 4,7-dichloroquinoline and the HCQ side chain all ready, you can make it, but these source materials are also short. And if you try to make everything de novo, it’s like a couple of dozen steps, tedious even to write it all up, let alone actually doing it.

Ivermectin was announced yesterday [https://www.sciencedirect.com/science/article/pii/S0166354220302011] as a very interesting option. In vitro around 5 μM would nail it, which is about 10 times less than HCQ. Problem is that ivermectine is a large molecule, 875 g/mol, and the usual doses are just 6 or 12 g. You would have to drive a high dose above 600 μg/kg or up to 2000 μg/kg, something like 160 mg, which is like 20 times the standard dose! This sounds scary but it is not so much outside the possible, as such high doses have been tried and were generally well tolerated. What’s more, they have been tried in Africa on malaria patients, who were given this dose of ivermectin with anti-malarial for the purpose not to help the patient get better, but to kill mosquitos and thus stop the spread of malaria onto others! My point: there seems to be no ethical problem using ivermectine in higher dose to stop the spread, so what are we waiting for to use it in that dose to both heal the patient AND stop the spread? It will take far too long to get this followed up in the usual slow moving gears of clinical research.

Someone should go out now and look in Africa for people who are already taking high dose ivermectin and see if exposed people get infected. (The HCQ findings on rheumatology patients unfortunately are not so rosy, which is why it’s important to push ivermectin ASAP.) I guess you might even have contacts through the OpenMRS folks that started out in Eldoret, Kenya.

Finally there is Favipiravir. It has shown good promise, better than the lopinavir/ritonavir and should be easier to make (even if not that easy.) Japan is doing study, but it again is taking far too long. What’s the point of coming out with results in June? We need something now.

I feel we must radically change the approach and start rolling out the treatments now for a curative and public health intent and study the outcomes as we go. If it works well, we need to know on a weekly basis. If there are problems we need to know quickly. This paper writing is just bullshit! We need real time data as we move 3 waves of treatment throughout the world and then switch to what is most effective, safe, and available, which attacking the spread of this pandemic at full speed.

So I am here to talk about that. Support it. We can help with software, staff, data, making connections, stirring the pot, fund-raising, collaborating, heck I even have a little foundation of my own to put some money up. I am particularly looking at poor neighborhoods in Brazil where I have friends and I know they have growing numbers of occult cases and a totally defunct public health care system. These people have nothing and nowhere to go. I find it crazy not to go in hard with whatever possibly works and get ahead of this. But you bet the government makes this next to impossible, heck, they aren’t even interested in stopping the disease. So it’s the people who need to do it without the government. If we could make favipiravir we would. If we could figure out a way how to do evidence guided public health intervention by the people, for the people, we would start buying gallons of ivermectin from veterinary stock where it is relatively abundant and still available.

I have contacts to one of the largest Favelas of Latin America. I am really wondering how we could help there with an intervention that might bypass the government red tape. We might even get the “regional government” (= drug lords) involved. I have no scruples because I know that the official government is also full of murderous corrupt mafiosi. What I do care about is being effective and ethical given the real emergent situation.

IMO, the only treatment that will work to stop this is one that can be traded on the free (even if black) market at sufficient quality for cheap. The only other alternative is a massive action by Trump and Modi forcing the hand of the WHO to deliver masses of product into all the world and hand it out in ad hoc roadside health clinics. Going the government chain of command will not work in a timely fashion.

OK, this is what I am here for. Who wants to help? How can I help the effort that leads to this goal?

2 Likes

Hello @gschadow

“If we could figure out a way how to do evidence guided public health intervention by the people, for the people, we would start buying gallons of ivermectin from veterinary stock where it is relatively abundant and still available.”

It looks like a gap, with an action plan needed, including evidence to support the actions. Please let me know if I can help in the process of building the evidence and/or with input in the planning part.

@gschadow, I have a couple of solutions that can be implemented to mitigate the situation.

  1. RBC (erythrocyte) infusion for patients suffering from shortness of breath. Most of patients who are put on ventilators have only partial lung impairment and may be able to continue breathing on their own with extra red blood cells. It works with anemia. Mountain climbers produce extra erythrocytes when they get acclimated at high altitudes.

