Desperate for Covid-19 answers, U.S. doctors turn to colleagues in China/ Stat

From STAT, a report of an online meeting between Johns Hopkins infectious disease doctors and doctors from Zhejiang, one of China's top medical schools, who had responded to the COVID-19 epidemic: 

...We want to work together with you to help fight Covid-19, Wang told the Americans as the hourlong meeting began. Their first question: If you were in our position, at the very beginning of the outbreak, what are the most important things to know?

The Zhejiang contingent took over one makeshift ICU in Wuhan on Feb. 14, plus one ward for Covid-19 patients in an existing hospital. They had 72 ICU patients, 55% older than 65, yet only nine of the ICU patients died; 17% required intubation in order to breathe, a procedure that risks making virus particles not only airborne but also aerosolized — meaning they can remain suspended in the air for some time.

The Hopkins doctors were keen to hear how their counterparts cured 35 intensive-care patients completely and brought the status of another 28 to only mild disease. With no surefire Covid-19 therapy and a blizzard of conflicting information on what existing drugs might work, Antar said, “one of our main questions was about their experience with off-label use” — repurposing existing drugs approved for other illnesses to use in the fight against Covid-19.

That experience has involved everything but the kitchen sink, though informed as much as possible by science. Several antivirals, including the HIV drugs lopinavir and ritonavir, did not accelerate recovery or reduce mortality, ICU physician Xiao Lu said. Some immune system regulators — including alpha interferon, anti-IL-6 monoclonal antibodies such as tocilizumab, and immunoglobulin — showed hints of efficacy in some critical cases.

Some patients received the malaria drug chloroquine, which President Trump has touted and which is being tested in a World Health Organization-supported clinical trial, but the Zhejiang team did not have rigorous data on its effects. They tried tocilizumab, too, a drug that has enough potential that on Monday, Genentech announced that it had received U.S. Food and Drug Administration approval for a clinical trial in Covid-19 patients with severe pneumonia; the rheumatoid arthritis drug, which goes by the brand name Actemra, might quell the out-of-control immune reaction that has killed many Covid-19 patients.
“All of us want to practice evidence-based medicine,” Antar said. “But the timeline for this might not allow us to wait for that.”

The right equipment helped. The Zhejiang team brought oxygen supply systems, monitors, ultrasounds, ventilators, and protective equipment from Hangzhou.

Who should be hospitalized, the Hopkins physicians asked? Suspected cases can be isolated and observed in their homes, they were told, as doctors in overwhelmed Italy are also telling U.S. doctors. Mild and moderate cases can be treated in mobile units, away from other patients; coronavirus spread within hospitals has been disastrous in Italy. Severe and critical cases in China get hospitalized, but at a dedicated facility, to reduce spread from Covid-19 patient to hospital worker to non-Covid-19 patient.

How do we know when a patient can be discharged, Antar and her colleagues asked? After a normal body temperature lasting three days, minimal respiratory symptoms, two negative tests for the virus more than 24 hours apart, improvements seen in lung imaging, and no serious underlying conditions, especially for older patients.
The Hopkins teams was impressed with China’s scrupulous measures to minimize viral transmission, “especially among health care workers,” Auwaerter said. “Such measures have successfully slowed the epidemic in China.” In contrast, failing to do so has fueled the disastrous spread of Covid-19 in Italy, physicians at a hospital in the country’s hard-hit north warned over the weekend.