Battling the Coronavirus: Treatment and Vaccines
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Battling the Coronavirus: Treatment and Vaccines Versione
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Come battere il Coronavirus: terapie e vaccini disponibile
on-line
Susan Levenstein
Aventino Medical Group, Rome (Italy)
Corresponding author: doctorlevenstein@gmail.com Keypoints
n Therapeutic options for COVID-19 are largely limited
to monoclonal antibodies, steroids for inpatients, and
ABSTRACT supportive care.
n Excellent vaccines were developed rapidly, but their
Close patient contacts can be protected by using monoclo- efficacy is being challenged by new viral variants and
nal antibodies alongside non-pharmacological measures. waning effect over time.
Antibodies also effectively ward off hospitalization in high-
risk outpatients, while colchicine, inhaled budesonide, and
fluvoxamine help modestly. Inpatient treatment is based on cologiche. Gli anticorpi, inoltre, prevengono efficacemente
dexamethasone, anticoagulants, immunosuppressives, and il ricovero in pazienti ambulatoriali ad alto rischio, mentre la
– dubiously – remdesivir. ‘Long COVID’ has no treatment. colchicina, la budesonide per via inalatoria e la fluvoxamina
Vaccination is the best overall strategy for defeating the Cor- aiutano in maniera più limitato. Il trattamento ospedaliero si
onavirus, especially with the highly effective mRNA vaccines basa su desametasone, anticoagulanti, immunosoppressori
from Pfizer and Moderna, though viral vector (e.g., Astra- e – in modo dubbio – remdesivir. Per il cosiddetto long CO-
Zeneca, Johnson & Johnson), protein subunit (Novavax), and VID non esistono cure. La vaccinazione è la migliore strate-
attenuated or killed virus vaccines may play a role. Efficacy gia globale per sconfiggere il Coronavirus, in particolare se
against variants, vaccine hesitancy, mixing-and-matching of effettuata con i vaccini a mRNA altamente efficaci di Pfizer
products, and booster shots remain major issues. e Moderna, sebbene il vettore virale (per esempio, AstraZe-
Keywords: COVID-19, SARS-CoV-2, treatment, vaccines neca, Johnson & Johnson), la subunità proteica (Novavax) o
con virus attenuato o inattivo possano fare la loro parte. L’ef-
ficacia contro le varianti, l’esitazione vaccinale, il cosiddetto
RIASSUNTO eterologo e le vaccinazioni di richiamo rimangono proble-
i contatti stretti dei pazienti possono essere protetti utiliz- mi importanti.
zando anticorpi monoclonali insieme a misure non farma- Parole chiave: COVID-19, SARS-CoV-2, terapie, vaccini
When the novel Coronavirus, casirivimab and imdevimab) lowers the Remdesivir, the only anti-SARS-CoV-2
now known as SARS-CoV-2, clobbered rate of illness by a whopping 81.4%.1 antiviral in current use, requires intra-
first China then Italy in early 2020, most This has been known since April 20212 venous infusion. A trial of a more con-
epidemiologists thought it could be and blessed by the US Food and Drug venient inhaled version in outpatients
contained easily, most virologists pre- Administration at the end of July, but was completed in March, but has not
dicted effective treatments would arrive has not yet caught on, and the Euro- released any results.6
fast, and practically nobody expected a pean Medicines Agency hasn’t spoken. For newly diagnosed patients at low-
vaccine before the end of 2021. They moderate risk of going downhill, we
were all wrong. Non-pharmacological OUTPATIENT THERAPY have little to offer beyond antipyretics
mitigation measures have failed, largely A year and a half into the pandemic we and home monitoring of oxygen satu-
due to lack of political will; one magic are not even close to finding a pill that ration. The ancient gout remedy col-
bullet after another has proved ineffec- can nip COVID-19 in the bud. Unfor- chicine does cut hospitalization rates
