Tag Archives: remdesivir

Falling Through the COVID19 Cracks

When COVID19 snared President Trump in early October, he promptly received a dose of Regeneron and an airlift to Walter Reed Army Hospital;  physicians dispensed a course of therapeutics – Remdesivir and the steroid dexamethasone, and  supplemental oxygen as needed. That extraordinary spell of cutting edge treatment soon put the president back on the campaign trail almost within the week.

The price tag for the president’s helicopter ride and specialized, experimental treatment cost roughly about $1 million say experts, and was free, and funded by taxpayer dollars.

“I would not be surprised if it were to exceed $1m,” said Dr Bruce Y Lee, a healthcare researcher at the City University of New York.

The five star treatment afforded to Trump, however, is beyond the reach of average Americans, even those with insurance. With private insurance to cushion the cost, an average American would have to pony up $520 a vial  or $3120 for a course of anti-viral treatment.

At the other end of the healthcare spectrum are the uninsured – people who cannot afford even a single dose of Remdesivir, let alone an entire course of treatment, said Dr. David Hayes-Bautista Director of the Center for the Study of Latino Health and Culture, UCLA Health, at an October 23 Ethnic Media Services briefing.

His study of how the coronavirus impacts populations of color found that low-paid and uninsured workers in underserved communities rarely have health insurance to pay for treatment.

Without any protection, said Bautista, COVID19 finds gaps in care in the social services umbrella and the healthcare maze that marginalized communities have to navigate, and “the coronavirus falls upon them like rain.”

For uninsured workers who forage for healthcare access or have none, treatment is simply out of the question.

Quoting a UC Davis study, Bautista explained that $3120 for farmworkers in California is the equivalent of two month’s salary. What that means for farmworkers – many of whom are at high risk of exposure to COVID19 within the industry that employs them –  paying for treatment if they get infected means having to forgo food, rent, and other necessities that two months of income covers.

Disadvantaged populations have far higher case rates and mortality rates than non-Hispanic whites, said Dr. Bautista

When the virus hit, California shut down. People ‘grabbed their laptops’ and went home to work, but essential workers could not. Doctors, nurses and healthcare workers had to make sure they had PPE and equipment to treat COVID19 patients.

Other essential workers said Bautista, included meat packers, truck drivers, shelf stockers, grocery store workers, “folks working to make sure the rest of us can eat”, and check-out clerks who were far more exposed to the virus because “about 300 people pass within an arms-length.”

Those that tend to work in these occupations are mostly people of color, explained Bautista and the industries that expose them to the pandemic offer less access to care, treatment and follow up. As a result, California has high rates of exposure and mortality. The state now has a total of 922,005 positive cases. and a total of 17,626 deaths reports the California Department of Public Health.

In California, farm workers have been especially hard hit by COVID19. During the pandemic, migrant farmworkers continue to work shoulder to shoulder in ‘cuadrillas,’ and packing houses, or ride in crowded buses, putting their lives on the line to put food on our tables.

Vulnerable farmworkers (largely Latino, almost 100% immigrant, and 60-80% undocumented), are left out of the Affordable Care Act (ACA) because of their temporary status and cannot afford private health insurance. And yet, the county gave them letters confirming their essential status to travel, so they could go to work when the pandemic broke out. Workers were urged to see a doctor if they had symptoms, but without health insurance, “how would they pay to see a doctor, asked Bautista. “Some do not even know any doctors!” Their situation was further complicated by a requirement in the first few months of the pandemic, for sick people to get a doctor’s recommendation just to get a test – one they could barely afford.

“You could wind up paying $100 to almost $2000 for one test!” said Bautista. “In a farm worker family that quickly adds up.”

Even if a vaccine becomes available, said Denise Octavia Smith, Exec Director, National Association of Community Health Workers (NACHWA), it may be refused. Among Black and indigenous communities who have endured hundreds of years of medical testing and research on enslaved populations against their will, there exists a longstanding fear of vaccines, “We won’t be used as a guinea pig for white people.’’

