The Comment by Satchit Balsari and colleagues1 on the second COVID-19 wave in India offers an interesting read. While it is admirable for the authors to propose simple testing and management recommendations, it is disappointing to note that they incriminate the indiscriminate and unwarranted use of several medicines in the tribulations that surfaced during the second wave.
Undoubtedly, the second wave hit India very hard and overwhelmed the health-care system simply by the sheer number of patients. Surprisingly, Balsari and colleagues label favipiravir as an ineffective therapeutic intervention when one of the authors (ZU) was the lead author of the paper that showed efficacy of favipiravir.2 Likewise, a meta-analysis concluded the efficacy of ivermectin in the prevention and treatment of COVID-19.3 There are many other publications supporting the use of other medicines (albeit at appropriate time) that the authors mention.
In the tsunami of information, practicing evidence-based medicine is a challenge. When the evidence is lacking, opinions matter, and clinicians were justifiably led by opinions of seniors and experts. To complicate matters, retraction of published evidence leading to change in guidelines is not unknown. The most recent example relates to two papers on angiotensin-converting enzyme inhibitors and hydroxychloroquine that were retracted within weeks of publication.4 In a desperate attempt to save lives, indiscriminate use might have happened in a few instances (I believe this to be more common with steroids), but to generalise it is a bit far-fetched.
It is also not correct to say that for nearly a year patients were being advised institutional isolation. It is on record that large COVID-19-care centres were urgently commissioned for this very purpose in July, 2020, and a triaging protocol based on simple clinical parameters like oxygen saturation and respiratory rate was successfully used.5
I also humbly differ in opinion on the recommendation that patients with moderate disease can be managed at home. We have learnt that these patients worsen suddenly, and timely intervention by way of bilevel positive airway pressure or high-flow nasal oxygenation is crucial in saving them. This intervention is best provided in a hospital.
Finally, I wish to underscore that clinicians—by putting up a brave fight and best efforts—saved several lives. Overwhelming patient load led to unavoidable problems, especially in the absence of any proven treatment, and even some developed countries did not escape from them.
I declare no competing interests.
References
- 1.Balsari S, Udwadia Z, Shaikh A, Ghafur A, Kataria S. Contextualising evidence-based recommendations for the second wave of the COVID-19 pandemic in India. Lancet Infect Dis. 2021;21:905–907. doi: 10.1016/S1473-3099(21)00329-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Udwadia ZF, Singh P, Barkate H, et al. Efficacy and safety of favipiravir, an oral RNA-dependent RNA polymerase inhibitor, in mild-to-moderate COVID-19: a randomized, comparative, open-label, multicenter, phase 3 clinical trial. Int J Infect Dis. 2021;103:62–71. doi: 10.1016/j.ijid.2020.11.142. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kory P, Meduri GU, Varon J, et al. Review of the emerging evidence demonstrating the efficacy of ivermectin in the prophylaxis and treatment of COVID-19. Am J Therapeutics. 2021;28:e299–e318. doi: 10.1097/MJT.0000000000001377. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Boetto E, Golinelli D, Carullo G, Fantini MP. Frauds in scientific research and how to possibly overcome them. J Med Ethics. 2020 doi: 10.1136/medethics-2020-106639. published online Oct 6. [DOI] [PubMed] [Google Scholar]
- 5.Kotnala RK, Tempe DK, Mishra P, Ramji S, Patil AP. Clinical triage in a large 2000-bed COVID-19 care facility: role of the anesthesiologist. J Cardiothorac Vasc Anesth. 2021;35:2827–2830. doi: 10.1053/j.jvca.2021.01.047. [DOI] [PMC free article] [PubMed] [Google Scholar]