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| MEDICINE AND SOCIETY |
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| Year : 2020 | Volume
: 1
| Issue : 1 | Page : 38-41 |
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COVID-19: No end to controversies
Mahendra Singh, Yogesh Bahurupi, Abhishek Sharma, Bhavna Jain, Surekha Kishore, Pradeep Aggarwal, Ajeet Singh Bhadoria
Department of Community and Family Medicine, AIIMS, Rishikesh, Uttarakhand, India
| Date of Submission | 10-May-2020 |
| Date of Decision | 09-Jun-2020 |
| Date of Acceptance | 16-Jun-2020 |
| Date of Web Publication | 20-Jul-2020 |
Correspondence Address:
Dr. Yogesh Bahurupi
Department of Community & Family Medicine, AIIMS Rishikesh, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JME.JME_29_20
The pandemic of COVID-19 is a global public health emergency which has seriously affected India. Poor and marginalized sections of the society have been affected the most. This relatively new disease is still evolving in various parts of the world with lots of implications like global socioeconomic disruption. In this article we have attempted to enumerate and discuss the evidence, for and against, regarding some of the commonly reported controversies regarding our management strategies in India. We collected information from various databases published by the World Health Organization (WHO), Indian Council of Medical Research (ICMR) and Ministry of Health and Family Welfare. Newer clinical, epidemiological and laboratory guidelines to control the corona virus are constantly being generated and updated but there is less understanding of the urgent need for strengthening our public health infrastructure.
Keywords: Controversies, COVID-19, pandemic
How to cite this article:
Singh M, Bahurupi Y, Sharma A, Jain B, Kishore S, Aggarwal P, Bhadoria AS. COVID-19: No end to controversies. J Med Evid 2020;1:38-41 |
| Introduction | |  |
A cluster of COVID-19 cases were reported from the “Huanan Seafood Market” in Wuhan City, China.[1] From there Covid-19 spread across various countries leading to pandemic. Subsequently in a meeting on the 30th of January 2020, the World Health Organization (WHO) declared the infection a “Public Health Emergency of International Concern (PHEIC)” and advised setting up a “Pandemic Supply Chain Network” to mitigate the economic effects of the pandemic.[2] This new disease is still evolving in various parts of the world with many 'unknowns' regarding the source of the virus, the management and transmissibility of the disease and its impact on the economy and livelihoods. We therefore felt it was pertinent at this juncture to discuss a few of the controversies around COVID-19 and to enumerate and discuss the evidence for and against some of the commonly reported controversies.
| Is the Bacille Calmette–guérin Vaccine Against Coronavirus Effective? | | |
Many pre-print ecological studies have claimed a strong relationship between Bacille Calmette–Guérin (BCG) vaccination and protection against COVID-19.[3],[4] In one of these researchers studied new cases of COVID-19 in countries where BCG vaccination is routinely administered and compared these with the experience of countries where BCG vaccination is not used.[3] They reported fewer COVID-19 cases in countries where BCG vaccination was given routinely to newborns and infants.
However, according to the WHO, there is no evidence of a beneficial effect of BCG vaccination and this it does not recommend BCG vaccination to prevent COVID-19 infection.[5]
| Is Waiting for the Development of 'herd Immunity a Risky Gamble?' | | |
Some experts believed that there is unlikely to be vaccine for COVID-19 in the near future, which means that the only way a country's population can develop immunity is by getting the infection. Herd immunity in a population can be achieved by allowing the infection to spread through the community so that they will become immune and there will be no persons left for the virus to infect. This idea has been supported by the UK's Chief Scientific Adviser and the Prime Minister of the Netherlands.[6]
However, many experts believe that, just trying to achieve herd immunity for COVID-19 will not be enough. Such policy a may result in a large number of hospital admissions and eventually more patients requiring critical care. It will end by compromising our already inadequate health care infrastructure result in a large numbers of people dying.[7] There are also unanswered questions regarding, how long people who get infected with COVID-19 will sustain immunity.
| How Much Social Distancing Is Enough? | | |
Social distancing is recommended as a preventive measure for COVID-19. However, it is not clear much social distancing should be considering enough?
According to the Centres for Disease control and Prevention (CDC), USA social distancing should be of at-least six feet[8] and this supported by majority of other guidelines. On the other hand, the WHO advocates social distancing of three feet.[9]
However, there is evidence that infection from COVID-19 patients can spread much further. It has been reported that the virus can travel a minimum of 13 feet through the air (more than twice the social distancing guidelines)[10] and aerosols used in various medical and dental procedures can transmit this virus up to four meters.
Finally, Professor Bourouiba, at Massachusetts Institute of Technology (MIT), who has been conducting research related to coughs and sneezes for many years, has stated that the guidelines have followed outdated 1930 models, and. According to him the coronavirus can travel up to 23–27 feet.[11]
| What is the Role of Hydroxychloroquine in the Treatment of Covid-19? | | |
Hydroxychloroquine came into the limelight when the US President Donald Trump hyped its role as a “game changer” in treating COVID-19 patients and clinical trials are now being conducted of its role in pre- and post-exposure prophylaxis and in the treatment of patients with different grades of COVID-19 infection.
However, all the studies (trials, observational including one retrospective cohort) till date have shown varying results. One showed a “significant reduction in viral load in COVID-19 patients” after hydroxychloroquine treatment[12] but in China and France,[13],[14] no improvement was observed. Mehra et al. analysed multinational registry of 96,032 patients to study efficacy of hydroxychloroquine singly or combined with a macrolide for treatment of Covid-19.[15] No confirmatory benefit was observed on in-hospital outcomes. The authors reported that reduced hospital survival and increased ventricular arrhythmias were associated with both drugs. This study was retracted due to concerns in respect with data reliability and analysis. Independent and private peer review of data could not be done due to unobtainability of complete dataset, client contracts and full ISO audit report.
