Thesis 2

CURRENT BEST PRACTICES FOR THE MANAGEMENT AND TREATMENT OF COVID-19: A CASE STUDY

HCIN 699-51- B-2020/Fall

Applied Project in Healthcare Infor

Professor Chaza Abdul and Professor Glenn Mitchell

Prepared by:

Name: Wassim Alzayed

Student ID: 264319

Harrisburg University

12/06/20

TABLE OF CONTENTS

ABSTRACT 5 INTRODUCTION 6 Background Information 6 Problem Statement 9 Purpose Statement 10 Research questions 10 LITERATURE REVIEW 11 Overview of the study 11 Literature Review 11 Virology 12 Therapeutics and treatment options 12 Convalescent plasma or blood plasma therapy 17 RESEARCH METHODOLOGY 20 Research Design Overview 20 Inclusion criteria 20 Data collection method 21 Data analysis 21 RESULTS 23 Discussion 25 Limitations 26 Conclusion 26 REFERENCES 29

List of figures

In December 2019, The severe Acute Respiratory Syndrome Coronavirus 2 ( SARS-CoV-2) virus was originated in Wuhan City of Hubei Province in People Republic of China. The viral disease caused by ( SARS-CoV-2) virus is named Corona Virus disease 2019 ( COVID-19 ). Currently the virus invaded 213 countries and territories worldwide, with 17.3 million confirmed cases of COVID – 19 and around 650,000 death globally (WHO, 2020, P.1). As of today, Based on John Hopkin, the United stated of America is considered today the most reported COVID – 19 confirmed cases of 4.6 million people and the highest mortality rate of over 192,000 death cases.(CDC, 2020, John Hopkin University, 2020).Some of these medication where granted an emergency dispensing authority to assure optimal safety and efficiency treatment in the life threatening cases of Corona Virus disease 2019 ( COVID-19 ). Therefore we shall summarize the currently used and the potential promising agents to combat the ( SARS-CoV-2) virus. In addition, we shall highlight the current status and stages in the development of the vaccines as well.

Keywords: Severe Acute Respiratory Syndrome Coronavirus 2 Virus (SARS-CoV-2), Corona Virus disease 2019 (COVID-19 ), World Health Organization (WHO), Vaccine.

The new strain of corona virus SARS-CoV-2 was recognized as the causative agent of the pandemic COVID-19. The SARS-CoV-2 was originated in the city of Wuhan in Hubei providence in the Republic People of China. The origination of the SARS-CoV-2 was dated back in December 2019, where the virus initially reported as an outbreak however with the accelerated infection rate, the COVID-19 have been declared in March of 2020 by World Health Organization as a pandemic. In February 14, 2020 China reported 44,672 confirmed cases with 2.3% mortality rate, which was comparatively lower than the previously known epidemics caused by human coronaviruses (Severe Acute Respiratory Syndrome Coronavirus [SARS-CoV] and the Middle East Respiratory Syndrome Coronavirus [MERS-CoV]) in 2003 and 2012, respectively (Neupane et al. 2020).

Thus, this is among some of the rare cases of an animal to human transmission of virus infection with pandemic potential (Mackenzie & Smith, 2020). It rapidly spread outside of China to the rest of the world, mainly through human-to-human transmission by respiratory droplets or possibly through the fecal-oral route. Consequently, the World Health Organization (WHO) declared COVID-19 as a global pandemic on March 11, 2020 (Zhang et al., 2020). Transmission of infection between humans is facilitated by close contact with COVID-19 patients, as evidenced by the rapid global spread of the virus all around the world in a short period. SARS-CoV-2 likely originated in bats and may have amplified in an intermediate host before infecting humans. SARS-CoV-2 enters the human body via angiotensin-converting enzyme 2 (ACE2) receptors (Letko, Marzi & Munster, 2020).

