To: Sh Narendra Modi, Honble Prime Minister of India

From: Dr KK Aggarwal, President Confederation of Medical Associations of Asia and Oceania, HCFI

Could India have done better than other Asian countries if it had acted in February?

Time to have IB (health intelligence) also investigate health threats from other countries

CMAAO Countries Status as on 11^th May

Currently, India is doing far better when compared to Europe and North America but not when compared to other CMAAO Asian countries. Being the President of CMAAO, I am only comparing it with these countries. India should have acted fast in February. The PMO should have been alerted much earlier by the health ministry. Had the PMO been informed about the seriousness of the illness and the PM acted (the way he is known to act and acted (sealing the International borders) when came in the picture) in February, I am sure, the situation would have been different.

The Health Minister is a medical doctor and should have anticipated the seriousness. He has DGHS and NCDC to advice. Probably the ministry took lightly the early cases in Kerala and though Kerala would be able to tackle it like Nipah, but Nipah was not in multiple countries when it came to India.

Let us see the timelines

7^th January: CMAAO began reporting on Coronavirus pneumonia to all the CMAAO countries. Hong Kong responded that are we heading towards SARS which had killed almost 800 people about 17 years ago? 

8^th January: A CMAAO Alert on COVID-19 was issued warning Asian citizens travelling to China about the mystery pneumonia outbreak

9^th January: Heart Care Foundation of India (HCFI) wrote to the Union Health minister Dr Harsh Vardhan requesting a meeting to discuss various issues relating to public health. We only got a reply on 19^th February (T 21020/07/2020/NCD II/NPCDCS) “It is informed that the O/O Hon’ble Minister has desired to know the antecedents of HCFI as well as history of their engagements with the ministry of health and family welfare in the past in health-related matters”

10^th January: A new type of coronavirus (novel coronavirus, nCoV) was identified, which was isolated on 7th January 2020

10th January: We wrote “Chloroquine which has potent antiviral activity against the SARS-CoV has been shown to have similar activity against HCoV-229E in cultured cells and against HCoV-OC43 both in cultured cells and in a mouse model”??

13^th January: We wrote “The outbreak was linked to a single seafood market in the central city of Wuhan and has not so far spread beyond there” (WHO)

The first confirmed case of the disease outside of China was reported in Thailand

17^th January: Since we did not get any response from the Health Minister, after an edit on 16^th, on 17^th we started writing to the PMO. We wrote to the Prime Minister of India (PMOPG/E/2020/0033278, dated 17th Jan 2020) about the threat of Coronavirus spreading to India. “Today, in Malaysia (where I am travelling) I saw all people at immigration wearing the masks. Also, WHO has issued a warning about symptoms of Coronavirus.”

India issued its first travel advisory to travelers visiting only to China, but no thermal screening of travelers was done.

 21^st January: The WHO confirmed human-to-human transmission of the virus. Following this, we warned that the new “New coronavirus can spread between humans”.

India started simple thermal screening of passengers arriving from China at only 7 airports but was expanded to 20 airports towards the end of January.

22^nd January: We wrote to the PMO (PMOPG/E/2020/0040448) that the coronavirus had now spread to five countries (US, Thailand, Japan, South Korea and Taiwan). Was India ready for this?

We suggested 10 things to be done by all CMAAO countries including India:

1. Declare coronavirus disease as a notifiable disease.
2. Anyone returning from China to India if has symptoms will not declare, take anti histaminic and paracetamol and rush back to India. No one will tell that he or she is suffering from flu.
3. Asymptomatic cases cannot be picked up at the airport and so may still be infectious. If they carry infection and visit India, they will bring the virus here.
4. One symptomatic case will infect other travelers during the flight, all cannot be isolated.
5. Unless the government announces that if someone develops flu-like symptoms in the visiting affected countries, his stay and expenses will be taken care of by India if they get treated there.
6. High degree of suspicion and awareness is required.
7. We have been talking about N95 masks being included in the list of essential drugs and price capping. It is still not being done.This would control both the problem of pollution and such infection threats.
8. Tamiflu or Oseltamivir, the flu drug, should also be price-capped and made available at all airports.
9. All flights should have air masks available for all passengers, so that in long flights, if one passenger declares he has fever, other passengers can use them.
10. Not declaring flu-like symptoms while boarding or landing should be a punishable offence.

“Roughly 30,000 people fly out of Wuhan on an average day” as reported in the New York Times.

