WMJ 2 2021

vol. 67
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 2, July 2021
Contents
Interview with Otmar Kloiber by WMJ Editor Peteris Apinis . . . . . . . . . . . . . . . . . . . . . . . . . . 1
WMA 2021 Council Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
WMA Council Resolution in Support of the Countries Worst Affected by the
Covid-19 Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
WMA Council Resolution in Support of Medical Personnel and Citizens
of Myanmar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
WMA Council Resolution in Support of Alexei Navalny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Current Research and Future Direction of Haematology in China . . . . . . . . . . . . . . . . . . . . . . 16
Covid-19 in Spain: Health System Response and 2021 Perspective with the
Vaccination Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
The Czech Strategy of the Controlled Establishment of Herd Immunity Ended
in Disaster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Austria’s Approach to Combatting Covid-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Covid-19 Response Plan and Vaccination in Bangladesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Covid-19: Brazilian Medical Association (AMB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Obituary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
Medicīnas apgāds, Ltd
Skolas street 3, Riga, Latvia.
ISSN: 0049-8122
Dr. David BARBE
WMA President
American Medical Association
AMA Plaza, 330 N. Wabash, Suite
39300 60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Osahon ENABULELE
WMA Chairperson of the Socio-
Medical Affairs Committee
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa
Crescent Wuse Zone 4, FCT,
PO Box 8829 Wuse
Abuja
Nigeria
Dr. Heidi STENSMYREN
WMA President-Elect
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE-114 86 Stockholm
Sweden
Dr. Kenji MATSUBARA
WMA Vice-Chairperson of Council
Japan Medical Association
113-8621 Bunkyo-ku,Tokyo
Japan
Dr. Joseph HEYMAN
WMA Chairperson of the Associate
Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Miguel Roberto JORGE
WMA Immediate Past-President
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Marit HERMANSEN
WMA Chair of the Medical Ethics
Committee
Norwegian Medical Association
P.O.Box 1152 sentrum
107 Oslo
Norway
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
Indian Medical Association
Indraprastha Marg 110 002
New Delhi
India
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Jung Yul PARK
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40 Cheongpa-ro,
Yongsan-gu
04373 Seoul
Korea, Rep.
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
The Covid-19 pandemic has created a globally
troubling situation. In the whole world, gov-
ernments and politicians, more or less in con-
sultation with specialists of infectious diseases
and epidemiologists, take controversial deci-
sions both – on restrictions and on patient di-
agnosis and treatment. Although the situation
is different in different countries, it seems that
thanks to politicians and the media the world
forgets about other diseases. In many countries
of the world, people do not go to hospital or do
not receive medical assistance for cardiovascu-
lar diseases, oncology diseases, endocrine dis-
orders and other ailments because patients are
afraid of either overburdening doctors or get-
ting sick with ­
Covid-19 and therefore do not
visit hospitals and outpatient facilities. What
is the viewpoint of the World Medical Associa-
tion on it?
This is indeed a very serious phenomenon.
We all know, not everything that is being
presented at a medical appointment, is an
illness, an injury or a condition that needs
medical attention. However, we have seen
reduction of “hard cases” like, for instance,
significantly fewer patients with heart in-
farction and strokes show up in emergency
rooms and that is troubling. There may, in-
deed, be fewer cases – a positive interpre-
tation by itself – but it is more likely that
patients with milder symptoms have not
shown up. And that is worrying because
they would have profited from an immedi-
ate diagnosis and treatment. We must ex-
pect an increase in the number of delayed
and more serious cases.Pandemic prepared-
ness is a solution. It must be planned, con-
tinuously trained and executed.
Proceeding from this point of view, I  would
like to ask you: why can’t patients listen to the
warning for timely careful treatment of their
chronic diseases? We know that chronic car-
diovascular diseases, endocrine disorders, high
blood pressure, overweight are the main rea-
sons for a severe course of the Covid–19 dis-
ease and mortality from it. At the moment, the
need to treat chronic diseases in parallel with
­
Covid-19 is focused on inadequately.
Your question gives the impression as if
these problems are the responsibility of our
patients. Many patients, especially those
with chronic conditions, have learned to
master their conditions quite well.For many
others, the deterioration of their health
starts later in life and sometimes it is diag-
nosed very late.Then,changing habits is dif-
ficult and needs assistance. The challenges
of the ­
Covid-19 pandemic are certainly
not to be attributed to patients. They have
been caused by lack in pandemic prepared-
ness, wrong political decisions and, first of
all, confusing communication. The fact that
some conditions turned out to be aggravat-
ing factors is nothing patients could have
rectified at the time of the pandemic.
Global vaccination against Covid–19 has
started now. A number of vaccines are new
and can be considered a completely new step
in medical science. However, the attitude to-
wards vaccination is very different in different
countries. Worldwide, distrust in vaccination
increases and anti-vaccination materials are
disseminated. Has this problem been caused to
a large extent by national politicians and of-
ficials intervening in the vaccination process?
Indeed, some politicians have been more
part of the problem than the solution. In
general, we observe several problems in the
vaccine rollout and it is true for all kinds
of vaccinations. First – and this is still the
biggest problem – there are not enough re-
sources to vaccinate all people. Covid-19
has made this very visible, but the problem
exists concerning all vaccinations. Second,
there is political distrust in vaccination in
some developing countries. Third, there is
vaccination hesitancy in affluent countries.
These are mainly educated people who
believe that pandemics won’t affect them
because they have been raised in what we
believed were post-pandemic societies.They
are not aware of the dreadful consequences
of pandemics and they have kind of pseudo-
scientific knowledge that makes them sus-
ceptible to misinterpretation, fake news and
lies. Fourth, there are anti-vaxxers who live
in their own universe of alternative facts.
During the Covid-19 pandemic many peo-
ple have been confused with inconsistent,
partly chaotic, information by some of the
companies and some of the politicians.That
did not help.
We know that the world moves toward uni-
versal health coverage. The view of the World
Medical Association about it differs from that of
the World Health Organization, but especially
from the point of view of bankers and financiers.
Unfortunately, Covid–19 has brought its own
corrections as regards the introduction of cover-
age – both in developing and developed coun-
tries. What is your opinion: how is the universal
coverage model developing now?
Let us hope that your optimism is cor-
rect that we are moving towards Universal
Health Coverage (UHC). To be very clear:
We do not disagree with the World Health
Organization on UHC – not at all! We sup-
port the WHO call for UHC wholeheart-
edly and we see this as the most important
strategic aim. Anybody who still believes
that UHC is luxury has not understood the
message from this pandemic. The human
and economic price we pay for the pandem-
ic is extremely high, but it is much higher
for those countries which have no UHC.
Achieving UHC is not only a humanitarian
challenge, it is also an absolute economic ne-
cessity.The pandemic has given proof of this.
Will the current errors and difficulties in or-
ganising vaccination leave any traces in terms
of vaccination against influenza, diphtheria,
papillomatosis and other diseases, the cases when
vaccination should become even more important?
Let’s be optimistic and hope we still can
learn from mistakes ourselves.
Interview with Otmar Kloiber by WMJ Editor Peteris Apinis
BACK TO CONTENTS
2
The most important document of the World
Medical Association is the Helsinki Declara-
tion that highlights very accurately the attitude
of doctors to medical research. Unfortunately,
there is a tendency to blame both vaccine devel-
opers and doctors taking various preparations
against Covid–19 and see it as a clear incon-
sistency with the Helsinki position. Is the World
Medical Association also prepared to discuss the
issue: Covid–19 and the Declaration of Hel-
sinki (DoH)?
The development, testing, production and
authorization of the new vaccines have been
the highlight during this pandemic. Com-
pliments to scientists, the industry and the
regulators and thanks to all who have par-
ticipated as volunteers and researchers in
their development!
Concerning the ethics of the trials, we have
not seen or heard of violations of the ethical
principles in those studies that have been
duly published. The problem may lie with
those developments that have been hidden,
where clinical trials and their results are not
completely transparent.
There are serious questions about placebo-
controlled studies for additional Covid-19
vaccines as now we have effective vaccines.
Those are discussions which we follow care-
fully. Prevention research will be an issue in
the discussion of the next DoH revision.
If there is anything during the pandemic
that has really gone well, it is the develop-
ment of the vaccines. Our challenge now is
equitable access to it.
A complementary question: Covid-19 has
raised the issues declared by the WMA Dec-
laration of Taipei on Ethical Considerations
Regarding Health Databases and Biobanks.
Intensive database building is taking place
around the world, particularly with patient
material produced for the diagnosis and treat-
ment of Covid-19. Is this work worldwide
fully in line with the principles of the Taipei
Declaration?
Good question! There is still a lot of uncer-
tainty about how to deal with health data.
The Declaration of Taipei offers a very
practical approach to use health data in
an ethical manner and at the same time to
maintain individual autonomy and protec-
tion. Like the DoH, it is a very realistic set
of principles that can facilitate research and
at the same time protection for the partici-
pants.
Covid-19 has brought new emphasis into
global health communication. It is on the need
to isolate, keep a distance, wear masks, stay at
home, not to meet friends and relatives. At
the same time, rhetoric on healthy lifestyles,
physical activities, the need to prevent alcohol
consumption and tobacco smoking has faded
significantly. Should the World Medical As-
sociation and national medical associations
remind people more of the need to take care of
their health by reducing weight, eating health-
ily, taking care of their psychosocial well-being?
There certainly has been that shift and it was
necessary at that time. When somebody is
walking on thin ice, you probably don’t warn
that person not to smoke. But it is likewise
correct that we have to refocus on the risks
that cause ill-health and disability. And in-
deed, , the WMA, the World Health Orga-
nization and other partners are engaged in it.
This is even more important as the pandemic
has shown us that pre-conditions – many of
which are avoidable – increase the risk of se-
rious damage or even death.
It is precisely the Covid-19 pandemic that has
highlighted the global problems Sir Michael
Gideon Marmot highlighted at the World
Medical Association a few years ago. In dif-
ferent countries of the world the poorest and
poorly educated people suffer more from se-
vere morbidity and mortality from Covid-19.
Should we not organise a meeting on Covid-19
and social determinants at the World Medical
Association?
We will have to accumulate our knowledge
and we will have to rework our strategy to
improve pandemic preparedness.The Social
Determinants of Health are a key point in
this process, no doubt.
How has the Covid-19 pandemic affected
the work of doctors in the world? We know
that many doctors have been severely ill with
Covid-19, many have died. But even more
doctors have burned out, encountering depres-
sion and anxiety. What should the national
medical associations do at this time? How has
the Covid-19 pandemic affected the work of
the World Medical Association? We were used
to meet in person, discuss and debate. Will it
not be another WMA with completely differ-
ent aims and agendas, other people and other
priorities?
This is a bundle of questions. Many of us, of
the health professions and other care giv-
ers have carried an extreme burden of the
disease. Many have died. And it is a shame
that in many countries health profession-
als and other health workers have not been
protected when it was the time to equip
them with the right protective material and,
even worse, they or their remaining families
are often still left alone with their suffer-
ings. Medical Associations in many coun-
tries around the world are is struggling with
the problems. Covid-19 must be accepted
as an occupational disease for health profes-
sionals.
Like many others, the WMA has changed
its way of working. We were lucky that
much of our work, if not most of it, was al-
ready telework.The gatherings of our work-
groups, the executive committee and many
of our informal discussions were based on
virtual meetings long before Covid-19. And
last year, very successfully, we had our first
General Assembly online. And that despite
quite complicated weighted voting proce-
dures. Thanks to the software platform cre-
ated by young physicians – many thanks to
them!
Virtual meetings have been necessary, and
they will stay with us as will hybrid work
patterns. But I doubt that they are a com-
plete replacement of personal meetings.
International work is about knowing and
trusting one another. It is about sitting face
to face and there is a lot of non-verbal com-
munication in a meeting room and a lot of
talking in the lobby. Online meetings, even
with good video, don’t deliver this.
BACK TO CONTENTS
3
WMA News
The WMA’s 217th
Council meeting was due
to be held in Seoul,South Korea.But regret-
tably because of the pandemic, the meeting
had to be held online,as was the case in 2020.
From April 20–23 the WMA organised a
four-day virtual conference, with more than
100 delegates from 40 national medical asso-
ciations registering for the committee meet-
ings, and the Council sessions.
Tuesday 20 April
Council
The Council meeting was opened by the
Secretary General, Dr. Otmar Kloiber, and
began with a short video from the Korean
Medical Association about Seoul and the
KMA’s history in the WMA.The President
of the KMA, Dr. Choi Dae zip, then wel-
comed delegates.
He said: ‘To all the medical professionals
around the world who are fighting fear-
lessly against Covid-19 with devotion
and sacrifice to protect the life and safety
of humanity, I wish to express my respect
and gratitude. I also grieve for the victims
of Covid-19 and extend my deepest condo-
lences to the bereaved families. Each coun-
try has a different set of medical environ-
ments, standards, public health policies and
systems. As such, for the growth of medi-
cine and medical services, it is critical to co-
operate and exchange with overseas experts.
In times like these, with billions suffering
globally due to Covid-19, our communica-
tion and co-operation is required more than
ever. Thus, our four-day Council session is
a precious and meaningful time for such
a cause, as a reliable guideline for global
medical professionals. I also hope we can
establish the basis for another WMA leap
forward and for encouraging exchanges be-
tween members, committing ourselves to
the mutual goal practising compassion for
patients’.
Korea’s Minister of Health and Welfare,
Gwon Deok cheol, also welcomed the
meeting. He said: ‘In the face of this public
health crisis we are deeply grateful to the
dedication and hard work of medical pro-
fessionals around the world who are com-
mitted to your responsibilities. We also
thank you for the effort of organising this
important international event. Although it
has been more than a year since the spread
of Covid-19,the global pandemic continues
to this day. With the dedication of medi-
cal professionals and the proactive coopera-
tion of citizens, the entire nation of Korea is
striving to respond to Covid 19.
‘As you have been ceaselessly combating
the pandemic at the forefront, despite sev-
eral crises, the Republic of Korea has been
able to manage this public health crisis
relatively stably. Once again, we wish to
sincerely convey our respect and gratitude
for your service. Since February we have
begun vaccinations. Thanks to your active
participation in this process, we expect to
achieve herd immunity by November, our
target deadline.
Until the day we overcome Covid-19 the
Government will mobilise all of our capa-
bilities for co-operating with you to respond
to the pandemic situation’.
Dr. Kloiber read out a list of apologies and
welcomed new Council members.
Council
Elections
Dr. Frank Ulrich Montgomery (Germany)
was nominated for a second two-year term
as Chair of Council. He was nominated by
Dr. Zion Hagay, President of the Israeli
Medical Association, who praised him for
his leadership and for ensuring that the
WMA’s voice had been widely heard during
the pandemic.
Dr. Montgomery was re-elected unopposed
and took the Chair.
Vice-Chair of Council
Dr. Kenji Matsubara (Japan) was re-elected
unopposed as Vice Chair of Council.
Treasurer
Dr. Ravindra Sitaram Wankhedkar (India)
was re-elected unopposed as Treasurer.
Resumed Socio-Medical
Affairs Committee
Recommendations from the resumed ses-
sion of the Socio-Medical Affairs Com-
mittee, held online in January 2021, were
considered.
WMA 2021 Council Report
Seoul (Virtual), April 20–23, 2021
Nigel Duncan
BACK TO CONTENTS
4
WMA News
Taiwan
A proposed revision of the Council Resolu-
tion on Observer status for Taiwan to the
World Health Organisation was tabled for
approval by the Council and for forwarding
to the General Assembly for adoption. The
Resolution called for Taiwan’s participation
in all the WHO’s health programs based on
a substantive, timely and professional basis,
as well as a full participating party to the
International Health Regulations, allowing
Taiwan’s critical contribution to the global
health protection network.
However, the Chinese Medical Associa-
tion objected to the Resolution and pro-
posed an amendment to withdraw it, argu-
ing that it was factually wrong. It said that
on the precondition the one China prin-
ciple was observed, a number of measures
had been taken to promote cross-Straits
health co-operation. And it said there was
no barrier to the participation of Taiwan,
China in global health affairs, including
the WHO.
The Taiwan Medical Association respond-
ed, saying that the Covid pandemic had
posed a serious threat to all human beings,
and Taiwan was helping the international
community in combating the virus. It had
shared its findings with the world. It would
be a great loss to the international commu-
nity if Taiwan was not included in the inter-
national partnership.
In a vote, Council rejected the Chinese
amendment by 20 votes to 4, with two ab-
stentions.
The Chinese Medical Association contin-
ued to express its strong opposition to the
vote, saying that it would never recognize
the Resolution.
On a further vote, the Resolution was ad-
opted by 22 votes to one with two absten-
tions for forwarding to the General Assem-
bly.
Plain Packaging of Cigarettes
The Council considered a proposed revision
of the Resolution on Plain Packaging of
Cigarettes.This strongly encourages nation-
al governments to support the introduction
of initiatives that break brand recognition,
including plain packaging of cigarettes and
other tobacco products. It also deplores
strategies from the tobacco industry to op-
pose the adoption and implementation of
such a policy.
The South Africans asked for e cigarettes
to be included as well, as these were now
being attractively packaged, particularly
to children. The committee heard that
many young children were using these
products. They looked harmless, cool and
high tech, but they were in fact very dan-
gerous.
An amendment to this effect was approved
and the Council agreed that the Resolution,
as amended, be forwarded to the General
Assembly for adoption.
The Council also agreed that the proposed
Statement on Photoprotection and a paper
on Disaster/pandemic Preparedness be for-
warded to the General Assembly for adop-
tion.
President’s Report
Dr. David Barbe (American Medical As-
sociation), in his written report, said his
first six months as President had been
both unusual and unprecedented. Essen-
tially all meetings had been held virtually
and there had been fewer of them. Invi-
tations had been fewer and presentations
shorter. But the WMA had continued to
have a significant impact on the global
discussion on health care and he had
participated in several very important in-
ternational meetings and events. The ef-
forts of the WMA on the Covid virus and
physicians around the world had not gone
unnoticed.
The highlight of the year was the presenta-
tion to the WMA of the “Golden Arrow”
award at the 18th
Vienna Congress in late
January. The WMA was the first organiza-
tion to receive this very prestigious award.
Previous recipients had all been individuals,
including presidents of countries and Nobel
laureates.The WMA on behalf of all physi-
cians had received the award due to the ex-
traordinary efforts and sacrifices physicians
had made on behalf of their patients and
their communities during the coronavirus
pandemic.
Dr. Barbe thanked all the Council and
Committee members and the NMAs for
their work during these difficult and un-
precedented times and said that physicians
and their patients needed their NMAs and
the WMA now more than ever. Because
of the limitations caused by the pandemic,
it would take extra effort by all of them to
have that positive impact that was desper-
ately needed in each of their countries. He
also reported on the support that the WMA
had given to the Turkish Medical Associa-
tion during the year.
Secretary General’s Report
An extensive written report was tabled, de-
tailing to Council all the activities of the
Secretariat since the last meeting.
Chair of Council’s Report
Dr. Montgomery gave a brief oral report,
expressing his disappointment about not
being able to meet face to face.
Items of Urgency
Myanmar
Dr. Joseph Heyman, Chair of the Associate
Members, reported to the meeting about
the current situation in Myanmar, where
doctors were being forced by the military
to stop delivering care. Doctors working
BACK TO CONTENTS
5
WMA News
in clinics were being arrested, beaten and
killed by the military for attempting to save
lives. He suggested that the meeting should
issue a statement supporting Myanmar
doctors. The Indian Medical Association
reported that it had close relations with the
Myanmar Medical Association and was in
contact with doctors in Myanmar.
The Chair suggested that an emergency
resolution would be welcome.
The Council meeting was then adjourned.
Finance and Planning Committee
The committee was called to order by the
Chair of the Council.
Election
Dr. Jung Yul Park (Korea) was re-elected
Chair of the Committee.
Membership Dues Payments
The committee received a Report on Mem-
bership Dues Payments for 2021 and consid-
ered a Report on Membership Dues Arrears
The Treasurer, Dr. Ravi Wankhedkar, and
the financial adviser, Mr Adolf Hällmayr
reported that the membership dues sta-
tus in 2021 was solid and in a comfortable
position, as in the previous year. Two new
members (Paraguay and the Netherlands)
and some Constituent Members (Azerbai-
jan, Guinea and Haiti) had paid their dues
as new additions. The Treasurer expressed
gratitude to some members for the valuable
contributions they had made by increasing
their dues.
The Council approved the Report.
Financial Statement for 2020
The committee considered the interim Fi-
nancial Statement for 2020 to be audited
in June 2021.The Treasurer provided an in-
depth analysis of the contents of the docu-
ment, saying they represented a very solid
basis. Dr. Kloiber explained that the audited
version would be shared with all members
before the General Assembly. In addition,
the summary balance sheet had been pub-
lished in the annual report.
The Council approved the Report.
Strategic Plan
The committee heard an oral report from
the Secretary General on the Strategic
Plan for 2020–2025. He said the plan was
still valid and no change or adaptation was
needed. The achievements and activities on
the three major strategic areas – Universal
Health Coverage, medical ethics and hu-
man rights and health – were continuing.
Future Meetings
The Committee considered the planning
and arrangements for future WMA meet-
ings:
• it was agreed that the 229th
Council Ses-
sion be held from 24–26 April 2025 and
that the 76th
General Assembly be held
from 8–11 October 2025.
• an invitation from the Royal Dutch Med-
ical Association to host the 77th
General
Assembly in 2026 in one of four cities –
Amsterdam, Rotterdam, The Hague or
Utrecht – was accepted.
• it was agreed that “Medical Ethics in a
Globalized World” be accepted as the
theme of the Scientific Session at the
General Assembly, Berlin 2022. It was
suggested that the meeting could also
discuss the revision of the International
Code of Medical Ethics.
The Spanish Medical Association invited
all members to participate in the post-
poned Scientific Session in Cordoba on 17
September 2021, which would take place
either in-person, in a hybrid format or on-
line.
The British Medical Association expressed
its regret that the BMA had had to con-
vert the October General Assembly into a
virtual format due to the uncertainty of the
pandemic situation.
Dr. Kloiber reported that the 13th
Geneva
Conference on Person Centred Medicine,
organised by the International College of
Person Centred Medicine, was successfully
held on 5–7 April 2021. Some WMA Past
Presidents actively participated as part of
the organising committee. He also reported
on the International Symposium on Vac-
cination, which was originally planned as
in-person meeting in the Vatican in 2020
but had to be postponed to 1–2 July this
year. It was now planned to hold a small
in-person meeting and reconsider holding
an in-person meeting in larger format next
year. He said the WMA would try to con-
tinue regional discussions on the Interna-
tional Code of Medical Ethics, which had
proved very fruitful. It was also planning a
series of webinars in the second half of this
year to look into the consequences and les-
sons learned from the pandemic, as well as
to discuss the outlook and preparation for
pandemic situations.
Associate Membership
A report was received from the Associate
Members for 2020.
The total number of Associate Members
in good standing was 1,487. The regional
breakdown was Japan with 605 members
in good standing, all other countries 882
members in good standing, made up of 370
paid members, 29 life members, 326 junior
doctors and 157 medical student members
in free membership. Online applications for
the different member types had been imple-
mented on the WMA website.
The Associate Members and the World
Continuing Education Alliance were offer-
ing its Associate Members free access to a
new education platform to help accelerate
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6
the learning of physicians. This benefit had
been available since June 2019.
The committee received the report.
The Chair of the Associates Members, Dr.
Joseph Heyman, reported on the group’s
work on restructuring the membership
rules.Volunteers from 29 countries had now
drafted proposals for consideration. Their
aim was to make the associate membership
more valuable to the Association.
The Associates Members’Google group had
grown to 422 members, and they reviewed
all documents that were circulated for com-
ment by the Council.
Junior Doctors Network Dr. Yassen Tchola-
kov, Chairperson of the Junior Doctors
Network, gave an oral report on the Net-
work’s activities. A new management team
had taken office in October 2020 and had
operated completely virtually since then.
But there had been many new members
and a strong member engagement had been
maintained during this period. The JDN
was currently working on streamlining its
membership process,creating a virtual new-
comer session to introduce members who
had recently joined to the activities and
modes of work. The Network had three ac-
tive working groups on Medical Exchange,
Education, and International Mobility, Pri-
mary Health Coverage (PHC) and Medi-
cal Ethics. This year, the JDN planned to
complete the two regular biannual editions
of the JDN Newsletter in April and October
2021. It was also working on maintaining
strong links with other health profession-
als’ associations, and was currently work-
ing with other youth organizations and the
World Health Organization on the estab-
lishment of a WHO Youth Council to ad-
vise the Director General.
Past Presidents and Chairs of Council Network
The Past Presidents and Chairs of Council
Network had continued its work. Dr.Yoram
Blachar had been playing an active role on
the official relationship with the Interna-
tional Chair of Bioethics. Past President
Dr. Jón Snaedal served as President of the
International College for Person Cen-
tred Medicine, which had been cooperat-
ing with the WMA on organising its an-
nual Geneva conference on person centred
medicine since 2006. Drs Ardis Hoven and
Jón Snaedal had continued on the Steering
Committee of WMA Associate Members
and had participated in the discussion on
ideas for improving the membership activi-
ties and engagement.
The meeting was adjourned.
Wednesday 21 April
Finance and Planning Committee
The committee resumed with Dr. Park in
the Chair.