tive; and vaccines arrived a full year ear- tunately, scientists fixated early on hy- by 25%7 and the asthma drug, inhaled
lier than predicted. droxychloroquine, largely due to French budesonide, by 18%.8 Fluvoxamine,
celebrity microbiologist Didier Raoult’s an SSRI antidepressant, after very pre-
PREVENTION dreadful research3 (e.g., the abstract liminary positive results last November,9
Our most effective means of prevention of this study neglects to mention that seems in a larger study to cut hospital
are lockdowns, masks, distancing, ven- 4 of the 20 patients who received the recourse in high-risk patients by 30%.10
tilation, and vaccination, but we can drug vs none of 16 controls, wound Patients at high risk because of age
also protect close contacts of infected up in the ICU or dead). Vast resources or comorbidities should additionally be
individuals pharmacologically. Subcuta- were squandered on hundreds of trials treated with one of 3 existing mono-
neous REGEN-COV (Regeneron’s com- before it became clear that hydroxy- clonal antibody products aimed at the
bination of two monoclonal antibodies, chloroquine is useless or worse.4,5 SARS-CoV-2 spike protein (others are
anno 45 (4) luglio-agosto 2021 Epidemiol Prev 2021; 45 (4):In press. doi: 10.19191/EP21.4.A001.074www.epiprev.it
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A year and a half
into the pandemic
under development). Hospitalizations we are not even close over respirators. An authoritative re-
fell by about 70% when high-risk out- to finding a pill view of medications is freely available
patients were given Lilly’s combination at UpToDate.26
of bamlanivimab and etesevimab11 that can nip n Remdesivir: The only SARS-CoV-2
or Regeneron’s REGEN-COV,12 and COVID-19 antiviral in clinical use, it was rushed to
by about 84% with GSK-Vir’s sotro- approval on the basis of a single study
vimab,13 within days of diagnosis (pre- in the bud finding merely that it shortened hos-
Delta). These drugs are underused – only pitalization of COVID-19 pneumonia
one in 4 eligible patients receives mono- rosis drug raloxifene – a trial has been patients by a few days, with a nonsig-
clonals in the US, and fewer than 7,000 completed but no results presented nificant trend toward fewer deaths.27 A
patients have ever been treated in Italy. yet. Ivermectin has been more or less Cochrane review as of April concluded
One reason is that they are usually given debunked in a Cochrane review,19 and remdesivir “probably has little or no ef-
in a hospital setting by slow intravenous some ongoing studies might stop now fect on all cause mortality.” The CDC
infusion – but the FDA (not the EMA) re- that a major article has been withdrawn still recommends its use, but the World
cently approved half-dose REGEN-COV for data fabrication.20 Health Organization does not,28 and
as a convenient subcutaneous shot.14 Players around the world, including the the death blow may be a July 2021
We do not yet know how well the anti- “Medici Covid19” group in Italy and Norwegian add-on to the WHO Solidar-
bodies work in breakthrough infections. the “Front Line COVID-19 Critical Care ity trial that found no effect on clinical
How about the variants? Alpha Alliance” in the US as well as the gov- measures or viral load.29
(B.1.1.7, first seen in England, and ernments of Brazil and India, promote n Corticosteroids: Dexamethasone
never a problem), Beta (B.1.531, South multidrug cocktails to COVID-19 out- is the sole drug proven to save lives in
Africa), Gamma (P.1, Brazil), and Delta patients on the “Don’t just stand there, COVID-19, decreasing mortality of pa-
(B.1.617.2, India) are the main ones do something” principle. The most tients on ventilators by 36%.22 Virtually
thus far. Lilly’s original monoclonal common components are known to be all hospitalized patients on oxygen re-
antibody, bamlanivimab, was useless ineffective (hydroxychloroquine, zinc, ceive it.
