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Ivermectin and Covid: no time to lose and lives to save

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By Prof. Saroj Jayasinghe,

MBBS, MD (Colombo), FRCP (London), MD (Bristol) PhD (Colombo), FCCP, FNASSL

Consultant to the Faculty of Medicine

Sabaragamuwa University of Sri Lanka.

Former Professor of Medicine, University of Colombo

It is with a degree of reluctance that I am stepping into the controversy relating to Ivermectin use in COVID. Unknown to many, the pros and cons of Ivermectin in COVID have been discussed in private forums of physicians, academia and doctors from 2020. It has been in the international media ever since laboratory studies in Australia showed that the drug inhibits the growth of the virus. However, the public in Sri Lanka became more aware of the controversy recently, when a confidential letter sent to an official of the Ministry of Health appeared in the social media. I had written this in June 2021 as an individual professional after several months of raging controversy among professionals. It was about treatment of COVID, and I firmly believe vaccination is the best option to prevent the illness. One reason for the very cautious approach of not approving the use of Ivermectin in the West could be because anti-vaccine groups are promoting it as an alternative. Sri Lanka has no such problems, and our population is willingly getting vaccinated.

Proposals to use Sri Lanka as a large study area as a clinical trial or as an observational study were made as far back as early 2021. I understand a clinical trial has begun in patients admitted with COVID, after considerable delays due to procedures related to clinical trials. Such studies are scrutinised by independent ethics committees, the drug must be approved by the National Medicinal Drugs Authority, and the study must be registered in an entity that makes is publicly available for anyone to read about it. This study will at least take another few weeks to months to yield results.

Most discussions in Sri Lanka Centre around the question whether the evidence to prescribe Ivermectin in COVID-19 is strong or inconclusive. One group says there is inconclusive evidence to use Ivermectin while another group says there IS sufficient evidence. As with many issues, this is not black or white but shades of grey, i.e. there are grades on the ‘strength of evidence’ from the field of Evidence Based Medicine (EBM). A parallel in the legal field is when we say that the evidence is ‘beyond reasonable doubt’ or there is ‘proof of the crime’, vs. circumstantial evidence.

Let us assume that using the principles of EBM we find that the evidence to use Ivermectin in COVID is ‘inconclusive’. Such a dilemma is very relevant to a situation where a decision is needed immediately, but the stakes are high. In other words, how would doctors decide to treat in a situation when the evidence for efficacy of a drug is inconclusive, but the stakes are high? Let me share an example.

Imagine a doctor who sees a very ill-looking patient with features of a serious infection (e.g. high fever, vomiting and body aches). She or he requests tests to identify the cause of the illness and the bacteria that may be causing the illness. In such an instance, should the doctor wait till the reports of the tests (e.g. culture reports) are available before treating? If a decision is made to treat immediately, the doctor does not have the ‘strength of evidence’ on the cause of the illness. However, if treatment is delayed until the reports arrive in two days the patient may be dead. This hypothetical example highlights a common dilemma: How do doctors balance between reliance on strength of evidence vs. taking an immediate decision when the evidence is inconclusive. This is best addressed by theories of decision-making and is a question very familiar to practicing doctors.

Now I will demonstrate the parallel with Ivermectin. In the case of ivermectin let us assume that the current evidence for its efficacy in COVID is inconclusive. However, the stakes are very high because COVID is currently raging, hundreds are dying, and there are no alternative drugs to treat early disease. Furthermore, Sri Lanka needs to bridge only a short vulnerable period of 4-6 weeks during which time our vaccination programme would become effective.

Let us assume that doctors begin to prescribe Ivermectin for treatment and prevention of COVID, for the next 4 to 6 weeks, despite the inconclusive evidence. There are two possible key outcomes:

Outcome 1: Future research confirms that it is effective, and it would contribute to saving many lives.

Outcome 2: Future research shows that it is ineffective, and we would have wasted money on the drug. Therefore, Ivermectin could either save lives or waste money. Even the money wasted is miniscule because the cost of a course of Ivermectin is less than Rs 200.00 (i.e. less than one US dollar)! Is it safe to use over the next 4 to 6 weeks? We know it is a very safe drug that has been used for almost 40 years. It is used in mass scale by the WHO to eliminate ‘River Blindness’ and is in their Essential Drug List.

A combination of other factors add support to the decision to prescribe Ivermectin.

1. Evidence is evolving, and studies are in progress. Therefore, conclusive evidence may emerge to confirm its efficacy.

2. There is laboratory (in vitro) evidence that Ivermectin is active against the COVID-19 virus.

3. It’s easy to give (tablets and not injections).

4. Currently there are no effective drugs in Sri Lanka to treat early COVID or prevent it.

5. Certain regions in India and South American countries are using Ivermectin to treat and prevent COVID-19

Summary

Therefore, my humble question is, should doctors in Sri Lanka consider whether to use Ivermectin to treat or prevent COVID-19? We need this only for 4-6 weeks. During this period, rates of COVID are likely to increase due to the very rapid transmission of Delta variant. We have no time to lose, nothing to lose, and lives to save. There is no time for clinical trials. Those who wish to embark on trials to wet their thirst for more evidence are welcome to do so. By the time the results of a new trial are available the horse would have bolted, and hundreds would have died.