The COVID-19 is characterized by primary flu-like symptoms such as dry cough, high fever, sore throat, and breathing problems, severe pneumonia, respiratory failure requiring mechanical ventilation, sepsis, myocardial injury, multi-organ failure, and mortality increases in patients having underlying comorbidities such as cardiovascular disease, diabetes, and chronic respiratory disease (Cascella, Rajnik, Cuomo, Dulebohn & Napoli, 2020). However the hallmark symptoms that accompany the Corona Virus disease 2019 ( COVID-19 ), are reported as dry cough, high fever, sore throat and breathing problems. Therefore we are to discuss the best current treatment pharmacological management options based on the patient conditions and symptoms.

To date, the medical management of the confirmed COVID-19 patients’ treatment and management has focused on assuring that COVID-19 symptoms are being decreased and diminished. However, there are no specific COVID-19 international or national treatment guidelines followed by healthcare professionals globally, where various healthcare institutions are recognizing variations in the treatment step therapies. Supportive care is usually being offered only in case of specific COVID-19 symptoms. Where scientists and health authorities are testing and evaluating all the current treatment strategies to seize the spread of ( SARS-CoV-2) virus and its Corona Virus disease 2019 ( COVID-19 ). All of the current medications that the healthcare institutions are utilizing today to treat and manage Corona Virus disease 2019 ( COVID-19 ) are not intended solely for the treatment of ( SARS-CoV-2) virus and actually they have been approved previously for other indications. Some of the current medications classification are anti-viral, anti-malaria, corticosteroid, Immunomodulator …..etc., and their therapeutic indications been are currently repurposed or just been commonly used by certain authorities.

By far, developing a vaccine shall be the most effective cure approach toward the SARS-CoV-2 virus; however, currently, where are not at that stage, and no approved vaccine is available in the market. Therefore, until we have an approved vaccine, the pharmacological treatment approach of repurposing the current therapeutic drugs' indications to manage the COVID-19 symptoms is being utilized. The indications repurposing of the existing medicinal drugs is handled via clinical trials while keeping in mind that the aim is to minimize the morbidity and mortality rates if the COVID-19. The purpose here is to provide a comprehensive glimpse of the most current pharmacological treatment approaches with our fight against the SARS-CoV-2 virus and recent vaccine development updates while emphasizing the importance of unified international guideline and step therapy in our management against the COVID-19 disease symptoms.

The globe is on a race against time to find and approve the cure for the ( SARS-CoV-2) virus however none was approved officially yet. Therefore till we reach the desired cure stage, health authorities across the globe are adopting semi independently treatment guidelines and prevention methods, each country within its own capacity, as the most efficient on hand tool to fight against the ( SARS-CoV-2) virus till cure approvals are gained. Several governments mandated its citizens to impose the social distancing, also executed strict public prevention measurements and enforced self - quarantine for the qualified citizens. Some governments went to a complete lock down of the country as in New Zealand example. Also Governments are urgently raising the public education and health awareness about the ( SARS-CoV-2) virus and illustrating to public the best prevention management approaches and self-hygiene methods against Corona Virus disease 2019 ( COVID-19 ). This education is conducted via planned and scheduled governmental campaigns about the pandemic.

Since the discovery of the SARS-CoV-2 virus in December 2019, followed by the rapid spreading of Coronavirus Disease 2019 (COVID-19) across the continents, several therapeutic regimes applied independently by regulatory health authorities. However, no unified therapeutic and step therapy guideline was established and unified by various regulatory health authorities until today. Today we are still in the early phases to confirm the most effective therapeutic approach, which may be due to the regulatory health authorities' strict clinical trial conditions imposed on the candidate COVID-19 cure and treatment agents. Vaccines and other medicinal tested approaches that are not confirmed yet shall not cease scientists' new exploration of new interventions to manage and treat Coronavirus Disease 2019 (COVID-19). From the Potential therapeutic options against potential molecules binding to the virus, inhibitors can target specific enzymes that replicate or viral transcription. Small-molecule inhibitors can target helicase, essential proteases, or other proteins of the virus, and host cell protease inhibitor (Kumar, Jung & Liang, 2020). By farinhibitorsing a vaccine shall be the most effective cure approach toward the SARS-CoV-2 virus; however, currently, where are not at that stage, and no approved vaccine is available in the market. Therefore, until we have an approved vaccine, the pharmacological treatment approach of repurposing the current therapeutic drugs' indications to manage the COVID-19 symptoms is being utilized. The indications repurposing of the existing medicinal drugs is handled via clinical trials while keeping in mind that the aim is to minimize the morbidity and mortality rates if the COVID-19. The purpose here is to provide a comprehensive glimpse of the most current pharmacological treatment approaches with our fight against the SARS-CoV-2 virus and recent vaccine development updates while emphasizing the importance of unified international guideline and step therapy in our management against the COVID-19 disease various symptoms.