against Beta, and its bamlanivimab/ azithromycin, vitamin D, ivermectin…). n Anticoagulation: Severe COVID-19
etesevimab combo was withdrawn for Others are valid, but only in selected carries a high risk of thrombosis, so
inefficacy against Gamma; REGEN-COV hospitalized populations, notably sys- heparin derivatives are given preven-
and sotrovimab do fine against both. temic corticosteroids and anticoagu- tively to most hospitalized patients,
But Delta is the scariest. It is 2-3 times lants. We know that COVID-19 patients though patient selection, dose, and
as contagious as the Wuhan origi- taking steroids long-term for rheumatic mortality benefit are uncertain.30
nal, with a viral load up to 1,000-fold diseases are at higher risk of hospitali- Patients critically ill with COVID-19 are
greater than Alpha,15 and replication zation,21 and that they make inpatients prone to ‘cytokine storm’, an excessive
so efficient that infected people start not on oxygen more likely to die;22 the immune reaction that can lead to organ
spreading the virus within days. It may FDA recommends strongly against their damage. The immunosuppressive toci-
also cause more severe illness.16 Delta use in outpatients.23 Anticoagulants lizumab (Actemra), an IL-6 antagonist
already causes almost all new cases are useless for outpatients, with the used in rheumatoid arthritis, slightly
in India, England, Israel, Italy, and the major trial stopped in June for futility.24 lowers mortality and need for mechani-
United States, and seems poised to take cal ventilation when added to steroids
over the world. The Regeneron and Lilly INPATIENT THERAPY in selected patients.31 The oral JAK
products neutralize it fairly well in the Monoclonal antibodies can help inpa- inhibitor baricitinib, which works simi-
testtube,17 and sotrovimab very well,18 tients too, if they have not been sick larly, has won emergency authorization
though their real-world effectiveness long enough to develop their own an- in Europe and the US for patients who
remains unproven. tibodies.25 Non-pharmacological ad- cannot be given steroids.32 Other im-
Still under study: two oral antivirals, vances include proning, high-intensity mune modifiers under study include
Pfizer’s PF-07321332, which began nursing in the intensive care unit, atten- Saccovid and infliximab (by intravenous
Phase 2-3 trials in July in combination tion to respirator settings, and strong infusion), opaganib and the antimalarial
with ritonavir, and masitinib, which is preference for noninvasive oxygen de- artesunate (by mouth), and EXO-CD24
still in preclinical testing. The osteopo- livery (C-PAP, high-flow nasal oxygen) (by inhalation). WHO’s Solidarity trial is
anno 45 (4) luglio-agosto 2021 Epidemiol Prev 2021; 45 (4):In press. doi: 10.19191/EP21.4.A001.074www.epiprev.it
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Already
70% of Italians,
also studying the cancer drug imatinib, 61% of Americans, more contagious, than with previous
intended to counter pulmonary capil- and 33% of all viral strains.
lary leak in COVID-19 pneumonia. n Moderna: This all-American mRNA
n Long COVID: Unfortunately, there humans on the planet vaccine achieved a 94% overall efficacy
is thus far no treatment worth speaking have had at least one against clinical COVID-19 in Phase 3 tri-
of for the post-acute sequelae of acute als, and 100% against severe disease.47
COVID-19,33 which afflict as many as dose of vaccine Moderna behaves much like Pfizer ex-
77% of survivors after 6 months.34 cept in one crucial way: it performs bet-
trial before flaming out with only 48% ter against the Delta variant, with effec-
Numerous once-promising drugs have efficacy.37 Israel is even testing a vac- tiveness of 86% in Qatar42 and 76% in
disappeared from view or failed to pan cine in a pill. the Mayo Clinic study.43
out. Oral: vitamin D, vitamin C, zinc, The chief downside of both mRNA vac-
aspirin, fenofibrate, famotidine, ralox- Approved by the World Health cines is the low temperatures needed
ifene, enalapril, azithromycin, lactofer- Organization for shipping and storage, an absurd
rin, multiple antivirals (lopinavir/rito- n Pfizer-BioNTech: This US-Ger- -70ºC for Pfizer. Though Pfizer can now
navir, darunavir, cobicistat, EIDD-2801), man product injects messenger RNA under some circumstances be shipped
and a Russian mystery drug claimed to (mRNA), which instructs our cells to at -20º and stored in a refrigerator for a
be “99% effective.” Inhaled: nitric ox- fabricate SARS-CoV-2 spike protein, month, the cold chain is still something
ide and interferon-beta. Nasal sprays: which in turn stimulates the immune of a barrier, especially in the developing
dimeric lipopeptide, sticky polysaccha- system. The platform has already pro- world. Another issue is cost, euros 18-
rides, povidone-iodine, single-domain duced vaccines against diseases from 20 per dose now in Europe and about
antispike llama antibodies, and REGEN- rabies to cancer, but this COVID-19 vac- to go up.
