How CMC Vellore Dealt With Shifting Evidence During the COVID-19 Pandemic
Independent thought in any profession is hard to build and even harder to sustain especially in a world where social media reinforces consensus opinion on complicated subjects like medicine, politics, gender, etc. In India, the Christian Medical College Vellore (CMC Vellore) has for a long time been regarded as one of the country’s most distinguished medical colleges. Over the past 12 months, junk science, quacks and politicians across the world have had a field day amidst the panic created by Covid-19 – click here for the blog written by Mark Mobius and our colleagues at Marcellus on this subject: https://marcellus.in/blogs/
Even as junk science, rumours and vested interests have spread all sorts of misinformation regarding Covid-19 and treatments for the disease, CMC Vellore has been an island of sane, rational and independent thought on the subject. So how have they pulled it off given the extreme pressure that all medical professionals have been under over the past year? “In an interview with The Wire Science, Priscilla Rupali, an infectious disease specialist who heads CMC Vellore’s guideline development team, and Joy Mammen, a pathologist and a specialist in transfusion medicine, talked about the challenges of developing treatment guidelines during a pandemic, when evidence is shifting rapidly.”
Three aspects of this interview stand out. Firstly, health authorities across the world – obviously under severe pressure – repeatedly approved drugs & treatments for Covid-19 which were eventually found to be ineffective. CMC Vellore ensured that it was not swept along with the panic. “The Indian drug regulator was also quick – soon found to have been too quick – to approve two drugs tested in Indian trials, favipiravir and itolizumab, even though these trials didn’t really demonstrate these drugs’ efficacies….Could doctors have taken a more measured approach to experimental drugs in the anxious atmosphere of a pandemic? Some medical institutions did, and indeed still do so – reviewing evidence frequently and intensively, and eschewing the routine use of drugs that don’t have strong evidence to support them.
One such was the Christian Medical College (CMC), Vellore, whose treatment guidelines didn’t recommend drugs such as tocilizumab and favipiravir until now, unless they could be administered in clinical trials. As a centre for several clinical trials, including the WHO’s SOLIDARITY trial and the Indian Council of Medical Research’s PLACID trial for convalescent plasma, CMC Vellore was able to offer such a choice to patients.”
Secondly, beyond taking an evidence-based approach to medicine, CMC Vellore also seems to have spent a lot of time and effort figuring out standardised treatment guidelines for Covid-19. There are 40-45 doctors in CMC Vellore’s guideline development team. “One reason we thought it important to develop guidelines for COVID-19 was that it was a new disease, and there was nothing known about appropriate treatments. There was widespread panic and anxiety among both patients and staff alike. We deal with nearly 9,500 patients on an outpatient basis, have more than 2,300 inpatients and 10,000 employees at any given time.
So for a new disease, it is important to standardise treatment guidelines. And while the WHO interim guidelines first came out on May 27, India saw its first case in January 2020, and our hospital saw its first case in March. That means that following WHO’s guidelines wasn’t an option for us. Hospitals like ours had to set up their own guidelines.”
Thirdly, CMC Vellore regularly audits its doctors & nurses to ensure that they are following the stipulated guidelines. “Clinical audits are not meant to be punitive; they’re meant to refine treatment. For example, some individuals believed in remdesivir firmly when it first came out. And there were some individuals who were not for it, because until today, there is no convincing evidence that it reduces mortality.
But there is some evidence that remdesivir decreases progression to severe disease. So, given the uncertainty about whether it actually works, it made sense for us to look at our patient data, apart from peer-reviewed literature. So far, we have seen more than 11,000 COVID-19 patients. And so, we have a large enough patient sample to be able to study whether remdesivir is useful or not.
We had a data team that would regularly sift through information from these patients, and monitor clinically significant outcomes and lab parameters. And we were able to pick up, through clinical audits, that remdesivir worked in a particular population.
Today, we recommend remdesivir in patients on oxygen but not in those who are mechanically ventilated.”