This study's primary purpose is to emphasize on the current adopted medicinal and therapeutic guidelines for the management and treatment of COVID-19, and the necessity to unify the pharmacological treatment/cure guidelines based on the literature available studies. Also, this document's aim is substantial as it foremost shall help guide the healthcare professionals in hospitals and other primary healthcare settings in their management against the COVID-19 and its various symptoms. Also, assist the healthcare professionals' in the efficient tactics against Coronavirus Disease 2019 (COVID-19) and constringe the spread of the disease based on the current treatments.

This study aims to answer the following research questions:

RQ. 1: What is the best pharmacological standard of care approach to implement based on the available world real data?

RQ. 2: What are the most rapid evaluation method to the adjunctive and supportive therapies (administered in addition to the main treatment)?

RQ. 3: What are the best ways to accelerate the evaluation of investigational therapeutics and vaccines?

The purpose of the study is to provide a comprehensive overview of the adopted current pharmacological interventions approaches with our management of the SARS-CoV-2 virus, different tackling based on the symptoms expressed by the patients and the recent vaccine development updates while emphasizing the importance of having a standard international guideline and step therapy in our management against the COVID-19 disease various symptoms based on the literature available studies. The study research raised questions pertaining the best pharmacological standard of care approach to implement based on the available world real data, locating the most rapid evaluation method to the adjunctive and supportive therapies (administered in addition to the main treatment) and the evaluation of investigational therapeutics and vaccines.

As the SARS-CoV-2 virus is rapidly invading the globe and causing the COVID-19 disease as transmission among people occurs through respiratory droplets (Li et al., 2020). The symptoms related to COVID-19 disease vary from mild to moderate, and it might reach severe symptoms cases. The mild symptoms are dry cough, high fever, sore throat, and breathing problems. However, severe symptoms of symptoms commonly lead to pneumonia and organ failures such as kidneys and lungs. With such evolving symptoms, we urgently need to develop a living, frequently updated evidence-based guidelines to support patients, clinicians, and other healthcare professionals in their decisions about treatment and management of patients with COVID-19 (Scavone et al.,. 2020).

Proper understanding of the SARS-CoV-2 virus virology and its related life cycle will help scientists define the potential drugs that might combat the SARS-CoV-2 virus. Figure 1 represents the virus lifecycle step by step, which will allow us to synchronize it with the potential drug therapy.

Figure 1: Simplified Representation of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Viral Lifecycle and Potential Drug Targets (Sanders et al., 2020)

Antiviral drugs

The vast majority of patients who are critically ill with COVID-19 have attributes and comorbidities; thus, successful management depends on attention to the primary process leading to an ICU admission, as well as to comorbidities and nosocomial complications (NIH, 2020).

Table 1 summarizes the mechanism of action and major pharmacologic parameters of the select proposed treatment agents and for adjunctive therapies for COVID-19.