He proposed that because of shortage of
time yesterday, four items on the agenda
should be deferred until the Council meet-
ing on Friday – JDN Terms of Reference,
reports on the World Medical Journal,Pub-
lic Relations and Cooperative Relations,
and three items should be deferred to the
next meeting in October – LGBTQ Equity
in Venues Hosting WMA Meetings and
Functions, Green Guidelines for WMA
meetings and Guideline for WMA Work-
group Operations.
This was agreed
Bylaws Amendments
The Committee considered two proposed
amendments to the WMA Bylaws, both
from the Nigerian Medical Association.
The first proposal related to the issue of
Presidential voting in the General As-
sembly, where the Nigerians proposed
an amended rule on notifying candidates
about the number of votes cast. After a brief
debate, the Nigerians agreed to a friendly
amendment from the Israeli Medical As-
sociation that candidates may request to be
notified of the number of votes cast follow-
ing an election. Only the candidates would
be informed of the votes scored by each
candidate.
This was agreed by the committee to be sent
to the Council for forwarding to the Gen-
eral Assembly for adoption.
The second proposal from the Nigerians
related to the number of seats on Council.
It proposed an amendment that the Pacific,
Latin American and the Caribbean,and Af-
rican regions should have one extra Coun-
cil seat to be rotated between those NMAs
that had no Council seats each Council
term. The allocation of the seat should be
decided by majority vote among those re-
gional NMAs unrepresented in Council,
after election results were announced by the
Secretariat.
This proposal, which prompted a lengthy
debate, was introduced with the aim of en-
suring better representation and enhanc-
ing participation from underrepresented
regions.
The Secretary General explained the cost
implications and consequences of addition-
al council seats. He reminded the commit-
tee about previous proposals for changing
the membership of Council and suggested
that more discussion was needed on the op-
tions of modality and how to implement the
proposal.
Several NMA delegates commented on
the proposal. Some supported the idea of
expanding the Council, others advised cau-
tion, suggesting that the amendment could
create unintended imbalances on the Coun-
cil.
The committee agreed that further dis-
cussion of the amendment be postponed
WMA News
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7
­
until the Finance and Planning Com-
mittee meeting in April 2022 in Paris,
which is planned to be an in-person
meeting.
Legal Seat of the WMA
The committee considered a report from
the Secretary General on the legal seat
of the WMA. He explained the problem
of the organization being legally domi-
ciled in New York, while its headquarters
were in France. He proposed moving the
legal seat back to France where the As-
sociation had been situated for the past
40 years.
This was agreed by the committee for rec-
ommending to the Assembly.
Rules Applicable to WMA Associate Member-
ship
The committee considered a proposed revi-
sion of the Rules Applicable to WMA As-
sociate Membership.
Dr. Joseph Heyman, Chair of the Associ-
ate Members, explained the background
to changing the rules. The changes would
ensure that activities of the group were no
longer determined by a single person. Term
limits would be imposed on officers of the
Associate membership, there would be an
increase in the number of people who par-
ticipated in leadership by setting up a steer-
ing committee and an increase in democ-
racy by allowing everyone to vote on issues.
At the moment, medical students and ju-
nior doctors were not allowed to vote. They
were increasing engagement and getting rid
of some arcane rules.
Dr. Kloiber said Associate membership had
been revived. He recommended that the
proposals should be circulated before reach-
ing a decision in October.
This was agreed by the committee to recom-
mend to the Council.
Medical Ethics Committee
The Medical Ethics Committee was called
to order by the Chair of Council.
Election
Dr. Marit Hermansen (President of Nor-
wegian Medical Association) was elected
Chair in a contest with Dr. René Héman
(Netherlands).
International Code of Medical Ethics
The committee received a written report on
the International Code of Medical Ethics
workplan, including a draft of the proposed
changes to the code. Dr Ramin Parsa-Parsi,
Chair of the workgroup, said that the group
had held two very productive video confer-
ences to continue discussing the draft revi-
sion. The draft was now ready to be opened
up to external review in the form of a public
consultation, which would be held in May.
It was proposed that the draft should be
made available on the website and circu-
lated to ethics experts worldwide.
The committee agreed to forward to the
Council the proposed draft for public con-
sultation.
Reproductive Technologies
An oral report was received from the South
African Medical Association Chair of the
workgroup. The group was tasked with ad-
dressing the large and growing number of
reproductive technology options and work-
ing further on the proposed revision of a
Statement on Reproductive Technologies
in coordination with the workgroup on
Genetics and Medicine, given the number
of cross-cutting issues. The committee was
told that a number of key ethical and moral
issues needed to be elaborated, including
multiple pregnancies and termination of
pregnancies.
The committee received the report.
Physicians Treating Relatives
The committee considered the proposed
Statement on Physicians Treating Rela-
tives submitted by the South African
Medical Association. The Statement de-
clared that physicians should not treat
relatives, except in an emergency, for short
term health problems or in a setting where
there was no other qualified physician
available.
The draft Statement had been circulated
and NMA comments had been included.
It was now proposed to include an amend-
ment relating to the duty of the physician
to refer a relative patient’in the event of any
doubt or conflict with the health care of the
patient, or in the situation taking a sensitive
history and performing a physical exami-
nation may be difficult or uncomfortable
for the patient or the physician’. A further
friendly amendment was agreed to include
the word ‘emotionally’before the words ‘dif-
ficult or uncomfortable’.
However, the view was put forward that the
document was not yet ready to be approved.
One speaker spoke of the need for some
nuancing in the document on the issue
of primary care, where what constituted a
prescribable prescription differed from one
country to another.
The committee voted on a proposal that
the document, as amended, be sent to the
Council for forwarding to the Assembly.
When the vote ended in a tie, it was decid-
ed to re-circulate the document for further
discussion.
Organ Donation in China
The German Medical Association gave an
oral report on organ donation in China,
saying that the Chinese Medical Associa-
tion and German Medical Association had
agreed to postpone this issue until October
and would continue their discussions in the
meantime.
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8
Declaration of Venice
The committee received an oral report from
the American Medical Association on its
work revising the Declaration of Venice on
Terminal Illness. The committee was told
that the Review Committee had now sug-
gested that the Declaration be combined
with the Declaration on End-of-Life Med-
ical Care. The AMA said that as a result of
this, it would be submitting a further report
to the October meeting.
The committee received the report.
Women’s Right to Health Care
The South African Medical Associa-
tion presented a proposed major revision
of the Resolution on the Women’s Right
to Health Care and How that Relates to
the Prevention of Mother-to-Child HIV
Infection. It suggested that the document
be split into two policies – a Statement on
Access of Women and Children to Health
Care and a Statement on Women’s rights
to Health Care and How that relates to
the Prevention of Mother-to-child HIV
infection.
The Statement on Access proposed mea-
sures to combat centuries of gender inequal-
ity and gender bias on access to health care.
The Swedish Medical Association pro-
posed amending the Statement on Access
to include calls for the provision of pre-
conception, prenatal and maternal care and
post-natal care, including immunization,
nutrition for proper growth and healthcare
development for children. In addition, a
paragraph was suggested on advocating for
educational,employment and economic op-
portunities for women.These were accepted
as a friendly amendments.
The committee agreed to recommend to
Council splitting the original Resolution
into two Statements, one on HIV and the
other on access to health care.
Health Care for Sports Medicine
The American Medical Association sub-
mitted a proposed major revision of the
Declaration on Principles of Health Care
for Sports Medicine. The revised document
recommends ethical guidelines for sports
medicine physicians and says that the use of
anabolic agents and performance enhancing
drugs and methods is a threat to the health
of athletes and is in conflict with the prin-
ciples of medical ethics.
The committee was told that the revised
document included a reference to the In-
ternational Association of Athletics Fed-
eration regulations that had been opposed
by the WMA. Consideration had also been
given to the increasing use of anabolic ste-
roids in non-professional athletes and ado-
lescents.
The committee approved the document
for sending to Council for adoption by the
General Assembly.
Medical Ethics in the Event of Disasters
The committee received an oral report on
the revision of policies on health emergen-
cies in relation to natural disasters, epidem-
ics and pandemics. It was told that a draft
document would shortly be sent out for
consideration.
Classification of Policies
As part of the Association’s policy to review
all documents that were 10 years old, the
committee considered three policy state-
ments and agreed that:
• the Declaration on End-of-Life Medi-
cal Care undergo a major revision and be
merged with the Declaration of Venice;
• the Statement on the Professional and
Ethical Use of Social Media undergo a
major revision;
• that the WMA Recommendation on the
Development of a Monitoring and Re-
porting Mechanism to permit Audit of
Adherence of States to the Declaration of
Tokyo be reaffirmed with a minor revi-
sion.
The committee agreed to recommend these
proposals to the Council.
Human Rights
The committee was referred to the written
activity report, in which details were given
about action taken during the year to as-
sist doctors in Turkey, Israel, Iran, Azerbai-
jan, Myanmar, Singapore and Sri Lanka.
Among many other activities, work had
continued with the International Commit-
tee of the Red Cross on the ‘Health Care in
Danger’ project.
Thursday 22 April
Socio-Medical Affairs Committee
The Chair of Council called the meeting to
order.
Election
Dr. Osahon Enabulele (Nigeria) was re-
elected Chair of the Socio-Medical Affairs
Committee by acclamation.
Health and Environment
The committee heard an oral report on the
Environment Caucus meeting that had
been held earlier that month. There had
been an exchange with the Director of the
Global Health and Climate Alliance, who
had highlighted current activities. These
included the #HealthyRecovery initiative
launched by the WHO-Civil Society Working
Group to Advance Action on Climate Change
and Health. Through this successful initia-
tive,more than 350 organisations represent-
ing 40 million medical and health profes-
sionals, raised their collective voice to G20
leaders, calling for a healthy recovery from
the COVID-19 pandemic.
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9
The committee was also told about the global
survey on climate change launched in Octo-
ber by the Global Climate and Health Alli-
ance and George Mason University’s Center
for Climate Change Communication, in
collaboration with WHO.The survey aimed
to assess the perspectives of health profes-
sionals from countries in the six WHO re-
gions around the world and about climate
change and its impacts on health.
Medical Technology
The Israeli Medical Association gave an
oral report on the workgroup on medical
technology. The group had met to consider
its remit, which was to examine all WMA
policies and recommend those areas where
the WMA should voice its opinion, where
there should be policy and decide overall
how the WMA should work in the area of
medical technology. It was agreed that the
group should work on a glossary to detail
what the word ‘technology’ covered.
The report was received.
Disaster/pandemic preparedness
The committee received an oral report on
the revision of WMA policies related to di-
saster/pandemic preparedness.
It was proposed to streamline policies to en-
sure they remained applicable and enabled
the WMA to react quickly in the event of a
pandemic/epidemic or disaster. Among the
actions proposed were to archive both Eb-
ola-specific documents and to have a major
revision of the WMA Statement on Medi-
cal Ethics in the Event of Disasters to ensure
that it captured ethics in emergencies in one
document. The Statement should touch on
new therapies,vaccines,emerging technolo-
gies, triage, priority criteria for hospitaliza-
tion, the role of primary care and ethics of
research. In addition, the Declaration on
Disaster Preparedness and Medical Re-
sponse in its current form was outdated and
would benefit from a major revision.
The report was received.
Availability, Quality and Safety of Medi-
cines
The committee considered a proposed
Statement in support of Ensuring the
Availability, Quality and Safety of All
Medicines Worldwide.The Statement urges
national governments to improve the avail-
ability of medications and calls on national
governments to establish a national body
charged with gathering information about
the demand for and supply of medicines, to
avoid shortages.
The committee was told by the French
rapporteur that there had been a discus-
sion about splitting the draft document
into two parts and he thought this was
logical. It was important that the text ad-
dressed countries all over the world, in-
cluding wealthy countries. There was also
the question as to whether the document
should refer to the current pandemic that
might no longer be relevant in a few years’
time.The pandemic had exacerbated medi-
cine shortages and vaccine shortages in
particular. Delegates needed to talk about
these issues and address all of the shortages
they had seen in relation to Covid. The vi-
rus was here to stay for a few years and it
might well continue to give them problems
for many years.
In the debate that followed it was suggested
that the document might benefit from in-
cluding more global references, and several
friendly amendments were accepted.
The issue of vaccine equity was raised, in
particular shortages in India, and the fact
that countries were not exporting vaccines.
It was said that every country should have
access, not only to vaccines, but to a range
of central medicines.
Dr. Kloiber said that several statements on
vaccine equity had been made by the WMA
over the past year.
The Statement, as amended, was approved
by the committee for sending to the Coun-
cil for forwarding to the General Assembly.
Medical Liability & Defensive Medicine
The Israeli Medical Association introduced
a proposed revision of the WMA State-
ment on Medical Liability. The Statement
calls for an end to frivolous medical liability
claims and warns that the increasing culture
of blame could lead to defensive medicine.
The committee was told that NMAs had
been consulted and their comments had
been included in the document.
The British Medical Association suggested
that delegates should look at this docu-
ment not in isolation but as part of a wider
discussion, with the possibility of a White
Paper on patient safety and medical regula-
tion. The BMA had conducted a survey in
which 95 per cent of the doctors responding
said they were afraid of making medical er-
rors,and many of them said this was a worry
they had every day of their working lives.
They said this was due to lack of resources,
work force shortages and other constraints.
Doctors were working in an environment
where the system resulted in error rather
than doctors as individuals. What was now
needed was a discussion about systemic fac-
tors, systems of liability and no fault com-
pensation.
The committee approved the revised State-
ment for sending to Council and forward-
ing to the General Assembly for adoption.
Access to surgery and anaesthesia care
The Junior Doctors Network presented a
proposed Statement on Access to Surgery
and Anesthesia Care, which it said had un-
dergone significant changes.The committee
was told that access to surgery care had for
many years been neglected. The need for
improvements were critical for reaching
universal health care coverage. This was not
about a single specialty, but could cover ob-
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10
stetrics, pain control, gynaecology, trauma
care and primary care.
There was a suggestion that this paper did
not fall within the WMA’s core business
and the paper should be much broader than
just anesthesia.
However, the committee agreed to send
the proposed Statement to Council for for-
warding to the General Assembly for adop-
tion.
Trade Agreements and Public Health
A proposed revision of the Council Reso-
lution on Trade Agreements and Public
Health was presented by the JDN. The
document represented an update. But the
Danish Medical Association suggested that
the document failed to find the right bal-
ance between the advantages of interna-
tional trade and the potential side effects on
the healthcare sector. It focused too much
on the disadvantages of trade. As a result, it
was suggested that the document should be
recirculated to evaluate the benefits of trade
and to strengthen the document.
The proposal to recirculate the document
was agreed and the committee recommend-
ed this to Council.
Migration and Health
The Norwegian Medical Association pro-
posed a revision to the Statement on Medical
Care for Refugees, including Asylum Seek-
ers, Refused Asylum Seekers and Undocu-
mented Migrants, and Internally Displaced
Persons. The Statement reminds physicians
of their duty to provide appropriate medical
care to all refugees, including asylum seekers,
undocumented migrants and internally dis-
placed people and that they should do this
based solely on clinical necessity, regardless
of the civil or political status of the patient.
The Norwegian Medical Association, who
had acted as rapporteur for the revision,said
that most of the comments and amend-
ments received from constituent members
had been included in the consolidated doc-
ument.
The committee agreed to forward the docu-
ment, as amended, to the Council for for-
warding to the General Assembly for adop-
tion.
Family Violence
A revision to the Statement on Family Vio-
lence, which calls for zero tolerance for all
forms of violence against women, was pre-
sented by the Nigerian Medical Associa-
tion.
The German Medical Association referred
to the preamble which stated that family
violence was ‘a grave universal public health
and human rights problem that affected in-
dividuals, regardless of age, gender, racial/
ethnic background, culture, religion, socio-
economic status or any other factor’. It
wanted to include the words ‘sexual orienta-
tion’, arguing that this was a very prevalent
reason for family violence. The change was
agreed as a friendly amendment.
The document, as amended, was approved
for sending to Council for adoption by the
General Assembly.
Use of Telehealth for the Provision of Health
Care
A proposed revision to the Statement on
Guiding Principles for the Use of Tele-
health for the Provision of Health Care
was presented by the Chinese Medical As-
sociation with the new title of Statement
on Digital Health. The Statement, which
merges three WMA policies, urges patients
and physicians to be discerning in their use
of digital health and to be aware of the po-
tential risks and implications.
The British Medical Association talked
about the effect that Covid-19 had had on
this issue. As a result, they believed this
paper needed to be reframed. The word
telehealth encompassed such a broad
range of means of communication. The
BMA had surveyed doctors on this issue
and they did not want to return to the old
normal. They wanted remote technology
to continue. They had all seen the benefits
of remote consultations, not a substitute
but an adjunct, such as the monitoring of
oxygen levels remotely. They needed to re-
define what good care could look like. It
was no longer appropriate to say, as the
Statement did, that face to face consulta-
tions were the gold standard. Blood pres-
sure monitoring, for instance, was better
done at home. Also, telehealth could im-
prove equity of access.
Several amendments to the document
were suggested, such as the deletion of the
sentence ‘At present, face-to-face consul-
tation should remain the gold standard
of clinical care’. These were agreed by the
committee.
However, the committee decided to recom-
mend that the document, as amended, be
recirculated for consideration.
Rights of Patients and Physicians in the Is-
lamic Republic of Iran
The Kuwait Medical Association proposed
a major revision to the WMA Resolution
Supporting the Rights of Patients and Phy-
sicians in the Islamic Republic of Iran. The
revised Resolution now declared that phy-
sicians in the Islamic Republic of Iran had
reported deliberate denial of medical care
in detention, withholding of essential and
readily available medications by physicians
and other health professionals and a lack of
appropriate and functioning medical equip-
ment. They had also reported widespread
use of torture and ill-treatment in deten-
tion, denial of the rights of hunger strikers,
and physicians’ complicity in facilitating
the death penalty for juveniles in assault on
children’s rights.
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11
The German Medical Association proposed
an amendment to add a new sentence at the
end of the document that the WMA ‘stress-
es that physicians who adhere to the pro-
fessional and ethical obligations outlined
in the aforementioned declarations must
be protected’. It argued that in many cases,
physicians who adhered to their profession-
al and ethical codes became victims of coer-
cion, punishment, or executions themselves.
It was therefore very important to stress the
protection of physicians who fulfilled their
duty and respected their professional and
ethical obligations.
The amendment was accepted as a useful
addition.
The committee agreed that the document,
as amended, should be recirculated for fur-
ther consideration.
Patient Safety and Medical Regulation
The British Medical Association proposed
revisions to the WMA Declaration on Pa-
tient Safety. The committee was told that
discussion on medical liability could not be
separated from the issues around improving
patient safety. They should change the para-
digm of how they looked at regulation of the
profession. It was often not the individuals
who were negligent, it was the system. The
fear of blame resulted in defensive practice
and there was little learning. Many doctors
would not even raise patient safety concerns.
The BMA was suggesting that the WMA
should widen the definition of professional
regulation to say that it must regulate the
system and not just the individual. That
would require the WMA to redefine its
statements on professional regulation. The
first question should be what went wrong,
not who got it wrong. What was required
now was a White Paper to set out these is-
sues and make recommendations.
This led to a lengthy debate, with delegates
discussing the need to improve systemic
failures. It was argued that significant num-
bers of medical errors occurred within the
context of wider systemic factors and fail-
ings, especially where doctors were working
within pressurised environments. A narrow
focus on regulating the acts and omissions
of individual doctors without first fully con-
sidering these wider contributory factors
resulted in the inappropriate and unfair tar-
geting of individuals.This in turn resulted in
a toxic culture of fear and blame, in which
doctors were less likely to be open about
errors and safety concerns and were more
likely to practice defensively.This ran coun-
ter to the aim of improving patient safety
through openness, learning and addressing
root causes of error. Action was therefore
required to foster a supportive health ser-
vice culture in which medical regulation.
and investigations of errors appropriately
examined and took into account any sys-
temic pressures and systems failures.
The BMA proposed a review of the WMA
Statement on Patient Safety to address sys-
temic factors and pressures that could lead
to medical error, and a document broaden-
ing the scope of medical regulation. This
was supported by several speakers and the
view was expressed that regulation was cur-
rently being used to fix the question of pa-
tient safety from the wrong side by just a
blaming and shaming approach.
The committee approved the proposals for
the BMA to continue work on the revision.
Classification of Policies
The committee considered recommenda-
tions from members, which was that five
policies should undergo major revision:
• Statement on Health Hazards of Tobacco
Products and Tobacco-Derived Products
• Declaration of Edinburgh on Prison Con-
ditions and the Spread of Tuberculosis and
Other Communicable Diseases;
• Statement on the Global Burden of Chronic
Disease;
• Statement on the Protection and Integrity of
Medical Personnel in Armed Conflicts and
Other Situations of Violence;
• Resolution on Occupational and Environ-
mental Health and Safety.
• It was recommended that four policies
should undergo minor revision
• Declaration on Leprosy Control around the
World and Elimination of Discrimination
against persons affected by Leprosy;
• Resolution on North Korean Nuclear Test-
ing;
• Resolution on Child Safety in Air Travel;
• Resolution on Implementation of the WHO
Framework Convention on Tobacco Con-
trol.
• It was recommended that two policies should
be rescinded:
• Resolution on the Protection of Health Care
Facilities and Personnel in Syria;
• Resolution on Zika Virus Infection.
The German Medical Association said it
would rather see the Syria Resolution un-
dergo a minor revision to keep it alive. At-
tacks on medical personnel were still being
reported in the tenth year of the war.
The committee agreed that this Resolu-
tion should undergo a minor revision and
that the remainder of the recommendations
should be accepted.
The Socio Medical Affairs Committee
meeting was then adjourned.
Friday 23 April
Plenary Council
Emergency Motions
Alexei Navalny
The Council considered an emergency Res-
olution in support of Alexei Navalny.
The Resolution was moved by the Chair of
Council.
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12
The Chinese Medical Association said
that caution should be exercised on this
matter. The Council was told there was
no Russian representative present at the
meeting and the content of the Resolu-
tion had not been verified. It was sug-
gested that the secretariat should write to
the National Medical Chamber of Russia
to consult about the actual situation and
their opinions before the proposed Reso-
lution was submitted for consideration. A
motion was proposed that the Resolution
be delayed. But in the absence of a sec-
onder, the motion fell.
A number of minor textual amendments
were proposed and accepted.
On a vote, the Council approved the Reso-
lution by 19 votes to one.
Myanmar
A proposed emergency Resolution in sup-
port of Medical Personnel and Citizens of
Myanmar was submitted by the Chair of
Council. After a brief debate, during which
several textual amendments were accepted,
the Council approved the emergency Reso-
lution without a vote.
Covid-19
The BMA presented an emergency Reso-
lution in support of the countries worst af-
fected by the Covid-19 crisis. It was argued
that it was time for proper global co-oper-
ation. Countries owed a debt to countries,
such as India, which had manufactured and
exported vaccines. No-one was safe until
everyone was safe.
There was a debate about whether the Reso-
lution should refer specifically to particular
countries, such as India and Brazil. The
Council was divided, with some speakers
opposing the idea of mentioning specific
countries,preferring to use the word ‘world-
wide’, and others arguing that it was essen-
tial to include them by name. The Council
was told that more than 100 nations had
not received any vaccines.
On a vote it was decided by 12 votes to 11,
with one abstention, to name India and
Brazil in the Resolution.
Several friendly amendments, such as add-
ing the need to strengthen ’health service
resilience’, were accepted without a vote
and the Council approved the Resolution,
as amended.
Medical Ethics Committee Report
The Council approved the following recom-
mendations:
• That the current policy draft of the In-
ternational Code of Medical Ethic be ap-
proved for the workgroup’s ongoing work
and that it be made available for a public
consultation starting in May 2021;
• That the proposed revision of the State-
ment on Physicians Treating Relatives, as
amended, be re-circulated to constituent
members for comment;
• That the Declaration of Venice be merged
with the Declaration on End-of-Life
Medical Care;
• That the proposed Declaration on Princi-
ples of Health Care for Sports Medicine
be approved with the recommendation
that it be forwarded to the General As-
sembly for adoption;
• That the policy Medical Ethics in the
Event of Disaster, once received, be cir-
culated to constituent members for com-
ment;
• That the Declaration on End-of-Life
Medical Care undergo a major revision and
be merged with the Declaration of Venice;
• That the Statement on the Professional
and Ethical Use of Social Media undergo
a major revision;
• That the WMA Recommendation on the
Development of a Monitoring and Re-
porting Mechanism to Permit Audit of
Adherence of States to the Declaration of
Tokyo be reaffirmed with a minor revision.
Access of Women and Children to Health Care
The Council considered the proposed State-
ment on Access of Women and Children to
Health Care, as amended, and the recom-
mendation that it be approved, pending
a compromise amendment between the
South African and British Medical Asso-
ciations on artificial intelligence algorithms.
The South African Medical Association
said it had agreed with the BMA to add
the following paragraph to the document:
‘In order not to amplify any gender in-
equalities, information being programmed
into artificial intelligence algorithms being
created to inform medical diagnoses and
management must take into account the
specific health considerations of women, for
example women may present with different
symptoms to men’.
A further addition was proposed reading:
‘Governments have an obligation to ensure
that the information being programmed into
artificial intelligence algorithms being creat-
ed to inform medical diagnoses and manage-
ment must include a representative sample
of data from women to ensure the gender
inequality gap is not amplified further’.
The Council approved the document as
amended for forwarding to the General As-
sembly for adoption.
