A new observational study by a group of scientists explores the rise in the public's fear-driven interest in unproven therapies for COVID-19, particularly chloroquine and hydroxychloroquine, by tracking the internet searches relating to the purchase of drugs in news reports or publicized by public figures. They conclude: "Stay grounded in evidence and fight misinformation." The research letter and accompanying editorial comment are published in the journal JAMA Internal Medicine.
The Rise of Miracle Cures
Since the onset of the COVID-19 pandemic, several therapies have been in the news, one after the other, some claiming to be "miracle cures" for the disease. Several drugs that seemed to show promise in vitro or preclinical trials have been touted by high-profile figures, triggering a wave of warnings from the scientific and pharmaceutical communities. However, no drug has yet been proven to be highly effective in treating the virus.
One such incident occurred recently when the high-profile entrepreneur Elon Musk and US President Donald Trump publicly promoted the use of chloroquine and hydroxychloroquine in mid-March. In Trump's tweet, he said: "Hydroxychloroquine and azithromycin have "a real chance to be one of the biggest game-changers in the history of medicine."
The endorsement came soon after a very preliminary letter to a scientific body describing promising outcome changes after the administration of these drugs to people with COVID-19.
A chloroquine-related fatality was reported soon after the public endorsements, which was attributed to unsupervised ingestion of chloroquine phosphate, a common aquarium cleaner.
Why Is This Trend Concerning?
Chloroquine is used in malaria prophylaxis, while hydroxychloroquine, a derivative of chloroquine with lower toxicity, is used to treat certain autoimmune diseases, like lupus and rheumatoid arthritis.
The researchers stated that the public endorsement of chloroquine and hydroxychloroquine were highly unsetting for three reasons - one, that they were only known to inhibit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19 disease, in vitro; two, both drugs had been known to cause toxic effects to the cardiovascular system, and lastly, that the name "chloroquine" could lead the public to confuse the drug with several commercial products, including aquarium cleaner.
Hydroxychloroquine causes a prolongation of the QT interval, a measurement made on an electrocardiogram used to assess some of the electrical properties of the heart, which can cause sudden cardiac death in a high-risk population. Shortages of these drugs could hit people with autoimmune arthritis. The poor could be the first to suffer from the unavailability of these drugs.
How Was the Study Done?
The study examined the percentage of Google searches targeting the sale of these items from the three biggest e-commerce companies in the US. Researchers monitored how often specific key terms, including buy, order, Amazon, eBay, or Walmart in combination with chloroquine or hydroxychloroquine, were searched for on Google. The proportion of such searches per 10 million total searches were examined using Google Trends and comscore.com.
The study evaluated the daily searches from February 1, 2020, to March 29, 2020, and compared observed search volumes with expected search volumes. The time-period was split into two post-periods - one, all the days after March 16, the day when Musk endorsed the drugs, and two, all days after March 22, when news reports on chloroquine-related poisoning started airing.
Queries related to purchasing chloroquine showed only 542 estimated searches (per 10 million searches) on February 1, which rose to 3,052 estimated searches on March 16, when Musk first endorsed the drug, 7,506 estimated searches on March 22, after the first chloroquine-attributed fatality was reported, and a dip to 2,177 searches on March 29. Overall, the rise was on the order of 442%.
Similar trends were observed for hydroxychloroquine, with 494 estimated searches on February 1, 871 searches on March 16, 9,006 searches on March 22, and a drop to 3,625 searches at the end of the study on March 29. The overall increase in searches to buy hydroxychloroquine was an astonishing 1390%.
The first surge in searches came with Musk's tweet endorsing the drugs, and the biggest came with Trump's televised endorsements. The spike in interest led to nearly 100,000 more searches than expected for purchase of chloroquine and hydroxychloroquine, under normal circumstances. In total, 216,000 total searches were linked to the purchase of the drugs in a 14-day period.
This corresponds to almost 95,000 more searches than expected for either drug. Even after the media reported the first fatality, searches to buy the drugs remained high, at over 200%, and 1,170% above the expected demand.
The Adverse Health Effects of Such Promotions
The team stated that the findings showed that the unrestricted endorsement of unproven drug therapies by public figures - leading to high news coverage - could have severe consequences for the public.
"Endorsements can lead to unsupervised use of the products with dangerous consequences to the people who take them, and hoarding of these medications can result in shortages for those who require them for legitimate health reasons," the paper warned.
It added that this problem was even more concerning because chloroquine-containing commercial products are available to the public through e-commerce sites, among other sources.
The Way Forward
Modern medicine is above all an evidence-based approach. The researchers stress that even when faced with a lack of options to treat the pandemic, clinicians should not "jettison the tenets of evidence-based medicine and the admonition to do no harm."
Instead, they should speak about the evidence, enroll patients in randomized clinical trials, and take into account the impact of large-scale buying of these drugs on non-COVID-19 patients who desperately need them.
The paper recommended that measures be taken by "regulatory agencies and public-facing companies" to reduce the impact of such endorsements. For instance, the US Food and Drug Administration (FDA) should issue timely warnings against procuring "unapproved therapies unless prescribed."
Another impactful avenue could be incorporating information about the unproven nature and potential hazards of these drugs into the educational website that online giant Google has already integrated into search results related to the COVID-19 epidemic.
The researchers also advised that retailers publish warnings or withhold products that have the potential for misuse in the face of the pandemic, citing eBay's recent move to remove chloroquine sales from its website.
The researchers look forward to continued monitoring to further unveil the real impact of the public promotion of such untried avenues. For instance, there could be an estimate of the numbers of chloroquine-containing products sold.
The study concludes: "In times of public health crises, demand for unproven and potentially hazardous COVID-19 treatments is massively increased by endorsements. Public health leaders, regulatory agencies, media, and retailers must amplify accurate information."
Liu, M. et al. (2020). Internet Searches for Unproven COVID-19 Therapies in the United States. JAMA Internal Medicine. Doi:10.1001/jamainternmed.2020.1764
DeJong, C., and Wachter, R. M. (2020). The Risks of Prescribing Hydroxychloroquine for Treatment of COVID-19—First, Do No Harm. JAMA Internal Medicine. Doi:10.1001/jamainternmed.2020.1853