Table 1. Summary of Pharmacology for Select Proposed COVID-19 Treatments (Sanders et al., 2020)

As from the figure above, currently, there is still no licensed specific antiviral treatment for the human coronavirus disease, and a vaccine will not be ready soon. Therefore, treatment depends on the severity of the patient's symptoms and supportive care (Provenzani, Alessio & Polidori, Piera, 2020). It is worth highlighting that Remdesivir does have promising evidence with emergency authorization from the FDA to be used in COVID-19. The main advantages of favipiravir are that it is administered orally and that it can be given in patients who are symptomatic but not ill enough to be hospitalized. As most COVID-19 patients (85%) have mild to moderate disease and can be treated at home, this drug could potentially be used in large numbers of patients. ( Agrawal et al., 2020 )

There is no evidence to support the use of umifenovir for improving patient‐important outcomes in patients with COVID‐19 ( Huang et al.,2020 ). In hospitalized adult patients with severe Covid-19, no benefit was observed with lopinavir–ritonavir treatment beyond standard care. ( Cao et al., 2020 ) Another antiviral flu agent called EIDD-2801 had shown high therapeutic potential against seasonal and pandemic influenza virus infections. This represents another potential drug to be considered for the COVID-19 virus symptoms management (Rothan, Hussin A., et al. 2020).

Other potential drug candidates/therapies

The vast majority of patients who are critically ill with COVID-19 have In the absence of proven therapy for SARS-CoV-2, the cornerstone of care for patients with COVID-19 remains supportive care, ranging from symptomatic outpatient management to full intensive care support. Eg, corticosteroids, anti-cytokine or immunomodulatory agents, and immunoglobulin therapy. (Sanders, Monogue & Jodlowski, 2020). Also, we should not neglect the role of Adjunctive treatments, which are frequently used in patients with COVID-19, which shown efficacy in the prevention and treatment of the SARS-CoV-2 virus and COVID-19 virus or its complications. (NIH, 2020).

Hydroxychloroquine and Chloroquine

Hydroxychloroquine and chloroquine have generated unprecedented attention as potential therapeutic agents against COVID-19 following several small clinical trials, uncontrolled case series, and public figure endorsements. While there is a growing body of scientific data, there is also a concern for harm, particularly QTc prolongation and cardiac arrhythmias (Pastick et al., 2020).

Given the lack of evidence, we strongly call on public health organizations to collaborate effectively with local governments to support unified randomized controlled trials (RCTs) to test the potential therapeutic effects of CQ/HCQ against COVID-19. If the ethical use, safety, and advanced clinical efficacy of CQ/HCQ can be established by RCTs, as proposed by the WHO, it would be a significant advancement in the treatment of COVID-19 patients. ( Ali et al., 2020 )

Tocilizumab

Tocilizumab, an interleukin‐6 inhibitor, may alleviate the inflammatory manifestations associated with severe coronavirus disease 2019 (COVID‐19) and improve clinical outcomes. (Alattar et al., 2020).

Baricitinib

Baricitinib is a high-affinity AP2-associated protein kinase-1 (AAK1)-inhibiting drug with Janus kinase 1/2 (JAK 1/2) inhibition, which also binds to cyclin G-associated kinase (a regulator of endocytosis) (Sorrell, Szklarz, Abdul Azeez, Elkins & Knapp, 2016). Due to the high affinity of Baricitinib for AAK1 and JAK, its ability to ameliorate allied chronic inflammation in interferonopathies and pharmacokinetic properties makes it a potential candidate for combination with direct-acting antivirals (Lopinavir or Ritonavir and Remdesivir) to combat SARS-CoV-2 (Stebbing et al., 2020).

Interferon- α

IFN-α is a broad-spectrum antiviral that is usually used to treat hepatitis, though it is reported to inhibit SARS-CoV reproduction in vitro (Liying, Hu & Gao, 2020). The α-interferon atomization inhalation can be considered (5 million IU per time for adults in sterile injection water, twice a day (Jin et al., 2020). The COVID-19 Treatment Guidelines Panel recommends against the use of interferons for the treatment of patients with severe or critical COVID-19, except in a clinical trial (AIII) ( NIH, 2020 )

Dexamethasone

As a steroid, dexamethasone always been used for allergies and inflammation. In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28 - days mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support (Horby et al., 2020). The lack of substantial beneficial evidence for the use of steroids in general COVID-19 patients and data against their use during the past coronavirus epidemics has led the World Health Organization to state that routine steroid use should be avoided, except in specific cases such as management of asthma and chronic obstructive pulmonary disease exacerbation, septic shock, ARDS, and acute respiratory failure (Mattos-Silva et al., 2020).