It also approved the proposed Statement on
Women’s Right to Health Care and How
that Relates to the Prevention of Mother-
to-Child HIV Infection, as amended, also
for forwarding to the General Assembly for
adoption.
Finance and Planning
Committee Report
The Council approved the Report on Mem-
bership Dues Arrears, the Financial State-
ment for 2020 and moving the legal seat of
the WMA back to France.
WMA News
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13
Future Meetings
The Council accepted the committee’s rec-
ommendation that:
• the 229th
Council Session be held from
24–26 April 2025;
• the 76th
General Assembly be held from
8–11 October 2025;
• the invitation from the Royal Dutch
Medical Association for one of the cities
Amsterdam, Rotterdam, The Hague or
Utrecht to host the 77th
General Assem-
bly in 2026;
• “Medical Ethics in a Globalized World”
be the theme of the Scientific Session of
the General Assembly, Berlin 2022;
• the proposed revision of the Rules Ap-
plicable to WMA Associate Membership
be circulated.
The Council agreed to defer to the next
committee meeting in October three items:
• proposed Resolution on LGBTQ Equity
in Venues Hosting WMA Meetings and
Functions;
• proposed Green Guidelines for WMA
Meetings;
• proposed revision of the Procedures and
Operating Policies on the Workgroup.
Bylaws Amendments
The Council considered the proposed amend-
ments to the WMA Bylaws relating to
Presidential voting in the General Assembly
and to the number of seats on Council. The
American Medical Association said these
were very important issues for the WMA and
should be considered by a workgroup rather
than during an online meeting.A report could
then be made to the next meeting in October.
The Council approved the setting up of a
workgroup.
JDN Terms of Reference
The Council approved the proposed revi-
sion of the Junior Doctors Network Terms
of Reference.
World Medical Journal
The Council considered a report from the
Editor in Chief of the World Medical
Journal. In his written report, he said the
Covid–19 pandemic had impacted signifi-
cantly on communication, discussions and
contacts. Four Journals had been published
during 2020, both in paper and digital for-
mat. In his oral report, he said that this
year they would focus on articles about
Covid–19, doctors’ problems, sickness and
burnout during the pandemic, and mental
health. He said they would be interested in
articles describing how national medical as-
sociations had coped during the pandemic,
what difficulties they had suffered, and how
they saw the future of the WMA and medi-
cine,including issues relating to vaccination.
Public Relations
The Council received a report on the As-
sociation’s public relations. The WMA had
continued to maintain a good profile in
the media over the past six months. The
media’s attention had naturally focused on
Covid-19. The Association had issued a
number of press releases on the pandemic,
and the Chair of Council had continued to
field a large number of media requests from
around the world, ensuring a high global
profile for the WMA.
The number of WMA twitter followers had
increased to 14,000 and the WMA had
increased its visibility by publishing peri-
odically visual quotes of its latest policies
that could be easily shared by its followers.
The WMA Facebook account had more than
13,400 followers. The Association had also
increased its online presence during the
pandemic with a series of interviews with
health leaders from around the world.
Cooperative Relations
The Council considered the proposed Ap-
pointment of the International Chair in
Bioethics as WMA Cooperating Center.
The Council agreed that the Secretary
General sign the proposed Memorandum
of Understanding with the “International
Chair in Bioethics”ICB and to list the ICB
as WMA Cooperating Center.
Socio-Medical Affairs
Committee Report
The Council agreed that the following pro-
posed documents be forwarded to the Gen-
eral Assembly for adoption:
• Statement in Support of Ensuring the
Availability, Quality and Safety of All
Medicines Worldwide;
• Statement on Medical Liability;
• Statement on Family Violence;
• Statement on Access to Surgery and An-
esthesia Care;
• Statement on Medical Care for Migrants
and that the Resolution on Global Refugee
Crisis, the Resolution on Refugees and Mi-
grants and the Resolution on Migration be
rescinded and archived;
It was agreed that the following documents
be circulated for comments:
• Resolution on Trade Agreements and
Public Health;
• Statement on Guiding Principles for the Use
of Telehealth for the Provision of Health
Care;
• Resolution Supporting the Rights of Pa-
tients and Physicians in the Islamic Re-
public of Iran;
Patient Safety
• It was agreed that the British Medical
Association be tasked with preparing a
proposed Statement on broadening the
scope of medical regulation and with re-
vising the Statement on Patient Safety.
Classification of Policies
The Council agreed with the committee’s
recommendations on the classification of
policies that were 10 years old and that five
policies should undergo major revision:
WMA News
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14
• Statement on Health Hazards of Tobacco
Products and Tobacco-Derived Products;
• Declaration of Edinburgh on Prison Con-
ditions and the Spread of Tuberculosis and
Other Communicable Diseases;
• Statement on the Global Burden of Chronic
Disease;
• Statement on the Protection and Integrity of
Medical Personnel in Armed Conflicts and
Other Situations of Violence;
• Resolution on Occupational and Environ-
mental Health and Safety.
That five policies should undergo minor re-
vision:
• Declaration on Leprosy Control around the
World and Elimination of Discrimination
against persons affected by Leprosy;
• Resolution on North Korean Nuclear Test-
ing;
• Resolution on Child Safety in Air Travel;
• Resolution on Implementation of the WHO
Framework Convention on Tobacco Con-
trol;
• Resolution on the Protection of Health Care
Facilities and Personnel in Syria.
And that one policy should be rescinded:
• esolution on Zika Virus Infection.
Advocacy and Communication
An oral report was given from the Chair of the
Advocacy and Communications Workgroup
on refocusing the Association’s advocacy work.
The Council was told this was a new plan to en-
gage with a group of people from the constitu-
ent members to reach out on communications.
World Health Organization
The Secretary General reported on the
forthcoming World Health Assembly which
would be discussing the pandemic and how
to improve international health regulations.
A WHO group had been looking at how the
organisation had performed during the pan-
demic and what had to be changed.
Vaccine Hesitancy
The meeting ended with a comment from
Nigeria, complaining about vaccine hesi-
tancy being encouraged on You Tube by
doctors, the majority of whom came from
the western world and the United States.
He said that the messages were very dis-
couraging, confusing and worrying for
people when they made statements about
the Covid-19 vaccines not being accept-
able. It was suggested that a statement
should be prepared on the issue. The Chair
of Council said this was a very important
issue.The WMA was aware of the problem
of both fake information on social media
and the activities of anti-vaxxers. He sug-
gested that a paper should be prepared on
the issue.
After final thanks from the Secretary Gen-
eral to the meeting’s organisers, the Council
meeting was brought to a close.
Mr. Nigel Duncan
Public Relation Consultant,
WMA
E-mail: nduncan@ndcommunications.co.uk
WMA Council Resolution in
Support of the Countries Worst
Affected by the Covid-19 Crisis
Adopted by the 217th
WMA Council Session, Seoul (online), April 2021
The World Medical Association is deeply concerned to see the
alarming and worsening Covid crisis in many countries world-
wide, such as currently in India and Brazil. We recognise the huge
challenges doctors and other healthcare professionals are facing in
maintaining healthcare systems in such harrowing conditions. The
WMA calls on the international community and governments to ur-
gently prioritise support and aid to these the worst affected nations,
including oxygen, drugs, vaccines, Personnal Protective Equipment
(PPE) and other equipment as needed,and to strengthen healthcare
system resilience in the face of future pandemics.The pandemic will
not end until we tackle Covid in every nation and this is a time for
global cooperation, solidarity and support for one another.
WMA Council Resolution in
Support of Medical Personnel
and Citizens of Myanmar
Adopted by the 217th
WMA Council Session, Seoul (online), April 2021
The World Medical Association notes with alarm the continuing
actions of the current police and Myanmar security forces includ-
ing arbitrary arrests and detention of health personnel and other
citizens, attacks against physicians and other health personnel and
facilities, and continuing harassment and intimidation of protesters,
human rights defenders and journalists. The WMA and its mem-
bers are seriously disturbed by their terrorizing, arresting, kidnap-
ping and murdering health care workers for treating protesters.
These activities are in total opposition to the international recom-
mendations in the WMA Declaration on the Protection of Health Care
Workers in situation of Violence, the WMA Statement on the Protection
WMA News
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15
and Integrity of Medical Personnel in Armed Conflicts and Other Situ-
ations of Violence as well as the United Nations Declaration on Human
Rights Defenders.
Thus, the WMA and its members demand that the Myanmar secu-
rity forces take immediate action to:
• Guarantee, in all circumstances, the physical and psychological in-
tegrity of protesters, including health personnel who are arrested;
• Release protesters and personnel immediately and uncondition-
ally, and drop all charges against them since their detention is
arbitrary as it only aims at preventing freedom of expression and
their human rights activities;
• Put an urgent end to attacks against health personnel and facili-
ties and ensure their protection to provide adequate health care
provisions to all.
• Stop all acts of harassment, intimidation, and killing, against pro-
testers, human rights defenders and journalists and comply with
all the provisions of the United Nations Declaration on Human
Rights Defenders;
• Ensure in all circumstances respect for human rights and funda-
mental freedoms in accordance with international human rights
standards and international instruments, including the Interna-
tional Covenant on Economic, Social and Cultural Rights.
• Cooperate with international fact-finding commissions.
WMA Council Resolution in
Support of Alexei Navalny
Adopted by the 217th
WMA Council Session, Seoul (online), April 2021
The World Medical Association notes with alarm the critical health
condition of the Russian opposition activist Alexei Navalny de-
tained in Moscow since January 2021.
Navalny has been on a hunger strike since 31 March and was
transferred to a prison hospital on Monday 21st
of April. Cor-
roborating information indicates that he is facing denial of ad-
equate medical care and threatened to be force-fed by the prison
authorities.
The WMA recalls its Declaration of Malta on Hunger Strikers lay-
ing down the medical ethical principles governing hunger strikes,
in particular the respect of the individual’s autonomy and dignity.
Force-feeding and any other forms of coercion constitute a form of
torture and is contrary to medical ethics.
The WMA recalls the standards of international human rights
law, including the International Covenants on Civil and Political
Rights and on Economic, Social and Cultural Rights, guarantee-
ing, amongst other matters, the freedom of expression, access to
adequate healthcare as well as the prohibition of torture or cruel,
inhuman or degrading treatment. The Russian Federation ratified
the covenants in 1973 and is held accountable for its commit-
ments.
Thus, the WMA and its members call on the Russian authorities
to ensure full respect for its human rights obligations, and demand
immediate action to ensure that Alexei Navalny be treated with
humanity and with respect for the inherent dignity of the human
person, in particular:
• That he be urgently examined by independent and qualified med-
ical experts,
• That the Russian authorities take all the required measures to
provide adequate conditions in line with the Malta Declaration
to respect his decision to hunger strike and to ensure that he is
not force-fed,
• That he be released immediately as he is a prisoner of conscience
deprived of his liberty for his peaceful political activism and ex-
ercising free speech.
WMA News
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16
Haematology
Overview
Haematological diseases are a heteroge-
neous group of malignancies that affect
people’s health worldwide such as leukae-
mia, lymphoma and multiple myeloma.
Based on Global Cancer Statistics 2020, it is
an estimated of 474,519 newly diagnosed
leukaemia worldwide, with 311,594 of
new death in 2020 [1]. Its high mortality
and long treatment cycle seriously hinders
quality of patients’ life and social and eco-
nomic development. Treatment options for
leukaemia include chemotherapy, hema-
topoietic stem cell transplantation (SCT),
small molecular targeted drugs, monoclonal
antibodies, CAR-T cell therapy etc.The de-
velopment of treatments for haematological
malignancies leads to the new era of pre-
cise targeted therapy, which benefit from
stratified and individualized treatment. The
treatment innovation on haematological
malignancies from Chinese researchers and
clinicians has enriched to the development
of global leukaemia precise therapy. In the
following paragraphs, we will discuss the
exploration of precision therapy, current re-
search and future direction of haematology
in China.
Allogeneic stem cell
transplantation
Allogeneic stem cell transplantation (allo-
SCT) is a method for the therapeutic cure
of haematological malignancies [2–4].
However, donor limitations restrict the
wide use of allo-SCT. In the past two de-
cades, researchers have established several
haplo-SCT protocols based on different ap-
proaches to induce immune tolerance [5–7].
Those approaches include 1) ex vivo graft T
cell depletion (TCD) in combination with
mega doses of CD34+ cells and/or anti-
third-party CD8 T cells, in vitro CD3αβ/
CD19 depletion, 2) granulocyte colony
stimulating factor (G-CSF) plus anti-thy-
mocyte globulin (ATG)-based regimens
with unmanipulated T cell replete graft,
which originated from the Peking group,
China [8,  9], and 3) post-transplantation
cyclophosphamide (PT/CY) for tolerance
induction [10–12].
In a series of pilot studies on G-CSF-in-
duced immune tolerance by Huang’s group,
bone marrow T cell hypo-responsiveness
could be induced by the upregulation of
monocytes and plasmacytoid dendritic cells
and the downregulation of co-stimulatory
signals during in vivo G-CSF administra-
tion.The polarization of T cells from Th1 to
Th2 could be maintained after in vitro mix-
ture of G-CSF-mobilized peripheral blood
grafts (G-PB) and G-CSF primed bone
marrow grafts (G-BM) [13, 14]. Combina-
tions of G-CSF and ATG were proposed
to play a fundamental role in overcoming
HLA barriers [15] through the action of
regulatory B cell, regulatory T cell, Th17/
Tc17, and myeloid-derived suppressor cells
[16–22].
Based on the mechanistic research on cy-
tokine-induced immune tolerance, in 2000
Huang and colleagues at Peking University
initiated a pilot study investigating unma-
nipulated haplo-SCT without in vitro
TCD for the treatment of acute leukaemia.
The study mainly included mixed grafts
of G-PB and G-BM, modified busulfan/
cyclophosphamide (Bu/Cy) plus ATG for
myeloablative conditioning, and cyclospo-
rine A + methotrexate + mycophenolate
mofetil for intensified graft-versus-host
disease (GvHD) prophylaxis. All patients
(n = 58) in the pilot cohort achieved sus-
tained, full donor-type engraftment with
an acceptable incidence of grades II–IV
acute GvHD (aGvHD, 37.9%) and chron-
ic GvHD (cGvHD, 65.4%). The 2-year
disease-free survival (DFS) rates for stan-
dard- and high-risk patients were 77.6%
and 63.2%, respectively [23, 24].The cohort
was updated [9, 25–27] and expanded to
756 cases in 2010, with 99.5% sustained
myeloid engraftment, 43% grades II–IV
aGvHD, and 53% cGvHD. The three-year
DFS for standard- and high-risk patients
was 68% and 49%, respectively [28]. Based
on T cell tolerance induced by G-CSF, the
Current Research and Future Direction of
Haematology in China
Wei Sun Xiao-Jun Huang
CHINA
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17
Haematology
Peking University group established a novel
G-CSF-primed haploidentical blood and
marrow transplantation system (The Beijing
Protocol) [5, 6], including individualized
conditioning regimens, the combination of
unmanipulated G-CSF primed blood and
marrow as allografts, donor selection based
on non-human leukocyte antigen (HLA)
systems, risk-directed strategies for GVHD
and relapse [29].
HLA match plays a predominant role in the
selection of the best donor among unrelated
transplants but does not influence the out-
comes in haplo-SCT [30, 31]. A given pa-
tient might have multiple choices for a hap-
lo-donor, raising the question, “who is the
best haplo-donor?” Based on a large sample
size and relative consistency of transplant
variables, young male non-inherited mater-
nal antigen mismatched donors were sug-
gested to reduce the risk of severe GvHD or
relapse. As recommended, transplants from
older mothers and non-inherited paternal
antigens mismatched donors should prob-
ably be avoided [32].
According to a prospective study by Huang
et al., unmanipulated haplo-SCT with
G‑CSF and ATG was proven superior to
chemotherapy as a post-remission treat-
ment for intermediate- or high-risk AML
or ALL in CR1. The cumulative relapse in-
cidence for haplo-SCT was 12.0% vs. 57.8%
for chemotherapy,and the four-year DFS for
haplo-SCT was 73.1% vs. 44.2% for chemo-
therapy.Additionally,in multi-centre studies,
Wang et al. reported that haplo-SCT had
outcomes comparable to matched sibling
donor (MSD)-SCT for adults with interme-
diate- or high-risk AML in CR1.Similar re-
sults were achieved in Philadelphia-negative
high-risk ALL in CR1 and MDS [33–36].
Haplo-SCT may also improve outcomes
for children compared with umbilical cord
blood transplantation [37]. Accordingly,
haplo-SCT was adopted as the first-choice
alternative donor to HLA-identical sibling
donor (ISD). Based on these outcomes, this
unique system was named the “Beijing Pro-
tocol.” As Kodera et al. from the Worldwide
Network for Blood and Marrow Transplan-
tation (WBMT) commented, “The Beijing
Protocol was shown to be a reliable treat-
ment strategy for patients without a suitable
HLA-matched donor”[38].
The “Beijing Protocol” was adopted in the
majority of Chinese SCT centres (n > 90).
The number of haplo-SCT cases increased
to approximately 2500 per year,making it the
largest source of allo-SCT donors (37.6%–
51.5%) in China since 2013. The “Beijing
Protocol” was also reproduced successfully
in Italy, Israel, Korea, and Japan [39-41].
The European Society for Blood and Mar-
row Transplantation reported that G-CSF
+ ATG-based regimens comprise 43%–45%
of haplo-SCT compared with PTCy, which
comprises 27%–57% of haplo-SCT in Eu-
rope [42–44]. As R. Handgretinger com-
mented, “more than half of the HLA haplo-
type mismatched transplantations performed
worldwide will follow similar protocols (to
the Beijing Protocol)”[45].Correspondingly,
haplo-SCT has been a global phenomenon
as the frequency of haplo-SCT has grown
steadily from 3% to 5% to more than 10%
of allo-SCT in Europe and USA [46]. The
global contribution of the “Beijing Protocol”
and PT-CY thus heralds a new era where
“everyone has a donor”.
Acute promyelocytic leukaemia
Acute promyelocytic leukaemia (APL) was
associated with a severe bleeding tendency
and an extremely poor prognosis in history
[47]. In the last thirty years, the therapeutic
outcomes of APL have markedly improved.
The combination of all-trans retinoic acid
(ATRA) and arsenic trioxide (ATO) is re-
ported to result in complete remission (CR)
rates exceeding 90% and overall survival
(OS) rates of 85–99% [48, 49].
In the evolution of therapeutic approaches
for APL, the first historical milestone was
chemotherapy based on anthracyclines [50].
In the pre-ATRA period, anthracycline-
based chemotherapy regimen with or with-
out cytosine arabinoside (Ara-C) was ap-
plied in newly diagnosed APL patients.The
use of daunorubicin in induction therapy
improved CR rate from 13 to 55% in APL
[50]. However, the median duration of re-
mission remained poor, ranging from 11 to
29 months [51, 52].The adoption of ATRA
and ATO as treatments constituted a land-
mark in the development of targeted therapy
for APL. In the 1980s, leukemic promyelo-
cytes were found to possess the unique ca-
pability to undergo differentiation when ex-
posed to ATRA [53].Later,ATO was found
to be capable of eradicating APL-initiating
cells, resulting in a curative effect [54]. The
introduction of the ATRA/ATO combi-
nation as a synergistic therapy created new
possibilities for the treatment of APL. In
the initial attempt, combined ATRA/ATO
for the induction of remission followed by
consolidation chemotherapy resulted in a
CR rate of 95.2% and a DFS rate of 100%
with a median follow-up of 18 months [55].
In China, the study of oral arsenic formula-
tions has a long history. Beginning in the
1970s, arsenic oxide (As2O3) was used to
treat APL [47]. Realgar-Indigo naturalis
formula (RIF) is a drug compound con-
taining 30 mg of realgar, 125 mg of Indigo
naturalis, 50 mg of Radix salviae miltiorrhi-
zae,45 mg of Radix pseudostellariae,and 20
mg of garment film in one pill. Based on
its clinical results and the anti-APL activity
in vitro and in vivo [56], RIF has been ap-
proved by the Chinese FDA and has been
commercialized and commonly available in
China since 2009.
Huang et al. conducted a single-centre pilot
study to evaluate the efficacy of oral arsenic
and ATRA without chemotherapy in newly
diagnosed non-high-risk APL patients.
All patients achieved haematologic CR
after a median time of 29.5 days. The rate
of complete molecular remission was 65%
at 3 months and 100% at 6 months [57].
This preliminary result is encouraging and
CHINA
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18
provides initial evidence for the success of a
largely home-based treatment protocol for
the treatment of non-high risk APL. Sub-
sequently, these findings were confirmed by
a multicentre, non-inferiority, open-label,
randomized, controlled phase 3 trial at 14
centres in China [58]. This study has sug-
gested that non-high risk APL can be cured
using oral arsenic plus ATRA without con-
ventional chemotherapy.
Huang’s group has tried to extend the out-
patient model to newly diagnosed high-
risk APL patients [59]. With a median
follow-up of 33 months, 20 patients (100%)
achieved a CR after a median time of 30
days. The 3-year estimated OS and EFS
were 100% and 89.4%, respectively. Thus,
oral arsenic formulations can be adminis-
tered outside the hospital, which reduces
the need for hospital visits, resulting in a
superior quality of life than that associated
with intravenous ATO.
Chimeric antigen
receptor-T cell therapy
Chimeric antigen receptor (CAR) – T cell
therapy is one of the most promising treat-
ments of tumor immunotherapy. As of De-
cember 2019, a total of 593 clinical trials in
Oncology have been registered in Clinical-
Trials.gov database, of which 48% of trials
are from China and 39% from the USA.
Research on CAR-T cell therapy in China
focus on not only newly diagnosed haema-
tological malignancies, relapsed or refrac-
tory haematological malignancies, but also
bridging to allo-SCT and relapse preven-
tion after allo-SCT.
Newly diagnosed haematological
malignancies & relapsed or refractory
haematological malignancies
Xu KL et al. reported using humanized
CD19-specific CAR-T (hCART19) to treat
two newly diagnosed untreated adults with
B-cell ALL. CR was achieved after CAR-T
infusion. No recurrence was observed with
follow up for 31 and 21 months, respectively
[60]. A series of clinical studies have demon-
strated that CAR-T cell therapy shows fa-
vourable response rate (CR rate ranging from
54.5% to 88.7%) in relapsed or refractory
(r/r) B-ALL and lymphoma [61]. Multi-
specific target CAR-T and humanized CD19
CAR-T showed high efficacy for preventing
relapse [62, 63]. As for r/r multiple myeloma
(MM), Chen SY et al. demonstrated that
BCMA CAR T-cell product LCAR-B38M
displayed safety and durable responses in r/r
MM, with 88.2% of CR rate [64]. Zhou JF
et al. treated r/r MM with humanized BC-
MA-specific CAR-T cells, with 72.2% of the
patients achieving CR or sCR [65]. Xu KL
et al. reported that 22 patients with r/r MM
were infused humanized anti-CD19 CAR T
cells and murine anti-BCMA CAR T cells,
with 95% of ORR, including 43% sCR, 14%
CR, 24% VGPR, and 14% PR [66]. Taken
together, BCMA CAR-T cell therapy shows
impressive efficacy in r/r MM. However,
CAR-T for r/r AML hindered by additional
challenges. The central problem of potent,
antigen-specific immunotherapy for AML
is the absence of truly AML-specific surface
antigens. Myeloid ablation should occur with
the use of potent CART cells directed against
CD33 and pan-myeloablation could occur if
anti-CD123 CAR T cells were used. Chi-
nese researchers found that CLL1 is highly
expressed on AML leukaemia stem cells and
blasts cells, but not on normal hematopoietic
stem cells. A secondary AML patient was
treated with anti-CLL1 CAR-T therapy and
achieved morphological, immunophenotypic
and molecular complete remission for over
10 months [67]. Ongoing early clinical stud-
ies are still being performed in patients with
AML who have relapsed/refractory disease.
Bridging to allo-SCT & relapse
prevention after allo-SCT
In recent years, more and more researchers
focus on allogeneic CAR-T therapies. As
for allo-SCT donor-derived CAR-T, allo-
CAR-T can be used as a bridge to SCT,
as conditioning regimen, and as a powerful
means in preventing relapse after allo-SCT.
Pan J et al.described an approach for “CAR-
T bridging to allo-SCT”in r/r B-ALL, with
90% of r/r patients achieving CR or CRi,
85% of CR/CRi patients bridged to allo-
HCT remained in MRD – with a median
follow-up time of 206 days [68]. Therefore,
CAR-T bridging to SCT in r/r B-ALL
shows high response rate and safety. Simi-
larly, allo-SCT donor-derived CAR-T can
be also used as the conditioning regimen un-
der the circumstances of allo-SCT. A group
of Chinese researchers reported a case,
whom was a 12-year-old girl with CD19 r/r
ALL preparing to underwent allo-SCT.The
patient received Flu, Bu, and Cy combined
with the same haplo- donor-derived CD19-
CAR-T cells as the conditioning regimen.