24^th January: We requested the Indian Government to have an Inter-Ministerial Meet on coronavirus (PMOPG/E/2020/0043706). “The coronavirus has reached neighbouring countries like Thailand, Singapore, North Korea starting from China. It is still not a Global Public Health emergency but is likely to reach India. The Indian public is confused, and it is time for PMO to make a statement.” “We hereby request (if already not done) the Prime Minister office to set up an inter-ministerial committee involving health ministry, civil aviation ministry, environment ministry, chemical and fertilisers ministry, tourism ministry, AYUSH Ministry, HRD Ministry, Agriculture Ministry, Ministry of Science and Technology, Women and Child Health, Animal Husbandry, Law and Justice, Information and Broadcasting Ministry, Home Ministry and any other ministry as required. The committee may put on board members from IMA, CMAAO, and other stake holders.’

The Group of Ministers (consisting only of Minister of External Affairs, Minister of Civil Aviation and Minister of State for Home Affairs, Minister of State for Shipping and Minister of Health & Family Welfare) was set up on 3rd February.

26^th January: We requested the PMO to announce a National Droplet Infection Control Program (PMOPG/E/2020/0046390). “It behaves like SARS; every ten years it mutates; it has origin from bats; it spreads like large droplets (maintaining three feet from infected person will prevent infection); spreads only from people having lower respiratory infections and not a worry for spread from upper respiratory infections or simple fever with cough and cold; we know LRTI will always have breathlessness so unlikely to spread from people traveling with no breathlessness; unlikely to spread in other countries causing serious illness”

“So, the answer is: National droplet infection control program; involving respiratory hygiene and cough etiquette; use of simple masks by patients; will take care of pollution illnesses also; universal precautions and not when there is panic”.

27^th January: History of anti-fever medicine should be added in airport advisory. We apprised the PMO about this in our letter to the PMO (PMOPG/E/2020/0047828). “The following advisory is being issued at the airports for all travelers who have traveled to China in the past 14 days.

The advisory needs a change and needs to add that all those Travelers who have taken Paracetamol or any fever medicine in the last 8 days should also report to the airport health officer. Thermal screening at the airport can miss fever if patient has taken Paracetamol in the recent past. “ The current advisory “For all Travellers who have visited China particularly, through Wuhan City, Hubei Province of China during past 14 days and are having one or more of the following symptoms: acute onset of fever, cough, shortness of breath should report to airport health unit. For other travellers (those without any symptoms) Travellers who have visited the affected city and do not have any symptoms on arrival but develop above-mentioned symptoms within 28 days of arrival in India should visit nearest hospital and report to the state/district health authorities and concerned airport health officer.”

30th January:

• Globally: 7818 confirmed cases
• China: 7736 confirmed, 12167 suspected, 1370 severe, 170 deaths
• Outside of China: 82 confirmed, 18 countries
• Global risk level was estimated to be high

India reported its first confirmed case of COVID-19 in Kerala; with travel history to Wuhan. (Source: Novel Coronavirus(2019-nCoV) Situation Report – 10, Data as reported by 30 January 2020). WHO declared Coronavirus a “Public health emergency of international concern (PHEIC)”

31^st January

• Globally:9826 confirmed cases
• China: 9720 confirmed, 15238 suspected, 1527 severe, 213 deaths
• Outside of China: 106 confirmed, 19 countries
• The first two confirmed cases were reported in Italy

India had one confirmed case

(Source: Novel Coronavirus(2019-nCoV) Situation Report – 11, Data as reported by 31 January 2020)

By this time the world scenario was as follows:

1^st February: 8th case in the United States was reported (a male in his 20s, in Boston, MA).

2^nd February:  

• Thailand said they discovered a promising medical treatment (combination of HIV medications lopinavir and ritonavir with large doses of the flu drug oseltamivir) that cured a patient of coronavirus “within 48 hours”
• Adeath in the Philippines marked the first death occurring outside of China. It was a 44-year-old Chinese man from Wuhan who was admitted to the hospital on Jan. 25 with fever, cough, and sore throat, developed severe pneumonia but in the last few days “was stable and showed signs of improvement; however, the condition of the patient deteriorated within his last 24 hours resulting in his demise" reported the Philippine Department of Health.
• “The first Coronavirus death outside the Wuhan epicentre is reported in China”.
• China shut down another major city as it closed roads and restricted the movement of residents in Wenzhou, a city with a population of 9 million that is located 800 km away from Wuhan, in Hubei province. The Zhejiang province, where Wenzhou is located, has the highest number of confirmed cases outside the Hubei province.