Anticoagulant

As the blood vessels lining considered one of the targets for SARS-CoV-2 thus, anticoagulant started to be considered. The SARS-CoV-2 virus can lead to targeting blood vessels to tiny clots followed by strokes if not managed. The relatively high mortality of severe COVID‐19 is worrying; our study suggests that anticoagulants may not benefit the unselected patients. Instead, only the patients meeting SIC criteria or with markedly elevated D‐dimer may benefit from anticoagulant therapy mainly with LMWH. Further prospective studies are needed to confirm this result (Tang et al., 2020).

The use of convalescent plasma is not new; it has been used for the severe acute respiratory syndrome (SARS), pandemic 2009 influenza A (H1N1), avian influenza A (H5N1), hemorrhagic fevers such as Ebola, and other viral infections (Roback & Guarner, 2020). Convalescent plasma (CP) therapy, classic adoptive immunotherapy, has been applied to preventing and treating many infectious diseases for more than one century. Over the past two decades, CP therapy was successfully used in the treatment of SARS, MERS, and the 2009 H1N1 pandemic with satisfactory efficacy and safety (Duan et al., 2020). The convalescent plasma can be extrapolated as an excellent and potential option that can be seriously considered with the current management agents and possible solutions to control COVID- 19 patients’ symptoms. Therefore, we hypothesized that treating patients with convalescent plasma early in the disease course may reduce morbidity and mortality associated with COVID-19 (Ye et al., 2020).

Vaccination for SARS-CoV-2

The use of next-generation sequencing and reverse genetics may also cut the development time of more conventional vaccines during epidemics. Figure 3 below, lists major platform types and examples of SARS-CoV-2 vaccine types being developed on each ( Lurie, Sharfstein & Goodman, 2020 ).

Table 2: Table for the vaccines platform, attributes and status of vaccines attributes.( Lurie et al. 2020 )

Therefore the ongoing advances in designing vaccines and therapeutics to counter COVID-19 while also focusing on such experiences and advances as made with earlier SARS- and MERS-CoVs, could enable efforts to halt this emerging virus infection (Kuldeep et al., 2020).

This reflects the lack of global research coordination in delivering medical countermeasures during the MERS outbreaks and the SARS epidemic. This should be kept in mind when designing treatment protocols for COVID-19 and is being addressed by WHO. ( Harris et al., 2020 )

This study research aims to conduct a case study inquiry as a qualitative research method. The adopted qualitative research will allow conducting intensive, in-depth document analysis. The study evaluated 24 literature reviews / studies however 11 were qualified to be part of the research overview and the 13 were not qualified. The main reason for not including them in the research qualification because the aforementioned studies didn’t provide a clear conclusion on the inclusion or exclusion criteria of the pharmacological agent in research to be part of the therapeutic guidelines in the covid19 treatment. Also the studies with clear clinical symptoms of the study included patients were considered only, however studies with un clear inputs pertaining the patients clinical symptoms were excluded. The evaluated 24 literature reviews / studies were peer-reviewed articles by CDC, NIH and WHO, medical websites, articles from medical magazines, and journals. The evaluated literature reviews / studies reported original data related to the virus SARS-CoV-2 and the disease it causes, COVID-19, from December 1, 2019

The COVID19 infected patients’ clinical manifestations made a clear disease characteristics that allowed the treating healthcare professionals to categorize the patients accordingly. This study also utilized the basic categorization declared by NIH for the clinical manifestations presented with COVID19 patients which can be classified in to five main categories: Asymptomatic Infection with no symptoms consistent with COVID19, Mild Illness with various symptoms of COVID19 that doesn’t include shortness of breath, dyspnoea or abnormal chest image, Moderate Illness with lower respiratory disease showing oxygen saturation of more than 94%, Severe Illness with oxygen saturation less than 94%, lung infiltrates more than 50% and respiratory frequency more than 30 breaths per minute. The final and fifth category is the Critical illness with respiratory failure, multiple organ dysfunction and septic shock. ( NIH, 2020 )

