Discussion of spatial analysis techniques and targeted mass hydrochloroquine administration as an additional strategy against COVID-19 pandemic in high risk populations
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Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study
Discussion of spatial analysis techniques and targeted mass hydrochloroquine administration as an additional strategy against COVID-19 pandemic in high risk populations
Dear Editor
COVID-19 emerged in Wuhan, China in December 2019 and despite tremendous efforts to contain, it has spread to the whole of the world (1). On 11th March 2020 WHO declared it a pandemic. (2) Strategies are continually under development to reduce coronavirus burden and consequently interrupt the transmission.
Historically, mass drug administration, of a therapeutic regimen to a whole or high-risk population at the same time, without screening or diagnostic testing prior to administration (3) has been used to contain in many public health challenges across the world such as interrupting malaria transmission in endemic areas by administering antimalarial drugs in a single or multiple rounds to vulnerable population groups such as pregnant women, infants, and non‐immune travelers, to prevent clinical disease and similarly, controlling tuberculosis where isoniazid is given to exposed and vulnerable persons in a household, reducing the risk of clinical infection. (4,5)
Some literature has shown that hydrochloroquine besides being an anti-malarial drug might also be an antiviral drug (9). Recently, the potential use of hydro-chloroquine for treating COVID-19, has been investigated as a treatment strategy for COVID-19 (7,8). In vitro studies have shown that hydroxychloroquine contributes to attenuating the inflammatory response and can efficiently inhibit SARS-COV-2 infection (6). Its safety profile is better than other antimalarials of the same category such as chloroquine, as it allows higher daily doses and fewer side effects (10).
Given the high human case fatality rate, we propose that targeted oral mass administration of the drug might be useful, starting with a loading dose of 400 mg twice followed by a maintenance dose of 200 mg twice daily for 4 days in high-risk groups such as health care providers, travelers from high-risk countries, and their immediate contacts (6). To implement this, hot spots of infection need to be identified using spatial analysis technique. Integrated drones and geographic information system which has promising outputs could be used in tracking and combating contagion. Drones can also be used for disinfection in highly contaminated areas such as the containment zone (11,12). This public health approach might be cost-effective, available and feasible to contain the pandemic of COVID-19. Identified hot spots can then be divided into:
1) Containment zone, which is a particular area, such as locality or hospital where corona positive cases and their possible contacts are present. In this zone drugs such as hydro chloroquine should be given to everyone and non-pharmaceutical intervention should be used such as hand and respiratory hygiene, social distancing measures, voluntary quarantine for 14 days, movement restrictions in and out of the containment zone.
2) Buffer zone, which is an area surrounding the containment zone where active and complete surveillance including laboratory testing, emphasis on containment communication should be done. There could be movement of some people from the containment zone to the buffer zone.
However, this drug has a few side effects in the long term; therefore, it should be used cautiously in diseases such as psoriasis, porphyria, and glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, and in patients with liver disease, alcoholism, heart rhythm disorder (such as long QT syndrome).
References
1. Chinese Center for Disease Control and Prevention (CCDC). The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19)–China. 2020.
2. World Health Organization. Statement on the second meeting of the International Health Regulations Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV), Geneva, Switzerland, 30 January 2020. 2005.
3. Eisele TP. Mass drug administration can be a valuable addition to the malaria elimination toolbox. Malaria journal. 2019 Dec;18(1):1-5.
4. https://www.cdc.gov/malaria/malaria_worldwide/reduction/mda_mft.html.
5. https://clinicaltrials.gov/ct2/show/NCT04261517.
6. Yao X, Ye F, Zhang M, Cui C, Huang B, Niu P, Liu X, Zhao L, Dong E, Song C, Zhan S. In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Clinical Infectious Diseases. 2020 Mar 9.
7. Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Bioscience trends. 2020.
8. Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research 2020;30:269–271.
9. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P. A novel coronavirus from patients with pneumonia in China, 2019. New England Journal of Medicine. 2020 Jan 24.
10. Liu J, Cao R, Xu M, Wang X, Zhang H, Hu H, Li Y, Hu Z, Zhong W, Wang M. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discovery. 2020 Mar 18;6(1):1-4.