Smith, who is tracking the disproportionate impact of Covid19 on under-resourced health systems, suggests supporting more community health workers familiar with barriers to care and wellbeing that marginalized populations experience, as trusted messengers to build bridges within these communities. This way, people who believe in efficacy of vaccine can get it when it becomes available

That moment could come sooner that they think. In a move that could transform life in COVID19  times for marginalized communities, the CDC is considering recommendations by ACIP (Advisory Committee on Immunization Practices ) to “remove unjust and barriers to good health and well-being” in some racial/ethnic minority groups that bear the disproportionate burden of the COVID19 disease.

The recommendations ask the CDC to “commit to fair stewardship in the distribution of a scarce resource.” Under review are outreach strategies that will  overcome barriers to access, and reduce health disparities in each phase of vaccine distribution.

The interventions must ensure that all affected groups, populations, and communities are treated fairly and have equal opportunity to access the vaccine and treatment, not just the privileged few.

The coronavirus doesn’t discriminate. Even the President got infected. What’s different is he had access to treatment well beyond the reach of essential workers who work to put food on our table. They are the ones “we forgot about,” said Bautista, and who will fall between the cracks of our healthcare jigsaw puzzle without a safety net.


Meera Kymal is a contributing editor at India Currents

Image: WorldBank, migrant worker in strawberry farm

A Family With Five Doctors & Two COVID Deaths

On the morning of April 1, Dr. Priya Khanna inched her way from the bedroom to the front door, using walls, doors and railings to hold herself up long enough to get to the stretcher waiting outside. She had been battling COVID-19 for five days and was struggling to breathe.

Her mother, also COVID-positive, watched helplessly as EMTs in full personal protective equipment guided Priya into the ambulance. Priya waved to Justin Vandergaag, a childhood friend walking alongside her. “I’ll see you later,” he said.

Ten days earlier, a similar scene unfolded when Priya’s father, Dr. Satyender Dev Khanna, was hospitalized for COVID-19.

The Khannas would soon suffer the most appalling of fates, as the two doctors from the same family encountered an illness against which they were fatally powerless.

Their story reveals the conundrum facing health care workers, who care for their patients while exposing themselves and their loved ones to risk. And it underscores how unprepared U.S. hospitals still were more than a month after news of community transmission of COVID-19 was first detected in the country.

COVID-19 has hit New Jersey hard, particularly in the north where the Khannas live. According to a database maintained by The New York Times, the state has recorded nearly 165,000 confirmed coronavirus cases and more than 12,300 deaths.

News of the pandemic had unsettled Priya, a 43-year-old nephrologist in the town of Glen Ridge. She suffered from a rare autoimmune disorder called small-cell vasculitis, and the medication she took to treat it compromised her immune system. She knew that if she contracted COVID-19 she would become very ill.

Priya, which means “beloved” in Hindi, had decided in college to become a doctor and graduated from Kansas City University of Medicine and Biosciences in 2003. Both her sisters were also doctors. She became certified in both internal medicine and nephrology, opened her own practice and was the director of two dialysis centers.

Priya Khanna (right) with younger sister Anisha Khanna-Sharma. (Courtesy of the Khanna family)

“She navigated the world with kindness and delight,” said a childhood friend, Laura Stanfill. She was “extremely selfless, a fiercely devoted friend and loyal,” said another, Melissa Auriemma. She gave long bear hugs and loved Lizzo, Hello Kitty, designer purses and anyplace with a beach.

Priya’s father fell ill in early March; the family is unsure how. Satyender, 78, was an immigrant from India who came to the U.S. with a medical degree and so little money that he did not know if he could afford the taxi ride to the hospital where he was to start his internship. In the 1980s, he became one of the first doctors in New Jersey to perform laparoscopic surgery, and was a trauma and general surgeon his whole career.

Five days after Satyender became sick, Priya’s mother, Kamlesh, a retired pediatrician, did, too. Priya, who lived with her parents, immediately isolated herself from them. She grew worried about her own health after a patient coughed directly in her face.

On March 20, Satyender was hospitalized, and a day later was placed on a ventilator. As a courtesy to Priya’s mother, the ICU physicians let her see her husband at the hospital he had worked at for more than 35 years. She suited up in her own personal protective equipment (PPE) and held his hand for a few minutes before being ushered away. It was a few weeks before what would have been their 50th anniversary.