My suggestion is for patients to ask your doctors about Ivermectin. You have a right to do so. Doctors are divided on the issue because of their sincerity to the views they have about science, scientific evidence, and decision-making. Please do not assume that there is a conspiracy against the drug in Sri Lanka! I can vouch for the honesty of all the doctors who are having different views on the topic. This is a disagreement between professionals who have diverse views, and we seem to have dug into our lines of defence!

The Ministry of Health has allowed the use of Ivermectin under the direction of a doctor. A range of doses for treatment and prevention is available at BIRD-group.org a group working in the UK. The opinions I have stated here are my own independent views and not in any way linked to the institutions I am affiliated to.



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Opinion

In Memorium: Daya and Alfred Wijewardena

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Daya Wijewardena was many things to many people. These included, but were not limited to, being: a wife to her husband, Alfred; a surrogate mother to her nephew, Dayananda; a grandmother/great-aunt to Dayananda’s children; a teacher to countless students at Anula Vidyalaya; a trusted confidante to my mother; and a beloved aunt to my brother and me. In her later years, she greatly supported the work of her husband, spending many countless hours, being a sort of unpaid personal assistant charged with doing, things, like taking down dictation for his planned workshops. Her one complaint was about her own handwriting, which she didn’t consider to be very good since she had been forced in school to write right-handed, despite being a natural left-hander. It’s been a decade since her passing, but the void left by her absence has not diminished.

Alfred Wijewardena – or D.A. Wijewardena, as he was professionally known – was a multi-hyphenate Renaissance man, who lived by the motto ‘plan your work and work your plan’. A qualified Attorney-at-Law, with a Degree in Laws and a B.Sc. in Logic, he was also a Justice of the Peace, but in his early days he’d done a variety of jobs, including being the Game Ranger at Yala National Park and a teacher at Ananda College. He subsequently focused on administrative matters, becoming the first Secretary of the then newly-formed State Services Disciplinary Board (which had replaced the Public Service Commission, where he was an Assistant Secretary). He ultimately set up his own institution known as The Centre for Studies in Disciplinary Management. An avowed workaholic, he worked well past retirement, only stopping in the last two or three years of his life. When he had some free time, he enjoyed playing tennis at the SSC, where he was a Vice President for many years. He left us three years ago, but there’s rarely a day that goes by when we don’t think of or talk about him.

My brother and I called Alfred’s wife ‘Daya Aunty’, although in reality those two words tended to morph into one, creating a brand new descriptor specific to her: ‘Dayaunty’. She loved us abundantly, with that love even extending to our childhood puppy, Shiny, who similarly adored Dayaunty, particularly as she often brought Shiny a succulent bone to chew on when she came to visit. Dayaunty was kind, caring, nurturing and she loved to laugh, albeit very softly… She didn’t ever have a cross word for us.

We never referred to Dayaunty’s husband as ‘Alfred Uncle’, despite our multi-generational age gap. To us he was ‘Alfie’, because he was our pal: someone who was always on our level, someone we could relate to. For years he drove a Volkswagen Beetle, which we referred to as the ‘Alfie Car’. He was such a character that he constantly had us in stitches, giggling until our sides hurt, thanks to the yarns that he spun. Picture the perfect babysitter (or, from our perspective, a best buddy) and that was Alfie. He set the bar very high when it came to fun uncles.

Our childhood was enriched beyond measure for having Dayaunty and Alfie in it. When Alfie (often distracted by other thoughts but still wanting to be a part of the ongoing conversation) would say something grammatically correct but factually unfeasible — like his infamous “You spoke to him when he was dead?” line of inquiry — Dayaunty would titter almost silently, which naturally made us crack up even more.

Dayaunty had a sense of adventure and would have happily travelled the world if only Alfie wasn’t tethered to work. (“Inquiries, baba, inquiries” is how he explained his professional life to us.) So, a solitary trip to India on pilgrimage notwithstanding, Dayaunty had to make do with escapades in-country. These included one memorable visit to Yala during which her quiet chuckling threatened to actually form sound when someone, on seeing a herd of elephants, queried incredulously: “Why does that elephant have five legs?!” Dayaunty was much quicker on the uptake than the rest of us, but when the penny finally dropped, it was a wonder that all the wildlife in our immediate vicinity didn’t run for the hills, such was the laughter emanating from our vehicle!

On the singular occasion that our parents were unable to have us join them when they went abroad for a conference, they entrusted us into the care of Alfie and Dayaunty — and we had a ball. Even though we loved and were used to spending time together, and they treated us like their own children, both Dayaunty and Alfie must have felt the weight of responsibility that came with such a serious undertaking; however, we never saw any hints of anxiety from either.