No blast cells were detected on day +22 after
transplantation,suggesting that treatment of
r/r ALL with RIC including CD19-CAR-
T cells followed by haplo-SCT was safe and
effective [69]. As a powerful means in pre-
venting relapse after allo-SCT, CAR-T can
be used for patients with relapsed B-ALL,
for patients with MRD positive but no re-
sponse to DLI, and for prophylactic infu-
sion in patients with high risk B-ALL. For
example, Peking University Institute of He-
matology reported 83.3% of MRD-negative
CR rate after allo-SCT donor-derived CAR
T-cell infusion in patients with relapsed B-
ALL after haplo-SCT [70]. Coinciden-
tally, the team also confirmed that donor-
derived CAR-T was effective for patients
with MRD no response to DLI in B-ALL
after allo-SCT with 83.33% of MRD-
negative remission, half of the patients cur-
rently alive without leukemia (Huang et al.
2019). A study conducted by Huang XJ et
al. also confirmed that despite the CR rates
is relatively high for relapsed patients after
all-SCT, cumulative recurrence rate at 18
months was 68.3%, the OS rate for the CR
patients was 30.0% at 18 months,with a me-
dian OS of 12.7 months [71]. CAR-T cell
therapy shows significant short-term effect
CHINA
Haematology
BACK TO CONTENTS
19
and favourable response in patients with B-
ALL that relapse. Therefore, CAR-T is an-
other platform following chemotherapy and
allo-SCT,which is beneficial to comprehen-
sive therapy.
Future direction
Precise treatment of haematological malig-
nancies is the mission and direction of Chi-
nese haematology oncologists in the new
era. Chinese scholars should work together
to develop new therapeutic targets for leu-
kaemia, starting with the pathogenesis of
leukaemia, immune cells and hematopoietic
microenvironment. We should establish a
perfect clinical system and commit to high-
level clinical research. Meanwhile, it is the
precise treatment needs to build a stem cell
transplantation platform that changes the
current status from everyone can transplant
to everyone will receive personalized trans-
plantation.
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matopoietic stem cell transplantation. Br J Hae-
matol 2017;179:598-605.
71. Chen YH, Zhang X, Cheng YF, Chen H, Mo
XD, Yan CH, Chen Y, Han W, Sun YQ, Wang
Y, Zhang XH, Xu LP, Liu KY, Yang J, Zhang
J, Zhang GL, Shi Y, Su YC, Li WQ, Xu L,
Song D, Zhang M, Lu P, Huang XJ. Long-term
follow-up of CD19 chimeric antigen recep-
tor T-cell therapy for relapsed/refractory acute
lymphoblastic leukemia after allogeneic hemat-
opoietic stem cell transplantation. Cytotherapy
2020;22:755-761.
Wei Sun,
Xiao-Jun Huang
Peking University People’s Hospital, Peking
University Institute of Hematology,
National Clinical Research Center
for Hematologic Disease
Past-President of Chinese Society of
Hematology, Chinese Medical Association
CHINA Haematology
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22
Covid-19
The Pandemic in Spain
COVID-19 has been and continues to be, a
pandemic with devastating effects due to its
morbidity and mortality and the superven-
ing situation caused by the saturation of the
health services and blocking of social and
economic activity across the world. No simi-
lar references exist in our recent past; the pro-
fessional and scientific world has risen to the
global challenge with an enormous invest-
ment in talent and resources that has made
it possible to create instruments and methods
for its diagnosis, clinical management and
treatment, and now, vaccines to fight it.
The COVID-19 pandemic has had a par-
ticularly high incidence and mortality rate
in Spain. Compared to other countries, the
adjusted excess deaths per 100,000 inhab-
itants in 2020 rank Spain occupies a piti-
ful fifth place in the 29 countries with the
highest incomes worldwide [1].
The death rate has been high, albeit un-
equal in Spain, and has followed a temporal
dynamic of four “waves” (with the last one
being much smaller), with widely differ-
ent profiles; said evolutionary profiles are
shown in Figure 1.
The incidence curves are compared to the
mortality curves; as shown in Figure 2, the
cumulative 14-day notification rate is lower
at the start of the pandemic, while the mor-
tality rate is extremely high during the early
phases.
The first wave (March and April 2020)
had an early and dramatic development in
Spain, with increasing exponential mor-
bidity and extremely high mortality, espe-
cially among institutionalised elderly peo-
ple. Health and social workers were greatly
affected by the lack of personal protective
equipment and the rapid exhaustion (due
to use and hoarding) of the available in-
ternational stock of coveralls, gloves and
face masks. The uncertainty of a new dis-
ease whose characteristics were unknown
posed an added difficulty in facing it. The
epidemic quickly spread to nursing homes,
in which the particular vulnerability of the
residents produced very high mortality
rates.
A radical lockdown was established, and it
was necessary to declare the State of Alarm:
the first one through RD 463/2020 of 14
March, which was extended until it ended
on 21 June, when the first wave had been
clearly overcome).
The emergence from the first wave posed
new challenges.On 15 April,the EU,which
had maintained a low profile and been sub-
ject to criticism for its inability to guarantee
supplies of materials and medicines,marked
out a “common road map” to lift the re-
strictions (which, in particular, affected the
movement of people and border control). In
Spain, the Council of Ministers Agreement
of 28 April 2020 approved the Plan for the
Transition to the New Normal [2] , which
set out the “reopening” process.
The first wave had exposed many structural
problems in the National Health System;
the weakened public health system,the lack
of investment in primary care, the lack of
resources and access to strategic supplies
and problems in the cohesive operation of
the National Health System, with its high-
ly decentralised structure divided among
17  Autonomous Communities made it
difficult to provide a coordinated response.
On 7 May the House of Representatives
set up the Commission for the Economic
and Social Reconstruction which, in just
over two months, approved a decision; its
71 recommendations relating to the “health
and public health” received strong political
backing and have a notably reformist con-
tent, which could be a road map for updat-
ing and revitalising the National Health
System [3].The idea of “reconstruction”was
somewhat relegated to the agenda when
the growing incidence of COVID-19 led
to a new wave.
This second wave was very quick to arrive
and started its ascent in July. It worsened in
October and it was not until November that
it started to fall slightly. On 22 October a
document was published with “Actions for a
Coordinated Response to control transmis-
sion” [4], approved by the National Health
System Inter-territorial Council which es-
tablished in great detail the levels of alert
and indicators that would determine the
risk assessment. Furthermore, on 25 Oc-
tober, in the middle of the second wave,
a new State of Alarm was declared (RD
926/2020) which, shortly afterwards, was
extended for a maximum of six months (it
ended on 9 May).
Tomás Cobo Castro
Covid-19 in Spain: Health System Response and 2021 Perspective
with the Vaccination Plan
SPAIN
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23
Covid-19
The prolongation of measures to restrict
movement (closing of regional borders
and curfews), restrictions on the number
of people who could meet, capacity limi-
tations and restrictions and the closing
of restaurants, bars and nightclubs had a
growing effect on the morale of the popu-
lation (what is known as pandemic fatigue).
As well as on the economy in general (2020
witnessed an unprecedented fall in the
GDP of 11%), and on certain sectors, in
particular.The eager promise of funds from
the EU (which wanted to regain its role in
the crisis) led to the creation of an exten-
sive programme to protect employment
(financial aid and subsidies for unemployed
workers), but the prolongation of the pan-
demic has tended to reduce the sustainabil-
ity of such measures.
The third wave began in December 2020,
reaching a maximum number of cases on
15  January, as a result of the increase in
population movements and family and
commercial interactions at Christmas. Dur-
ing this third wave, political tension and
institutional rivalry have played a greater
than desirable role, both due to the per-
ceived contradiction between health and
the economy and the competition aroused
by the distribution and administration of
the first vaccines (18 January 2021) and the
distribution criteria.
Vaccination strategy and process
On 18 December the National Health Sys-
tem Inter-territorial Council (the body that
coordinates the central health authorities
and those of the 17 Autonomous Commu-
nities) drafted a Vaccination Strategy  [5]
that required enormous flexibility and man-
agement capacity. The initial slowdown in
supply and the idea of not being able to
“save the summer” had a negative effect on
the collective morale while controlling the
third wave also took its toll by saturating
hospitals and UCIs in many Autonomous
Communities.
The COVID-19 vaccines are now the de-
cisive factor in controlling the pandemic in
2021.The EU went one step further with its
centralised approach [6] which, despite the
problems (related to production and fulfil-
ment of contracts), has permitted a stable
flow and prevented even greater problems.
Because it should be considered that the
European member states continue to be
Figure 1. 
Daily number of confirmed cases of COVID-19 in Spain. Source: Ministry of
Health Website https://cnecovid.isciii.es/covid19/#ccaa
Figure 2. 
Comparison of Incidence and Mortality in cumulative 14-day notification rate.
Source: RENAVE-Centro Nacional de Epidemiología, Instituto de Salud Car-
los III (Figure 9 of the text). https://www.isciii.es/QueHacemos/Servicios/Vigi-
lanciaSaludPublicaRENAVE/EnfermedadesTransmisibles/Paginas/InformesCO-
VID-19.aspx
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24
Covid-19
united in relation to the negotiation, con-
tracting and distribution, thus preventing
what might have been an inefficient and
embarrassing struggle between countries to
obtain as many vaccine doses as possible for
their citizens.
The Vaccination Strategy in Spain was up-
dated on seven occasions, until 11 May [7].
The challenge was to combine the progres-
sive availability of vaccines with the estab-
lishment of priorities. On 7 May the EU
had four vaccines authorised by the Euro-
pean Commission: The Pfizer/BioNTech
Comirnaty vaccine, authorised on 21 De-
cember2020; the Moderna vaccine, autho-
rised on 6 January 2021; the AstraZeneca
Vaxzevria vaccine, authorised on 29 January
2021 and the Janssen/Johnson & Johnson
vaccine, authorised on 11 March 2021.
On 24 May, 17.2 million Pfizer vaccines,
5  million Astra-Zeneca vaccines, 2.1 mil-
lion Moderna vaccines and 0.3 million
Janssen vaccines had been administered in
Spain. A total of 8 million Spaniards have
now received two doses (17.1% of the pop-
ulation) and 16.7 million have received at
least one dose (35.2%).
The strategy has experienced complications
due to problems of availability; in addition
to delays or failure to honour production
commitments which, in the case of the
Astra-Zeneca vaccine, has led to litigation
between the European Commission and
the laboratory, the pharmacovigilance sys-
tem raised the alarm between March and
April 2021 in relation to thromboembolic
events in the AZ and Janssen vaccines (par-
ticularly among people under 60). In Spain,
the Vaxzevria vaccination programme was
suspended between 16 and 23 March. On
24 March it was resumed, increasing the
age of those eligible to receive this vaccine
to 65 years. From 8 April, following the as-
sessment report drafted by the European
Medicines Agency (EMA), the use of this
vaccine was confined to people over 60 years
of age.
Since the end of April and in May, the vac-
cine supply and administration rate has rap-
idly increased, making it feasible to achieve
the Government’s goal of having 70% of the
population immunised before the end of the
summer.
The defining of priorities in administering
the vaccine has been based on 10 groups
with 9 additional subgroups, taking into
consideration criteria related to severity of
the disease, the capacity to become infected
and workers performing essential jobs.
The risk-benefit balance of the vaccines is
extremely positive; the medicine regulation
agencies (EMA and FDA) have endorsed
the use of the vaccines being administered
in Spain.Nonetheless,many European gov-
ernments have established recommenda-
tions combining the type of vaccine with
the age of the persons receiving it.
Managing a vaccination programme with
so many age groups and criteria has proved
to be extremely complicated; public de-
bate about adverse reactions, the age of the
persons receiving the vaccine and priority
groups have given rise to much distrust,
which has increased with the doubts and
difficulties in explaining the changes in
strategy. At all events, the fact that the vac-
cination process is now progressing at a very
fast rate is now resolving many of the prob-
lems related to priority.
The idea of reducing the use of Vaxzevria
due to the adverse effects detected has tak-
en precedence, despite their low frequency
(up to 25 April, out of a vaccinated popula-
tion of 5 million, 11 cases of thromboem-
bolic events have been detected in Spain,
causing three deaths). This has led the
central health authorities to recommend
the administering of the second dose of an
ARNm vaccine (Pfizer or Moderna), but
this has not been included in the summary
of product characteristics due to not hav-
ing been tested in clinical trials. Instituto
de Salud Carlos III has conducted a rapid
study on reactogenicity and immunogenic-
ity in administering a second dose of Pfizer,
with positive results For this reason, the
use of guidelines is being considered, but
accepting that people can voluntarily ask
to receive Vaxzevria as the second dose by
signing a consent form.
In Spain, the number of people who re-
fuse to be vaccinated is very small, but in
the case of Astra-Zeneca, a considerable
number of people have asked to change to
another in some Autonomous Communi-
ties, following the news about the adverse
effects. The prospect of implementing the
­
EU-COVID-19 digital certificate (ap-
proved on 20  May 2021) to allow vacci-
nated persons to travel will no doubt help to
encourage vaccination among those who are
more likely to refuse it.
The perspective of the
medical profession
The pandemic has taken a heavy toll on
Spanish doctors. 112 of our colleagues were
among the first to die and many have fall-
en ill, as a result of their commitment and
dedication to treating patients, especially
during the first phases, in which there was a
shortage of personal protective equipment.
And also, as second victims, since we had
to assume the enormous effort of taking
on heavy workloads and witnessing human
suffering for more than one year; fatigue
and the physical and psychological conse-
quences will continue to accompany us for
quite some time.
We have criticised both governments and
the health authorities [8]. We were insuf-
ficiently prepared to deal with the pan-
demic and furthermore, in the previous
decade, the National Health System suf-
fered heavy cutbacks due to the economic
crisis from which we have not yet recov-
ered; public health and primary care were
in very precarious conditions and were
underfunded.
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25
Covid-19
Nonetheless, we have also been supported
by citizens, who have recognised the effort
and commitment of all the health and social
workers to their patients. It has been com-
forting to see how we have honoured our
Hippocratic Oath and how all doctors have
joined forces in the common task of sav-
ing the lives of patients, regardless of their
speciality or rank. It has been an emotional
re-encounter with the finest of the medi-
cal profession, which has continued to exist
beneath the cold and impersonal surface of
technomedicine.
And today, we hope that, through the vac-
cines, the fruit of science and medical tech-
nology will control this pandemic that has
caused so much harm.
In all cases, from the perspective of the
medical profession, what is relevant here
and now is to make headway in the vaccina-
tion programme, and to do this, it is impor-
tant to generate trust among citizens and
ask institutions to behave with caution and
clearly maintain the priority of immunising
those who are most vulnerable (an objective
that to a great extent already been achieved).
Encouraging vaccination and strengthen-
ing the role of the Public Health authorities;
even though new scientific information may
exist that generates uncertainty, we are in
need of a firm collective decision maker. It is
necessary to find mechanisms for participat-
ing in decisions that do not entail generating
distrust and erode the credibility of the tech-
nical bodies whose duty is to establish the
measures to be taken, normally with great
uncertainty and variables that need to be
taken into consideration. Without forget-
ting that to control the pandemic,it is essen-
tial to encourage vaccination in all countries
as soon as possible, to guarantee collective
immunity. As the vaccination progresses, it
will be more important to strengthen re-
sources to investigate outbreaks, perform
systematic tracking procedures and ensure
that isolation and quarantine processes are
complied with; only by doing this will we be
able to extinguish the embers and apply our
best efforts to the prevention of avoidable
morbidity and mortality.
References
1. Islam N, Shkolnikov V M, Acosta R J, Klimkin
I, Kawachi I, Irizarry R A et al. Excess deaths
associated with covid-19 pandemic in 2020: age
and sex disaggregated time series analysis in 29
high income countries BMJ 2021; 373 :n1137
doi:10.1136/bmj.n1137
2. Ministry of Health, Government of Spain. Plan
for the Transition to the New Normal. 28 April
2020. Available at: https://www.mscbs.gob.es/
profesionales/saludPublica/ccayes/alertasAc-
tual/nCov/documentos/PlanTransicionNue-
vaNormalidad.pdf
3. Economic and Social Reconstruction Commit-
tee Decision. House of Representatives. June
2020. Available at: https://www.congreso.es/
docu/comisiones/reconstruccion/153_1_Dicta-
men.pdf
4. National Health System Inter-territorial Coun-
cil. Actions for a coordinated response to control
the transmission of COVID-19. Ministry of
Health. 22 October 2020. Available at: http://
www.mscbs.es/profesionales/saludPublica/
ccayes/alertasActual/nCov/documentos/Actua-
ciones_respuesta_COVID_22.10.2020.pdf
5. National Health System Inter-territorial Coun-
cil. COVID-19 Vaccination Strategy in Spain.
Ministry of Health. 18 December 2020. Availa-
ble at: https://www.mscbs.gob.es/profesionales/
saludPublica/prevPromocion/vacunaciones/
covid19/docs/COVID-19_Actualizacion1_Es-
trategiaVacunacion.pdf
6. EU Vaccination Strategy. European Commis-
sion. Informative Note. Available at: https://
ec.europa.eu/info/live-work-travel-eu/corona-
virus-response/public-health/coronavirus-vac-
cines-strategy_es
7. Ministry of Health Website with information
related to vaccination and strategies. https://
www.mscbs.gob.es/profesionales/saludPublica/
ccayes/alertasActual/nCov/vacunaCovid19.htm
8. Repullo JR and COVID-19 Advisory Com-
mission of Spanish General Medical Council.
The medical profession in the face of the reac-
tivation of the COVID-19 pandemic in Spain.
Journal of Healthcare Quality Research. Vol-
ume 36 (1). 2021: 1-2 https://doi.org/10.1016/j.
jhqr.2020.11.002
Dr.Tomás Cobo Castro
President of the Spanish
General Medical Council
E-mail: internacional@cgcom.es
Politicians made a false dilemma of whether to pro-
tect the health or the economy. We wanted to out-
smart the virus, but we lost everything. More than
30,000 dead and a ruined economy – this is the
result of the worst catastrophe in our recent history.
The Czech Republic has a population of
10,5 million and is one of the countries
most affected by Covid-19. Last year, due
to an increase in the number of deaths, the
population decreased, and the average life
expectancy shortened. This happened for
the first time since World War II.
1 March 2020 was the day when the first
case of Covid-19 was confirmed in the
Czech Republic. There were no anti-ep-
idemic plans, and no personal protective
equipment was available to health pro-
fessionals. Fortunately, the government
initiated a swift response by implement-
ing effective anti-epidemic measures, and
the spread of the epidemic halted. People
monitored horror situation in more af-
The Czech Strategy of the Controlled Establishment of Herd
Immunity Ended in Disaster
CZECH REPUBLIC
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Covid-19
fected countries and were disciplined and
helped each other. The symbol of our suc-
cessful fight against the epidemic became
homemade masks, which substituted a lack
of protective equipment. In the first half
of 2020, only 347 patients died from Co-
vid-19 in the Czech Republic.
After successfully managing the first wave
of the epidemic,a sense of self-complacency
and false security prevailed in our country.
With the participation of leading politi-
cians, a common picnic of thousands of
people took place on the Charles Bridge
in Prague on 1 June 2020, and it became
a symbol of foolishness. In the summer of
last year, in contrast to many other coun-
tries, there were practically no anti-epidem-
ic measures applied. The government did
not use the relaxation period – given by the
summertime  – to prepare for the autumn
wave of the epidemic,which experts warned
against. 
The situation began to worse at the end of
August – after people returned from holi-
days abroad, and the critical point came
in early September after children returned
to school. It was not mandatory to wear
a mask, testing was insufficient, and the
numbers of infected began to increase rap-
idly. Given that the regional elections took
place in early October, politicians did not
dare to implement unpleasant but effective
anti-epidemic measures.That turned to be a
catastrophic mistake.
Popular but incompetent Minister of
Health, Vojtěch, was dismissed on 21 Sep-
tember, and he was replaced by a firm pro-
fessor of epidemiology and a former sol-
dier, Prymula. The government declared a
state of emergency. However, the epidemic
was already burst out. The most affected
group of people were the elderly, especially
residents of retirement homes and social
facilities, who were dying by the hundreds. 
Before the result of the anti-epidemic
measures could reveal, Minister Prymula
was forced to abdicate due to compromis-
ing photographs showing him not observ-
ing the rules he had ordered. Paediatrician
Blatný, at that time unknown to the public,
became the third minister. However, he did
not take the epidemic seriously enough. For
example, the Czech Medical Chamber has
repeatedly (and vainly) appealed to him to
take more effective anti-epidemic measures
so we can bring the epidemic under control
before people run out of patience and stop
respecting restrictions. 
The second wave of the epidemic culmi-
nated in early November. An average of
250 people died of Covid-19 a day, and the
disease became the most common cause of
death (140 people die of cardiovascular dis-
ease, and 75 people die of cancer every day
in the Czech Republic).At the beginning of
November, overall mortality doubled com-
pared to the five-year average. At that time,
on a per capita basis, the Czech Republic
had the highest number of people who died
of Covid-19. To handle the epidemic, elec-
tive care had to be drastically reduced, and
most hospital wards were transformed into
so-called Covid units.  
After the situation began to improve in the
second half of November,the government –
under constant pressure from the opposi-
tion requiring loosening anti-epidemic
measures or the protest demonstrations  –
made another fatal mistake. Three weeks
before Christmas, they opened restaurants
and shops. Nobody listened to the warn-
ings of experts or disproval of the Czech
Medical Chamber. Free antigen testing
turned to be counterproductive, too. People
who received a negative result thought they
could not infect others. However, this was
not the case due to the low sensitivity of
these tests.
During Christmas, people were visiting
their relatives and at the beginning of this
year, the third wave of the epidemic started.
Vaccination became a ray of hope, although
in the first months there was a lack of vac-
cines. The elderly were the first group to be
vaccinated. The Czech Medical Chamber
enforced priority vaccinations for all health
professionals who were the most affected
professional group. At a critical time, we
had almost 10,000 infected health profes-
sionals, including 1,200 physicians. In total,
we had 77,000 infected health professionals,
among them 12,000 physicians.The saddest
thing is that 88 health professionals died,
including 34 physicians. 
In January 2021, hospitals in the most af-
fected regions started to collapse, and pa-
tients had to be distributed throughout the
country. Due to insufficient sequencing of
PCR tests, we did not know that the more
contagious so-called British (alpha) muta-
tions of the virus began to prevail in our
country sooner than at the beginning of
February. At that time, after a slight im-
provement, the implemented anti-epidemic
measures occurred to be insufficient, and
the fourth wave of the epidemic – the most
massive one  – began to unfold. Health
professionals fought for human lives while
politicians argued over whether, or not, a
state of emergency should stay declared and
whether, or not, closure of schools, restau-
rants and shops was legal. It is sad that, in
addition to some politicians, the epidemic
Milan Kubek
CZECH REPUBLIC
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Covid-19
was downplayed, and the anti-epidemic
measures were questioned also by some
physicians, including the rector of Charles
University. Various fake news regarding the
safety of vaccination and another question-
ing of Covid-19 seriousness spread through
the internet, too.
During the epidemic, our government,
whose credibility in the eyes of the Czech
population gradually fell to a historical
minimum, unfortunately, did not venture to
close factories or reduce all economic activi-
ties except for the critical infrastructure. In
the winter, however, at least antigen testing
at regular intervals became mandatory for
all employees. 
In mid-March, more than 200 patients
died of Covid-19 per day again. Some el-
derly have already been vaccinated, though
there were still casualties within the young-
er population. In critical weeks, the total
number of deaths in the Czech Republic
(for all causes) increased by up to 60% com-
pared to the five-year average. There were
10,000 patients with Covid-19 in hospitals,
of whom more than 2,000 were in critical
condition.Thanks to the enormous effort of
health professionals, the Czech healthcare
system withstood this huge pressure, while
in some of the neighbouring countries, it
collapsed even with the smaller numbers
of infected people. At the peak of the epi-
demic, 160,000 patients were infected in
our country.
The decline of the epidemic was too slow,
and people’s discontentment grew. Vac-
cination was slow, too. On 7 April 2021,
Minister Blatný was recalled and replaced
by renowned dermatologist Professor
Arenberger. He initiated the gradual anti-
epidemic measures loosening but was re-
called within a month due to his unclear
property situation. Prime minister Babiš
appointed a lawyer, Vojtěch, to the post
of the Minister of Health for the second
time  – he already held this post at the
beginning of the second wave of the epi-
demic. As if to show that the epidemic is
over, and we are to forget both more than
30,000 deaths (the total number of deaths
during the epidemic has exceeded the av-
erage of the past five years by more than
40,000) and the ruined economy.
Covid-19 has been confirmed in more than
1,700,000 people, with probably another
1 million patients not confirmed by tests.
At present, the epidemic situation is fa-
vourable, but the Czech Republic remains
below the EU average in terms of vaccina-
tion rates. At the end of June, only 25% of
the population has been vaccinated with
both doses. Although children from the age
of 12 will be vaccinated from the beginning
of July, politicians focus on their campaigns
before the October parliamentary elections,
rather than on vaccination-promoting
campaigns.
A year ago, we celebrated  a victory  over
Covid-19 in the Czech Republic. That was
before another 30,000 patients died of this
disease. It is hard to avoid a déjà vu feeling
when most people are now only interested
in how to enjoy their holidays again, we
have the same minister again, and at the
beginning of October, elections will take
place again. Before this event, politicians
will compete in populism. We hope for the
best, but we should prepare for the worst.
Wish us luck.