“That was the last time she physically saw him alive,” said Dr. Anisha Khanna-Sharma, Priya’s younger sister and a pediatrician. “After that, we could only virtually see him on the iPad.”

Priya herself was taken to Clara Maass medical center, the 427-bed facility where her father was being cared for, on April 1. Because her sister Sughanda, an ER doctor, had her own full-body protective suit, she was able to gain better access than most visitors and found a situation reminiscent of a war zone.

Dr. Priya Khanna (seated) poses with friends Laura Stanfill (from left) Justin Vandergaag and Melissa Auriemma at her sister Anisha’s wedding in 2015. (Courtesy of the Khanna family)

There wasn’t enough proper PPE. Sughanda recalled intervening when the registration clerk, not wearing protective gear, leaned into Priya’s face to ask her questions. Priya didn’t receive a blanket or a pulse oximeter, and was not continuously connected to a patient monitor, the family said.

Sughanda and Anisha took turns FaceTiming with Priya. She was having trouble breathing, despite receiving 100% oxygen, and almost urinated on herself because she was too weak to walk to the common bathroom. She asked for a commode but never got one.

“They didn’t feed her,” said Anisha. “My sister didn’t get a meal at the hospital for the first 2½ days.” Instead, Anisha and Sughanda asked a nurse they knew to deliver food to her, and raised the alarm with hospital executives.

“Providing high-quality patient care is our priority, and that has never wavered even as we continue to treat those who are suffering from the coronavirus,” said spokesperson Stacie Newton. “While we do not comment on individual patients, we can assure you that all of our patients are treated with the utmost dignity and respect and any family concern is treated with attention, discretion, and privacy.”

Priya was weak but still reviewed patient files and texted with her replacement physician up until she went on a ventilator. Meanwhile, her sisters tried valiantly to find treatments. They put Priya and her father on a waitlist for the COVID-19 drug remdesivir. They sought and found hundreds of matches for an experimental treatment in which blood plasma from people who have recovered from COVID-19 is administered to patients.

Yet there were numerous bureaucratic delays. By the time the sisters were able to administer units to Priya and Satyender, it was too late, they said. Although it remains unclear at what point in the course of the illness the unapproved therapy is most helpful, Priya’s sisters are convinced their family could have benefited from earlier treatment.

“I think the doctors and nurses and staff did a phenomenal job in terms of doing what they could with what they had,” Sughanda said. “Was the hospital prepared for this? Absolutely not. Did they have enough resources to treat? Absolutely not. They did not have enough of anything to cover the surge of patients that were coming through the hospital.”

On April 13, Priya passed away, followed by her father on April 21.

After Priya died, Sughanda and Anisha both received packages in the mail of clothing Priya had bought for their children.

Every now and then, Auriemma, the childhood friend, rereads messages she sent Priya while she was in the hospital to cheer her up.

We gotta go to Oregon.

We gotta go out for lunch.

We gotta do our movie date.

“She was an excellent nephrologist. But it was short-lived,” said Kamlesh, Priya’s mother. “She touched so many lives, I can’t even tell you. She was the kindest, sweetest person I ever met in the whole world. I think that’s why God took her away from us. She was an angel.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Chasing A COVID Cure – An Elusive Dream?

Although scientists and stock markets have celebrated the approval for emergency use of remdesivir to treat COVID-19, a cure for the disease that has killed nearly 260,000 people remains a long way off — and might never arrive.

Hundreds of drugs are being studied around the world, but “I don’t see a lot of home runs right now,” said Dr. Carlos del Rio, a professor of infectious diseases at the Emory University Rollins School of Public Health. “I see a lot of strikeouts.”

Researchers have launched more than 1,250 studies of COVID-19. Pharmaceutical companies are investing billions to develop effective drugs and vaccines to help end the pandemic.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, was cautious when announcing the results of a clinical trial of remdesivir last week, noting it isn’t a “knockout.” Although remdesivir helped hospitalized COVID-19 patients recover more quickly, it hasn’t been proved to save lives.

