Post Publication Independent Review of
“Making decisions to mitigate COVID-19 with limited knowledge”
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Post Publication Independent Review of “Making decisions to mitigate COVID-19 with limited knowledge”
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Post Publication Independent Review of
Making decisions to mitigate COVID-19 with limited knowledge
Published: April 07, 2020 DOI: https://doi.org/10.1016/S1473-3099(20)30280-2
1. Quote "In their Comment, Yonghong Xiao and Mili Estee Torok1 rightly stated that infection prevention and control measures should be based on sound scientific principles. However, we disagree with the authors' views on certain measures that they consider to have “no scientific basis and have proven to be ineffective”. A difference exists between measures with unknown effectiveness and those that have been proven ineffective or of no value." End of Quote.
The authors here are triggering a rational thought process that needs to be applied (on every aspect) when dealing with pandemics like COVID-19.
Everyone may have the acceptance that infection prevention and control measures need to be based only on sound scientific principles. However, there can always exist a possibility that some measures may be quite effective, but have not been investigated thoroughly using scientific methods. When a pandemic like COVID-19 erupts, and when it takes sufficient time to even analyse and understand how the infection can be prevented and controlled, it is sure that there can always be some effective measures that have not been investigated and proved significant immediately. Prevention and Control Measure may be carried out based on only those methods which are tested scientifically. There will always be a fatality rate, though the numeric value of the fatality rate could vary based on various factors.
Consider the following situation.
methods which have not been scientifically tested currently,
are tested in due course of time and
in case if
they yield better life saving results compared to current effective methods, and
prove themselves superior in life saving compared to current effective methods
is there any provision to reverse time, bring back to life all those who are dead due to COVID-19 and restart treatment?
It is not possible.
Hence the consequent significance to the Authors' Statement "A difference exists between measures with unknown effectiveness and those that have been proven ineffective or of no value".
Hence, prevention and control measures with unknown effectiveness should be given due consideration, though caution can be exercised.
2. As an illustration and to prove their point, the authors are presenting a case as follows.
Quote "We disagree with Xiao and Torok's view that “the practice of blocking traffic and lockdown of villages is of no value for the prevention and control of COVID-19”. One of the references provided to support this statement was a local transport authority policy reported in a newspaper, which should not be considered as scientific evidence. Several studies have been done to assess the effectiveness of travel restrictions,2, 3 and the benefit of such restrictions might vary in different settings. Further studies and more data are required to reach a solid conclusion."
End of Quote
Earlier, it wasnt proved scientifically that blocking traffic and lockdown of villages would help in pandemic control. Reference 2 and 3 cited by the author are research articles published on March 6 and March 11, 2020. Consequently, upto March 6, 2020 and March 11, 2020, blocking traffic and lockdown of villages had no scientific merit in controlling the COVID-19 outbreak. But after March 6, 2020 and March 11, 2020, blocking traffic and lockdown of villages had scientific merit.
Compare this with the Nation-wide lockdown in India to control COVID-19 outbreak. Statistics of COVID-19 spread seems to indicate that Nation-wide lockdown is better that lockdown of villages (as indicated in Reference 2 and 3). But these statistics are available only in the last few days of March 2020 and in the first fortnight of April 2020 (while this review was written on April 12, 2020).
If the Indian statistics of COVID-19 containment due to Nationwide lockdown was available earlier, then Nationwide lockdown may have become the gold standard for containing pandemic outbreak. Now, a look at the Quoted text in this review comment will help to understand better.
Consequently, the authors of this research article are right in stating that prevention and control measures with unknown effectiveness should be given due consideration.
3. As a fallout of the above, the authors are calling to attention a concern in COVID-19 treatement.
Quote "With regard to hospital treatment of patients with COVID-19, Xiao and Torok suggested that patients should not be given drugs of unknown efficacy. However, considering that no treatments are known to be effective at present, we believe that off-label or compassionate use of drugs should be considered ethical, especially for patients with life-threatening infections. However, when considering off-label or compassionate use of drugs, the safety profile of the drug should be clear and the clinicians should carefully balance the risk and potential benefit of use" End of Quote.
Reading together Review Comments 1 & 2, and considering the symptomatic changes that happen in a patients biological systems due to incidence of COVID-19, the suggestion by the authors that "compassionate use of drugs should be considered ethical, especially for patients with life threatening infections" assumes a lot of significance.
Compassionate use of drugs is never recommended, and the rule book alone is followed. But, the authors make an earnest entreaty, that when the patient is suffering from infections that are life-threatening due to a pandemic like COVID-19 (over which previous scientific knowledge does not exist, and scientific knowledgebase is currently getting built up), compassionate use of drugs may be considered ethical and consequently permitted to be used.
At the same time, compassionate use of drugs cannot be given a blanket permission but can be given only on a case by case basis.
4. Quote "During this urgent phase of the COVID-19 pandemic, decisions at the level of the public health response or clinical management have to be made using the scarce data available. Scientific evidence will be gradually established as a result of ongoing research. However, measures that have good rationale, but for which little data are available, should also be considered as options and should be assessed and amended in a continuous manner."
End of Quote.
Read together with Review Comment 3, compassionate use of drugs and other clinical/medical decisions at the level of public health response or clinical management may need to be provisioned.
Suggested that a "call-centre" type of service may be provisioned, with the first level of access manned by junior doctors, healthcare professionals, paramedics, counsellors/psychiatrists, emergency professional etc., who can then divert the call to appropriate agencies or secondary/tertiary level of medical experts for decisions and suggestions. If necessary, the tertiary level can escalate to the Core Teams handling COVID-19 National Level Protocols. Access can be provided to the general public
This call-centre may be provisioned at the mobile distress dialling code 112, so that all distress calls arising during COVID-19 containment & treatment time may uniformly via all channels be routed to the call-centre which also can serve as National Emergency Response Call Centre during current COVID-19 outbreak and be re-convened in future whenever required for any time of National Level Emergency Response.