MUDr. Milan Kubek
President of the Czech Medical Chamber
E-mail: foreign@clkcr.cz
Covid-19 in the Czech Republic – numbers
Currently infected Hospitalized
In critical
condition
Daily deaths
1. wave 11.4.2020 4 570 8.4.2020 423 12.4.2020 100 8.4.2020 15
2. wave 28.10.2020 122 539 5.11.2020 8 141 3.11.2020 1203 3.11.2020 261
3. wave 6.1.2021 118 468 7.1.2021 7 513 12.1.2021 1 155 8.1.2021 196
4. wave 14.3.2021 159 922 15.3.2021 9 458 16.3.2021 2 061 15.3.2021 236
Source: The Institute of Health Information and Statistics of the Czech Republic
Cases per million inhabitants
(cumulative)
Deaths per million inhabitants
(cumulative)
Czech Republic 155 600 2 827
Hungary 83 600 3 100
Poland 76 000 1 975
Austria 72 100 1 185
Slovenia 71 700 2 285
Germany 44 500 1 078
Source: John Hopkins University (22.6.2021)
https://ourworldindata.org
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Covid-19
By the start of the first lockdown on 16
March 2020 at the latest, the pandemic was
present in everybody’s life.Schools switched
to distance learning, non-essential shops
shut down and intensive care beds started
to fill up. Within a few days, the number of
infected people doubled. Fortunately, how-
ever, the “near overload” in Austria’s hospi-
tals never occurred, partly due to the coun-
try’s shutdown with following lockdowns
and the willingness of the general popula-
tion to comply with the necessary measures
(mouth/nose protection, ventilation, hand
hygiene, social/physical distancing, etc.) [1],
but also due to the well-equipped hospitals
in regards to the number of available hospi-
tal beds and the relatively high capacities in
intensive care units. This put Austria in the
favourable situation of being able to sup-
port other European countries by supplying
respirators and offering hospital beds with
respirator access to some of their patients
in Austrian ICUs. One important step to
relieve the Austrian health care system, es-
pecially the intensive care units, was the ap-
proval of safe and effective vaccines. How-
ever, it wasn’t long until demand became
higher than supply. This was due to the
initial reluctance to procure vaccines, which
meant that there was not enough vaccine
available for a rapid vaccination campaign.
To date, more than 6 million vaccinations
have been administered, with more than
2 million people already having full vacci-
nation protection [2].Although the govern-
ment’s target of administering vaccinations
to all those willing and eager to be vacci-
nated by the end of June will not be reached,
we are now well on our way [3].
Challenges of the COVID
Pandemic in Austria
A week after the global spread of the dis-
ease was declared a pandemic by the World
Health Organization (WHO), a nation-
wide lockdown was imposed as a quick and
rigorous response to help flatten the curve
in Austria. Despite growing case numbers
in late summer 2020, a second lockdown
wasn’t ordered until mid-November. In
the beginning of the pandemic, suspected
infected persons were ordered to quaran-
tine at home, while attempts were made to
locate any contact persons so that, if nec-
essary, home quarantine could also be im-
posed on them. However, contact tracing
became more and more difficult due to the
rising number of cases. Early on, Austria’s
government relied on testing to quickly
identify infected individuals and break the
spread of the virus by isolating them. The
Austrian testing strategy for the detection
of SARS-CoV-2 has three main objectives:
Testing-Tracing-Isolation (TTI), transmis-
sion prevention and information gathering.
In order to best contain transmission, it is
necessary to regularly test as many asymp-
tomatic individuals as possible in addition
to TTI,which specifically targets symptom-
atic individuals [4].Willingness to be tested
has increased in Austria, albeit slowly.Thus,
despite the rather unsuccessful mass testing
efforts, which were modelled after previous
experiences in South Tyrol and Slovakia, it
was decided to provide free access for all
citizens to antigen testing,as well as to PCR
testing for those experiencing symptoms.
This offer is to remain in place at least un-
til the end of summer 2021, especially since
the group of 12- to 15-year-olds probably
won’t be vaccinated until July or August [5].
The pandemic has made undesirable devel-
opments in the health system clearly visible.
Too little investment in the health sector
over the years has led to a lack of training
opportunities, vacant positions and poor
remuneration. The challenging work that
doctors do on a daily basis is often ignored
and not sufficiently rewarded [6]. Together
with complications in the non-transparent
procurement of the vaccine and the rapid
spread of negative coverage in the media,
debates and uncertainties arose in the popu-
lation, which now need to be resolved and
clarified.
At the beginning of the pandemic, doctors
had to struggle with the lack of protective
equipment. As in other countries, in the
first weeks of the pandemic there wasn’t
sufficient or adequate protective equip-
ment – especially masks were scarce. Doc-
tors worked under very difficult conditions
during this period.This was further compli-
cated by the global competition for masks
and other protective equipment, even to the
point of countries confiscating trucks carry-
ing aid supplies and respirators, not letting
the drivers cross the border to reach their
destination country. In the Austrian federal
system, some states provided their general
practitioners with masks, while others un-
fortunately did not. As a result, doctors
put themselves at risk in the fight against
the pandemic and some fell ill or even suc-
cumbed to their infection while fulfilling
their obligations as doctors.
To prevent medical collateral damage dur-
ing the lockdown and shutdown periods,
Herwig Lindner
Austria’s Approach to Combatting Covid-19
AUSTRIA
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29
Covid-19
practices remained mostly open, especially
for primary care and initial examinations
and consultations. Telemedicine (especially
telephone, videocalls, e-mail) was made
possible for the period of the pandemic to
drastically reduce direct patient contact.
To what extent telemedicine was used in
addition to or instead of personal patient
consultations was up to the general practi-
tioners themselves. A limit on the number
of patients in waiting rooms prevented the
accumulation of groups of people and en-
sured compliance with the distancing rules.
Prescriptions can currently still be sent to
patients or directly to a preferred pharmacy,
where patients can pick up their medica-
tion. Challenges we are now facing more
and more frequently are patients continuing
to skip their check-ups and their reluctance
to seek medical treatment. During the first
lockdown, patients – partly with severe ill-
nesses – avoided practices and clinics out of
fear of contracting an infection. Many pa-
tients did not have their scheduled preven-
tive check-ups, despite most practices and
clinics being open. This trend must now be
counteracted in order to increase the num-
ber of examinations again and to be able to
detect diseases early and treat them quickly.
Because, while COVID is undeniably a se-
rious disease, it is not the only one.
Implementation of the
Vaccination Strategy
On 27 December 2020, during Austria’s
second lockdown, the first few members
of one of the “at risk groups” were chosen
to be vaccinated by Dr. Thomas Szekeres,
President of the Austrian Medical Cham-
ber, and Dr. Ursula Wiedermann-Schmidt,
President of the Austrian Society for Vac-
cinology and Chair of the Austrian Vacci-
nation Commission, to herald the start of
the Austrian vaccination program. This was
seen as a historic day and a turning point af-
ter a months-long battle with the pandemic.
At that time, the 3 phases of the Austrian
government’s vaccination strategy were to
first immunize the “high-risk group”, e. g.
people over 80, followed by “older people
and employees of the critical infrastructure”,
before all Austrians were to be vaccinated in
the third and final phase [7]. Unfortunately,
it became clear relatively quickly that due
to delivery delays and the slow distribution
of the vaccines, the vaccination program
could not be carried out as planned. At that
time, the Austrian Medical Chamber issued
numerous press releases to urge those who
were politically responsible to buy more
vaccines. The Austrian Medical Chamber
already called for vaccines to be obtained
quickly and in sufficient quantities in the
summer of 2020. Unfortunately, those re-
marks remained unheard. While supply
shortages from and scepticism about Astra-
Zeneca resulted in fewer people being vac-
cinated, increased supply from BioNTech/
Pfizer accelerated the vaccination schedule.
Nonetheless, many of those willing to be
vaccinated still have to wait for their first
shot to be administered [3].
The implementation of the vaccination
strategy was further complicated by the dif-
ferent interpretations of the national vac-
cination strategy in Austrian federal states,
resulting in varying implementations of the
same strategy, with different “priority rules”
and schedules throughout the country [8].
Perceived disadvantages and uneven dis-
tribution further fueled the debate around
the vaccination strategy and its implemen-
tation, which increased uncertainty among
the population.
Being a comparatively small country, Aus-
tria appreciates being part of the procure-
ment and distribution process of the Eu-
ropean Union. In regards to administering
the vaccines, the authorities opted for a
dual system early on – with vaccinations
being administered in vaccination centres
and practices of general practitioners. Un-
fortunately, as has been seen in many other
countries, Austria is now struggling with
an increasing number of people refusing
to wear masks and opposing vaccinations
altogether. Doctors play an important role
in dispelling such doubts and gaining trust,
especially since physicians in private prac-
tices know their patients best and can pro-
vide information and administer vaccines
quickly [9].
Long COVID as a
Lengthy Endeavour
Due to the global emergence of cases and
enormous collection of data worldwide,
COVID is now among the best-researched
infectious diseases. It is mainly the rapid
developments and investments in research,
but above all the hard work of doctors all
over the world, that has led to the devel-
opment of vaccines to stop the spread of
infectious disease in such a short amount
of time. While the risk of contracting
­
COVID for previously uninfected persons
is decreasing as vaccination progresses, the
number of Long COVID patients is ex-
pected to increase steadily. These patients
face particularly difficult challenges since
neither symptoms, therapies nor the length
of impairment can be assessed at this point.
Due to the varying duration, intensity and
symptoms of the disease, it is often difficult
to determine whether a patient is struggling
with Long COVID at all. As this is an
emerging and constantly evolving phenom-
enon, there is a lack of data as things stand.
Therefore, information from psychosocial
hotlines or survey data from the ‘Austrian
Corona Panel’is currently used as a basis for
findings concerning the development and
emergence of a growing number of Long
COVID cases [10].
As the name already suggests, however, it
can be assumed that Long COVID will
keep us occupied for a longer period of time,
especially given that an estimated 10-20%
of COVID patients suffer long-term con-
sequences from the disease. Since the exist-
ing range of care is far from sufficient and
most expenses related to Long COVID are
not covered by the health insurance funds,
AUSTRIA
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30
Covid-19
the first Long COVID outpatient clinic
was recently established in Vienna [11].
This is a first step towards being able to
treat patients with protracted courses more
adequately, but more affordable and acces-
sible treatment options are still needed [12].
Especially given the fact that in addition
to physical difficulties, many patients also
have to face psychological, neurological and
psychiatric consequences. However, there
still needs to be research on the connection
between these and the patient’s COVID
infection. [10] With the continued rapid
development in research and practice, it
is hoped that it will be possible to quickly
find out which therapies and drugs help and
which do not – a ray of hope for patients
affected by Long COVID.
Outlook
Currently, when entering cultural and ca-
tering facilities, sports stadiums and gyms, a
certificate confirming a negative test result,
an administered vaccination or recovery
from infection has to be shown. The proof
can be found on paper or in the form of
the “green passport”, which is valid within
Austria in the first phase and EU-wide in
July [13]. It was important to refrain from a
quick implementation of an “Austrian green
passport” and instead focus on an uncom-
plicated, Europe-wide solution [14]. Due
to delays and technical difficulties, however,
access to the green passport valid in Aus-
tria was only recently made possible. The
respective certificates are to be mutually
recognized by EU member states, whilst
recognizing the different applicable rules of
each member state. [15]
Thanks to the availability of vaccines and
growing vaccination coverage, the situation
this summer is not comparable to last sum-
mer when another wave was already immi-
nent. What is important now is to use the
summer months, which, as we know from
experience,are less critical,to boost the pace
of the vaccination program and take early
action in autumn to prevent another new
wave of rising cases.We need to take advan-
tage of the calm situation – the “breathing
space” – and low case numbers to counter-
act the infectious disease by implementing
a strong vaccination program, not only in
Austria but worldwide.We have to speed up
the administration of vaccinations all over
the world and push the COVAX program.
Otherwise, the infection rate is set to yet
again spike in countries with currently low
infection rates, which must be prevented.
We do need to be aware of the fact that vac-
cinations will not bring us back to normality,
but that we instead need to adjust to a new
normality. According to current research, it
can be expected that, in the near future, our
lives will be affected by COVID in the same
way as they are affected by annual influenza.
For both, vaccinations offer good protec-
tion overall. We must hope that the spread
of mutations will slow down sufficiently to
give pharmaceutical companies the time to
tailor effective vaccines and pharmaceutical
drugs to them. At the same time, we have
to keep in mind that the further course or
even the end of the pandemic depends not
only on the emergence of mutations and
escape variations for which the currently
available vaccine may have no effect but also
on the willingness of the population to be
vaccinated. Despite the steadily growing
willingness of the Austrian population to
be vaccinated, it must not be ignored that
scepticism has prevailed since the beginning
of the vaccination campaign, especially due
to the broad media coverage of cases where
individuals had to struggle with severe side
effects. This must be counteracted with a
broad-based information campaign involv-
ing health professionals and political repre-
sentatives. What will contribute decisively
to vaccination readiness and willingness is
the cooperation of EU countries with regard
to the green passport, the freedom to travel
and the handling of tested, recovered and
vaccinated persons. Only through transpar-
ent communication and cooperation can
we cope well with the uniquely challenging
situation we are currently experiencing.
Since the COVID-19 pandemic is a supra-
national challenge, tackling the pandemic
requires supranational thinking and act-
ing. During the establishment of rules and
structures, the strengths and weaknesses of
the federal system became apparent. Many
lessons have been learned and many more
lessons need to be learned to get better at
combatting sooner, harder, and in a more
orderly way together in the fight against the
COVID-19 pandemic.
References
1. Als die “neue Normalität” mit der Pandemie
begann (When the “new normal” began with the
pandemic). Wiener Zeitung. 2021 February 25
[cited 2021 June 16]. Available from: https://
www.wienerzeitung.at/nachrichten/politik/
oesterreich/2093872-Als-die-neue-Normali-
taet-mit-der-Pandemie-begann.html
2. Corona-Schutzimpfung in Österreich – Dash-
board (Corona vaccination in Austria – dashboard).
Bundesministerium für Soziales, Gesundheit,
Pflege und Konsumentenschutz (Federal Minis-
try for Social Affairs, Health, Care and Consumer
Protection). 2021 [cited 2021 June 16]. Available
from: https://info.gesundheitsministerium.at
3. Impfbereitschaft nimmt weiter zu (Vaccination
readiness continues to increase). Wiener Zeitung.
2021 June 1 [cited 2021 June 16].Available from:
https://www.wienerzeitung.at/nachrichten/
politik/oesterreich/2106492-Impfbereitschaft-
nimmt-weiter-zu.html
4. Österreichische Teststrategie SARS-CoV-2
(Austrian testing strategy SARS-CoV-2). Bun-
desministerium für Soziales, Gesundheit, Pflege
und Konsumentenschutz (Federal Ministry
for Social Affairs, Health, Care and Consumer
Protection). 2021 March 11 [cited 2021 June
16]. Available from: https://www.sozialminis-
terium.at/dam/jcr:cc1471e2-154b-48bc-aad6-
d43ce13d7098/201013_%C3%96sterr_Test-
strategie_SARS-CoV-2_Update_071020_
S2.pdf
5. Tests bleiben den Sommer über gratis (Tests re-
main free of charge throughout the summer). Ku-
rier. 2021 May 31 [cited 2021 June 16]. Avail-
able from: https://kurier.at/chronik/oesterreich/
mueckstein-tests-bleiben-ueber-sommer-gra-
tis/401397336
6. PK Pandemiebilanz: Österreichische Är-
ztekammer sagt Danke – und schlägt Alarm
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Covid-19
(Press conference Pandemic assessment: Austrian
Medical Chamber says thank you – and sounds the
alarm). Austrian Medical Chamber. 2021 May
26. Available from: https://www.aerztekam-
mer.at/presseinformation/-/asset_publisher/
presseinformation/content/pk-pandemiebi-
lanz/261766
7. “27. Dezember 2020 ein historischer Tag”
(“December 27, 2020 a historic day”). Wie-
ner Zeitung. 2020 December 27 [cited
2021 June 16]. Available from: https://
www.wiener z eitung.at/nachr ichten/
politik/oesterreich/2086599-27.-Dezember-
2020-historischer-Tag.html
8. Linsinger E. Die Debatten über die Reihenfolge
beim Impfen werden schriller (Debates over vac-
cination order grow shriller). Profil. 2021 May 3
[cited 2021 June 16]. Available from: https://
www.profil.at/oesterreich/corona-debatten-
ueber-die-reihenfolge-beim-impfen-werden-
schriller/401370155
9. ÖÄK-Vizepräsident Steinhart: COVID-Impf-
priorisierungen jetzt aufheben (Austrian Medical
Chamber Vice President Steinhart: Lift COVID
vaccination prioritizations now). Austrian Medi-
cal Chamber. 2021 April 30 [cited 2021 June
16]. Available from: https://www.aerztekammer.
at/presseinformation/-/asset_publisher/pres-
seinformation/content/impfpriorisierungen-
aufheben/261766
10. Palmai J. Psychische Belastungen durch Pand-
emie zeigen sich verzögert (Psychological stress
caused by pandemic shows delayed effects). der-
Standard. 2021 May 20 [cited 2021 June 16].
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story/2000126769592/psychische-belastungen-
zeigen-sich-verzoegert
11. Kapeller E, Kroisleitner O. Long Covid: Gen-
esen und doch krank (Long Covid: Recovered but
still sick). derStandard. 2021 June 1 [cited 2021
June 16]. Available from: https://www.derstand-
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en-und-doch-krank
12. ÖÄK-Steinhart fordert Long-COVID-Be-
handlung auf Kassenkosten (Austrian Medical
Chamber-Steinhart demands Long-COVID treat-
ment at health insurance costs). Austrian Medical
Chamber. 2021 June 1 [cited 2021 June 16].
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presseinformation/-/asset_publisher/pressein-
formation/content/long-covid-auf-kassenkos-
ten/261766
13. So kommt man zum „3-G-Nachweis“ (How to
get the “3-G proof ”). ORF. 2021 June 1 [cited
2021 June 16]. Available from: https://orf.at/
corona20/stories/3215403
14. ÖÄK-Mayer: Kein Alleingang bei grünem Pass
(Austrian Medical Chamber-Mayer: No go-it-
alone approach to green passport). Austrian Medi-
cal Chamber. 2021 May 12 [cited 2021 June 16].
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presseinformation/-/asset_publisher/pressein-
formation/content/kein-alleingang/261766
15. Verzögerung | Grüner Pass startet digital – al-
lerdings nicht für Geimpfte (Delay | Green
passport launches digitally – but not for vaccinat-
ed people). Kleine Zeitung. 2021 June 7 [cited
2021 June 16]. Available from: https://www.
kleinezeitung.at/politik/innenpolitik/5990074/
Verzoegerung_Gruener-Pass-startet-digital-
allerdings-nicht-fuer
Dr. Herwig Lindner
1st
Vice-President of the Austrian
Medical Chamber
President of the Styrian Medical Chamber
E-mail: international@aerztekammer.at
Bangladesh, like any other country of the
world, is fighting relentlessly against ­
the
COVID-19 pandemic.The fighting is spread
on many fronts.Detecting the cases,prevent-
ing transmission, responding to pandemic,
containment and mitigation of the pan-
demic – all the tasks are to be accomplished
simultaneously. At the outset of the fight, a
Pandemic Preparedness and Response Plan,
BPRP, was formulated to steer whole-of-the
government and the whole of the society [1].
Again, when the COVID-19 vaccine was
available for deployment, Bangladesh joined
the comity of nations to vaccinate its citi-
zens. A National Vaccine Deployment Plan
(NVDP) was formulated to conduct the
mass vaccination [2]. However, we faced a
challenge to keep the pace of vaccination due
to a shortage of supply by the manufacturers.
Bangladesh has a good network of healthcare
facilities (HCF), both government and pri-
vate.Private HCF are more clustered around
big cities. Bangladesh also developed a good
network of public health service facilities,
particularly in rural areas. But a robust pub-
lic health system is lacking, particularly in
largely populated big cities.Pandemic usually
starts in densely populated urban areas, then
spread to semi-urban and rural areas. But
the very urban area is yet to develop public
health system to combat public health emer-
gencies, like the COVID-19 pandemic. To
date,Bangladesh is struggling to contain and
mitigate the pandemic with low resource,
keeping the concentrated epidemic away
from densely populated urban areas. It will
be an acid test to keep the pandemic away
from being explosive in the coming days.
COVID-19 pandemic
situation in Bangladesh
Bangladesh identified the first COVID-19
case on 8th
March 2020 and the first death
was reported on 18th
March 2020. According
to the Directorate General of Health Servic-
M Mushtuq Husain
Covid-19 Response Plan and Vaccination in
Bangladesh
BANGLADESH
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32
Covid-19
es (DGHS), as of 29 June 2021, there were
904,436 COVID-19 cases confirmed by RT-
PCR (Real time polymerase chain reaction),
GeneXpert, and Rapid Antigen tests includ-
ing 14,388 related deaths (Case Fatality Rate
1.59%) [3]. Bangladesh stands among the
top 30 countries in the world in terms of
the total number of confirmed ­
COVID-19
cases, and accounts for 0.45% cases of the
world,while the country is among the top 40
countries in total death count.
A significant number of physicians and
other healthcare professionals were infected
and died. To date (as of 21 June 2021) 156
physicians, 3 dental surgeons died from
­
COVID-19; while (as of 23 May 2021) 2,925
doctors,2,003 nurses,and 3,297 other health-
care staff were infected with ­
COVID-19 [4].
Bangladesh is witnessing the third wave of a
pandemic now. In the epidemiological week
25,2021 number of new cases in Bangladesh
was 36,378; a 48.5% increase compared to
the week before;the case per 100 000 popula-
tion per week was 21.6.The country reported
624 new deaths, a 45.1% increase; death per
100 000 per week was 0.4. The weekly new
test was 179 047 (daily average: 25 578), a
17.3% increase than the week before; tests
per 100 000 per week was 105; the weekly
average test positivity rate (TPR) is 20.5%,
TPR increased by 26.5% from last week.
Bangladesh Preparedness
and Response Plan
(BPRP) for COVID-19
Bangladesh is responding to the pandemic
following a Preparedness and Response
Plan (BPRP). The country is implementing
the response activities through committees
from the national level down to the upazila
level with multi sectoral involvement repre-
senting the relevant ministries, the United
Nations agencies, national and interna-
tional organizations including Bangladesh
Medical Association (BMA) and develop-
ment partners through a pillar-based multi
sectoral coordination mechanism. The plan
includes mechanisms for developing surge
capacity to manage the patients, sustain es-
sential services and reduce social impact.The
response strategy and actions are continu-
ously reviewed and adjusted as necessary to
ensure efficient use of financial and human
resources for the effective response to the
pandemic, and to be reflective of any new
information, operational research advances,
good practices internationally and updated
recommendations from WHO. Disease
surveillance alongside response is an impor-
tant component for prevention and control
of the transmission. The country is screen-
ing at points of entry (PoE) and quaran-
tines a large number of persons. The Rapid
Response Teams (RRT) from national to
upazila level are responding to the outbreak
and overseeing quarantine and isolation at
home, facilities or community. With es-
tablished community transmission, high
dependence health services along with In-
tensive Care Units (ICU) facilities are being
strengthened. Emphasis is given to prevent
hospital-acquired infections and protection
of the caregiver both at the health care facil-
ity,at home and within the community.Em-
phasis is given also to prevent catastrophic
health expenditure with the principle of ‘No
One is Left Behind’ and social and gender
inclusion. Strong concerted efforts have
been taken for communication and advo-
cacy nationally and locally using all media
and means of risk communication and com-
munity engagement. In case of quarantine,
especially during community-based quaran-
tine, measures are taken to ensure the basic
needs of the people are met and the security
of people’s property is ensured through ac-
tive involvement of the law enforcing agen-
cy. Sufficient budget allocation along with a
political commitment from the highest level
is of paramount importance for the success-
ful implementation of the plan.
BANGLADESH
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33
Covid-19
National Vaccine Deployment
Plan (NVDP)
The NVDP document aims to present Ban-
gladesh’s plans for the deployment, imple-
mentation, and monitoring of potential
COVID-19 vaccine(s). Due to the current
uncertain environment for ­
COVID-19 vac-
cine development, the document is based
upon key assumptions and will likely need
to be reviewed and revised over time.
Vaccine situation in Bangladesh
Oxford/AstraZeneca (COVISHIELD) 2nd
dose vaccination has been continuing with re-
maining balance doses only in very few health
facilities in the country. Since the beginning,
as of 29 June 2021,a total of 10,107,884 dos-
es of COVISHIELD vaccine were adminis-
tered, out of which 5,820,015 population re-
ceived their 1st dose and 4,287,869 competed
for their two doses schedule.
Sinopharm vaccine (BIBP) vaccination has
been continuing from the selected 67 cen-
tres in the whole country. As of 29 June
2021, a total of 55,590 target population
received 1st jab and 1329 finished their two
doses schedule.The government has decided
to expand the centres in another 41 health
facilities in Dhaka North and South City
Corporations and some of the sites in the
different Districts to expedite the consump-
tion of 1.1 million Sinopharm vaccines.
Vaccinators and other related health staff
of those facilities receive training on 29 and
30 June 2021.
The first run of COVID-19 Pfizer–BioN-
Tech COVID-19 vaccine has launched in
three government hospitals in Dhaka City
Corporation on 21 June. Total 240 target
population age >40 years of age who reg-
istered earlier have received their 1st
jab
on that day. The government decided next
week for wide inoculation of Pfizer vac-
cine. However, it is decided the Pfizer vac-
cine will be given from the selective health
facilities of Dhaka City Corporation to
consume 100,620 doses from the COVAX
Facility.