When Dayaunty unexpectedly had a stroke 10 years ago, I thought she would soon recover. So, when Alfie called me to convey the news of her passing with the words “the firecracker has gone”, it took a long time for the reality of the situation to sink in. Dayaunty’s departure was a seismic event and it felt as though she took a part of our childhood with her when she went.

Then, in 2018, after bemoaning his loss of productivity and his perceived lack of usefulness to society as a result of stopping work, Alfie decided to follow suit. Never again would we hear him recite ‘Inky, Pinky, Polly’ incorrectly, just to make us laughingly (and somewhat exasperatedly) exclaim: “Oh, Alfie, you don’t know anything!” Gone were the tales of his exploits on the tennis court (“I have bad knees now because my doubles partner used to make me run for all the drop shots!”) and his adventures in emailing (“I was worried about writing to you too much because I thought I’d fill up the computer!”). If part of our childhood went with Dayaunty, the rest accompanied Alfie.

How does anyone recover from — or at least mitigate — such grief, devastation and loss? One step is to remember the good times and focus on all the positive things that Daya and Alfred Wijewardena brought to so many people — in their immediate and extended families, amongst their friends, in their lives and in their careers.

As we mark, on successive days, what would have been Alfie’s 100th birthday (7th December) and 10 years since Dayaunty’s passing (8th December), we pause to reflect on two extraordinary lives that touched so many others in a multitude of ways. We will always love Alfie and Dayaunty, and we’ll be forever grateful for the roles that they played in our lives, particularly our childhood. We hope their sansaric journey is short. May they both attain Nibbana!

Dr. Mihirinie Wijayawardene

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Opinion

Need for traffic lights at Pamankada junction

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Now that the Havelock Road is open to traffic on both sides up to the Pamankada bridge, the Pamankada T-junction has become a real bottleneck, especially during the rush hours in the morning and again in the evening. There were no problems when it was one way. With unruly drivers manning private buses and three wheelers and the motor cyclists, it is indeed a hassle for the law-abiding drivers to manipulate their vehicles in a melee.

As Havelock Road has been opened to vehicular traffic both ways, there is a large number of buses belonging to the CTB as well as private buses on route numbers 120( Horana and Kesbewa to Pettah) ,162 (Bandaragama to Pettah), 135(Kelaniya to Kohuwala) and 141 (Wellawatte to Narahenpita) that ply up and down passing this T- junction.

It would be good before some serious motor accident takes place to install traffic lights at this junction. Every driver tries to get out of the melee as quickly as possible and ultimately all vehicles get stuck and take a longer time to move on. Installing the lghts would instill some discipline to the reckless drivers especially during the time that school children are transported.

HM Nissanka Warakaulle

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Opinion

Lessons learnt from outrageous power outage

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The countrywide power outage that took place on Friday 03 November, 2021, shook the nation.

As everyone is suspicious of everyone else in this country, most people suspected that it was sabotage masterminded by the Engineers of the CEB Unions. The engineers have threatened the government that they will resort to a strike if their demands, particularly on the subject of the New Fortress Energy agreement are not met.

It became quite clear that the 21 million Sri Lankans living in this country could be held hostage by the union leaders, even if, in this instance, they had not been responsible for it. Public spiritedness which has to be the basis of any national action had in any case been ignored by the CEB Unions when they threatened the government a few days back.

The situation has shown how delicate our predicament is. A small group of people could hold the entire country to ransom if they disagreed with the authorities. Both the country and the Government has now taken cognizance of this. This can also be a massive security risk.

Continuation of the outage could have even led to a violent uprising of the public against the Union officials who would have been targeted. Fortunately, the government held its nerve and better judgment prevailed on the side of the Engineers to correct the situation.

However, like with all adversities, several new opportunities have surfaced. One is how to diminish the monopoly that the CEB, which is a bane of the country. Here one option could be to decentralize the generation and supply of power to the districts. A study should be undertaken to enable every District to control it’s electricity supply and, over a period of ten years make it into a viable profit-making undertaking. This will be particularly endorsed and greeted by those of the Northern and Eastern Provinces who are agitating for more decentralised powers. Also, the other Districts will support this proposition. Engineers from the Districts will be able to use their ingenuity in working out techniques for cheaper and more cost-effective generation of electricity and giving assistance to the multiple industries that will commence in the future.

With regard to the security dimension of electricity supply it is imperative that the armed forces are made conversant with every aspect connected with the running of the Electricity facilities. In this way, the country can never be held to ransom by any group. The armed forces will be trained to move and take over the operations in case of sabotage or even if one day an attack takes place by external forces.

In all this it seems evident that the New Fortress Energy Agreement is not acceptable to the general public and not only to the Unions. The Government has to take this into account and if necessary call for a plebiscite on this issue. If Parliament and the people of this country want the government to proceed with it so be it. However, if the people reject it the government has a valid justification to withdraw from the agreement.

A. Jayatilleke

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