COV. Intravenous: convalescent plas- cine was the first to reach the market. Rare complications include anaphylactic
ma,35 placental stem cells, ruxolitinib, Its overall efficacy against illness and reactions to 10 doses per million, pos-
leronlimab, and icatibant. Not to men- asymptomatic infection with the origi- sibly Bell’s palsy,48 and – of greatest
tion Trump’s bleach, Erdogan’s mulber- nal Wuhan strain was an astonishing concern – cardiac reactions, which may
ry molasses, and John Magafuli’s arte- 95% in Phase 3 trials,38 and Phase 4 be more frequent with Moderna. Myo-
misia (the President of Tanzania, killed effectiveness in real-world vaccination carditis usually affects young men after
by COVID-19 in March). campaigns has been at least as good.39 their second dose, and pericarditis older
Complete vaccination with Pfizer pro- men (10 and 18 cases per million doses
VACCINES tects 95% against COVID-19 caused by respectively).49 Most cases require brief
We are doing vastly better on the vac- the Alpha variant, 75% or more against hospitalization, but almost none in the
cine front than on the treatment front, Beta and probably Gamma. But Pfizer US have been fatal, and the risk to the
with a huge investment of effort and loses its punch against Delta, especially heart from COVID-19 is far greater.
money, notably from Donald Trump’s as time passes since vaccination.40 Re- n AstraZeneca: The “Oxford vac-
Operation Warp Speed, producing and ported effectiveness has varied wildly, cine,” which uses a harmless adenovi-
distributing multiple effective vaccines from 88% in England41 to 79% in rus to deliver the spike protein to the
in record time. Already 70% of Italians, Scotland,16 56% in Qatar42 and 42% immune system, was for months the
61% of Americans, and 33% of all hu- in a Mayo Clinic Health System series.43 most promising of all, and has the ad-
mans on the planet have had at least The Israeli government has estimated vantages of being cheap and easy to
one dose of vaccine.36 Pfizer’s protection against Delta infec- handle. But the research methodology
Most of the 138 candidate vaccines tion at 41% to 64% overall, falling to behind its chief Phase 3 report was
never made it into human arms, doz- a scary 16% by 6 months after vacci- embarrassingly poor, the overall ef-
ens, including, apparently, Italy’s Re- nation.44,45 Protection against severe ficacy at standard doses in volunteers
ithera, quit around Phase 2 (do we re- disease after 6 months was still 86%, (all under age 60) was only 59%,50 and
ally need another viral vector vaccine, but in people over 65 it was reportedly it is uniquely ineffective at preventing
anyway?), and the German mRNA vac- just 55%.46 Vaccinated individuals with asymptomatic infection.51
cine CureVac went through an entire breakthrough Delta infections also have A later Phase 3 trial, performed proper-
randomized placebo-controlled Phase 3 higher viral loads, and are therefore ly in the US and Mexico, seems to have
anno 45 (4) luglio-agosto 2021 Epidemiol Prev 2021; 45 (4):In press. doi: 10.19191/EP21.4.A001.074www.epiprev.it
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In Western Europe,
Germany now has
shown (all we have is press releases) the highest vaccine to surges in Brazil, Chile, Indonesia,
that AstraZeneca does work reasonably skepticism rate (19%), Mexico, Thailand, and Turkey.
well, at all ages, if the second dose is
given on time after 4 weeks. Astonish- Spain the lowest (9%), Phase 3 trials reported,
ingly, the investigators seem to have with Italy no WHO approval yet
tried to fudge their results for this trial, n Novavax: A protein subunit vac-
despite knowing it would be scruti- in the middle (16%) cine, like the hepatitis B jab, that in-
nized with a fine-tooth comb; they had jects the spike protein itself. Results of
to adjust the top-line efficacy result giving AstraZeneca (and Johnson & Phase 3 trials in the UK (published)67
down from 79% to 76%.52 Johnson) only to older people. Particu- and North America (announced)68 both
I emphasize dose timing, because a UK larly wrong-headed, because, as I just showed 90% efficacy. It is only about
study claiming AstraZeneca worked pointed out, AstraZeneca performs 50% effective against Beta, though,
better with 12 weeks between doses53 much less well in the elderly, at the 10- and we do not know yet about Gamma
convinced many countries to institute 12-week dose gaps used in Europe. or Delta. On August 3rd, the European
that lengthy gap. Real-world research Atypical cases of Guillain-Barré syn- Union ordered a supply, pending WHO
has shown, though, that one dose drome (sudden paralysis) have also and EMA approval.
