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THE HEALTH | SEPTEMBER , 2021
| Hot Topic |
Speed and scale in pandemic management
Early prevention of disease severity progression , which is perhaps the most pressing need in pandemic management , is still overlooked
THE MOST recent research findings suggest that the SARS-CoV-2 Delta variant replicates at a much higher speed than the original virus resulting in a higher viral load and infectiousness . Hence , the unprecedented speed and reach of Delta variant in the population make staying ahead of the virus more challenging and essential .
First of all , the Delta variant spread places a higher demand on the system of finding , testing , tracing , isolating and supporting ( FTTIS ) for its aggressiveness — nearly real-time speed and scale .
Mass testing and fast tracing are still essential despite the high positivity rate ( indicating pandemic management is getting out of control ). Quick early detection is still everything in preventing greater escalation of the spread and , importantly , higher death tolls . Furthermore , empirical evidence shows that robust and an adequate FTTIS system can be traded for aggressive lockdowns . Increased lab capacity , widespread utilisation of rapid test kits , and Big Data are essential policy responses to speed up FTTIS . To capture a potentially large number of non-obvious exposures , the government should consider relooking the use of Bluetooth-powered nearcontact detection functionality into the MySejahtera app .
Aggressive testing is crucial for yet another reason — early prevention of disease severity progression , which is perhaps the most pressing need in pandemic management and is still overlooked .
Treatment-specific phases
There are four distinct stages in Covid-19 disease progression : incubation , symptomatic stage , early pulmonary phase , and late pulmonary phase .
However , we can categorise these stages more broadly into two treatment-specific phases : 1 ) active viral replication , 2 ) dysregulated inflammatory response .
The prophylaxis , earliest detection of the second phase and its early treatment makes a difference in the Covid-19 management outcome !
Notably , the second phase does not develop in all patients . In some patients , more likely than in others , the immune system fails to downregulate cytotoxic ( proinflammatory ) response .
One stream of research explains this inability through Vitamin D deficiency observed in severe Covid-19 patients with profound regularity . EMIR Research ’ s earlier article
“ Prophylaxis pathway to flatten the curve ” delved into the detailed science , strong empirical evidence and policy implications of this connection .
Another stream of Covid-19 frontier research begins to discover that the inflammatory phase develops as an autoimmune reaction to ACE2 receptors
SHAKEN , NOT STIRRED
BY DR RAIS HUSSIN
DR MARGARITA PEREDARYENKO
JASON LOH
AND AMEEN KAMAL amply present in human lung and small intestine epithelium as well as in vascular endothelium . This leads to disruption of the epithelium and endothelium smoothness followed by blood coagulation , clotting and eventually pulmonary involvement .
Covid-19 Associated Coagulopathy ( CAC ) has been described as a “ hypercoagulable ” condition in many reports . According to Dugue and colleagues , CAC is an “ emerging hallmark of the Covid-19 pandemic , contributing to macro and microvascular complications ”. And CAC is the main reason behind “ organisational pneumonia ” ( not viral or bacterial ) observed in Covid-19 patients .
These findings carry profound implications for Covid-19 management as the treatment of severe inflammatory response , including organisational pneumonia , is well established through the use of corticosteroids and anticoagulants .
General public must be well guided
This led some researchers to posit timely and aggressive corticosteroidsanticoagulation regimen incorporated in the MATH + protocol , as a critical disease progression prevention strategy .
The key paper describing MATH + presents a rigorous review of scientific rationale and empirical evidence ( including well-designed clinical trials in SARS-CoV , MERS , H1N1 and SARS-CoV-2 ) that underpins the protocol .
Remarkably , all MATH + core therapies are highly familiar , low-cost , approved medications with well-established safety profiles .
According to proponents of MATH +, as the hospital treatment protocol for Covid-19 patients , early-stage interventions to support innate immune response ( nutritional supplementation ) alongside addressing autoimmune reaction ( corticosteroids ) and hypercoagulation ( anticoagulants ) are an essential part of disease management , and most importantly , prevention of disease progression .
Importantly , corticosteroids and anticoagulants should be started at the first signs of pulmonary involvement . Hence the general public must be well guided to seek immediate medical assistance at the earliest signs of pulmonary involvement .
Table 1 ( adopted from Kory et al .) demonstrates the remarkable results for mortality reduction by the MATH + protocol practicing hospitals .
In contrast to MATH +, our current clinical management appears to suggest
There are four distinct stages in Covid-19 disease progression : incubation , symptomatic stage , early pulmonary phase , and late pulmonary phase . ” that no treatment is required for the patient at Category 3 except clinical observations to determine disease progression . However , the same document indicates that Category 3 patients already demonstrate signs of serious pulmonary involvement and , therefore , according to MATH +, should be started on steroids and anticoagulants .
The local protocol suggests only starting corticosteroids ( dexamethosone and methylprednisolone ) for Category 4 patients . This is likely because it is established that steroids use during viral replication could hamper natural antiviral activities of the body , therefore , working against it – increasing viral replication and worsening symptoms .
However , MATH + proponents suggest that viral replication ends before entering the pulmonary phase , and one study indicates that corticosteroids use in the pulmonary phase does not inhibit viral clearing , while another study shows that it does not negatively impact specific type of antibodies production . Furthermore , a systematic meta-analytical review found that beyond day-9 of illness , none of the studies detected live viruses . This supports the notion that viral replication stops before entering the pulmonary phase in line with MATH +.
Immune system requires multi-pronged support
Also , in contrast to local protocol , MATH + suggests using antivirals earlier — in the pre-pulmonary-involvement stage . In addition to antivirals , MATH + recommends using vitamins such as Vitamin C and D early on .
There is no mention of vitamins in local protocols in any disease phases .
Vitamin C has been reported to assist in the production of interferons and decrease proinflammatory cytokines , both of which affect the body ’ s antiviral response . Therefore , such nutritional supplementation must be provided in the early stages .
Increased disease progression may be associated with increased inflammatory responses by the body and it has been reported that cytokine storms may lead to even more proinflammatory cytokines and reactive oxygen species that lead to oxidative damage . In this scenario , it is reported that Vitamin C could work in concert with steroids to prevent oxidative damage to the steroid receptors .
This is why MATH + recommends Vitamin C and D supplementation throughout all stages . In addition , there are other medications suggested under MATH + such as thiamine , zinc , melatonin and other medications that could supplement current local protocols .
SARS-CoV-2 pathogenicity is complex , and the immune system requires multipronged support .
It is understood that the Ministry of Health ( MoH ) has conducted a review on micronutrients in Covid-19 management and concluded that more studies are needed to support the link between micronutrients intervention and Covid-19 patients ’ outcomes . However , EMIR Research ’ s earlier article “ Prophylaxis pathway to flatten the curve ” strongly supports the notion with the most recent empirical evidence .
The above science-driven policy recommendations are crucial to reduce pressure on the healthcare system capacity and reduce the mortality rate . MATH + protocol deserves the health authorities ’ attention .
Furthermore , private hospitals