3^rd February: Two new cases were reported in Germany

4^th February: By this date cases were seen in India, Japan, Thailand, Canada, USA, Taiwan, Hong Kong, Malaysia, Singapore, Belgium, Philippines

• India had 3 confirmed cases with travel history to China
• Japanese authorities quarantined some 3,700 passengers cruise ship in the port of Yokohama near Tokyo in an attempt to contain the virus from causing an outbreak.
• US had 11 new confirmed cases; 8 of these had travel history to China
• One new case in Canada (second one in metro Vancouver): a woman in her 50s who had been hosting relatives from the Wuhan area
• Four-year-old in Malaysia was the first case in the country to have recovered after being infected by the coronavirus.
• Chinas National Health Commission (NHC) said: About 80% of those who died were over the age of 60; 75% had pre-existing conditions such as cardiovascular diseases and diabetes.
• 6 new cases in Singapore; of which, 4 did not travel to China; health officials announce first local coronavirus transmission.
• 2 new cases (both in their 60s) in Hong Kong: Health officials said it was suspected the virus had been transmitted locally. A 39-year-old man died from the coronavirus in Hong Kong. According to reports, the patient had an underlying illness and had travelled to Wuhan on January 21.
• 1 new case in Taiwan is a returning evacuee who had displayed symptoms on Feb. 2 on arriving in Taiwan on a China Eastern Airlines charter flight.
• 6 new cases in Thailand
• 2 new cases in Japan,
• 1 in Australia (the third in Queensland): an eight-year-old child from Wuhan
• 1st case of coronavirus confirmed in Belgium (one of the nine repatriated from Wuhan on Feb. 2).

 5^th February: 31 passengers on board the cruise ship in the port of Yokohama near Tokyo, tested positive for the coronavirus

8^th February: We again wrote to the PMO (PMOPG/E/2020/0066034) that “To prevent coronavirus spreading in India if it enters and gets established the only way is to prevent flu like illness by adopting the Universal precautions. In India, a doctor seeing patients has many of them waiting outside his chamber and are likely to get cross infection of flu or corona-like illness. Therefore, teleconsultation in cases of respiratory tract infections should be permitted.  It can be in the form of a video consultation so that the patient doctor relationship is established. In cases of flu, it is easy to diagnose patients who require admission as they will be breathless.  Breathlessness can easily be tackled on video consultation.

11^th February: WHO officially named the disease as coronavirus disease (COVID-19)

12^th February: In a letter to the PMO (PMOPG/E/2020/0071143), we suggested that “The only way to control corona-like illnesses is to include its prevention in the National Swatch Bharat Mission. Cough etiquettes, frequent hand wash, respiratory hygiene, air borne precautions and flu prevention should be a part of this mission. Flu se bachoge to corona se bachoge. It will also reduce the prevalence of TB.”

13^th February: For the first time, China also reported clinically diagnosed cases in addition to laboratory-confirmed cases

14^th February: “Quarantine not working in the ship with trapped COVID-19. Is India ready with its Quarantine policy?” This was our question in a letter to the PMO (PMPPG /E/2020/0074828).

• China imposed unprecedented quarantines across Hubei, locking in about 56 million people, in a bid to stop spread of the infection. Tens of millions of other cities far from the epicentre are also enduring travel restriction
• In the quarantined ship in Japan, the total number of infections has increased to 218. With nearly 6% of the 3,711 passengers and crew members now infected, the 952-foot cruise ship also has the highest infection rate of the coronavirus anywhere in the world.
• Villages in Vietnam with 10,000 people close to the nations capital are placed under quarantine on 13^thFeb after six cases of the deadly new coronavirus were discovered there. The locking down of the commune of Son Loi, about 40 kilometres from Hanoi, is the first mass quarantine outside of China since the virus emerged from a central Chinese city late last year.

Limitations

1. A better way to quarantine is to break up these people into smaller groups and quarantine them separately.
2. The longer you have several thousand people cohoused you will continue to propagate waves of infection.
3. Why not separate people with comorbid conditions at high risk of deaths and quarantine them 1:1?
4. Why cohort of cases, as reflected in India, danced together with surgical masks
5. Boats ventilation system connects one room to the next. If so, that could be a problem, as there has been previous concern that the coronavirus can spread through pipes.
6. Stress and anxiety are known to suppress the immune system, making people more susceptible to contracting the virus. 
7. The people on quarantine are under 14-day quarantine. But if anyone is diagnosed during this period, the quarantine will add another 14 days.