protected only 70% against severe been described following both viral n Sputnik V: A viral vector vaccine,
COVID-19 in elderly Scots53 and even 2 vector vaccines.60 from the Russian Gamelaya Institute. A
doses reached only 80% in England,54 AstraZeneca never seems to have pro- well-published interim report of a Phase
compared to 90-100% for the mRNA vided the complete data promised 5 3 trial claimed 91% efficacy,69 but
vaccines. Unfortunately, European months ago to the Food and Drug data discrepancies in my opinion justify
countries did not take the hint from the Administration, but the United States, skepticism;70 Russia has denied access
US trial, and have maintained long gaps with its limitless supply of mRNA vac- to raw data. The claim that Sputnik is
between AstraZeneca doses. (The UK cines, can allow itself the luxury of giv- the best vaccine against Delta is still just
kept using the 12-week gap for Pfizer ing AstraZeneca a pass. a claim. Sputnik also seems to have a
as well, even after data showed effec- n Johnson&Johnson/Janssen: Simi- quality control issue, with Brazil and Slo-
tiveness to fall off).55 lar to AstraZeneca in its viral vector vakia having to turn back bad batches.
AstraZeneca works fairly well against technology, but marketed as a con-
the Alpha and Gamma variants, but so venient single dose, its overall efficacy No detailed Phase 3
miserably against Beta (10% efficacy) peaks after 4 weeks at 66%.61 Johnson reports available
that South Africa cancelled its orders. & Johnson shares AstraZeneca’s limited n CanSino: A one-dose viral vector
Against Delta, a test-negative design efficacy and its clotting problems, and vaccine used in China, Pakistan, and
study in Scotland estimated effective- probably its low effectiveness against Mexico, claimed to be 66% effective.
ness at 60% overall.16 the Delta variant.62 But it works much n Covaxin: A killed Coronavirus vac-
Side effects have become a major is- better against Beta (64% vs 10%) and cine developed in India and already
sue. Severe blood clotting and bleeding in preventing asymptomatic infection used in a dozen countries after claims
(Vaccine-Induced Thrombotic Throm- (74% vs 2% [stet]). of 78% efficacy.
bocytopenia), especially in the brain, SinoPharm and Sinovac: Both Chinese n Abdala: Cuba claims 92% efficacy
first came to light in Scandinavia in vaccines use attenuated virus. Sinop- for its home-grown 3-shot protein sub-
early March.56 UK officials steadfastly harm’s Phase 3 trial in young, healthy unit vaccine.
denied having seen any such compli- volunteers claimed 78% efficacy,63
cations until having to admit a month and it is being used in more than 50 Vaccination issues
later that actually there had been 79 countries. The low efficacy of Sinovac’s The Holy Grail
of them, 19 fatal57 – later updated to widely-used CoronaVac, 51% in their One advantage of mRNA vaccines is
242 and 49,58 and perhaps occurring, pre-Gamma Brazilian Phase 3 trial,64 that they can be engineered to target
according to a study in Norway, as fre- 42% in a test-negative case-control a specific variant. But some scientists
quently as one in 26,000 doses.59 Most study against Gamma in the elderly,65 think it might be feasible, using any of
cases are in vaccinees under age 50, so and low antibody production against several approaches, to create a univer-
the EU, and eventually the UK, began Delta,66 is feared to have contributed sal mRNA vaccine effective against all
anno 45 (4) luglio-agosto 2021 Epidemiol Prev 2021; 45 (4):In press. doi: 10.19191/EP21.4.A001.074www.epiprev.it
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Dexamethasone
is the sole drug
strains of SARS-CoV-2 or maybe even proven to save lives er, though the Delta-blasting Moderna
of all Coronaviruses present and fu- in COVID-19, product might be preferable. The US
ture.71 Let’s hope! and Germany plan soon to follow suit.