The data was collected from peer-reviewed articles by CDC, NIH and WHO, medical websites, articles from medical magazines, and journals. Articles reporting editorials, opinions, and other articles that did not report original research data was excluded. All the included original studies where any study design reported original data related to the virus SARS-CoV-2 and the disease it causes, COVID-19, from December 1, 2019, onwards.

This study employs a case study research methodology as a data collection method where it will allow intensive exploration of the Coronavirus Disease 2019 (COVID-19) and its management and treatment variables.

Since no treatment yet has been declared officially to treat the COVID19 patients thus more of the pharmacological interventions are more of support and manage the clinical manifestation. The above listed Pharmacological agents varies from Antiviral, potential drug candidates/therapies ( Antimalarial drugs ( Hydroxychloroquine and chloroquine) , Immunosuppressants (Tocilizumab and Baricitinib), Anticoagulant ( Heparin ) and corticosteroids ( dexamethasone) ) and Convalescent plasma therapy. As the aim to have the vaccine soon however managing the COVID19 cases with the current pharmacological agents shall be utilized in the most beneficial way until the vaccine is found and the pandemic is contained.

Applying Pharmacological agents’ intervention within the included case studies as part of the therapeutic guidelines to manage the COVID19 patients, was based on patients clinical manifestations severities.

This section mainly have explored over the included studies within literature, the studies that possess a clear pharmacological therapeutic decision. Also the frequencies of prescribing the same pharmacological agents were captured and analyzed accordingly. From the graph below its very clear that all the 11 studies didn’t recommend any pharmacological interventions upon having COVID19 patients within Asymptomatic classification.

From the graph above, where the x axis reflect the frequency of prescribing the same pharmacological agent number from the qualified studies evaluated from the literature. The graph support the utilization and the frequency of prescribing certain pharmacological agents / classes upon introducing certain symptoms of the COVID19 disease by the patients.

Higher number of studies around 2 studies did support the introduction of Convalescent plasma in the Severe illness stage of COVID19 disease and 3 case did support the introduction of Convalescent plasma in the Critical illness stage of COVID19 disease.

Also the introduction of the immunosuppressant ( Toclizumab ) was supported by 2 case studies within Severe illness of the course of COVID19 and 2 case studies supported critical illness manifestation of COVID19 patients. However the introduction of the immunosuppressant ( Baricitinib ) was supported by 1 case study within Severe illness of the course of COVID19 and 1 case study supported critical illness manifestation of COVID19 patients.

The Antiviral drug ( Remdesivir ) have been captured only by 1 case study that supported their introduction within Severe illness and 1 case study supported their dispensing within the Critical illness stage of COVID19 disease. The interesting part, that the antiviral drug category represented by Favipiravir can be introduced as early as the Mild and Moderate illness stages of the COVID19 disease. Where in away it contradicts the presumption of introducing antiviral drugs only at the more advanced stages of the COVID19 disease course however Favipiravir have proven that it can be safe and can be introduced at these two early stages of the COVID19 disease. The antiviral drug ( Favipiravir ) was supported by 1 study where it was introduced in the mild illness stage of covid19 and also introduced by 1 case within moderate illness of the COVID19 disease.

The commonly known Antimalria drugs Hydroxychloroquine and chloroquine, 1 study support prescribing either of them where they can be introduced at the mild illness stage of the disease and the moderate stage of the disease.

The anticoagulant class through the low moceluar weight Heparin was introduced and supported by one study and at the severe and critical illness of the COVID19 disease. Same applies to the corticosteroid introduction as it was supported by one case study and also at the severe and critical illness of the COVID19 disease stages only.