At this time, it appeared that India was not yet ready with its Quarantine policy

India released guidelines for home quarantine only on 13^th March (MOHFW).

16^th February: Swatch Bharat Abhiyan and Corona Prevention Suggestions (PMPPG/E/2020/ 0080955) “ To stop the spread of COVID-19 in India we would like the government to include the following in Swatch Bharat programme (no spitting on the roads; no biometric attendance in offices requiring touch; namaste in place of shaking hands; regular disinfection of currency notes; availability of surgical masks in public areas; stop alcohol breath inhalation test for detection of alcohol; ban blowing air in the balloons on the roads; ban non-tobacco hukka in the public and ban on people entering public places schools, cinema with fever and cough).

Government Action taken during February: During February, the screening was extended to passengers from Thailand, Singapore, Hong Kong, Japan and South Korea. Nepal, Vietnam, Indonesia and Malaysia were added to the list towards the end of February. However, Italy, Iran, Belgium Philippines etc. were still not included in the list. Italy had 80 cases by 22nd but had 3049 cases by 4th March. Iran also had 140 cases by 26th February.

Indian citizens are further advised to refrain from non-essential travel to the following countries: Singapore, Republic of Korea, Islamic Republic of Iran, Italy.  People coming from Republic of Korea, Iran and Italy or those having history of travel to these countries may be quarantined for 14 days on arrival to India.  Consolidated Travel advisory in view of COVID-19, MOHFW, Revised on 26-02-2020

By 3^rd February, India had three cases. All three cases happened in Kerala and they were students who had returned from Wuhan, China). But no national emergency was announced. Only Kerala acted like it did during Nipah outbreak.

India waited till 2^nd March. But it was too late by then.

The transmission escalated during March, after several cases were reported all over the country, most of which were linked to people with a travel history to affected countries.

2^nd March: Two more positive cases: a 45-year-old man in Delhi who had travelled back from Italy and a 24-year-old engineer in Hyderabad who had a travel history to the United Arab Emirates. In addition, an Italian citizen in Jaipur, who was earlier tested negative, tested positive, making it a total of six confirmed cases in the country. Officials of the Government of Telangana stated that 36 people who had been in contact with the Hyderabad engineer had developed coronavirus symptoms.

4^th March: 22 new cases came to light; wife of the already confirmed Italian patient in Jaipur has been confirmed for COVID-19. 14 Italians and one Indian, who were part of the team of the Jaipur COVID-19 confirmed case, are also initially confirmed positive for COVID-19. Six (6) family members in Agra, who are family members of the COVID-19 confirmed case from Delhi, are confirmed for COVID-19.

Till this date, the IMA was not on board. “I (President CMAAO) have been told that Health Ministry, Govt. of India, has not yet involved Indian Medical Association on board. All 19 countries in CMAAO are on board with their respective governments. Will the government look into this on an urgent basis?”

11^th March

• Globally: 118 319 confirmed (4620 new); 4292 deaths (280 new)
• China: 80,955 confirmed (31 new); 3162 deaths (22 new)
• Outside of China: 37,364 confirmed cases (4589 new), 1130 deaths (258 new), 113 countries/territories/ areas (4 new)

WHO assessed the global risk level as very high; coronavirus outbreak declared a pandemic.

India: Total of 60 confirmed cases and 16 confirmed new cases; no deaths

(Source: Novel Coronavirus(2019-nCoV) Situation Report – 51, Data as reported by 11 March 2020)

The Group of Ministers suspended all existing visas, except diplomatic, official, UN/International Organizations, employment, project visas, till 15th April 2020 with effect from 1200 GMT on 13^th March 2020 at the port of departure. Visa free travel facility granted to OCI card holders is kept in abeyance till April 15th, 2020. This will come into effect from 1200 GMT on 13^th March 2020 at the port of departure. All incoming travelers, including Indian nationals, arriving from or having visited China, Italy, Iran, Republic of Korea, France, Spain and Germany after 15^th February, 2020 to be quarantined for a minimum period of 14 days; all international traffic through land borders will be restricted to designated check posts with robust screening

 12^th March: A 76-year-old man who had returned from Saudi Arabia became the first victim of the virus in the country. He was a known case of hypertension and asthma.

13^th March: Death of a 68-year-old female from West Delhi (mother of a confirmed case of COVID 19), is confirmed to be caused due to co-morbidity (diabetes and hypertension). She had also tested positive for COVID-19. She had history of contact with a positive case (her son who had travel history to Switzerland and Italy between 5th and 22nd February 2020). 