decreasing mortality The more SARS-CoV-2 is circulating in
Hesitancy of patients on the world, the more likely that terrible
In the US vaccination has been highly po- new variants will arise. That makes it
liticized, with undervaccinated Trumpian ventilators by 36% selfishly as well as morally imperative
areas now experiencing giant COVID-19 to vaccinate poor countries, via the
surges. But overflowing intensive care Mix-n-match World Health Organization’s COVAX
units in half a dozen states have hardly Most European countries now give initiative or bilateral agreements. But
budged novax sentiment, though out- Pfizer or Moderna as the second dose I cannot fully agree with those who
side the US it is falling everywhere.72 In to people who first received AstraZen- find it unethical78 for rich countries to
Russia, whose skepticism rate of 47% eca, at least if they are under 60. This is give boosters when fewer than 5% of
leaves the US’s 28% in the dust, vaccine mainly to avoid clotting complications, Africans have had even one dose.36 If
refusal long predates COVID-19. Ger- but there is also reason to believe it will Israeli press reports are right about the
many has now surpassed France for the enhance efficacy, including against the falloff in protection of our most vul-
highest rate in Western Europe (19%), Delta variant.73,74 It might also make nerable citizens,39 boosters for the el-
Spain has the lowest (9%), and Italy sits sense at this point to offer a second derly and the sick could be appropriate.
in the middle (16%). vaccine dose some months after John- Those grim figures have now, however,
Vaccine refusers most often say that son & Johnson, either of J&J itself or an been brought into question by very re-
the vaccines are “experimental”; oth- mRNA product. cent evidence hat the falloff is much
ers fear side effects, think they are in- less dire.79
vulnerable, or believe bizarre conspiracy Boosters
theories. The most urgent and poten- SARS-CoV-2 antibody levels fall and CONCLUSIONS
tially most effective move to increase breakthrough infections rise by 6 COVID-19 is a formidable opponent
vaccination rates was therefore in the months after vaccination.44,75,76 And to tackle. With therapeutic options for
hands of the US Food and Drug Admin- though COVID-19 survivors still have hospitalized patients likely to remain
istration and the European Medicines specialized anti-SARS-CoV-2 plasma limited for the foreseeable future, we
Agency: give the vaccines full rather cells in their bone marrow after a year,77 need to put our energies into prevent-
than emergency approval. The FDA has most experts think we will eventually ing severe disease in the context of a
already done so for Pfizer. Green Passes all need mRNA boosters, ideally either virus that is evolving for the worst fast-
and vaccination mandates for medical universal or engineered to cover current er than was expected. That means we
workers and college students are also variants. (Note that the word ‘booster’ must rapidly upscale the use of mono-
proving persuasive. Access issues must is sometimes erroneously used for the clonal antibody therapy, overcome bar-
be overcome by, for instance, facilitat- 3rd dose the immunosuppressed need riers to vaccination in rich countries,
ing home vaccination in Italy, where to jump-start their immune system.) vaccinate poor ones with effective
8.2% of octogenarians are still not fully Should we start now giving another products, and invest in the develop-
vaccinated, and ensuring that vaccinees dose to people who were vaccinated ment of universal vaccines.
do not lose wages in the US, where one in early 2021? Israel is already offering
in 4 workers have no paid sick leave. the healthy elderly a third dose of Pfiz- Conflicts of interest: none declared.
ABOUT THE AUTHOR
Susan Levenstein is an American internist
who has been practicing in Rome since 1980.
She has published a memoir Dottoressa: An American Doctor in Rome
(www.amazon.it/Dottoressa-American-Doctor-Susan-Levenstein/dp/1589881397).
Since March 2020, her blog Stethoscope On Rome (www.stethoscopeonrome.com)
has been dedicated entirely to COVID-19.
anno 45 (4) luglio-agosto 2021 Epidemiol Prev 2021; 45 (4):In press. doi: 10.19191/EP21.4.A001.074www.epiprev.it
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