Hydroxychloroquine has been found effective in deactivating COVID-19 virus in some laboratory studies but these findings should be interpreted cautiously because it was used prophylactically to prevent infection or lessen the period of infection amongst health-care workers. Even experts from The White House have warned that its efficacy has not been proved.
| Is Reinfection Possible among Covid-19 Patients Who Have Recovered? | | |
There is a low possibility of re-infection among COVID-19 patients who have recovered if they come into contact with virus again. Antibodies to this virus are detected among these patients between 7 and 10 days after getting infected. A non-peer review study from Shanghai showed, that among 175 patients of COVID-19, approximately one-third developed antibodies against COVID 19 at low levels, whilst many did not.[16]
In Shenzhen, China, a study was conducted among cured patients of COVID-19 and they found almost 15% (38 out of 262) were again found to be COVID-19 positive.[17] South Korea also reported re-infection of COVID-19 in 91 patients.[18] Both these examples pointed out that there is a possibility of COVID-19 re-infection.
However, some experts believe that these were not actual examples of re-infection and that there is a low possibility of infection among COVID-19 patients, who have been cured if they again come into contact with the virus. There were many possible reasons behind test positivity after recovery. One of these is that the COVID-19 positive finding among recovered patients was due to the false negative result of the test i.e., the patient was still infected when he was discharged because of the false-negative result.
False-negative results can be due to faulty or inadequate, low-quality specimens, or less sensitive confirmatory tests. In a COVID-19-positive patient, who has recovered, residual viral RNA can be found which is not enough to cause the disease.
| Does 'high Temperatures Significantly Reduce' the Spread of Covid-19? | | |
Like, other contagious diseases seasonal in nature experts expecting similar seasonality with COVID-19. Amongst a number of diseases, outbreaks it has been observed they took place at places with low temperature (winter) and gradually effect diminishes as temperature increases (summer).
According to the one study, “High temperature in the summer and a high relative humidity during the monsoon may significantly decrease the transmission of COVID-19”. “In the early dates of the outbreaks, countries with relatively lower air temperature and lower humidity (e.g. Korea, Japan and Iran) saw severe outbreaks than warmer and more humid countries (e.g. Singapore, Malaysia and Thailand)”. In extrapolating the results of study, the authors found that the beginning of summer and rainy weather in the Northern Hemisphere can “effectively reduce the transmission of COVID-19,” while on the other hand, spread of this pandemic will continue in some parts of countries in the southern hemisphere.[19]
Different contagious diseases experts differ in their opinions and doubt that the disease spread will be checked during the summer. Recently, researchers from the Harvard Medical School observed the pattern of spread of COVID-19 in Asia and found that this pandemic may not be sensitive to temperature.[20] They observed the pattern of this pandemic in relation to the increase in temperature and humidity among various geographical parts of China and Singapore and found no decrease in the summer and spring. Based on these observations, they emphasized the need for meticulous public health interventions to check the spread of this pandemic across the globe.
| Was a Lockdown an Effective Way of Containing the Spread of Covid-19? | | |
There is debate among experts on the role of lockdown measures (social and economic restrictions) in the spread of a COVID-19 outbreak. Is a lockdown really beneficial in containment of the transmission? How long should the continue and when lockdown should it be lifted?
Many countries which had already applied several weeks of social and economic restrictions now want to lift these and some who did not apply a lockdown are considering whether and when to introduce one.
Experts not in favour of a lockdown argue that in countries with large poor populations and in some “high income countries” these lockdown measures may not be practical.[21] A huge population including poor migrants and slum dwellers living in congested places and unhygienic conditions have very limited resources and health-care facilities. Access to health care and food are the most important issues for them. Thus, their only hope is the development of a safe and effective vaccine to stop community transmission of the disease.
There are, on the other hand, many voices in favour of the lockdown. Some experts believed that lockdown it helped to control the doubling rates and allowed the states for mitigation to reduce impact of the pandemic.[22],[23],[24] strict containment of people in the red zones (high-risk areas) may have broken or slowed down the transmission of Covid-19. A slow growth rate and higher “doubling time” of cases was reported in Wuhan, which was attributed to the lockdown policy of China. Strict lockdown was implemented in Wuhan, China, for 77 days for 1.1 crore people and was attributed to control of its spread.[24]
According to the Ministry of Health, Government of India, “If India had not implemented either containment or a nationwide lockdown, the growth in the number of cases would have been by 41% and we would have recorded 8.2 lakh COVID-19cases by April 15”. “If there were only containment measures but no lockdown – India would have recorded 1.2 lakh cases by Apr 15. Since we have acted there were 7,447 cases on April 11”.[25]
The WHO suggests that control measures should be lifted slowly, and under strict control and have called lockdown measures as creating a “second window of opportunity” to contain the virus and advised against early easing of restriction which possibly lead to resurgence.
| Conclusion | | |
As the name suggests, this corona infection is a novel infectious virus. Epidemiological studies are in progress. Trials are being conducted to develop a vaccine, and various medical treatment protocols are being followed to treat patients infected with COVID-19. It will take time and meticulous research to finally arrive at a consensus. Yet, we hope that to save humanity the coordinated efforts of scientists, epidemiologists and medical professionals will decode the mystery behind this COVID-19 pandemic.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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