“This [drug] is opening the door,” Fauci said. “As more companies and investors get involved, it’s going to get better and better.”

In future trials, researchers plan to combine remdesivir with other experimental drugs to try to improve its results, Fauci said.

But COVID-19 is an elusive enemy.

Doctors treating COVID patients say they’re fighting a war on multiple fronts, battling a virus that batters organs throughout the body, causes killer blood clots and prompts an immune system overreaction called a “cytokine storm.”

With so many parts of the body under siege at once, scientists say, improving survival rates will require multiple routes of attack — and more than one drug. While some of the experimental medications target the virus, others aim to prevent the immune system from inflicting collateral damage.

“There are so many pieces of this, and they will all require different therapies,” said Dr. Lewis Kaplan, president of the Society of Critical Care Medicine, whose doctors provide intensive care.

High-tech approaches include using stem cells, virus-specific T cells and synthetic antibodies to neutralize the coronavirus.

Scientists are also taking a fresh look at existing medications that might be repurposed to fight COVID-19. These include antivirals for influenza, arthritis drugs, estrogen patches and even antacids. If repurposed drugs are successful, they could reach patients relatively quickly, because doctors are already familiar with their side effects and safety concerns.

Some doctors are skeptical that drugs for heartburn or hot flashes have any chance of treating a killer like COVID-19.

Dr. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic, said he fears that hype over unproven products will harm patients, even if it temporarily boosts company stock prices. Patients who demand antacids or antimalarial drugs being studied in COVID-19 could be harmed by side effects, for example. Those who hoard drugs — on the hope of protecting themselves from COVID-19 — could deprive other patients of medications they need to stay healthy. Some people may refuse to participate in clinical trials because they fear being given a placebo.

“This rush to get every imaginable treatment into a study, it’s not prudent,” Nissen said. “It’s not good medicine. It’s an act of desperation.”

Other experts say scientists should cast a wide net.

“I don’t think we want to rule anything out because it sounds out of the ordinary,” said Dr. Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh.

Antivirals In The Spotlight

Antivirals such as remdesivir aim to prevent viruses from replicating, said Dr. Peter Hotez, a professor at Baylor College of Medicine in Houston.

That doesn’t always work. A small Chinese study of remdesivir, published last month in The Lancet, found no benefit to severely ill COVID-19 patients. Remdesivir had previously failed when tested against Ebola.

Antivirals tend to be most helpful in the early stages of infection, when most of the harm to the patient is caused by the virus itself, rather than the immune system, Hotez said.

Remdesivir is just one of many antivirals being tested against COVID-19.

International researchers are studying the antiviral favipiravir, developed to fight the flu.

The antimalarial drugs chloroquine and hydroxychloroquine — which have been heavily touted by President Donald Trump — also have antiviral effects. Although the Food and Drug Administration approved forms of those drugs for emergency use against COVID-19, the agency later warned that they could cause dangerous heart rhythm problems.

A study in the New England Journal of Medicine likewise found no benefit in giving two antivirals used to treat HIV ―a combination of lopinavir and ritonavir, sold as Kaletra— in adults hospitalized with severe COVID-19.

Harnessing The Immune System

One of the therapies generating excitement is also one of the oldest: antibody-rich blood from COVID survivors.

The immune system produces antibodies in response to invaders such as viruses and bacteria, allowing the body to recognize and neutralize them. Antibodies also recognize and neutralize the virus the next time that person is exposed.

Doctors hope that patients who develop antibodies against the novel coronavirus will become immune, at least for a few years, although this hasn’t been proved.

Scientists developing this “convalescent plasma” are studying whether COVID-19 survivors can share this immunity with others by donating their plasma, the liquid part of blood that contains antibodies, said Dr. Shmuel Shoham, an associate professor of medicine at the Johns Hopkins University School of Medicine.

In addition to treating people who are already sick, donated plasma could potentially prevent people exposed to the virus — such as health care workers — from developing symptoms.

Donated antibodies ― and any immunity they might provide — don’t last forever, said Dr. William Schaffner, a professor at the Vanderbilt University Medical Center. The body destroys aging antibodies as part of its routine maintenance, he said. In general, half of donated antibodies are eliminated in about three weeks.