Vaccination: Planning
and coordination
The government of Bangladesh has estab-
lished Planning and Coordination Com-
mittees at all levels to facilitate, coordi-
nate and support the development of the
­
COVID-19 vaccine deployment plan, and
to oversee the planning, implementation
and monitoring of the deployment and in-
troduction of COVID-19 vaccine(s) in the
country.
A separate Committee has also been estab-
lished to coordinate and support planning,
implementation and monitoring and evalu-
ation of COVID-19 vaccination among
Forcibly Displaced Myanmar Nationals
(FDMNs), who are popularly known as
Rohingya.
The overall coordination of different committees and working groups shown below
BANGLADESH
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34
Covid-19
Vaccine: regulatory preparedness
In Bangladesh, the national regulatory au-
thority in respect to vaccine is the Directorate
General of Drug Administration (DGDA).
There are three main objectives for regula-
tory preparedness for COVID-19 vaccines in
Bangladesh: (1) specify regulatory pathways
of the Directorate General of Drug Admin-
istration (DGDA) to approve market access
for ­­
COVID-19 vaccines; (2) put in place re-
quired regulatory instruments and resources
in advance to ensure timely decision-making;
and (3) put in place required regulatory instru-
ments to ensure reporting on vaccine safety.
The import requirements will vary based on
the origin of the vaccines and the purchase
method. The registration time is expected
to take 2-3 days for vaccines purchased
through the COVAX facility, 12-15 days
for other imported vaccines and 12-15 days
for locally produced vaccines, assuming the
registration requirements have been met.
The DGDA is not performing testing on
vaccines procured from assured sources,
such as WHO prequalified vaccines, vac-
cines listed as Emergency Use Listing
(EUL) or approved by stringent regulatory
authorities. In this case, review of the sum-
mary lot protocols is conducted, and vac-
cine release is expedited through the review
of the minimum documents as advised by
WHO. In contrast, laboratory testing of the
first three batches will be required for local-
ly produced vaccines or vaccines imported
from non-WHO prequalified sources. Ad-
ditional batches may be tested at the discre-
tion of DGDA for monitoring, pharmaco-
vigilance and post-marketing surveillance.
A risk management plan (RMP) is in place
to safeguard against any harm associated
with the use of the products. In case of
any harm occurring while using the prod-
ucts there should be a clear understanding
between the COVAX facility, national au-
thorities and the manufacturer(s) regarding
liability and indemnity.
Vaccine: Advocacy, Communi-
cation and Demand Promotion
Three activity areas have been identified,
namely social mobilisation and community
engagement, multimedia and Information &
CommunicationTechnology (ICT) Initiatives
and policy and advocacy dialogue. The objec-
tives are: (1) to create awareness and improve
knowledge among the general population
about the COVID-19 Vaccination Campaign.
(2) to contribute towards the maximum partic-
ipation of the priority target groups in the vac-
cination campaign.(3) to mobilize and engage
communities and individuals through accurate
and timely information. (4) to mitigate and
manage the media impact of potential AEFIs
and other negative events among the general
population and target groups.A crisis commu-
nication plan have been developed and links
has been created with the Risk Communica-
tion and Community Engagement (RCCE)
team of COVID-19 pandemic response.
Vaccine deployment
Bangladesh has developed a plan, together
with its National Immunization Technical
Advisory Group (NITAG), to ensure the
equitable allocation of limited doses. This
plan was informed by WHO Strategic Ad-
visory Group of Experts (SAGE)’s recent
guidance on the allocation and prioritiza-
tion of COVID-19 vaccination.
A phased rollout of the COVID-19
vaccine(s) is anticipated in Bangladesh,
initially focused on high-risk groups (in-
cluding health workers directly involved
in COVID-19 response, front line workers
and immunocompromised patients, etc.)
and eventually extended to other groups
(including older adults, adults with co-mor-
bidities, education staff, public transport
workers, migrant workers, etc.), according
to the principles of health and equity.
The vaccines are deployed in a nationwide
campaign using teams made up of six people
(two vaccinators and four volunteers) at a
variety of vaccination sites. The target popu-
lation are registered by electronic voluntary
registration using a national identity card
(NID)/Birth registration card/Passport or by
requesting different departments to provide
list of staff (through format) or by the first-
line health care providers. Ultimately every
vaccinee is being registered electronically and
their vaccine records are in the database of
DGHS.The vaccinee is able to download the
vaccine certificate from the website any time
providing her/his identification number.
Vaccine: Human Resources
DGHS has the infrastructure and human
resources across the country that is ca-
pable of deploying and administering the
­
COVID-19 vaccine(s). Vaccination imple-
mentation is done with technical support
from DGHS and administrative support
from MoHFW along with other relevant
administrative bodies, including law en-
forcement agencies.
Phases of the COVID-19 vaccine rollout in Bangladesh
Phase Stage Population % Population number
1
Ia 3% 5,184,282
Ib 7% 12,096,657
2 II 11-20% 17,280,938
3 III 21-40% 34,561,877
IV 41-80% 69,123,754
TOTAL 138,247,508
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35
Covid-19
A Training Plan is being implemented to
address the training needs, considering in-
terpersonal communication skills and the
need for infection prevention and control.
In the context of COVID-19, remote train-
ing is preferred to in-person training.Train-
ing materials developed by WHO has been
adapted and translated and additional train-
ing materials have been also created.
The standard operating procedure (SOP) for
infection prevention and control measures such
as hand hygiene, wearing a mask and physical
distance has been ensured before, during and
after the vaccination session.Human resources
have been provided with adequate personal
protection equipment (PPE) to minimize
exposure risk during immunization sessions.
Vaccine, Cold Chain and
Logistics Planning
The following table shows different options
of storage capacity needed national level if
the COVID-19 vaccines come in several
tranches.The required space calculation will
be revised/updated once the exact volume of
the COVID vaccine is announced.
The analysis estimates that there is currently
a shortfall of approximately 6m3
of space
in cold rooms and 2.40m3
of free space in
freezer rooms at the national level.The addi-
tional storage requirements for COVID-19
vaccines can be met by hiring cold rooms
from other sources at the national level, as
implemented for the recent Measles-Ru-
bella vaccination campaign. Additional cold
chain equipment would be required at dis-
trict and upazila levels. The estimated cost
of the additional ice-lined refrigerators/
freezers, cold boxes, vaccine carriers, Fridge
Tag-2s, Freeze Indicators is USD 8 million.
To store few particular types of vaccine,
ultra-low temperature freezers is needed.
There are several facilities in Dhaka City,
but it is far from adequate. Therefore, if
an ultra-low cold chain were required for
­
COVID-19 vaccines at a national scale,
the National Expanded Programme of Im-
munization (EPI) would need to procure
around 1095 ultra-low freezers to cover all
levels (upazila to national) which would
take substantial resources and time.
Safety boxes are used to keep sharps (sy-
ringes) produced from the COVID-19 vac-
cination. Used vials will be counted before
disposal. While the transportation of vac-
cine and logistics and waste management
activities are not expected to pose challeng-
es, they require additional resources, such as
the hiring of vehicles and labour.
In the routine immunization program,
there is no security concern for vaccination
session or any campaign activities with
routine vaccine. But for COVAX-19 there
is a need of special security at store, during
transportation and during vaccination ses-
sion which is provided by the law enforc-
ing agencies.
Vaccine Safety
The routine immunization programme in
Bangladesh currently uses passive surveil-
lance in a paper-based system with both
facility-based and community-based sur-
veillance. Following the introduction of
COVID-19 vaccines, it is likely that there
may be higher rates of Adverse Effect fol-
lowing Immunization (AEFI)s and Adverse
Events of Special Interest (AESIs).Howev-
er, there is no such serious incident reported
to date.The vaccination campaign will have
to go a long way, we have to remain alert for
any serious adverse effects. The surveillance
system is extended to include:
• Passive surveillance: Existing paper-
based reporting by health care workers
(HCW) at 792 sites.
• Stimulated passive surveillance: HCWs
to report and follow-up vaccinated peo-
ple through different channels, e.g., home
visit report AEFIs, phone call.
• Active surveillance: having designated
staff visiting in the specified health care
facilities
• Active vaccine surveillance and moni-
toring (AVSM): Using pharmacoepide-
miologic methods to monitor a cohort of
vaccine recipients for AESIs.
AEFIs during the COVID-19 vaccina-
tion program is reviewed and implemented
through the existing AEFI committees at
Cold chain capacity requirements of ­COVID-19 vaccines by the number of doses
Scenario
Total number
of doses for
single doses
Space required
in m3
consider-
ing 3.5 cm3
per
dose (single
dose vial)
Total number
of doses for
two doses
Space required
in m3
consider-
ing 3.5 cm3
per
dose (two dose
vial)
If it comes 2% of
the total doses
3,836,368 13.43 m3
7,672,736 26.85 m3
If it comes 3% of
the total doses
5,754,552 20.14 m3
1,15,09,104 40.28 m3
If it comes 5% of
the total doses
9,590,921 33.57 m3
1,91,81,842 67.14 m3
If it comes 10%
of the total doses
19,181,842 67.14 m3
3,83,63,684 134.28 m3
If 20% of vaccine
come altogether
(single supply)
38,363,684 134.28 m3
7,67,27,367 268.55 m3
BANGLADESH
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36
Covid-19
national and districts/City Corporation lev-
els. A specific AEFI report and line listing
form is used and data entered into the exist-
ing DHIS2 system. This is facilitating the
collection, collation, transmission, analysis
and feedback of the country’s vaccine safety
data. AEFI’s is investigated as required.
Monitoring and
Evaluation (M&E)
The M&E framework of the COVID-19
vaccination programme aims to assess per-
formance and to provide recorded infor-
mation to support the analysis of progress
against the vaccination programme and the
related strategy update. The specific objec-
tives are as follows:
1. To develop and implement electronic
data management systems for monitor-
ing COVID-19 vaccination activities
(resources,service delivery,supply chain,
vaccine wastage,cold chain,surveillance,
AEFI, injection safety and waste man-
agement etc.).
2. To develop and implement an online
monitoring mechanism for assessing
readiness progress and programme per-
formance against key milestones.
3. To integrate the COVID-19 surveil-
lance system.
4. To evaluate the COVID-19 vaccine im-
plementation programme to understand
programme efficiency, as well as vaccine
efficacy and safety.
A Results Framework has been developed
to define the indicators and an evaluation
framework prepared that outlines how
country preparedness, programme imple-
mentation,the impact of COVID-19 vacci-
nation and vaccine efficacy and safety will be
evaluated over time. For example, the Vac-
cine Introduction Readiness Assessment
Tool [VIRAT (WHO)] and the Vaccine
Readiness Assessment Framework [VRAF
(World Bank)] tools have been customized
according to the country context to support
the readiness assessments.
Vaccine: Resources
Bangladesh has joined COVAX Advance
Marketing Commitment (AMC) countries
to secure COVID-19 vaccine(s). As per the
COVAX allocation, Bangladesh expects to
receive vaccine doses equal to 20% of its
population (34,561,877) followed by ad-
ditional doses equal to at least 40% of its
population (69,123,754) based on avail-
ability of vaccine and weighted allocation.
Bangladesh will share vaccine cost of USD
1.6-2 per dose with COVAX.It is estimated
that it may cost USD 2 per person to sup-
port operation. A total of $179.8-$207.4m
is required for vaccine and operational cost
for the first 20% of the population, whereas
for 40% it is estimated that cost would be
$290.4m-345.7m for vaccine and opera-
tional cost. But the COVAX commitment
to Bangladesh is yet to speed into full swing.
Bangladesh government purchased vaccine
by its own arrangement through trilateral
negotiation with Serum Institute of India
(SII). The government planned to purchase
doses equal to 9% of its population. The
estimated cost of the vaccines was USD 5
per dose. A total of $150m and $ 37.5m is
required for vaccine and operational cost
for 9% of the population. But a surge of the
COVID-19 pandemic in India temporarily
halted vaccine supply from SII.The govern-
ment is exploring other sources to procure
vaccine bilaterally. To support the vaccine
preparedness and deployment activities, a
budget of USD 97.6 million is requested.
Bangladesh is exploring various funding
sources to support COVID vaccine deploy-
ment in the country. Several international
development partners already offered tech-
nical support for vaccine procurement.
Conclusion
Bangladesh is facing the challenge of the
COVID-19 pandemic through enforcing
public health and social measures (PHSM),
detection and isolation of cases and contacts,
clinical management, preventive measures
including mass vaccination. The BPRP and
NVDP are in the process of updating since a
new scenario emerges since the unfolding of
the pandemic and beginning of vaccination.
New and newer scientific evidence is coming
to light which is changing existing guidelines
and action plans. Community engagement
is an important prerequisite for pandemic
control. Community empowerment through
mobilization of community resources has
been proved successful in several urban and
rural clusters of infection. The suffering of
the disadvantaged population may be mini-
mized in this way of community partnership.
In the paucity of COVID-19 vaccine, more
emphasis on public health and social mea-
sures at community, institution, family and
personal level is the way to fight the pan-
demic.No single type of measure may not be
effective, a combination of all the measures
are the key to success. It is evident from the
experience of the pandemic that, no single
person may remain safe until everybody is
safe. Similarly­
, no country may become safe
until every country of the world become safe.
Reference
1. Bangladesh Preparedness and Response Plan for
COVID-19. Government of the Peoples Re-
public of Bangladesh. June 2021
2. National Deployment and Vaccination Plan for
COVID-19 Vaccines in Bangladesh.Ministry of
Health and Family Welfare. 6 December 2020
3. Morbidity and Mortality Weekly update no. 70.
COVID-19. World Health Organisation Bang-
ladesh Country Office. 28 June 2021
4. Bangladesh Medical Association (BMA) Press
Release 24 May 2021 and 21 June 2021.
M Mushtuq Husain,
Member of Central Executive Committee,
Bangladesh Medical Association (BMA);
Advisor, Institute of Epidemiology, Disease
Control and Research (IEDCR), Directorate
General of Health Services, Bangladesh;
E-mail: mushtuq@dr.com,
mushtuq@gmail.com
BANGLADESH
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37
Covid-19
Brazilian Epidemiologic
Situation
The impact of the COVID-19 epidemic in
Brazil is one of the most important in the
world,since the first case described in Febru-
ary 2020, 18 million Brazilian people were
infected (8.500/100 thousand inhabitants)
and more than half a million died by the
disease (240/100 thousand inhabitants) [1].
In terms of COVID-19 total deaths, Brazil
is the second country in the world most af-
fected, very close to U.S. that had registered
600.000 fatal cases, despite the Brazilian
population is just about 2/3 of U.S. [2].
Due to underdiagnosis, the fatality rate is
imprecise (2.8%), but the absolute number
of daily deaths today varies between 2 and
4 thousand, and the number of new cases
between 40 and 100 thousand. There is no
idea about the variables of the population
profiles involved, including a lot of specula-
tion regarding the variants. Related to vac-
cination for COVID 19 we have about 11%
of the population immunized. The disease
remains out of control.
Brazil emerged as a global epicentre of ­
the
COVID-19 epidemic in the beginnings of
2021,starting a second wave of high increase
of new cases and deaths (the first one oc-
curred in the middle of 2020), while other
countries achieved some success in reducing
the impact of the pandemic adding prevent
strategies, as mass vaccination, public poli-
cies to avoid agglomeration and educational
campaigns stimulating the use of masks, so-
cial distance and hands hygiene [3, 4].
Objective of this Article
This article aims to briefly summarize the
recommendations of the BMA in relation
to prophylaxis (prevention) and treatment
of mild COVID (outpatients).
Description of the Etiology
of Covid-19
Covid-19 has as causal agent the virus
SARS-CoV2, order Nidovirales, fam-
ily Coronaviridae, genus Betacoronavirus.
Other viruses already described as dis-
ease agents are part of this genus: OC43
and HKU4 that cause the common cold,
SARS-CoV and MERS-CoV, both po-
tential agents of serious diseases but with
limited epidemic action. Coronaviruses are
the largest RNA-viruses and can invade hu-
man cells through the protein S that forms
its envelope, which can couple to the ACE2
receptor of human cells A [5-7].
CoVs infect humans and a variety of avian
and mammalian species worldwide. There
are six CoVs known to infect humans, in-
cluding two a-CoVs (229E and NL63)
and four b-CoVs (OC43, HKU1, severe
acute respiratory syndrome [SARS]-CoV,
and Middle East respiratory syndrome
[MERS]-CoV). All human CoVs are zoo-
notic as a distinguishing characteristic. In
particular, bats are regarded as a key reser-
voir of CoVs, and many human CoVs are
believed to have originated from bats. Since
the beginning of this century, two zoonotic
CoVs, SARS- CoV and MERS-CoV, have
been identified to cause severe human dis-
eases. The outbreak of SARS-CoV in 2003
was responsible for 8096 cases and 774
deaths world- wide. Since its discovery in
Middle Eastern countries in 2012, MERS-
CoV has infected 2494 people with a cur-
rent case fatality rate of 34.4%. These out-
breaks have raised public health concerns
about the potential for the emergence of
another novel zoonotic CoV [8].
SARS-Cov2 is a previously unknown bat-
origin CoV causing severe and fatal pneu-
monia in five patients from Wuhan, China.
Sequence results revealed that this virus,
harboring a single open reading frame gene
8 (ORF8), is phylogenetically closest to bat
SARS-like CoV, but is in a separate lin-
eage. Furthermore, the amino acid sequence
of the tentative receptor-binding domain
(RBD) of this new CoV resembles that of
SARS-CoV, indicating that they might use
Covid-19: Brazilian Medical Association (AMB)
Summary Recommendations
Suzana Erico Tanni Helio Arthur Bacha César Eduardo
Fernandes
José Eduardo
Lutaif Dolci
Alexandre Naime
Barbosa
Wanderley Bernardo
BRAZIL
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38
Covid-19
the same receptor. These findings highlight
the urgent need for regular surveillance of
the interspecies transmission of bat-origin
CoV to human populations [8].
Classification and Definition
of Mild Disease
The disease (COVID 19) can be classified
by its severity as follows [9]:
Mild illness [9]
Patients with uncomplicated upper re-
spiratory tract viral infection may have
non-specific symptoms such as fever, fa-
tigue, cough (with or without sputum pro-
duction), anorexia, malaise, muscle pain,
sore throat, dyspnea, nasal congestion, or
headache. Rarely, patients may also pres-
ent with diarrhoea, nausea, and vomiting.
Older and/or immunosuppressed patients
may present with atypical symptoms.
Symptoms due to physiological adapta-
tions of pregnancy or adverse pregnancy
events (e.g., dyspnea, fever, gastrointesti-
nal symptoms, fatigue) may overlap with
COVID-19 symptoms.
Pneumonia [9]
Adults: pneumonia with no signs of severe
pneumonia and no need for supplemental
oxygen. Children: pneumonia with cough
or difficulty breathing plus fast breathing
(i.e., 30
breaths/minute; Severe respiratory distress;
SpO₂ ≤93% on room air.
Severe pneumonia in children [9]
Cough or difficulty breathing plus at least
one of the following: Central cyanosis or
SpO₂ <90%; Severe respiratory distress
(e.g., grunting, very severe chest indraw-
ing); Signs of pneumonia with a general
danger sign (i.e., inability to breastfeed or
drink, lethargy or unconsciousness, or con-
vulsions); Other signs of pneumonia may
be present in children including chest in-
drawing or fast breathing (i.e., <2 months
of age: ≥60 breaths/minute; 2-11 months of
age: ≥50 breaths/minute; 1-5 years of age:
≥40 breaths/minute); While the diagnosis
is made on clinical grounds, chest imaging
may identify or exclude some pulmonary
complications [9].
Diagnosis of Covid-19
Clinical (signs and symptoms)
COVID-19 affects many organs of the
body, so people with COVID-19 may have
a wide spectrum of symptoms. Symptoms
and signs of the illness may be important
to help them and the healthcare staff they
meet to know whether they have the disease
[10].
Symptoms: people with mild COVID-19
might experience cough, sore throat, high
temperature, diarrhoea, headache, muscle or
joint pain, fatigue, and loss or disturbance of
the sense of smell and taste. Signs are ob-
tained by clinical examination.Oxygen,peo-
ple with mild symptoms consult their doc-
tor (general practitioner). People with more
severe symptoms might visit a hospital out-
patient or emergency department. Depend-
ing on the results of a clinical examination,
patients may be sent home to isolate, may
receive further tests or be hospitalized [10].
In 26.884 participants the prevalence of
COVID-19 varied from 3% to 71% with
a median of 21%, without discrimination
of mild from severe COVID-19. A greater
proportion included participants who pre-
sented to outpatient settings,which is where
most clinical assessments for ­
COVID-19
take place [10].
Only cough and fever had a pooled sensi-
tivity of at least 50% but specificities were
moderate to low. The cough had a sensitiv-
ity of 67.4% and as specificity of 35.0%.
The fever had a sensitivity of 53.8% and a
specificity of 67.4%. Anosmia alone, ageusia
alone, and anosmia or ageusia had sensitivi-
ties below 50% but specificities over 90%.
Anosmia had a pooled sensitivity of 28.0%
and a specificity of 93.4%. Ageusia had a
pooled sensitivity of 24.8% and a specificity
of 91.4%. Anosmia or ageusia had a pooled
sensitivity of 41.0% and a specificity of
90.5%. The presence of anosmia or ageusia
may be useful as a red flag for COVID-19.
The presence of fever or cough, given their
high sensitivities, may also be useful to
identify people for further testing [10].
Patients with symptoms meeting the case
definition for COVID-19 without evidence
of viral pneumonia or hypoxia. Present-
ing signs and symptoms of COVID-19
vary: Most people experience fever (8% to
99%), cough (59% to 82%), fatigue (44%
to 70%), anorexia (40% to 84%), shortness
of breath (31% to 40%), myalgias (11% to
35%). Other non-specific symptoms, such
as sore throat, nasal congestion, headache,
diarrhoea, nausea, and vomiting, has also
been reported.
Loss of smell (anosmia) or loss of taste
(ageusia) preceding the onset of respiratory
symptoms have also been reported [11].
Additional neurological manifestations re-
ported include dizziness, agitation, weak-
ness, seizures, or findings suggestive of
stroke including trouble with speech or vi-
sion, sensory loss, or problems with balance
when standing or walking. Older people
and immunosuppressed people may pres-
ent with atypical symptoms such as reduced
alertness, reduced mobility, diarrhoea, loss
of appetite, confusion and absence of fever.
Symptoms such as dyspnea, fever, gastro-
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39
Covid-19
intestinal symptoms, or fatigue because of
physiological adaptations in women who
are pregnant, adverse pregnancy events or
other diseases such as malaria, may overlap
with symptoms of COVID-19. Children
may report fever or cough less frequently
than adults [11].
Laboratory tests
Universal access to accurate SARS-CoV-2
nucleic acid testing is critical for patient
care, hospital infection prevention and the
public response to the COVID-19 pandem-
ic. Information on the clinical performance
of available tests is rapidly emerging, but the
quality of evidence of the current literature is
considered moderate to very low. Recogniz-
ing these limitations,the Infectious Diseases
Society of America (IDSA) panel weighed
available diagnostic evidence and recom-
mends nucleic acid testing for all symptom-
atic individuals suspected of having COV-
ID-19. In addition, testing is recommended
for asymptomatic individuals with known or
suspected contact with a COVID-19 case.
Testing asymptomatic individuals without
known exposure is suggested when the re-
sults will impact isolation/quarantine/per-
sonal protective equipment (PPE) usage
decisions, dictate eligibility for surgery, or
inform solid organ or hematopoietic stem
cell transplantation timing. Ultimately, pri-
oritization of testing will depend on insti-
tutional-specific resources and the needs of
different patient populations [12].
Diagnostic testing will help in safely open-
ing the country, but only if the tests are
highly sensitive and validated under realis-
tic conditions against a clinically meaning-
ful reference standard. Measuring test sen-
sitivity in asymptomatic people is an urgent
priority. It will also be important to develop
methods (e.g., prediction rules) for estimat-
ing the pretest probability of infection (for
asymptomatic and symptomatic people)
to allow the calculation of post-test prob-
abilities after positive or negative results.
Negative results even on a highly sensitive
test cannot rule out infection if the pretest
probability is high, so clinicians should not
trust unexpected negative results (i.e., as-
sume a negative result is a “false negative”in
a person with typical symptoms and known
exposure) [13].
Nucleic acid amplification tests (NAAT)
Routine confirmation of cases of ­COVID-19
is based on detection of unique sequences
of virus RNA by NAAT such as real-time
reverse-transcription polymerase chain re-
action (rRT-PCR) with confirmation by
nucleic acid sequencing when necessary.The
viral genes targeted so far include the N, E,
S and RdRP genes. One or more negative
results do not rule out the possibility of CO-
VID-19 virus infection.Several factors could
lead to a negative result in an infected indi-
vidual, including poor quality of the speci-
men, containing little patient material (as a
control, consider determining whether there
is adequate human DNA in the sample by
including a human target in the PCR test-
ing); the specimen was collected late or very
early in the infection; the specimen was not
handled and shipped appropriately; technical
reasons inherent in the test, e.g. virus muta-
tion or PCR inhibition [14].
Considering the findings that more than
half of individuals with positive PCR test
results are unlikely to have been infectious,
RTPCR test positivity should not be taken
as an accurate measure of infectious SARS-
CoV-2 incidence. The results confirm the
findings of others that the routine use of
“positive” RT-PCR test results as the gold
standard for assessing and controlling infec-
tiousness fails to reflect the fact “that 50-
75% of the time an individual is PCR posi-
tive, they are likely to be post-infectious”.
