The Tamil Nadu government and the Christian Medical College (CMC), Vellore received praise for their treatment of COVID-19 patients from Dr PV Ramesh, who is Additional Chief Secretary to the Andhra Chief Minister.
In an online event for TNM Members on Sunday, Dr Ramesh, who is also a physician, said that there were two conditions causing death among COVID-19 patients – cytokine storm and disseminated intravascular coagulation (DIC). Cytokine storm is an overreaction by a patient’s immune system to fight off an infection, causing high fevers, respiratory distress and lung damage.
“The body’s response to the virus being so effusive is that lymphocytes (type of immune cell) flood into the lungs. Normally this doesn’t happen. There is usually a small antibody build-up against the viral infection. In this case (COVID-19), there is a sudden flush of lymphocytes into the lungs which is virtually our own body’s reaction to the virus and it smothers the lungs. What happens is the lungs drowning in one’s own body fluid,” explained Dr Ramesh.
The other cause of death, Dr Ramesh pointed out, was DIC, a condition that increases blood clotting. “There is hyperperfusion and coagulation taking place in the arteries and veins that supply that perfusion,” he said.
Observing that in serious cases of COVID-19, intubation and ventilators don’t work, Dr Ramesh went on to praise both the Tamil Nadu government and CMC, Vellore for their approach in treating COVID-19 patients.
“I think Tamil Nadu and CMC Vellore have adopted a sensible protocol for treatment that we’re now adopting in Andhra, which is really treating patients with steroids and low dose anti-coagulants,” he said, adding, “My own belief is that this is the line to go rather than giving hydroxychloroquine and azithromycin, which in my view is enough to kill an elephant, let alone a man.”
Dr Ramesh also told TNM that he has recommended the adoption of the protocol to the Andhra government. “From pathophysiology of the infection, the CMC protocol, rather what is being practised by the Tamil Nadu government, is perhaps the most apt course of management. AP is a complex state. I have recommended the adoption of the above protocol. However, ICMR has recommended so many medications and so many more are in the market. Above all, it’s the treating doctor who takes the call. AP still has some way before it adopts the protocol.”
The Indian Council for Medical Research (ICMR) had in March recommended anti-malarial drug hydroxychloroquine or HCQ in combination with the antibiotic azithromycin for COVID-19 patients with severe symptoms. The recommendation was criticised by medical health experts for its potentially dangerous side-effects. On June 13, ICMR revised its guidelines stating that evidence for the use of hydroxychloroquine “remains limited” and that the drug be used in consultation with the patient.
Speaking to TNM on the institute’s protocol to treat COVID-19 patients, Dr JV Peter, Director of CMC Vellore, said that every week a clinical management team reviews all current literature and publications on the disease caused by the SARS-CoV-2 virus. Based on this, the team comes up with guidelines for the treatment of COVID-19 patients based on their symptoms – mild, moderate and severe.
“This is updated on a weekly basis, taking into consideration all new evidence that has come for each of these categories,” Dr Peter said.
As far as treatment goes, the CMC Director said, “At the moment, what seems to be working is steroids which is based on a number of reports that are coming globally. And some degree of anti-coagulation, oxygen therapy and proning (having patients lie on their stomach or side) is something that seems to be working. All the other therapies have a lot of riders in terms of the situation they can be used, because the quality of evidence is not strong.”
Dr Peter added that HCQ in combination with azithromycin was being used only under strict medical supervision for specific cases. “It is up to the treating physician, taking into consideration the co-morbidities. At the moment, HCQ is not being used by most institutions based on evidence available at the moment.”
Tamil Nadu has adopted a treatment protocol based on the recommendations of a 17-member expert committee. As per a Times of India report, the treatment protocol for severe patients includes asking patients to sleep on their stomachs, high flow oxygen, steroids and immune moderators.