April 13, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
COVID-19 Update: Things are very stable in Kingston and our incidence curve remains flat. There are a total of 55 cases in the region and there have only been 2 new cases in the KFLA region in the past week. There are no new cases in the past 3 days. There are 2 patients with COVID-19 infection currently admitted to KGH on Medicine’s COVID-19 unit. Our point prevalence (% of COVID-19 tests that are positive) remains < 5%. In fact, in the last 3 days only 8/737 tests (1%) tests at the KHSC lab were positive. In the past 5 days none of our positive COVID-19 tests have been from the Kingston area. Sadly, but not unexpectedly, we recorded our first 2 deaths from COVID-19 this weekend.
Update on the care of inmates in Kingston to reduce COVID-19 risk: There are several thousand inmates in our region and protecting them from COVID-19 is critical, since the prison environment would readily allow disease to spread once cases occurred. Through intervention of KFLA (Dr. Kieran Moore) Corrections Services of Canada are now screening employees at the workplace entrance and guards are asked to wear gloves and masks throughout shift, to protect inmates. This should significantly reduce risk of outbreaks in prisons. Thanks Kieran!
Advice on “bad advice”-a bitter pill to swallow in the assessment of COVID-19 drugs: This segment of the update is a reminder not to jump the gun and take medications you may have access to until their effectiveness, dose and adverse effects are known. Certain US politicians have advocated trying hydroxychloroquine as a means of treating or preventing COVID-19. Indeed many patients in supervised setting are getting this medicine as a trial therapy because two small clinical trials (which were either not randomized or not peer reviewed) suggest benefit. In a study from France,hydroxychloroquine (600 mg daily ± azithromycin) reduced viral load and the duration of viral carriage in an open-label, non-randomized, trial in 36 patients with COVID-19 infection1. In a preliminary report, yet to be peer reviewed, Chen et all reported that in patients randomized to 5-days of hydroxychloroquine 400 mg/day vs placebo, 81% of the HCQ group had improvement of COVID-19 pneumonia, versus 55% of controls2. However, HCQ has toxicities, notably retinopathy and long QT syndrome (arrhythmia), commonest with chronic use at doses > 5 mg/kg. This is important because there is a lot of hydroxychloroquine and chloroquine in circulation amongst the population (for rheumatoid arthritis therapy and as an antimalarial, respectively). People may have a supply and be tempted to use it. Despite promising early results a recent study suggests caution and reflects our ignorance of maximal safe dosing.
A Brazilian study, from Manaus, Brazilian Amazon, recently issued a preliminary report. Their study included 81 hospitalized patients, who received 450 milligrams of chloroquine twice daily for five days (low dose) or 600 milligrams bid for 10 days (high dose). To put these doses in perspective, for malaria prevention the chloroquine dose is only 300mg once a week and to treat malaria it is 2.5 g chloroquine phosphate (1.5 g base) is given over 3 days. So the dose used in this study was high, relatively speaking. Also a reminder, this is not hydroxychloroquine which is in general less toxic. Nonetheless, patients taking higher doses of chloroquine experienced heart arrhythmias and 11 patients died by the sixth day of treatment. This caused the research on high dosages to end. Moreover, it was not obvious that high dose treatment helped treat their COVID-19. The authors noted” … 81 patients were enrolled. The high dose CQ arm presented more QTc>500ms (25%), and a trend toward higher lethality (17%) than the lower dosage… In 14 patients with paired samples, respiratory secretion at day 4 was negative in only one patient.”
I pass this information along only to remind people not to self-medicate despite random noises from south of the border or your own fears. This does not mean we will not continue to use hydroxychloroquine (a different drug) at safe doses. Please be assured that at KSHC our infectious disease doctors and collaborators are planning to join international clinical trial so in the near future there should be proof whether hydroxychloroquine (and other antiviral drugs that were used in China) are indeed beneficial. At many North American hospitals doctors are treating patients with hydroxychloroquine and azithromycin for 5 days or trying other (also unproven) antiviral agents, like remdesivir. In a hot of the press article in patients hospitalized at various international sites for severe COVID-19 who were treated with remdesivir on a compassionate basis, clinical improvement was observed in 68% of 53 treated patients. Like the Brazilian study this was not a placebo controlled, randomized trial…so stay tuned for actual evidence. In addition there is no medicine that is proven to prevent COVID-19 (including hydroxychloroquine).
- Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L, Mailhe M, Doudier B, Courjon J, Giordanengo V, Vieira VE, Dupont HT, Honore S, Colson P, Chabriere E, La Scola B, Rolain JM, Brouqui P and Raoult D. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020:105949.
- Chen Z, Hu, J.,Zhang, Z., Jiang, S., Han, S., Yan, D., Zhuang, R., Hu, B., Zhang, Z. Efficacy of hydroxychloroquine in patients with COVID-19: results of a randomized clinical trial. medRxiv 2020032220040758. 2020.
Here is a more global look at the pandemic today. America clearly remains the global hotspot and there are over 300,000 more cases than in my last report on Thursday 5 days ago!
There are currently 24,804 cases and 734 deaths related to COVID-19 in Canada. Cases are up by over 5000 compared to last Thursday’s report (click link for daily update)
KGH has good capacity, as seen on today’s graphic indicator below. Note that we have 56 available ventilators and 150 beds available, should there be an uptick in local COVID-19 (fortunately they have not occurred in large numbers so far).