The use of convalescent plasma goes back more than a century. It was used during the 1918 flu pandemic and was shown to improve survival during the 2009-10 H1N1 pandemic.

Doctors don’t know yet whether convalescent plasma will benefit people with COVID-19.

In general, convalescent plasma is expected to be more effective in preventing illness than in treating it. It may be less likely to help someone in intensive care, Shoham said.

Researchers are also studying the use of prepackaged plasma, called intravenous immunoglobulin, in COVID patients. This product, known as IVIG, is taken from healthy donors in the general population and has long been used to help patients with weakened immune systems fight off infections. Hospitals keep it in stock and some are already using it to treat COVID patients.

Although the antibodies in prepackaged IVIG don’t specifically target the coronavirus, researchers hope they will tamp down the immune response.

In a third form of immune therapy, researchers are trying to identify the specific antibodies that are most important for neutralizing the coronavirus, then reproduce them as drugs called monoclonal antibodies. Monoclonal antibodies are already used to treat a variety of conditions, from cancer to rheumatoid arthritis and migraines.

“When we give people an antibody, they are immediately at least partially immune to that specific virus,” said Dr. James Crowe, director of the Vanderbilt Vaccine Center, who hopes to have antibodies ready for a clinical trial in a few months. “We’re moving the immune system from one person to another.”

Ideally, doctors would develop a very potent monoclonal antibody or a cocktail of antibodies for COVID-19 patients, to ensure the best chance of success, Crowe said. But manufacturing these drugs can be complicated, expensive and time-consuming.

“Making two antibodies would be at least twice as complicated as making one,” Crowe said. “A cocktail might be preferred, but cocktails are harder to move quickly.”

Dr. Anar Yukhayev, pictured on March 24, was hospitalized at Long Island Jewish Medical Center for COVID-19. He agreed to join a clinical trial of Kevzara, an immune suppressant. (Courtesy of Dr. Anar Yukhayev)

Calming The Immune System

In most cases of COVID-19, the immune system neutralizes the coronavirus and patients recover without going to the hospital.

For reasons that doctors don’t totally understand, the immune system of some COVID-19 patients becomes hyperactive, attacking not just the virus but the patient’s own cells. A “cytokine storm,” in which the immune system floods the body with inflammatory chemicals, can do more damage than the virus itself.

In an effort to calm the immune system, researchers are testing immune-suppressing drugs, including monoclonal antibodies already used to treat autoimmune diseases such as rheumatoid arthritis, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.

Health care giant Roche is conducting large clinical trials of its drug, Actemra, in the hope of preventing cytokine storms, which can cause organ failure and a life-threatening condition called sepsis. Actemra is designed to lower levels of an inflammatory chemical, interleukin-6, which has been found to be elevated in some COVID-19 patients.

Scientists are also studying similar drugs, anakinra and siltuximab.

Another immune suppressant from Regeneron and Sanofi, called Kevzara, has had disappointing results in clinical trials. The manufacturers plan to continue studying the drug to see if it can help certain types of patients.

Dr. Anar Yukhayev, a New York OB-GYN who was hospitalized with COVID-19 on March 16, agreed to join a clinical trial of Kevzara.

“I was having so much trouble breathing that I was desperate for anything to help,” said Yukhayev, 31, who was treated at Long Island Jewish Medical Center.

About 36 hours after receiving an infusion, as Yukhayev was being treated in intensive care, his symptoms began to improve. He was able to avoid being put on a ventilator. Doctors didn’t tell him if he received Kevzara or a placebo, but his liver enzymes also began to rise, suggesting the organ was under stress. Elevated liver enzymes are a known side effect of Kevzara.

Yukhayev made a full recovery and went back to work full time April 13. He donated his plasma to researchers.

Until vaccines and other preventive medicines are developed, the best way to prevent coronavirus infections is to maintain social distancing, Adalja said.

“Social distancing is a blunt tool,” he said, “but it’s all that we have.”

Dr. Anar Yukhayev donates plasma on April 18, after making a full recovery from COVID-19. (Courtesy of Dr. Anar Yukhayev)

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.