Asymptomatic individuals with positive
RT-PCR test results have higher cut-off
(Ct) values and a lower probability of be-
ing infectious than symptomatic individu-
als with positive results. Although Ct values
have been shown to be inversely associated
with viral load and infectivity, there is no
international standardization across labora-
tories, rendering problematic the interpre-
tation of RT-PCR tests when used as a tool
for mass screening [15].
Rapid point-of-care tests [16]
Rapid point-of-care tests aim to confirm
or rule out COVID-19 infection in people
with or without COVID-19 symptoms.
They are portable,so they can be used wher-
ever the patient is (at the point of care); are
easy to perform, with a minimum amount
of extra equipment or complicated prepara-
tion steps; are less expensive than standard
laboratory tests; do not require a special-
ist operator or setting; and provide results
‘while you wait’. The interest is two types
of commercially available, rapid point-of-
care tests: antigen and molecular tests. An-
tigen tests identify proteins on the virus;
they come in disposable plastic cassettes,
similar to pregnancy tests. Rapid molecular
tests detect the virus’s genetic material in a
similar way to laboratory methods but using
smaller devices that are easy to transport or
to set up outside of a specialist laboratory.
Both test nose or throat samples [16].
In people with confirmed COVID-19, an-
tigen tests correctly identified COVID-19
infection in an average of 72% of people
with symptoms, compared to 58% of people
without symptoms. Tests were most accu-
rate when used in the first week a-er symp-
toms first developed (an average of 78% of
confirmed cases had positive antigen tests).
This is likely to be because people have the
most virus in their system in the first days
a-er they are infected. In people who did
not have COVID-19,antigen tests correctly
ruled out infection in 99.5% of people with
symptoms and 98.9% of people without
symptoms [16].
Although overall results for diagnosing and
ruling out COVID-19 were good (95.1%
of infections correctly diagnosed and 99%
correctly ruled out), some antigen tests are
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40
Covid-19
accurate enough to replace RT-PCR when
used in people with symptoms. This would
be most useful when quick decisions are
needed about patient care, or if RT-PCR
is not available. Antigen tests may be most
useful to identify outbreaks, or to select
people with symptoms for further testing
with PCR,allowing self-isolation or contact
tracing and reducing the burden on labora-
tory services. People who receive a negative
antigen test result may still be infected [16].
Image exams
Results from 1.834 patients reported the
diagnostic accuracy of both CT and RT-
PCR, in the same set of patients. Sensitivity
estimates for CT scan ranged from 0.69 to
1.00 and for RT-PCR varied ranging from
0.47 to 1.00. The pooled estimates of sensi-
tivity for CT and RT-PCR were 0.91 and
0.84, respectively. On subgroup analysis,
pooled sensitivity of CT and RT-PCR was
0.95 and 0.91 (p95%, low certainty). Eye protection also
was associated with less infection (n=3.713;
aOR 0.22, RD −10.6%; low certainty) [21].
Distance
A systematic review retrieved 172 obser-
vational studies across 16 countries and six
continents, with no randomized controlled
trials and 44 relevant comparative studies in
healthcare and non-health-care settings (n=
25.697 patients) Transmission of viruses
where lower with the physical distancing
of 1 m or more, compared with a distance
of less than 1 m (n=10.736, pooled adjusted
odds ratio [aOR] 0.18; risk difference [RD]
−10.2%; moderate certainty); protection
was increased as the distance was length-
ened (change in relative risk [RR] 2.02 per
m; p =0.041; moderate certainty) [21].
Current rules on safe physical distancing are
based on outdated science. The distribution
of viral particles is affected by numerous
factors, including airflow. Evidence sug-
gests SARS-CoV-2 may travel more than
2 m through activities such as coughing and
shouting. Rules on distancing should reflect
the multiple factors that affect risk, includ-
ing ventilation, occupancy, and exposure
time [22].
How should infection control practice be
changed if we provisionally accept that
aerosols have an important role in viral
transmission? The inhalational risk may be
reduced by social distancing, limiting inter-
action indoors, avoiding air recirculation,
improved natural and artificial ventilation,
and innovative engineering solutions which
collect and neutralise aerosols to provide
clean air in personal and community spac-
es. The infection risk associated with deep
breathing, talking, and singing indoors is
underappreciated and urgently needs at-
tention. Since the 2003 SARS outbreak,
research in aerobiology, physics, and com-
putational fluid dynamics has advanced our
understanding of the aerosol generation and
the carriage and fate of respiratory particles.
Airborne transmission of Covid-19 is now
the plausible cause of superspreading events
in a call centre in Korea, a choir practice
in Skagit County, US, and a restaurant in
Guangzhou, China. The pandemic is at a
critical juncture, and these strong signals
should not be ignored by politicians and
public health leaders [23].
Isolation
The studies consistently reported the
benefit of quarantine, contact tracing,
screening, and isolation in different set-
tings. Model estimates indicated that
quarantine of exposed people averted 44
to 81% of incident cases and 31 to 63%
of deaths. Quarantine along with others
can also halve the reproductive number
and reduce the incidence, thus, shortening
the epidemic period effectively. Early ini-
tiation of quarantine, operating large-scale
screenings, strong contact tracing systems,
and isolation of cases can effectively re-
duce the epidemic. However, adhering
only to screening and isolation with lower
coverage can miss more than 75% of as-
ymptomatic cases; hence, it is not effec-
tive. Quarantine, contact tracing, screen-
ing, and isolation are effective measures of
COVID-19 prevention,
particularly when integrated together. To
be more effective, quarantine should be im-
plemented early and should cover a larger
community [24].
General strategies
Two fundamental strategies are possible:
(a) mitigation, which focuses on slow-
ing but not necessarily stopping epidemic
spread – reducing peak healthcare demand
while protecting those most at risk of severe
disease from infection, and (b) suppression,
which aims to reverse epidemic growth,
reducing case numbers to low levels and
maintaining that situation indefinitely. Each
policy has major challenges. We find that
that optimal mitigation policies (combining
home isolation of suspect cases, home quar-
antine of those living in the same household
as suspect cases, and social distancing of the
elderly and others at most risk of severe dis-
ease) might reduce peak healthcare demand
by 2/3 and deaths by half. However, the re-
sulting mitigated epidemic would still likely
result in hundreds of thousands of deaths
and health systems (most notably intensive
care units) being overwhelmed many times
over. For countries able to achieve it, this
leaves suppression as the preferred policy
option [25].
The optimal control of COVID-19 with the
help of Non-Pharmaceutical Interventions
(NPIs). On the basis of sensitivity indices
of the parameters we apply Non-Pharma-
ceutical Interventions (NPIs) to control the
sensitive parameters and hence formulate the
optimal control model. The major NPIs are,
stay home, sanitiser (wash hands), early case
detection (PCR test) and face mask. These
NPIs helps in mitigation and reducing the
size of the outbreak of the disease [25].
Non-pharmacological interventions, such
as lockdown and mass testing, remain as
the mainstay of control measures for the
outbreak. Based on one modelling study,
mass testing reduced the total infected
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Covid-19
people compared to no mass testing. For
lockdown, ten studies consistently showed
that it successfully reduced the incidence,
onward transmission, and mortality rate
of ­
COVID-19. Limited evidence showed
that a combination of lockdown and mass
screening resulted in a greater reduction
of incidence and mortality rate compared
to lockdown only. However, there is not
enough evidence on the effectiveness of
mass testing only [26].
Our results suggest that exposure in settings
with familiar contacts increases SARS-
CoV-2 transmission potential. Additionally,
the differences observed in transmissibility
by index case symptom status and duration
of exposure have important implications for
control strategies such as contact tracing,
testing and rapid isolation of cases. There
was limited data to explore transmission
patterns in workplaces, schools, and care-
homes, highlighting the need for further
research in such settings [27].
Monitoring
Use the following signs and symptoms to
help identify people with COVID-19 with
the most severe illness [11]:
• severe shortness of breath at rest or dif-
ficulty breathing
• reduced oxygen saturation levels mea-
sured by pulse oximetry
• coughing up blood
• blue lips or face
• feeling cold and clammy with pale or
mottled skin
• collapse or fainting (syncope)
• new confusion
• becoming difficult to rouse
• reduced urine output.
When pulse oximetry is available in pri-
mary and community care settings, to as-
sess the severity of illness and detect early
deterioration, use: pulse oximetry in people
18 years and over with COVID-19 oxygen
saturation levels below 91% in room air at
rest in children and young people (17 years
and under) with COVID [11].
Criteria for discharging patients from isola-
tion (i.e., discontinuing transmission-based
precautions) without requiring retesting:
For symptomatic patients: 10 days after
symptom onset, plus at least 3 additional
days without symptoms (including with-
out fever and without respiratory symp-
toms). For asymptomatic cases: 10 days
after a positive test for SARS-CoV-2. The
initial recommendation of two negative
PCR tests at least 24 hours apart can be
used. Some patients may experience symp-
toms beyond the period of infectivity. Care
of COVID-19 patients after acute illness.
Discharge criteria from clinical care need to
consider the patient’s condition, disease ex-
perience and other factors. Release from the
COVID-19 care pathway is not the same as
clinical discharge from a facility or from one
ward to another [9].
Patients with mild and moderate illness
may not require emergency interventions
or hospitalization; however, isolation is
necessary for all suspect or confirmed cases
to contain virus transmission. The decision
to monitor a suspect case in a health facil-
ity, community facility or home should be
made on a case-by-case basis. This decision
will depend on the clinical presentation, re-
quirement for supportive care, potential risk
factors for severe disease, and conditions at
home, including the presence of vulnerable
persons in the household [9].
Early identification of patients at risk for
and with severe disease allows for rapid ini-
tiation of optimized supportive care treat-
ments and safe,rapid referral to a designated
destination in the COVID-19 care pathway
(with access to oxygen and respiratory sup-
port). Known risk factors for rapid dete-
rioration, severe disease, and/or increased
mortality are: older age (> 60 years) and
NCDs such as cardiovascular disease, dia-
betes mellitus, chronic lung disease, cancer
and cerebrovascular disease. Patients with
one or more of these risk factors should be
monitored closely for deterioration, prefer-
ably in a health facility. As described above,
the decision to monitor in a health facil-
ity, community facility or home should be
made on a case-by-case basis. This decision
will depend on the clinical presentation, re-
quirement for supportive care, risk factors
and conditions at home, including the pres-
ence of additional vulnerable persons in the
household. Risk factors for severe disease in
pregnancy include increasing maternal age,
high BMI, non-white ethnicity, pre-exist-
ing comorbidities, and pregnancy-specific
conditions such as gestational diabetes and
pre-eclampsia [9].
Some patients develop severe pneumonia
and require oxygen therapy and minority
progress to critical disease with complica-
tions such as respiratory failure or septic
shock. COVID-19 confirmation needs
to be made prior to determining severity;
particularly in children, for whom the dif-
ferential diagnosis for respiratory distress
is particularly important. Children with
suspected or confirmed COVID-19 infec-
tion should be kept together with caregiv-
ers wherever possible (if caregivers also have
suspected or confirmed COVID-19 infec-
tion), and cared for in child-friendly spaces,
considering specific medical, nursing, nutri-
tional, and mental health, and psychosocial
support needs of children [9].
Shared decision making [29]
With the patient, family, and community
some principal information can be shared:
• That the key symptoms are cough, fe-
ver, breathlessness, anxiety, delirium, and
agitation, but they may also have fatigue,
muscle aches, and headache;
• That they and people caring for them
should follow the guidance on self-isola-
tion and the UK guidance on protecting
vulnerable people;
• That if the symptoms are mild, they are
likely to feel much better in a week;
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Covid-19
• Who to contact if their symptoms get
worse.
Minimise face-to-face contact by [29]:
• Offering telephone or video consulta-
tions;
• Cutting non-essential face-to-face follow
up;
• Using electronic prescriptions rather than
paper;
• Using different methods to deliver medi-
cines to patients.
When possible, discuss the risks, ben-
efits, and possible likely outcomes of the
treatment options with patients with
­
COVID-19, and their families and carers,
so that they can express their preferences
about their treatment and escalation plans.
Put treatment escalation plans in place be-
cause patients with COVID-19 may de-
teriorate rapidly and need urgent hospital
admission. For patients with pre-existing
advanced comorbidities, find out if they
have advance care plans or advance deci-
sions to refuse treatment, including do not
attempt resuscitation decisions. Document
this clearly and take account of these in
planning care [29].
Be aware that older patients or those with
comorbidities, frailty, impaired immunity, or
a reduced ability to cough and clear secre-
tions are more likely to develop severe pneu-
monia. This could lead to respiratory failure
and death. If possible, encourage patients
with a cough to avoid lying on their back be-
cause this makes coughing ineffective [29].
Be aware that, on average, fever is most
common five days after exposure to the in-
fection.Advise patients to drink fluids regu-
larly to avoid dehydration (no more than 2
litres per day). Do not use antipyretics with
the sole aim of reducing body temperature.
Advise patients to take paracetamol if they
have fever and other symptoms that anti-
pyretics would help treat. Tell them to con-
tinue only while the symptoms of fever and
the other symptoms are present. Until there
is more evidence, paracetamol is preferred
to non-steroidal anti-inflammatory drugs
(NSAIDs) for patients with COVID-19
[29].
Prognosis
Re-infection
In this study during the first surge, 533.381
people were tested, of whom 11.727 were
PCR positive, and 525 339 were eligible
for follow-up in the second surge, of whom
11.068 had tested positive during the first
surge. Among eligible PCR positive indi-
viduals from the first surge of the epidemic,
72 tested positive again during the second
surge compared with 16.819 of 514.271
who tested negative during the first surge
(adjusted RR 0.195). Protection against
repeat infection was 80.5%. The alterna-
tive cohort analysis gave similar estimates
(adjusted RR 0.21), estimated protection
78.8%. In the alternative cohort analysis,
among those aged 65 years and older, ob-
served protection against repeat infection
was 47.1%. Evidence of waning protection
over time (3–6 months of follow-up 79.3%
vs ≥7 months of follow-up 77.7% [29].
Immunity
Using sequential samples from SARS-
CoV-2 infected individuals collected up to
94 days demonstrated declining neutraliz-
ing antibodies (nAb) titres in the majority
of individuals. For those with a low nAb
response, titres can return to baseline over a
relatively short period.Further studies using
sequential samples from these individuals
are required to fully determine the longevity
of the nAb response and studies determin-
ing the nAb threshold for protection from
re-infection are needed [30].
SARS-CoV-2-specific memory T cells
will likely prove critical for long-term im-
mune protection against COVID-19. It
was mapped the functional and phenotypic
landscape of SARS-CoV-2-specific T cell
responses in a large cohort of unexposed in-
dividuals as well as exposed family members
and individuals with acute or convalescent
COVID-19. Acute phase SARS-CoV-
2-specific T cells displayed a highly activat-
ed cytotoxic phenotype that correlated with
various clinical markers of disease severity,
whereas convalescent-phase SARS-CoV-
2-specific T cells were polyfunctional and
displayed a stem-like memory phenotype.
Importantly, SARS-CoV-2-specific T cells
were detectable in antibody-seronegative
family members and individuals with a his-
tory of asymptomatic or mild COVID-19.
This collective dataset shows that SARS-
CoV-2 elicits robust memory T cell re-
sponses akin to those observed in the con-
text of successful vaccines, suggesting that
natural exposure or infection may prevent
recurrent episodes of severe COVID-19
also in seronegative individuals [31].
Long COVID [32]
COVID-19 can cause persistent ill-health.
Around a quarter of people who have had
the virus experience symptoms that con-
tinue for at least a month but one in 10
are still unwell after 12 weeks. This has
been described by patient groups as “Long
­
COVID”. Our understanding of how to di-
agnose and manage Long COVID is still
evolving but the condition can be very de-
bilitating. It is associated with a range of
overlapping symptoms including general-
ized chest and muscle pain, fatigue, short-
ness of breath, and cognitive dysfunction,
and the mechanisms involved affect multi-
ple system and include persisting inflamma-
tion, thrombosis, and autoimmunity. It can
affect anyone, but women and health care
workers seem to be at greater risk. Long
COVID has a serious impact on people’s
ability to go back to work or have a social
life. It affects their mental health and may
have significant economic consequences for
them, their families and society.
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Covid-19
Policy responses need to take account of the
complexity of Long COVID and how what
is known about it is evolving rapidly. Areas
to address include [32]:
• The need for multidisciplinary, multispe-
cialty approaches to assessment and man-
agement;
• Development,in association with patients
and their families, of new care pathways
and contextually appropriate guidelines
for health professionals, especially in pri-
mary care to enable case management to
be tailored to the manifestations of dis-
ease and involvement of different organ
systems;
• The creation of appropriate services, in-
cluding rehabilitation and online support
tools;
• Action to tackle the wider consequences
of Long COVID, including attention to
employment rights, sick pay policies, and
access to benefit and disability benefit
packages;
• Involving patients both to foster self-care
and self-help and in shaping awareness of
Long COVID and the service (and re-
search) needs it generates; and
• Implementing well-functioning patient
registers and other surveillance systems;
creating cohorts of patients, and following
up on those affected as a means to support
the research which is so critical to under-
standing and treating Long ­
COVID.
Methods
Clinical Questions
In patients without a diagnosis of COVID
19, but submitted to environments with the
possibility of contagion,does the use of Hy-
droxychloroquine or Ivermectin or Antibi-
otics or Antivirals or Steroids or Anticoag-
ulants or Monoclonal Antibodies or Plasm
or Nitazoxanide or Colchicine prevent ill-
ness? Or in patients with mild COVID 19,
do these drugs reduce hospitalization or
mortality, and does not increase the risk of
adverse events?
Eligibility criteria for
studies to be included
PICO
Patient: without COVID confirmed by
PCR (prophylaxis) or with mild COVID
19 (treatment)
Interventions: Drugs studied (Hydroxy-
chloroquine or Ivermectin or Antibiotics
or Antivirals or Steroids or Anticoagulants
or Monoclonal Antibodies or Plasm or Ni-
tazoxanide or Colchicine)
Comparison: Standard treatment or placebo
Outcome: occurrence of illness, hospitaliza-
tion (infirmary or ICU), mortality and ad-
verse events
Study design: Phase 3 randomized clinical
trials (RCTs) and phase 3 RCTs system-
atically reviewing the PICO. No consulted
period, language, or full text availability
limits.
Bases consulted with their
respective strategies
The individual drug strategies included the
synonyms, however, in order not to extend
the content too much, the drugs will be
generically mentioned in the search strat-
egy of this article. The complete strategies
are available on the AMB website (project
guidelines).
Medline, EMBASE, Central Cochrane
and Clinical Trials
#1 =
COVID OR COV OR CORONA­
VIRUS OR SARS
#2 = (Hydroxychloroquine or Ivermectin or
Antibiotics or Antivirals or Steroids or An-
ticoagulants or Monoclonal Antibodies or
Plasm or Nitazoxanide or Colchicine)
#3 = #1 AND #2
#4 = #3 AND Random*
Data Extracted
Data regarding authorship, year of publica-
tion, description of patients, interventions
(drugs studied), outcomes and follow-up
time will be extracted from the studies.
Bias risk and Quality of evidence
The risk of bias will be assessed using the
items in Rob 2 [33], plus other fundamen-
tal elements, and expressed as very serious,
serious, or non-serious. The quality of the
evidence will be extrapolated from the risk
of bias obtained from the study (s) (if there
is no meta-analysis) using the GRADE ter-
minology [34] in very low, low, and high,
and through the GRADEpro software [34]
(if there is meta-analysis) in very low, low,
moderate, and high.
Analysis and Summary of Outcomes
The outcomes when categorical will be ex-
pressed by group (drugs studied and com-
parisons) and through the number of events
and the calculated risk (%) for each group
(a division of the number of events by the
total number of patients in each group). If
the risk difference (RD) between the groups
is significant (95% confidence) it will be ex-
pressed with the 95% confidence interval
(95% CI) and the Number needed to treat
(NNT) or to produce damage (NNH).
If there is more than one study included
with common outcomes, it will be aggre-
gated through meta-analysis using RevMan
5.4 software [35].
Results
The results presented will follow the fol-
lowing sequence: total articles retrieved and
selected,Hydroxychloroquine or Ivermectin
or Antibiotics or Antivirals or Steroids or
Anticoagulants or Monoclonal Antibodies
or Plasm or Nitazoxanide or Colchicine.
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Covid-19
Total results
A number of 2.674, 1.073 and 1.045 studies
were retrieved from Medline, Embase, and
Clinical Trials,respectively.Eliminating du-
plicates and meeting the eligibility criteria,
174 studies were selected so that their full
texts could be accessed, from which 158 pa-
pers were excluded. Then, available to sup-
port this assessment in accordance with the
eligibility criteria adopted, there are 16 ran-
domized trials [Hydroxychloroquine (n:9);
Ivermectin (n:1); Antibiotics (n:0); Anti-
virals (n:1); Steroids (n:0); Anticoagulants
(n:0); Monoclonal Antibodies (n:2); Plasm
(n:1); Nitazoxanide (n:1); Colchicine (n:1)],
whose characteristics, results, risk of bias,
quality of evidence and synthesis of evi-
dence are described below [36-51].
Hydroxychloroquine (HCQ )
Description of the included studies
of HCQ in covid-19 prophylaxis
In health professionals in two hospitals in
the USA, 132 patients were randomized
(out of 139 evaluated), 66 for the group.
Patients were randomized before taking the
COVID-19 positivity tests, as they were
excluded from the use of the drug (HCQ
dose 600 mg/day for 8 weeks). The main
outcome was measured by RT-PCR nasal
swab at 4 and 8 without or if symptoms of
COVID-19 infection were present.The sec-
ondary outcome was to assess modification
of the QT interval, but it was added as a
subsequent amendment to the protocol. In-
formation on adverse effects was collected,
where 64 patients in the HCQ group and
of these 52 swabs and 54 swabs were tested
in the 4 and 8 weeks respectively. In the
placebo group, there were 52 and 54 swabs
at 4 and 8 weeks [(PATCH) Investigators
NCT04329923] [36].
In subjects with up to 96 h of exposure to
high risk to HCQ: 400 mg was used for 3
days followed by 200 mg/day for 11 days,
with the vitamin C placebo. The outcome
of infection was measured at 14 days and 28
days with RT-PCR (NCT04328961) [37].
A study was carried out on people at high
risk of contamination due to exposure at
work and who had exposure to index cases
in 9 health centres in Spain. Open study,
which allowed cross-over, HCQ dose of
800 mg in D1 and 600 mg of D2-D6. The
outcome was a 14-day RT-PCR swab mea-
surement. Monitored adverse events were
assessed. Total of 672 index cases reflected
in 2485 contact persons, being randomized
in 1206 for HCQ and 1279 for standard
treatment. There were 171 missing data
in the main result [(BCN-PEP-CoV2)
NCT04304053] [38].
Individuals at high risk of contamination
(healthcare professionals) were random-
ized to use HCQ 400 mg once/week for
12 weeks, HCQ 400 mg twice/week for 12
weeks or placebo (folic acid). The outcomes
have a problem of detection if you consider
the possible or probable symptom criterion
of COVID-19, as not all individuals un-
derwent the RT-PCR test [NCT04328467
(PEP TEAM)] [39].
Individuals at high risk of contamination
were evaluated in a selected population
in the USA and Canada by media notices
within 4 days after having a positive index.
People were asymptomatic. HCQ was used
at the loading dose of 800 mg, followed by
600 mg in 6-8 hours after the attack, fol-
lowed by 600 mg for another 4 days. The
analyzed outcome was positive RT-PCR
at D14. Hospitalization rate and adverse
events were observed (NCT04308668)
[40].
Description of included studies of HCQ in the
treatment of mild COVID-19
A randomized study with HCQ arm, Lopi-
navir-ritonavir, and placebo.The HCQ dose
was 800 mg of attack followed by 400 mg/
day for 9 days. Out-of-hospital popula-
tion, symptomatic with positive RT-PCR
(­TOGETHER) [41].
A study in two health units in Qatar evalu-
ated patients with COVID-19 with mild
and out-of-hospital symptoms. Triple
blind study with the primary endpoint of
viral load at treatment D6. One arm used
HCQ 600 mg/day for one week and the
other placebo arm (had an arm with the
addition of azithromycin). Adverse event
with ECG to measure QT. The secondary
outcome is a description of hospitaliza-
tion. There were 152 randomized patients
in the HCQ group with ITT in 150, 152
in the placebo group with 147 for ITT
(NCT04349592) [42].
Open study with symptoms of covid-19
less than 5 days with positive RT-PCR.The
dose of HCQ was 800 mg in D1 followed
by 400 mg/day for 6 days. Outcomes were
viral load, hospitalization [(BCN-PEP-
CoV2) NCT04304053] [43].
American Canadian group, using treatment
protocol in mild symptomatic patients with
onset of symptoms within 4 days. HCQ
dose was 800 mg of attack, followed by 600
mg in 6-8 hours after and followed by 600
mg/day for 4 days (total days in treatment
was 5 days). Control was with folic acid
(NCT04308668) [44].
Result of included HCQ studies
on ­
COVID-19 prophylaxis
Incidence of COVID-19 (positive RT PCR)
There is no difference in the incidence of
COVID (RT PCR +) in patients with pro-
phylactic use compared between HCQ and
control, in the follow-up period between 2
and 8 weeks. Moderate quality of evidence.