11. Huber M. Drones Enlisted To Fight Corona Virus in China. AIN Online, 7 February 2020.
12. Brickwood B. XAG introduces drone disinfection operation to fight the coronavirus outbreak. Health Europa.
Competing interests:
No competing interests
30 March 2020
Dr. Neha Dahiya Dahiya
Public Health Specialist
Dr Mona Duggal, Professor Damodar Bachani
Post Graduate Institute of Medical Education& Research, Chandigarh
Rapid Response:
Discussion of spatial analysis techniques and targeted mass hydrochloroquine administration as an additional strategy against COVID-19 pandemic in high risk populations
Dear Editor
COVID-19 emerged in Wuhan, China in December 2019 and despite tremendous efforts to contain, it has spread to the whole of the world (1). On 11th March 2020 WHO declared it a pandemic. (2) Strategies are continually under development to reduce coronavirus burden and consequently interrupt the transmission.
Historically, mass drug administration, of a therapeutic regimen to a whole or high-risk population at the same time, without screening or diagnostic testing prior to administration (3) has been used to contain in many public health challenges across the world such as interrupting malaria transmission in endemic areas by administering antimalarial drugs in a single or multiple rounds to vulnerable population groups such as pregnant women, infants, and non‐immune travelers, to prevent clinical disease and similarly, controlling tuberculosis where isoniazid is given to exposed and vulnerable persons in a household, reducing the risk of clinical infection. (4,5)
Some literature has shown that hydrochloroquine besides being an anti-malarial drug might also be an antiviral drug (9). Recently, the potential use of hydro-chloroquine for treating COVID-19, has been investigated as a treatment strategy for COVID-19 (7,8). In vitro studies have shown that hydroxychloroquine contributes to attenuating the inflammatory response and can efficiently inhibit SARS-COV-2 infection (6). Its safety profile is better than other antimalarials of the same category such as chloroquine, as it allows higher daily doses and fewer side effects (10).
Given the high human case fatality rate, we propose that targeted oral mass administration of the drug might be useful, starting with a loading dose of 400 mg twice followed by a maintenance dose of 200 mg twice daily for 4 days in high-risk groups such as health care providers, travelers from high-risk countries, and their immediate contacts (6). To implement this, hot spots of infection need to be identified using spatial analysis technique. Integrated drones and geographic information system which has promising outputs could be used in tracking and combating contagion. Drones can also be used for disinfection in highly contaminated areas such as the containment zone (11,12). This public health approach might be cost-effective, available and feasible to contain the pandemic of COVID-19. Identified hot spots can then be divided into:
1) Containment zone, which is a particular area, such as locality or hospital where corona positive cases and their possible contacts are present. In this zone drugs such as hydro chloroquine should be given to everyone and non-pharmaceutical intervention should be used such as hand and respiratory hygiene, social distancing measures, voluntary quarantine for 14 days, movement restrictions in and out of the containment zone.
2) Buffer zone, which is an area surrounding the containment zone where active and complete surveillance including laboratory testing, emphasis on containment communication should be done. There could be movement of some people from the containment zone to the buffer zone.
However, this drug has a few side effects in the long term; therefore, it should be used cautiously in diseases such as psoriasis, porphyria, and glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, and in patients with liver disease, alcoholism, heart rhythm disorder (such as long QT syndrome).
References
1. Chinese Center for Disease Control and Prevention (CCDC). The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19)–China. 2020.
2. World Health Organization. Statement on the second meeting of the International Health Regulations Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV), Geneva, Switzerland, 30 January 2020. 2005.
3. Eisele TP. Mass drug administration can be a valuable addition to the malaria elimination toolbox. Malaria journal. 2019 Dec;18(1):1-5.
4. https://www.cdc.gov/malaria/malaria_worldwide/reduction/mda_mft.html.
5. https://clinicaltrials.gov/ct2/show/NCT04261517.
6. Yao X, Ye F, Zhang M, Cui C, Huang B, Niu P, Liu X, Zhao L, Dong E, Song C, Zhan S. In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Clinical Infectious Diseases. 2020 Mar 9.
7. Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Bioscience trends. 2020.
8. Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research 2020;30:269–271.
9. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P. A novel coronavirus from patients with pneumonia in China, 2019. New England Journal of Medicine. 2020 Jan 24.
10. Liu J, Cao R, Xu M, Wang X, Zhang H, Hu H, Li Y, Hu Z, Zhong W, Wang M. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discovery. 2020 Mar 18;6(1):1-4.
11. Huber M. Drones Enlisted To Fight Corona Virus in China. AIN Online, 7 February 2020.
12. Brickwood B. XAG introduces drone disinfection operation to fight the coronavirus outbreak. Health Europa.
Competing interests: No competing interests