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From recent reports, swine flu cases in 2019 are again on the rise in India and health authorities in both urban and non-urban areas have been caught off guard in terms of preparedness. 

Hospitals in Delhi, for example, are reporting a shortage and doctors have privately expressed worries to this author on the scarcity of especially adult flu vaccines.

It also looks like given that the virus might have mutated and with the shortage of vaccines, the medical community is preparing for alternative options like half-dose flu vaccine or intradermal lower dose influenza vaccine administration building on some recent clinical evidence that these could be used in emergency situations. 

But is it also time to look for more structural solutions to the situation, especially with an innovative mindset in how to address this issue sustainably.

Healthcare authorities should change the focus from targeting the virus (with the vaccines) to treating the host response, which is how patients respond when influenza pandemic strikes. 

Building on a body of work pioneered by former University of Virginia professor of medicine David Fedson, this line of thinking essentially comes from how statins and angiotensin receptor blockers (ARBs) led to remarkable improvements in patient survival after the Ebola outbreak in Sierra Leone in 2014. 

Fedson and co-authors now have documented scientific evidence on this host response approach and the utility of statins herein, in medical journals and also in a 2014 New York Times (NYT) column.  The idea is simple. It looks like statins plus ARBs have beneficial effects on the host response, including restoring the integrity of endothelial barrier (a condition even with swine flu), and related medical outcomes (like mitochondrial biogenesis and immunometabolism) beneficial for the patient. 

So rather than targeting the virus which keeps mutating (with an influenza vaccine that tries to keep pace), this approach deals with the patient’s clinical outcomes. The approach now is also supported by tests in a mouse model of influenza.

It is true, however, that the World Health Organization (WHO) has expressed concerns in the Ebola situation with such an approach of using statins to target host responses because it could unintendedly increase viral replication. 

David Fedson and Steven Opal note in their NYT 2014 column however, that actually statins reduce viral replication in human diseases like hepatitis C and improve clinical outcomes. 

That said, more research certainly needs to happen here, given that some other clinical journal discussions have arisen on the potential positive and negative relationships of statin consumption with implications for cancer.

But in a world where pandemic preparedness in India has remained inadequate despite the 2009-2010 swine flu crisis a decade back, that too heterogeneously across states, this is an option worthy of evaluation.  

Herding, social influences, and behavioural biases may make doctors and public health authorities in India inelastic to change, but we are now 100 years past the 1918 influenza pandemic that killed many and yet we see influenza pandemic striking not just India but repeatedly other parts of the world. 

In addition, it is also a good time for the clinical community at large to reflect on conducting more upstream research in this area, which given their daily downstream needs (of treating patients at overcrowded outpatient departments in Indian public and private hospitals)may have been neglected. 

Statins and ARBs have also proved to be effective not just in Ebola and influenza pandemic, but could also be an option to deal with Nipah virus and other such pandemic virus attacks that emerging economies like India with fragile health institutions are regularly being subjected to off late. Domestic firms like Cipla, which produced Tamiflu during the 2009-2010 swine flu crisis (albeit with a lukewarm response in terms of adoption from the medical community) could be roped in such efforts as well. 

Cipla has a presence in producing generic statins and ARBs, so does other prominent generic players like Dr. Reddy’s.  The idea is particularly pertinent in a world where incentivising innovative work to produce next-generation swine flu vaccines have proved to be difficult globally.

Even advanced market commitments to buy vaccines produced and soft loans have proved to be inadequate in India as my past research has shown.

A timely response with a multi-stakeholder approach to this idea of old drugs in a new avatar thus could solve the influenza pandemic crisis that keeps raising its ugly head every year now in India. 

This is also an opportunity to generate more clinical evidence on whether indeed the WHO line of thinking is correct or the medical community can structurally pivot to a host response approach to treating influenza pandemic. 

Suraj Parihar and co-authors have also written about this approach using statins and ARBs in Nature Reviews; India can take the lead here to build on these prior scientific studies and offer a new solution building on host responses to pandemic preparedness for the world. 

More generally, drug repurposing is increasingly gaining attention in the biopharmaceutical world, as research by MIT economist Ben Roin demonstrates. We now have examples of using ketamine to treat suicidal tendencies, Thorazine for treating schizophrenia or non-cancer drugs for anti-cancer activity, as recent articles in British Medical Journal and Scientific American have documented. So using statins to address influenza pandemic may not be that unorthodox after all. 

Author is IIM-A and Hoover Institution

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