The statistics for covid-19 patients on ventilators is really bad, most die.

  1. To accelerate herd immunity one can take healthy patients with no other risk factors, put them into isolation, inoculate with the virus. After 3-4 weeks they would be immune and non-infectious. Do it in groups to keep rare severe cases down.

  2. Antiparasitic drugs are interesting. I suspect they work by down-regulating ATP production. Maybe look for others that do the same.

  3. Consider using antihistamines. The severe cases appear to be caused by an allergic reaction. If one can suppress this allergic reaction outcomes may be better.

Some quick replies, noting that this isn’t really where I am trying to get at. I’m not that interested in tweaking ICU care to achieve slightly better outcomes. Nobody where I am will benefit from tweaked ICU care.

  1. To give RBCs is possibly counter-productive as it has hemodynamic effects. The optimal RBC value is 10/nL.

ARDS outcome is always bad, about a 50/50 coin toss.

  1. Herd immunity proposals are usually fraught with crazy implications. What you do with “herd immunity” is by default force 60% of world population to be vaccinated with an un-attenuated live vaccine with a very high adverse event rate for any vaccine. It is crazy to not use any other of the vaccine candidates right now, at least use a culture of radiation inactivated virus or fragments. But we don’t even know is that works, nor if post infection immunity is that great. Also, there are considerable numbers of severe cases among younger people and long term chronic morbidity due to impaired lung function hasn’t even begun to be counted.

  2. “Down regulating ATP production”? Sorry, but you sure you know what you’re talking about? You know that ATP is in the heart of biochemical energy, “down regulating ATP production” would mean starvation and asphyxiation of all cells – sure would kill the virus, but you can also do shooting squats :wink: . No, Ivermectin is a specific inhibitor of importin α/β-mediated nuclear import able to inhibit replication of HIV-1 and dengue virus.

  3. Again, I am not that interested in ICU protocols, and the mechanisms of cytokine storm and ARDS aren’t really type-I allergic reactions.

I can definitely talk to the AMPATH folks in Eldoret about Ivermectin. I don’t know what their current COVID-19 exposure is at the moment. I do know that other OpenMRS implementations in LMICs are seeing it.

The prevention “instruments” need to be available, first of all, to high risk individuals. We need the “instruments” and, at the same time, we need to identify the high risk individuals. And we probably have maximum 1.5 months because of the effects on economies of the current “instruments” available, respectively social distancing (to prevent infection - primary prevention) and the treatment options (to prevent severe clinical outcomes - tertiary prevention). There is gap we are trying to solve, until a safe and effective secondary prevention “instrument”, respectively a vaccine, will be ready. This is my opinion from the public health/high level perspective.

The cost of distancing is very high though. In countries where large portions of people’s livelihood depend on their day’s labor, it is unsustainable. Therefore the great need to stop the pandemic with extreme urgency.

If you had an anti-viral with known safety profile, that could cut down the time of shedding, the amount of shedding, the probability of exposure turning into disease, (along with the severity of illness), and is widely early available so that it could be self-administered at the first sign of any suspicion, and along with all contacts, we should be able to do to the pandemic what would be done in a new outbreak: identify, isolate, contact-trace. Only here: identify good enough, treat, contact-treat.

With a weapon like this, we should be able to eradicate the disease long before a vaccine is available. I’d love to see someone do a model that would determine the feasibility / impact of a drug like that for ending the pandemic now.

Thank you, I also got an email reply from Paul Biondic (@pbiondich) and he will also look for it. It is pretty urgent, so not a bad thing that multiple people are trying to find out. Even if it was unrelated to CoViD-19. A simple Letter to the Editor that just reports on existing (widespread?) practice of high dose might already spur some progress. Also to get in touch with the Australians who did the in-vitro study, and some pharmaco-kineticists who know ivermectin, to begin calculating more firmly what the required dosing might have to be, to see if it is feasible. IMO, it is just at the limit of feasibility, and if we can’t reach the concentration required, we will have to stretch harder or move on definitely to favipiravir with all energy, since favipiravir needs to first be produced and distributed.

t