Tamil Nadu chief minister M.K. Stalin, April 2018. Credit: PTI
The Government of Tamil Nadu has published new treatment protocols for COVID-19 patients that leaves out the use of ivermectin, which had been included in a previous version.
The new protocols describe three categories of COVID-19 patients based on the level of care they need: home-based, primary care and pre-hospital care. It leaves hospital care out. The tests to determine the category to which a patient belongs are oxygen saturation (SpO2) and respiratory rate.
The protocols don’t mention the need for RT-PCR tests keeping in line with Tamil Nadu’s decision to adopt a syndromic approach: i.e. if a person has symptoms that may indicate COVID-19, they will be treated according to the protocol irrespective of whether they actually have the disease.
Tamil Nadu courted controversy after its previous guidelines recommended treatment with ivermectin, a cheap anti-parasitic that has been gaining in popularity but not evidence. Around the same time, Goa had announced that it would distributed ivermectin to all adults in the state as a prophylactic – preventive measure – against COVID-19 despite there being no evidence that ivermectic could have this effect.
Shortly after, WHO chief scientist Dr Soumya Swaminathan tweeted that it recommends against ivermectin’s use outside clinical trials, and linked to a press release by Merck – the drug-maker that had a patent on ivermectin until 1996 – that repeated the same message.
However, they have still prompted expressions of concern from independent experts because they recommend vitamin C and zinc supplements for people receiving home-based and primary care (categories 1 and 2) and azithromycin for primary care recipients.
Vitamin C and zinc are popular in India as valuable supplements for general well-being. However, when these and other substances are included in state- or national-level guidelines, more people tend to ask for and use them, which could potentially lead to consequences that doctors may not yet be aware of.
This concern has already come up with azithromycin and blood plasma transfusions. Azithromycin as an antibiotic and has zero effect against COVID-19, which is caused by a virus. Its prescription makes sense only for bacterial infections that a patient may develop in addition to COVID-19, during their treatment period. Azithromycin is redundant if such an infection doesn’t develop – but its use may also increase opportunities for bacteria already in the body to develop antimicrobial resistance.
Similarly, the Indian Council of Medical Research (ICMR) treatment guidelines include the use of convalescent blood plasma, even though it is also marked “off-label”, i.e. not approved for use. Convalescent blood plasma therapy has been found to have no benefits for COVID-19 patients (and in fact could be dangerous in some cases). But anecdotal reports indicate its presence in the treatment guidelines has encouraged many hospitals to continue to recommend it as an option for COVID-19 patients.
As treatments go, vitamin and zinc supplements aren’t as ‘significant’ as azithromycin and blood plasma. However, we don’t know if they help, and if they don’t, they may be a drain on patients’ finances; they may also interact with other drugs that patients are receiving, leading to outcomes we haven’t prepared for.