What are the most effective strategies to reduce recent Covid-19 mortality?

Effective Strategies to Reduce COVID-19 Mortality

COVID-19 vaccination remains the most effective strategy to reduce mortality, with vaccines offering high levels of protection against severe illness and death, particularly when including booster doses for older adults and high-risk populations. 1

Vaccination Strategy

Vaccination is the cornerstone of COVID-19 mortality reduction:

• Data shows a 10-percentage-point increase in vaccination is associated with a 16.8% decrease in COVID-19 mortality after 12 months 2
• Booster doses are particularly effective, with a 10-percentage-point increase in booster vaccination rates associated with a 33.1% decrease in COVID-19 mortality 2
• Priority should be given to vaccinating adults ≥60 years who account for >80% of overall COVID-19 mortality 3
• All types of vaccines effectively prevent severe disease and death compared to no vaccination 4

High-Risk Population Focus

• Target vaccination efforts toward individuals at highest risk:
  • Adults ≥60 years
  • People with diabetes, cardiovascular disease, chronic lung disease
  • Immunocompromised individuals
  • Those with obesity, hypertension, and chronic kidney disease 5

Pharmacological Interventions for Hospitalized Patients

For patients who develop COVID-19 requiring hospitalization:

1. Corticosteroids: Dexamethasone 6 mg daily for up to 10 days for patients requiring oxygen or mechanical ventilation (strong recommendation, moderate quality evidence) 1, 6

   • Note: Corticosteroids are NOT recommended for patients not requiring oxygen as they may increase mortality 1

2. IL-6 receptor antagonists: Tocilizumab in addition to standard care for patients with elevated inflammatory markers (conditional recommendation, low quality evidence) 1, 6

3. Anticoagulation:

   • Non-critically ill hospitalized patients: Therapeutic-dose anticoagulation with heparin increases probability of survival 6, 1
   • Critically ill patients: Standard prophylactic dosing of anticoagulation (therapeutic dosing has not shown benefit) 6, 1

4. Antiviral therapy: Nirmatrelvir/ritonavir (Paxlovid) for high-risk patients, started within 5 days of symptom onset 5

   • Reduces hospitalization or death by 86% in high-risk patients 5
   • Carefully check for drug interactions as ritonavir is a strong CYP3A4 inhibitor 1

Nursing Home and Long-Term Care Facility Strategies

Nursing homes account for a disproportionate share of COVID-19 deaths:

• Implement robust infection control practices including testing and cohorting (physically separating) residents 6
• Ensure high vaccination rates among both residents and staff 6
• Maintain adequate staffing levels to ensure proper care 6
• Balance visitation policies to support resident mental health while maintaining safety 6
• Implement early treatment protocols for infected residents 6

Public Health Measures

Non-pharmaceutical interventions remain important:

• Maintain appropriate mask-wearing in high-risk settings 1
• Implement physical distancing measures during periods of high transmission 1
• Ensure proper hand hygiene and environmental cleaning 1
• Implement contact tracing and testing during outbreaks 1

Contraindicated Treatments

The European Respiratory Society recommends against:

• Hydroxychloroquine
• Lopinavir-ritonavir
• Azithromycin (alone or with hydroxychloroquine)
• Colchicine
• Interferon-β 1, 6

Special Considerations

• Continue standard cardiovascular medications including ACE inhibitors and ARBs 1
• Monitor for myocardial dysfunction, which occurs in 20-30% of ICU patients 1
• For patients with hematological malignancies, continue cytoreductive treatments and avoid stopping JAK inhibitors 6, 1
• Consider switching from oral anticoagulation to low-molecular-weight heparin in acute COVID-19 for patients with myeloproliferative neoplasms 6, 1

Monitoring for Complications

• Watch for fungal co-infections, particularly in severely ill patients 1
• Limit corticosteroid use in patients at risk for fungal infections 1
• Monitor for cardiovascular complications 6

By implementing these evidence-based strategies with a focus on widespread vaccination, particularly among high-risk populations, along with appropriate pharmacological interventions for those who become infected, COVID-19 mortality can be significantly reduced.