Hospitalization
There is no difference in the incidence of
hospitalization in patients with ­
prophylactic
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Covid-19
use compared between HCQ and control,
in the follow-up period between 2 and 8
weeks. Quality of moderate evidence.
Adverse events
The use of prophylactic HCQ increases the
risk of adverse events by 12% (95% CI 6
to 8%) – NNH: 9, when compared to the
control in 2-to-8-week follow-up. Very low
quality of evidence.
Serious adverse events
There is no difference in the incidence of
serious adverse events in patients with pro-
phylactic use when comparing HCQ and
control, in the follow-up between 2 and 8
weeks. Very low quality of evidence.
Deaths
There is no difference in the incidence of
deaths in patients with prophylactic use
when comparing HCQ and control, in the
follow-up between 2 and 8 weeks. Quality
of moderate evidence.
Result of included HCQ studies on
the treatment of mild COVID-19
Hospitalization
There is no difference in hospitalization,
when compared to HCQ and control,in the
treatment of patients with mild COVID.
High quality of evidence.
Adverse events
There is no difference in adverse events,
when compared to HCQ and control,in the
treatment of patients with mild COVID.
Very low quality of evidence.
Serious adverse events
There is no difference in serious adverse
events, when compared to HCQ and con-
trol, in the treatment of patients with mild
COVID. High quality of evidence.
Deaths
There is no difference in deaths, when com-
pared to HCQ and control,in the treatment
of patients with mild COVID.High quality
of evidence.
Risk of bias and quality of the
evidence of HCQ (included studies)
The risk of bias in the included studies to
support the conclusions about prophylaxis
is serious due to methodological limitations
related to losses, prognostic characteristics,
intention-to-treat analysis (ITT) and sam-
ple calculation.
The risk of bias in the included studies to
support the conclusions about treatment is
not serious.
The quality of the evidence in the prophy-
laxis analysis varied according to the out-
come analyzed: diagnosis of COVID (mod-
erate), hospitalization (moderate), adverse
events (very low), serious adverse events
(very low) and deaths (moderate).
The quality of the evidence in the treatment
analysis varied according to the outcome
analyzed: hospitalization (high), adverse
events (very low), serious adverse events
(high) and deaths (high).
Summary of the evidence
HCQ in the prophylaxis or treatment of pa-
tients with mild COVID
There is no difference in the incidence of
COVID (RT PCR +), hospitalization, se-
rious adverse events and deaths in patients
with prophylactic use comparing HCQ and
controls without HCQ, in the 2 to 8 week
follow-up. The use of prophylactic HCQ
increases the risk of adverse events by 12%
(95% CI 6 to 8%) – NNH: 9, when com-
pared to controls without HCQ, in the
2-to-8-week follow-up. The quality of the
evidence varied between very low or mod-
erate.
There is no difference in hospitalization,
adverse events, serious adverse events, and
deaths when comparing HCQ and controls
without HCQ, in the treatment of patients
with mild COVID. The quality of the evi-
dence varied between very low or high.
Ivermectin
Studies were not selected (meeting the eli-
gibility criteria) that allowed analyzing the
use of Ivermectin prophylactically in pa-
tients without the disease.
Description of included
studies of Ivermectin in the
treatment of mild COVID
The study tested the use of Ivermectin at
a dose of 300 μg/kg for 5 days (N: 238),
compared to placebo with a similar regi-
men of use (N: 238). The studied patients
had mild COVID (home or hospitalized),
with onset of symptoms in the last 7 days.
The analyzed outcomes were death, hos-
pitalization, and adverse events within
3 weeks [45].
Result of included Ivermectin studies
on the treatment of mild COVID-19
The results regarding the outcomes in the
comparison of Ivermectin and placebo
showed no differences in hospitalization
[DR 0.84% (95%CI -4.25 to +5.93)], in
mortality [DR -0.42% (95%CI -1.24 to
+0.40)] and in adverse events [DR -2.94%
(95%CI -11.44 to 5.55) [45]. Meta-analysis
was not performed because only one study
was included.
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Covid-19
Risk of bias and quality of the evidence
of Ivermectin (included studies)
The risk of bias was considered severe due
to the absence of appropriate primary or
secondary intermediate outcomes (relevant
outcomes through posthoc analysis only)
and the absence of intention-to-treat analy-
sis. The quality of extrapolated evidence of
the risk of bias considered is low [45].
Summary of the evidence. Ivermectin in
the treatment of patients with mild COVID
There is no consistent evidence available to
support the use of Ivermectin, either in pa-
tients at risk for COVID 19 or in patients
with mild disease.There is no difference in the
risk of hospitalization, mortality or adverse
events when compared to the use of a placebo.
The quality of available evidence is low.
Antibiotics
Studies were not selected (meeting the eli-
gibility criteria) that allowed analyzing or
indicating the use of antibiotics prophylac-
tically or in the treatment of COVID pa-
tients with mild disease.
Summary of the evidence. Antibiotics
in the prophylaxis or treatment
of patients with mild COVID
There is no RCT-based evidence currently
available to support the indication of pro-
phylactic antibiotic therapy or specific ther-
apy for patients with mild COVID 19.
Antivirals
Description of included studies of Anti-
virals in the treatment of mild COVID
In non-hospitalized adult patients with
COVID, the use of lopinavir-ritonavir
(800  mg and 200 mg, respectively, every
12 hours, followed by 400 mg and 100 mg,
respectively, every 12 hours for 9 days) was
compared in 244 patients, with placebo (n:
227). The analyzed outcomes of interest
were hospitalization, mortality and adverse
events [46].
Result of included Antivirals studies
on the treatment of mild COVID-19
The results (outcomes) will be expressed in
relation to the antiviral treatment (lopina-
vir-ritonavir) in patients with mild CO-
VID-19: hospitalization, mortality, adverse
events, and serious adverse events.
Hospitalization: there is no difference in
the risk of hospitalization between the two
groups compared (antiviral and placebo).
Mortality: there is no difference in mortal-
ity between the two groups compared (anti-
viral and placebo).
Adverse events: the risk of adverse events
in the compared antiviral and placebo
groups was 37.7% and 21.2%, respectively.
Therefore, there is an increase in the risk
of adverse events of 16.5% (95% CI 8.3 to
24.6%) with the use of antivirals in these
patients (NNH: 6; 95%CI 4 to 12).
Serious adverse events: The risk of serious
adverse events in the compared antiviral and
placebo groups was 37.7% and 20.2%, re-
spectively. Therefore, there is an increase in
the risk of adverse events of 17.4% (95%CI
9.4 to 25.4%) with the use of antivirals in
these patients (NNH: 6; 95%CI 4 to 10).
Risk of bias and quality of the
evidence of Antivirals
The risk of bias from the included study to
support the treatment conclusions is not
serious.The quality of evidence can be con-
sidered high.
Summary of the evidence.
Antivirals in the treatment of
patients with mild COVID
There is an increased risk of adverse events
and serious adverse events in out-of-hospi-
tal patients with mild COVID-19 treated
with an antiviral (lopinavir-ritonavir).
Steroids
Studies were not selected (meeting the eli-
gibility criteria) that allowed analyzing or
indicating the use of steroids prophylacti-
cally or in the treatment of COVID pa-
tients with mild disease.
Summary of the evidence. Steroids
in the prophylaxis or treatment
of patients with mild COVID
There is no evidence-based on randomized
clinical trials evaluating the use of ste-
roids (VO, IV, IM) in patients with mild
­COVID.
Anticoagulants
Studies were not selected (meeting the eli-
gibility criteria) that allowed analyzing or
indicating the use of anticoagulants pro-
phylactically or in the treatment of COVID
patients with mild disease.
Summary of the evidence.
Anticoagulants in the
prophylaxis or treatment of
patients with mild COVID
There is currently no RCT-based evidence
available to support the indication of pro-
phylactic or therapeutic anticoagulation
for patients with mild COVID 19. Several
randomized trials are ongoing evaluating
the use of prophylactic anticoagulation in
COVID-19.
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Covid-19
Monoclonal Antibodies
Description of included studies
of Monoclonal Antibodies in the
treatment of mild COVID
A study [47] evaluated the use of neutral-
izing antibodies in patients with mild CO-
VID-19 and outpatients with a positive
test for COVID-19 in the first three days
of symptom onset.This study had five arms:
placebo (n: 156), 700 mg bamlanivimab (n:
101), 2.8 g bamlanivimab (n: 107), 7.0 g
bamlanivimab (n: 101), 2.8 g bamlanivimab
with 2.8 g of etesevimab (n: 112) [47].
Another study determined the effect of
bamlanivimab on the incidence of CO-
VID-19 among residents and skilled nurs-
ing staff and assisted living facilities (resi-
dents and staff of 74 skilled nurses) with
exposure to at least one confirmed case of
SARS-CoV-2. A total of 1175 participants
were randomized to receive a single intra-
venous infusion of bamlanivimab, 4200 mg
(n = 588) or placebo (n = 587).The primary
outcome was the incidence of COVID-19,
defined as detection of SARS-CoV-2 by
PCR, or progression to mild or severe
­
COVID within 21 days of detection [48].
Result of included Monoclonal
Antibodies studies on the treatment
of mild ­COVID-19 [47]
The results (outcomes) will be expressed in
relation to treatment with neutralizing an-
tibodies in patients with mild COVID-19:
hospitalization, mortality and adverse
events.
Hospitalization: the risk of hospitalization
with the use of neutralizing antibodies was
0.9% (in combination with bamlanivimab
and etesevimab, and at doses of 700mg and
7.0g of bamlanivimab) and 5.7% for pla-
cebo. With these treatment regimens there
was a 4.8% reduction in the risk of hospital-
ization (NNT: 20).
Mortality: there is no difference in mortal-
ity between the two groups compared (neu-
tralizing antibodies in the treatment of mild
COVID and placebo).
Adverse events: there is no difference in
the risk of adverse events between the two
groups compared (neutralizing antibodies in
the treatment of mild COVID and placebo).
Result of included Monoclonal
Antibodies studies on prophylaxis
of mild ­COVID-19 [48]
The results (outcomes) will be expressed in
relation to prophylaxis with neutralizing
antibodies in individuals exposed to pa-
tients with COVID-19: infection (PCR +),
mortality and adverse events.
Infection (PCR+): bamlanivimab was asso-
ciated with a significantly lower incidence
of SARS-CoV-2 infection compared to
placebo (17.9% vs. 23.3%; P = 0.02), with
a difference an absolute risk of −5.4% (95%
CI, −10.5% to −0.3%). NNT: 20.
Mortality: there is no difference in mortal-
ity between the two groups compared (neu-
tralizing antibodies in COVID prophylaxis
and placebo).
Adverse events: there is no difference in
the risk of adverse events between the two
groups compared (neutralizing antibodies
in COVID prophylaxis and placebo).
Risk of bias and quality of the
evidence of Monoclonal Antibodies
The risk of bias from the mild COVID
treatment study [47] and the prophylaxis
study [48] is “non-severe” in both. And the
quality of evidence related to the outcomes
where there was a difference (hospitaliza-
tion in the treatment of mild COVID and
infection in the prophylaxis) can be consid-
ered high.
Summary of the evidence. Monoclonal
Antibodies in the prophylaxis and
treatment of patients with mild COVID
There is a reduction in the risk of hospital-
ization in patients with mild COVID-19
treated with neutralizing antibody (bamla-
nivimab associated or not with etesevimab).
There is a reduction in the risk of SARS-
Cov-2 infection with the prophylactic use
of monoclonal antibody (bamlanivimab)
in individuals exposed to patients with
­COVID.
Convalescent Plasm
Description of included studies of Plasm
in the treatment of mild COVID
In this selected study [49],160 patients with
up to 48 h of onset of symptoms related to
COVID-19 (mild) were randomized. Pa-
tients over 75 years of age, regardless of the
presence of comorbidities, and those aged
65 to 74 years with comorbidities were con-
sidered eligible.The intervention considered
the use within 72 h of symptom onset of
250 ml of convalescent plasma with IgG
titres greater than 1:1000 against the spike
of SARS-CoV-2, compared with 250 ml of
0.9% saline in the placebo group. The study
outcome was the development of a severe
respiratory condition with a respiratory rate
> 30 mpm or pulse oximetry 75 years or aged between 65
and 74 years, associated with comorbidities)
not hospitalized with mild COVID-19.
Nitazoxanide
Description of included
studies of Nitazoxanide in the
treatment of mild ­COVID
In this selected study [50] 1575 were evalu-
ated, of these 475 had positive RT-PCR
for COVID-19, symptoms starting up to
3 days and were randomized to interven-
tion with nitazoxanide 500 mg oral solu-
tion (20mg/ml) 3 times a day for 5 days or
placebo group that received a similarly co-
loured solution. The primary outcome was
the resolution of the symptoms of interest
(dry cough, fever and/or fatigue) after the
5th day of therapy. The hospitalization rate
after drug therapy, adverse effects on the
14th day of follow-up was also evaluated.
Result of included Nitazoxanide
studies on the treatment of
mild COVID-19 [50]
The results (outcomes) will be expressed in
relation to the treatment of Nitazoxanide
in patients with mild COVID-19: adverse
events and deaths.
Mortality: there is no difference in mor-
tality between the two groups compared
(­
Nitazoxanide and placebo).
Adverse events: there is no difference in the
risk of adverse events between the two groups
compared (Nitazoxanide and placebo).
Risk of bias and quality of the
evidence of Nitazoxanide
The risk of bias from the included study to
support the treatment conclusions is not
serious.The quality of evidence can be con-
sidered low due to the imprecision of the
results and in the intermediate and primary
outcomes.
Summary of the evidence. ­Nitazoxanide
in the prophylaxis and treatment
of patients with mild COVID
There is no benefit in terms of reduced
mortality or increased risk of adverse events
with the use of Nitazoxanide in patients
with mild COVID.
Colchicine
Description of included studies
of Colchicine in the treatment
of mild COVID [51]
Patients aged 40 years and over diagnosed
with COVID-19 within 24 h and who were
not being treated in hospital underwent
treatment with Colchicine (0.5 mg twice a
day for the first 3 days and then one once
daily for 27 days thereafter) compared to
placebo. A total of 4,488 patients were in-
cluded, divided into two groups: Colchicine
(2.235) and placebo (2.253).
The primary efficacy endpoint was a com-
posite of death or hospital admission due to
COVID-19 infection within 30 days of ran-
domization. Secondary outcomes consisted
of the components of the composite primary
outcome and the need for mechanical ven-
tilation within 30 days of randomization.
Pneumonia, and other serious adverse events
and non-serious adverse events were also col-
lected.
Result of included Colchicine studies
on the treatment of mild COVID-19 [51]
The results (outcomes) will be expressed in
relation to Colchicine treatment in patients
with mild COVID-19: hospitalization, me-
chanical ventilation, adverse events, serious
adverse events, deaths.
Hospitalization: the risk of hospitalization
in the Colchicine and placebo groups was,
respectively, 4.1% and 5.4%, with a signifi-
cant reduction in this risk of 1.3% (95%CI
0.04 to 2.5%) with the use of Colchicine.
Mortality: there is no difference in mortal-
ity between the two groups compared (Col-
chicine and placebo).
Adverse events: there is no difference in
the risk of adverse events between the two
groups compared (Colchicine and placebo).
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50
Covid-19
Serious adverse events: the risk of seri-
ous adverse events in the Colchicine and
placebo groups was, respectively, 4.8% and
6.1%, with a significant increase in this risk
of 1.3% (95%CI 0.004 to 2.6%) with the
use of Colchicine.
Risk of bias and quality of the
evidence of Colchicine
The risk of bias from the included study to
support the treatment conclusions is not se-
rious.The quality of the evidence due to the
imprecision of the results should be consid-
ered moderate.
Summary of the evidence.
Colchicine in the treatment of
patients with mild COVID
There is a reduction in the risk of hospital-
ization and an increase in the risk of seri-
ous adverse events with the use of Colchi-
cine in non-hospitalized patients with mild
­COVID-19.
Discussion
This document is to endorse medical
recommendations about the pharmaco-
logical treatment to prophylaxis and mild
­
COVID-19 based on the best scientific evi-
dence in the literature.
This article evidences the lack of pharma-
cological treatment to be used as a pro-
phylactic to COVID-19. For the mild
­
COVID-19, we could demonstrate that
most clinical randomized studies failed to
show benefits to control the progression of
the disease. On the other hand, we observed
that maybe there exists a specific population
that has the benefits of early use of conva-
lescent plasma. However, more RCTs are
needed to confirm the efficacy of convales-
cent plasma in older people.
In the mild presentation of covid-19, the
available and effective therapeutic options
blocking the disease’s poor clinical course
are scarce. At the same time, we do not have
safe clinical or laboratory markers to as-
sess the prognosis of disease progression. In
about 85% of cases, the evolution is benign,
but in the remaining 15%, it may present
with rapid deterioration, with clinical and
respiratory worsening. Thus, it is essential
to follow all initial outpatient cases of the
disease. It is necessary to monitor general
symptoms, temperature, heart rate, and
oxygen saturation. Patients with covid-19
should be ensured easy and fast access to in-
formation resources,clinical,laboratory,and
radiological controls when indicated.
Indeed, the importance of disposing of a
systematic review using only RCT phase III
is essential during the pandemic crisis, that
exists a thousand disconnected information
related to the disease. In this context, this
document can support the choice of the best
medical practice using a robust method.
Furthermore, scientific societies are too dy-
namic to post new evidence daily and have
never worked as they do now to bring this
information in a way that can be safely rep-
licated and used. Controversies in medical
treatment have always been constant in the
literature.This is part of the construction of
medical knowledge,that can be fragmented,
but the principle is to assess the probability
of finding the correct choice. However, af-
ter more than one year of pandemic, we still
find the dualism in some situations, such
as in this context of prophylaxis and mild
COVID-19 treatment. We always should
prevent the misuse and misinterpretation of
information, because it can be harmful.
Unfortunately, we continue without miracle
pharmacological treatment to prevent dis-
ease severity or prophylaxis. We still rec-
ommend the masks use, vaccination for
all population, avoid agglomeration and
perform diagnostic tests as a control tool
of dissemination. For future studies, is im-
portant to consider the variabilities of risk
­
COVID-19 infection and it is necessary
large trials to detect the benefit of the user’s
other pharmacological treatment.
Drugs Prescription in Covid
Prophylaxis or Mild Covid
Treatment Recommendations
1. The use of Hydroxychloroquine in the
prophylaxis of COVID or treatment of
patients with mild COVID is not rec-
ommended.
2. The use of Ivermectin in the prophylaxis
of COVID or treatment of patients with
mild COVID is not recommended.
3. The use of antibiotics in the prophylaxis
of COVID or treatment of patients with
mild COVID is not recommended.
4. The use of antivirals in patients with
mild COVID is not recommended be-
cause, in addition to not producing ben-
efit, it causes harm.
5. The use of steroids in the treatment of
patients with mild COVID is not rec-
ommended.
6. The use of anticoagulants in the prophy-
laxis of COVID or treatment of patients
with mild COVID is not recommended.
7. The use of neutralizing monoclonal anti-
bodies can be used in patients with mild
COVID (bamlanivimab associated or not
with etesevimab) or prophylactic (bamla-
nivimab) in individuals exposed to COVID.
8. The use of plasma (IV) in elderly pa-
tients with mild COVID (not hospi-
talized) can be a therapeutic option to
reduce the risk of worsening the respi-
ratory condition. However, its restricted
application or favorable to the hospital
environment can act as a barrier to its
applicability, and this recommendation
is not appropriate for pre-hospital use.
9. The use of nitazoxanide in the prophy-
laxis of COVID or treatment of patients
with mild COVID is not recommended.
10. The use of Colchicine in the treatment
of patients with mild COVID is not
recommended due to a null (1) ratio
between benefit (hospitalization)/harm
(serious adverse events).
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Covid-19
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Suzana Erico Tanni,
Associate Professor of Pulmonology
Division of Botucatu Medical
School; Epidemiology Comitee from
Brazilian Thoracic Society (SBPT)
Helio Arthur Bacha,
American College of PhysiciansFellow and
MD, M.Sci, Ph.D. of Infectious Disease
from Hospital Israelita Albert Einstein;
Brazilian Society of Infectious Diseases (SBI)
César Eduardo Fernandes,
Titular Professor of Gynecology at the
ABC Medical School (FMABC); Brazilian
Medical Association (AMB) – President
José Eduardo Lutaif Dolci,
Titular Professor of Otorhinolaryngology,
Faculty of Medical Sciences, Santa
Casa de São Paulo; Brazilian Medical
Association (AMB) – Scientific Director
Alexandre Naime Barbosa,
Infectious Diseases Department – São Paulo
State University (UNESP); Brazilian
Society of Infectious Diseases (SBI)
Wanderley Bernardo,
Medical School of São Paulo University –
Evidence Based Medicine Full Professor;
Brazilian Medical Association (AMB) –
Guidelines Projector Coordinator
E-mail: presidencia@amb.org.br
BRAZIL
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III
Obituary
Obituary
Tribute to Padma Shri Dr. K. K. Aggarwal
5 September 1958–17 May 2021
Dr. Ravi Wankhedkar
Treasurer, World Medical Association
Past National President Indian Medical Association
Dr. K. K. Aggarwal, a great teacher of medical science and a doyen
of public health, breathed his last on 17 May 2021 at All India In-
stitute of Medical Sciences, New Delhi. A true champion from the
scientific and medical fraternity, he was an Indian physician and
cardiologist who was President Confederation of Medical Associa-
tions in Asia and Oceania (CMAAO), President of the Heart Care
Foundation of India, the Past National President of Indian Medical
Association, Secretary General, Indian Medical Association, Presi-
dent of Delhi Medical Association and Indian Medical Association,
New Delhi Branch. Until 2017, he served at Moolchand Medcity,
New Delhi, as a Senior Consultant, Physician and Cardiologist, and
Dean, Board of Medical Education. He received Dr. BC Roy Na-
tional Award in 2005 which is given for outstanding service in the
field of Socio-Medical Relief. The government of India honoured
him in 2010 with the Padma Shri, India’s fourth-highest civilian
award, for his contributions to the field of medicine.
His contributions in public health during Covid 19 times was very
noteworthy. He was the first person in India to warn the medical
fraternity and general public about Covid. His daily educative mails
to update physicians were highly useful.For the lay persons his daily
“KK Meditalks” were extremely informative. It was indeed a great
irony that he himself succumbed to Covid.
Dr KK Aggarwal, MBBS, MD, Gold Medalist, had a very keen
sense of clinical research and was one of the pioneers of streptokinase
therapy for heart attacks in India who also introduced the technique
of Colour Doppler Echocardiography in India. Being the first to use
clot busters in patients with acute myocardial infarction in 1984, he
introduced colour Doppler echocardiography in North India in 1987.
He was also a Limca Book of World Record Holder for the maxi-
mum people trained in the life-saving technique of Hands-only CPR.
A legend of Cardiology, Dr Aggarwal worked tirelessly to establish
connections between technology and the tradition.He also used alter-
native medicine – Yoga and Ayurveda – to treat his patients. Dr. Ag-
garwal saved countless lives with his undeterred efforts of reaching out
to the masses to raise awareness amidst the raging pandemic.
Department of Science & Technology conferred upon him the
National Award for Outstanding Efforts in Science & Technol-
ogy Communica-
tion in 2013. He was
a reputed science
and health educa-
tion communica-
tor, with a social
media following of
more than 10 mil-
lion people, who did
phenomenal work
for creating mass
awareness on the
SARS COV-2 vi-
rus. He also worked
hard through annual
Perfect Health Me-
las which became a
huge success among
school children and various other stakeholders. He published many
books on health, including Alloveda – in which he combined an-
cient Vedic Medicine with modern Allopathy. He is credited with
six textbook chapters on echocardiography and thousands of ar-
ticles in the national and international press. Dr. Aggarwal will be
remembered for his indomitable dedication towards public health,
medical science, science communication and public welfare during
his 30 years of medical and social presence.
His pursuit of excellence continued in the diverse roles of physician-
scientist, Researcher, academic teacher, writer, editor, administrator,
Meditation teacher and public health activist. A recipient of Delhi
Hindi Sahitya Sammelan – Sahitya Shree Award 2007 as a doctor
and philosopher of Indian Culture, he also received Vishwa Hin-
di Samman in 2015. He was decorated with FICCI Health Care
Personality of the Year Award 2016, Dr D S Mungekar National
IMA Award, Indira Gandhi Priyadarshini Award 2003, and the
Rajiv Gandhi Excellence Award 1993, along with numerous other
awards and recognitions. It is noteworthy that he was also a mem-
ber of Ethics Committee, Medical Council of India, and Chair-
man Ethics Committee Delhi Medical Council. Dr Aggarwal also
served as Group Editor in Chief IJCP Group of Publications and
eMedinews- the first national daily medical newspaper. A holder of
Three Limca Book of World Records and a TEDx Speaker,he was a
prolific writer,an eloquent columnist and also a TV Anchor. Cham-
pioning the cause of medical professionals, health & human rights,
medical ethics, he was keenly interested in revamping the medical
education in India. His untimely passing away is a loss to the whole
scientific community and human kind.
His last do message from the hospital bed with O2 on,that the “Show
must go on” will remain an everlasting directive for the entire India.
BACK TO CONTENTS
IV
Covid-19
BACK TO CONTENTS