As the aim of this study is to capture an overview and establish a unified approach to the therapeutic aspect of managing the COVID19 patients from the current studies available in the literature, however we recognize different studies and entities have adopted various treatment approaches. As recognized from the study, the said variations sometimes became vast. We may contribute these variations to the healthcare professional’s evaluation to the severity of the symptoms presented by the COVID19 patients and their judgement to prescribe which pharmacological agents. Inboard terms, we can conclude that the more severe the clinical symptoms presented by COVID19 patients, the more likely the decision taken to start the COVID19 patients on the pharmacological agents. The prescribing preferences / options from up to 6 pharmacological agents at the critical illness stage of the COVID19 disease which can be administered either separate or as a combination therapy, also another example how studies in the current literature have tackled the COVID19 disease differently.

To mitigate the aforementioned variations for the most proper prescribing selection more intense, bigger scale and further specialized studies are needed on the pharmacological agents to evaluate their impact on the management and treatment of the COVID19 patients with diverse clinical symptoms presented. Despite the fact that numerous randomized studies are concurrently happening however all the outcomes shall be focused on the efficacious of these pharmacological agents within COVID19 patients. This definitely will route us to have a better position for each of the candidate pharmacological agents and the needed therapeutic dose within a unified therapeutic guidelines approach.

The existence of comorbidities chronic disease especially with senior patients will accelerate the deterioration of the COVID19 cases and unfortunately will shift the COVID19 patients to more severe illness thus health care professional shall optimize their treating regimes accordingly which have been highlighted in the various literatures however there are still a necessity for focus studies on these certain populations.

Due to the current prevention measurements taken by the health authorities and government across the globe, which is causing further increase in the lag time and delays between COVID-19 incidences and the pharmacological intervention publications. In addition, some of the local regulatory authorities, global health institutions and multinational pharmaceutical companies have indirectly imposed restrictions on some of the researchers’ publications and dispatching certain statistical figures as they consider it domestic sensitive data. Also the novelty of the pandemic, have contributed for the data available to be limited and yet not a significant amount data are being dispatched.

Therefore, I would recommend that the pharmacological and clinical outcomes of this study and the studies from current literature to be revisited at a later stage within next coming year, as more data is expected to be accumulated by then and more realistic approach and conclusion can be achieved via conducting data analysis from the various hospital sites.

Since the first coronavirus (COVID-19) outbreak in Wuhan, China, the disease spread worldwide and preventive measurement were imposed immediately by several medical agencies, authorities and government to combat the rapid spread of the virus aiming to reduce the infection rate and decrease mortality ratio among infected individuals. In order to enhance our measurements in the prevention and the effective management of COVID-19, these enhancements will start only after an extensive investments to be exerted, with the available short period of time interval, on the basic and clinical investigation. In which it need the continuous and scheduled support from the Health regulatory, the public and private sector as well. ‘ International cooperation and a unified strategy of pandemic preparedness were not a priority. In the end, there was no united response - a global leadership void painfully revealed at a moment when it was most needed. What resulted was an international cacophony of last moment efforts, strategies and opinions to suppress the viral pandemic - after it was already upon the world.’ ( Hiscott et al., 2020 )

Scientists are on a fast pace to manage the spread of the SARS-CoV-2 virus, via creating efficient treatment and finding a cure for the COVID-19 disease. The current therapeutic regimens are either in the research early stages or have been widely used with some evidence of efficacy as repurposed drugs. No therapies as of today has been approved as fully licensed to cure and treat COVID-19 despite that few drugs been granted an emergency use authorization. ‘ Right now, the best treatment offered is care and intensive support. Preventing the transmission and slowing down the spread by social distancing are the two major goals that are put forth. Clinicians are applying what they know from previous endemics like SARS, MERS, and Ebola. Though similar, COVID-19 is quite different from the previous diseases, hence treating a new disease with old medicine is not giving a satisfactory response.’ ( Acharya S., 2020 )

Global race is currently happening to develop COVID-19 vaccines however safeguards must be in place to reach to the ultimate goal of developing a safe and effective vaccine to manage the pandemic.