 17^th March

• In an additional advisory, India prohibited travel of passengers from Afghanistan, Philippines, Malaysia to India
• Advisory urging all states to implement social distancing as a strategy to limit the spread of the disease till 31st March

24^th March: Nationwide lockdown announced from 24th March midnight for 21 days. On 14^th April, the nationwide lockdown was extended till 3^rd May, with a conditional easing of restrictions from 20^th April in low risk areas that have been able to contain the spread. On 1st May, the nationwide lockdown was extended further by two weeks until 17 May.

Confirmed cases in India crossed 100 on 15^th March, 1000 on 28^th March, 5000 on 7^th April, 10000 on 14^th April, 20000 on 22^nd April, 30000 on 29^th April and 60000 on 10^th May.

The death toll crossed 50 on 1^st April, 100 on 5^th April, 500 on 19^th April and 1000 on 29^th April.

Super spreaders made it worst

• A Sikh preacher that returned from travel to Italy and Germany, carrying the virus, turned into "super spreader" by attending a Sikh festival in Anandpur Sahib during 10-12 March. Twenty-seven COVID-19 cases were traced back to him. Over 40,000 people in 20 villages in Punjab were quarantined on 27 March to contain the spread.
• On 31st March, a Tablighi Jamaat religious congregation event that took place in Delhi in early March emerged as a new virus hotspot after numerous cases across the country were traced back to the event. Over 9,000 missionaries may have attended the congregation, with the majority being from various states of India, and 960 attendees from 40 foreign countries. According to Ministry of Health and Family Welfare, 4,291 out of 14,378 confirmed cases were linked to this event in 23 Indian states and Union Territories as on 18 April.
• On 6th April 2020, in Mumbais Wockhardt Hospital, 26 nurses and 3 doctors were found to have been infected with the virus. The hospital was temporarily shut down and declared a containment zone.
• On 2nd May 2020, in Punjab, 609 pilgrims from around 4000 pilgrims who returned from Hazur Sahib in Nanded, Maharashtra tested positive. 27 bus drivers and conductors who took stranded pilgrims back to the state also tested positive. As of 5th May, 969 pilgrims have tested positive from around 2,900 pilgrims tested.
• On 5th May, the Koyambedu wholesale market, one of the largest wholesale vegetable markets in the country, has become a super spreader of COVID-19 in Tamil Nadu. The market has been closed until further orders. Almost all the 122 positive cases reported in Cuddalore on Monday can be traced back to Koyambedu; 49 people from Villupuram who visited the market tested positive on Monday, while 33 had tested positive on Sunday.
• In Rajasthan, the Jaipur municipal corporation identified 10 fruit and vegetable vendors as super spreaders after they infected at least 150 persons in the city. Jaipur has the highest number of COVID-19 cases in the state at 378 (HT, 11^thMay 2020).
• Nineteen super spreaders including vegetable vendors, milk vendors and grocery shop workers, became the carrier for the virus in 30 new localities in Ahmedabad, which accounts for about 70% of the total cases in Gujarat that have crossed 8,000 (HT, 11^thMay, 2020).
• In Odisha’s Bhubaneswar, a biryani delivery boy was identified as COVID-positive. In Lucknow’s Qaiserbagh, eight persons were infected from a vegetable vendor (HT, 11^thMay 2020).
• In Haryana’s Jhajjar, which had no case till April 24, 11 vegetable sellers who visited Delhi’s Azadpur fruit and vegetable market tested positive for the virus days later. Jhajjar civil surgeon Dr Randeep Punia said they came to know these vegetable vendors only when cases started coming up from the places the sellers frequented in the town.

Even WHO made mistakes 

1. Declared PHEIC late
2. Declared Pandemic status late
3. Did not warn about the disease in time at the start
4. Differences with CDC even today

CDC: “everyone wear cloth face coverings when leaving their homes, regardless of whether they have fever or symptoms of COVID-19.”

WHO: “Currently there is not enough evidence for or against the use of masks (medical or other) for healthy individuals in the wider community. WHO continues to recommend that medical masks be worn by individuals who are sick or those caring for them. WHO is actively studying the rapidly evolving science on masks and continuously updates its guidance."

India - other mistakes

1. NCDC is not seen on the front line, they should be the open face with the medical scientists
2. In the ministry, the JS health can be the face of the media but DGHS should be the face to talk to the medical profession
3. The Health Minister is a medical man and should have been leading with the science updates apart from public health or party statements
4. IMA was not brought on board till early March
5. CMAAO is not on board till date.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA