By Dr Sheri Fanaroff  MBBCh FCFP MFamMed, a Family Physician, practicing in Melrose, Johannesburg. Fanaroff is a member of GGPC (Gauteng General Practitioners Collaboration) which has created a platform for doctors to share resources during Covid-19. Look for  #voicesthatcare on the GGPC Facebook page.

 

Dr Sheri Fanaroff answers frequently asked questions patients asked this week about issues such as whether the Covid vaccine is safe, using Ivermectin and Colchicine

1. Are you going to have a vaccine?

Unequivocally yes! As will my family. I have registered on the healthcare worker database and will hopefully be in line to receive ASAP.

2. Which vaccine will you choose?

Whichever is available to me first.
On 1 February, the first vaccines arrived in the country. These are the Oxford/ Astra-Zeneca vaccines and were produced at the Serum Institute of India (many other vaccines that we use have been manufactured there for many years).

3. Aren’t you worried about the AstraZenica vaccine?  It only has a 65% efficacy and some countries aren’t using it with over 65s. 

It’s true that the Pfizer and Moderna vaccines have reported more than 90% efficacy against acquiring the virus, while Astra-Zeneca has a reported 60% to 90%. However, the vaccines have ALL shown nearly 100% reduction against severe COVID, hospitalisation and death, which is much more important.

There are still some ongoing trials awaited in older age groups for the Astra Zeneca vaccine. There is not really any reason to expect that the efficacy will be different in this age group, but it will be better received once more data is available.

New information in the last couple of days has raised further questions about the efficacy of the Astra-Zeneca vaccine, particularly against the new viral strains, the expiry date of vaccines received and efficacy data against mild to moderate infections.

We await answers to these questions, which may impact on the timing of rollout to healthcare workers.

4. Can we register and put our names down with you to receive a vaccine??

At this stage, there are a lot of unknowns about the vaccine rollout. Like many of the other GGPC GPs, I have registered my practice to be a vaccine site, and am completing the online vaccination course through the Department of Health so that I will hopefully be registered as a certified vaccinator by 15th February.

Although I aim to be able to function as a vaccination site, at this stage, I have no assurance that I will receive any vaccines. The electronic national registry has just launched. This will collect personal data and will allocate individuals to an allocated vaccination site, which may be a pharmacy, local clinic or a GP practice.

At the moment, the electronic database is only open for healthcare workers to register, but this will hopefully soon be extended to include the rest of the population.

5. When do you think vaccines will be available to the general public?

During Phase 2 Rollout, adults over 60 years, essential workers and patients over 18 years with comorbidities should be able to receive vaccines.

During Phase 3 Rollout, all adults over 18 years will be eligible.

The announcement this week that there are 20 million doses expected from Pfizer, 9 million from Johnson and Johnson, and 12 million from CoVax is wonderful news. I am hoping that vaccines will be available to many before winter, but this remains to be seen.

6. More on vaccines

There are so many more questions about vaccine side effects, safety etc that are beyond the scope of this article, but GGPC will address these in a future update. There are many skeptical anti-vaxers and a lot of misinformation.

This week there are some studies looking at vaccine boosters using more than one type of vaccine, lots about the efficacy of vaccines against the new strain, and more.

Vaccines may not be a “magic bullet” to end the pandemic, and it’s true that we will need to practice mask wearing, social distancing and hand sanitizing for some time after; however achieving herd immunity through vaccination is our best chance of returning to pre-pandemic social life, work and school.

7. Are you taking Ivermectin? Can you prescribe Ivermectin for me? 

“Compassionate use”

Last week, SAHPRA authorised Ivermectin for compassionate use, as part of a “controlled compassionate program” due to pressure from various groups, stating (as have FDA and NIH) that there is not enough evidence either for or against its use. “Compassionate use” implies each patient who wants to take it needs to apply via their doctor on a section 21 form to SAHPRA and it may or may not be approved. It’s not as simple as writing a script. SAHPRA are likely to only approve drugs under Section 21 if there are no other treatment options.

Procedure still unclear

On 3 February, the Gauteng High Court ruled in favour of Afriforum, giving doctors permission to treat COVID-19 using Ivermectin on an urgent basis, without waiting for the outcome of an application from SAHPRA. There are no clear guidelines as to when exactly Ivermectin should be administered and It is still unclear whether prophylactic use is allowed.

Big black market 

Another issue is the procurement of Ivermectin. Ivermectin for human use is not readily available at pharmacies. As Ivermectin up until last week was banned by SAHPRA, there is a large black market in South Africa for Ivermectin, and we have no way of knowing if what is on offer, smuggled into the country, is real and/ or safe. It may be just aspirin or even something harmful that has been packaged and labeled as Ivermectin. Most of the mainstream physicians and Johannesburg critical care senior doctors are still not advocating its use at this stage. Although some of the trials look promising, there is no unequivocal proof that it works.
There have also been some serious reported side effects, mainly neurological.

Side effects

There are many patients who have ended up in hospital with serious COVID-19 infection despite taking Ivermectin either for prevention or for treatment. And also many anecdotal good news stories.
The GGPC doctors have varying opinions on Ivermectin usage. See this article that was published in the Daily Maverick, written by one of our doctors, Dr Paul Freinkel.

I’m personally NOT taking Ivermectin at this stage, nor advocating its use, until there is more clarity. (See previous GGPC update on Ivermectin – little has changed since then!) The good news is that there are several ongoing randomised controlled trials with results expected in the next couple of weeks, which should either prove or disprove its efficacy and give us more accurate guidelines on a recommended dose.

Check the source

If you are taking Ivermectin, I urge you to check that it is from a reputable source, preferably a pharmacy and not a veterinary preparation, that you don’t exceed the very small recommended dose, and that you check the 20 page list of drug interactions if you are on any other medications. (Your GP can provide this to you).

8. What about Colchicine? New trials show this is promising.

The recent publication of the Colcorona study gave results of non-hospitalised patients treated with colchicine (a medication that reduces inflammation, mainly used to treat gout). This was a randomized controlled trial and concluded that the use of colchicine “significantly reduces hospitalizations by 25%, the need for mechanical ventilation by 50%, and deaths by 44%.”

While this sounds impressive, unfortunately if you look at it closely, the findings are actually not as significant as we would like. The absolute reduction in mortality was very small (from 0.4% to 0.2%.). The conclusions are that one would need to treat 500 people with risk factors with colchicine to save 1 life, and to treat 83 people to prevent one hospitalisation.

The 25% risk reduction in hospitalisation given in the study’s conclusion is only a relative risk reduction. (The risk of hospitalisation is 6% without colchicine and 4.6% with colchicine.) So the absolute risk reduction is only 1.4%. In other words, if you treated 100 patients , you would stop 1.4 of them from being hospitalised and dying.
Nonetheless, colchicine is a fairly harmless medication, with the main side effect being diarrhoea, and will definitely be a treatment consideration going forward.

Conclusion

We have learnt from the pandemic, that there is no single magic medication for either the treatment or prevention of  COVID-19. However, there is much that has been learned over the last few months, and despite the massive second wave and unpredictable new strain, treatment protocols are in place and doctors have better knowledge on how to treat it.

While we hold out for vaccines, we need to continue safe practices and continue responsible behaviour to protect our families and our community.

Useful related articles

COVID’s 2nd wave and sending kids back to school

How the AstraZeneca Covid vaccine works? A simple overview

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