June 27, 2020

Remdesivir, dexamethasone only effective drugs in current situation, says health expert Ashish Jha

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Dr Ashish Jha, is the K T Li Professor of Global Health at the Harvard T H Chan School of Public Health and the Faculty Director of the Harvard Global Health Institute. He is a practicing General Internist and also Professor of Medicine at Harvard Medical School. Most important, he has been looking closely at the journey of the pandemic both globally and in India. Busy through the day – at work from 6.30 am to 11 pm at least – and taking it par for the course, because, “we are in the middle of a pandemic,”  Dr Jha told Businesstoday.in on telephone. We began by asking him to explain the drugs that have been approved and what they actually do. Also, how they help deal with the coronavirus because every second day one hears of a new drug being approved and launched.

As we write this, Businesstoday.in learns that apart from the three drugs – dexamethasone, favipiravir and remdesivir – the Indian drug regulator has before it about 15 products (drugs to plasma products to others) awaiting approval. Of all the drugs, Dr Jha points us to two drugs, he says, have evidence that they work. One is remdesivir and the other is dexamethasone. “We have reasonably good evidence for both of them. At the end of the day, both of them only have one study and it is not like the evidence of those two are great but are good enough and in a difficult situation like this we should approve them. Everything else is speculation and I am not aware of any other drug that has shown to be effective. So, I think other drugs should be studied and researched.”

One a steroid, other an antiviral

So, what is that these two drugs do and how do they help deal with the virus better? Dexamethasone, he explains, “is a steroid and what it does is that it suppresses the immune system. The obvious question is why in an infection, would you want to suppress the immune system? That is because, based on what we have learnt over the last three to four months, it appears there are two phases of the disease. The first phase where the virus grows rapidly in the body and then there is a second phase when your immune system reacts to that virus and reacts very aggressively and starts damaging your body. So, what dexamethasone does is that it stops that aggressive response. And, here is the key issue, with dexamethasone, we are seeing that if you give it very early in the disease onset phase, it proves to be actually harmful. It could worsen the case because in the beginning of the disease, you actually need your immune system to work well.”

And, therefore, he sees a clear need for caution. “What I am worried about is that if people look at only the fact that dexamethasone approval as a drug and start taking it and if doctors prescribe them, it could be very harmful. And, this is where remdesavir comes in. What remdesavir does is that it stops the virus from replicating and thereby stops the growth of virus in the body. Therefore, remdesavir seems to be useful for those who are coping with the beginning part of the disease and dexamethasone is useful for those who have to deal with the disease in its later phase within the body.” 

But then what about the contention remdesavir proved that it reduces hospitalisation by about 30 per cent? Dr Jha has a simple answer: “Though the evidence on lowering the death rate is not as strong as I would like it to be, the data does make it look like it will probably lower the mortality rate too.”

Virus load in India

On how he views the journey of the virus in India and what should one be expecting? He has this to say: “I have to say, I am very worried about India. We are seeing acceleration of cases in many parts of the country and the question that I have been asking is what is it that is going to slow this virus down in India? The only three thing that we know that work are: First, lockdown and aggressive social distancing and I know Chennai for instance, has some sort of a lockdown but all of India is coming out of lockdown and it can be very difficult to go back to lockdown. Then, the only other thing we know of is masks can help. It is cheap and relatively easy to have and I believe, India should have some national masking law or at least every state should have that that ensures you wearing a mask when interacting with other people. Finally, the only third strategy that is available is that of ramping up testing , tracing and isolation – things that India has done very well in a few places.”

Reason for hope

Here he points to the success in dealing with the outbreak in Dharavi, one of Asia’s largest slums and in Mumbai. “By the way, I was very nervous when I heard about an outbreak in Dharavi and feared a possible disaster but it was not so bad because it was controlled with very aggressive testing and tracing. So, it is doable and that is what India has to focus on as also on social distancing. We should encourage people, who can work from home, to actually work from home. Of course, day labourers cannot work from home but should be wearing masks and make sure there are no large gatherings. So, there is a lot that can be done but it is going to be a very hard period of time. I am watching it every day and remaining concerned because the case number seems to be only going up.”

What next for India

So, where does he see India headed? “Well, what I am worried about is that let us say those three-four things that I just talked about (lockdowns, masks, social distancing and testing, tracing and isolation) are not done, then we are going to see a very, very large outbreak across the country and most of the modeling data suggest that within a month or so we will get to a point where there are 1 lakh or even 2 lakh cases per day (as against little over 18,000 today and the total so far crossing 5 lakh) and that off course will be very challenging to deal with. So, that is where India is heading if it does not take adequate care now and become aggressive (on the protection measures).”

Focus areas for Indian pharma

Given this backdrop and considering that the Indian pharma sees itself as the pharmacy of the world, what does he think should be the area of focus for Indian pharmaceutical companies? “India is the pharmacy of the world and Indian pharmaceutical companies right now must focus on ramping up production not just of the drugs approved to deal with the virus but also all the other drugs that are used in critically ill patients in hospitals because hospitals around the world are starting to get full and there are lot of regular medicines (pain to antibiotics) that are used in very sick people and a lot of them are made in India. And, Indian pharmaceutical companies must continue to produce them in as many numbers as they can because there are going to be global shortages of every major medicine that is used on a hospital patient.”

Dependence on China

As is to be expected in any discussion today, it is hard not to include the China angle. Therefore, when asked for his view on the way out from this huge global dependence on China in the medicine supply chain, including by the Indian companies (dependent on China for range of APIs – active pharmaceutical ingredients, he says: “Well in the short run, this is a question that America is facing too and in the short term we have to ensure that those supply chain remain intact as there is not enough time in the middle of this crisis to completely cut out China and in my mind, the focus has on making sure the drug supplies remain intact. Over the longer run, there is going to be a bigger question on how much different countries want to be dependent on each other.”

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