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With inputs from Dr Monica Vasudev
929: Lessons learnt from coronavirus strategies
- Italy reached the mark of around 100,000 COVID-19 cases and over 10,000 deaths by March 29, becoming the deadliest epicenter in the pandemic. They delayed the implementation of strict social distancing measures. Even when officials started instituting social distancing as cases began to rise, the public did not seem to respond to government directives immediately. Italy suffered a systematic failure to absorb and act upon existing information rapidly and effectively rather than a complete lack of knowledge of what ought to be done.
- In early days, officials were skeptical of the COVID-19 threat pointing to low fatality numbers and asking the reason behind panic, considering the large number of people who die of the seasonal flu every year. But the coronavirus spreads quietly.Those who contract it may not show symptoms for days, and the full gravity of their illness may not become clear until a week or two after infection.
Most political leaders of the world who have not faced the SARS and MERS earlier did not act pre-emptively despite evidence that such delays could increase the number of cases. State-of-emergency declarations were brushed aside by the leaders.
- Threats such as pandemics that evolve in a non-linear fashion(they start small but exponentially increase) are particularly tough to handle because of the challenges of rapidly interpreting what is happening in real time. The most effective time to take robust action is extremely early, when the threat appears to be small, or even before there are any cases. But if the intervention actually works, it will appear in hindsight that the strong actions were an overreaction. Many politicians don’t want to get into all this. The first step to a better pandemic response is acknowledging the current situation.
When three cases appeared in Kerala, India, between 31st January and 2nd February, even India did not close the International boarders thinking it to be a Kerala local problem. They only acted on 22nd March.
- Ignoring and not anticipating the problem of migrants: Italy started on a small level with coronavirus containment and expanded it as the scale of the problem became clear. It started with a targeted strategy: Areas with a lot of infections were designated as “red zones.” Within the red zones, progressive lockdowns were implemented depending on the severity of the outbreak in the area. The restrictions were broadened to the whole country when these measures did not stop the virus’s spread.
These limited lockdowns made it worse. The coronavirus transmits so silently that the “facts on the ground” i.e., the number of cases, deaths, etc., didn’t actually reveal the full scale of the problem. As partial lockdowns were introduced, people fled to less restricted parts of the country and possibly took the virus with them.
The selective approach possibly promoted the spread of the virus. There was a decision to initially lock down some regions but not others. When the closing of northern Italy was announced, it sparked a massive exodus to southern Italy, thus spreading the virus to regions where it had not been present.
Even in India, after the 3rd lock down was partially lifted, the migrants caused a surge in the cases. Around 3.5 to 7% of them became positive and carried the infection to other states.
- There will be a surge after the lockdown is lifted: The disease will continue to spread with no lockdown, social distancing, or other intervention with no change in transmission rate; R0= 2.66.
If there is moderate lockdown, it will reduce transmission to R0 of 2 during lockdown period, then transmission will resume at R0 of 2.4.
In hard lockdown, it will be reduced to R0 of 1.5 during lockdown period, then transmission will resume at R0 of 2.4.
And with hard lockdown and continued social distancing/isolating cases, there will be reduced transmission to R0 of 1.5 during lockdown period; then, through social distancing regulations and isolation of symptomatic individuals, will resume at R0 of 2.
- Uniform national policy vs. state policies: Both India and USA did not declare a public health national emergency and had asked states to take care of the problem. While Trump issued a recommendation that people stay home for 15 days to stop the COVID-19 spread, he did not renew the call. States took different approaches: some, like New York, California, and Washington, locked down completely. Others, like Florida, were reluctant to take the same step.
- Lockdown will only postpone the worse: Italy’s experience suggests that abridged social distancing periods and a mishmash of social distancing policies across different interlocked areas would prolonged and deepen the problem.
- Public ignorance: The message that personal social distancing and masking will never be lifted for the next few years has not been understood by the masses as yet.
- Having two strategies in the same country: The experiences of Lombardy and Veneto, two neighboring Italian regions that adopted two different strategies for their response and saw two different results, say a lot. Lombardy has 10 million people, and it has seen 35,000 COVID-19 cases and about 5,000 deaths; Veneto has 5 million people, and has seen just 7,000 cases and less than 300 deaths. The outbreak there is a fraction the size of its neighbor’s.
What did Veneto do to successfully control the outbreak?
Widespread testing: People with symptoms as well as asymptomatic ones were tested whenever possible.
Proactive tracing: When someone tested positive, everybody they live with was tested or, if tests weren’t available, they were asked to self-quarantine.
Home diagnosis and care: Healthcare providers visited the homes of people with suspected COVID-19 cases to collect samples so they could be tested, thus preventing exposure.
Monitoring of medical personnel and other vulnerable workers: Doctors, nurses, caregivers at nursing homes, and even grocery store cashiers and pharmacists were monitored closely for possible infection and were provided ample protective gear to limit exposure.
Lombardy worked less aggressively on all of these fronts. Hospitals in Lombardy were overwhelmed, while Veneto’s were comparatively spared. And it still took long for Lombardy to adopt the strategies that were working for its neighbor.
- Not reporting the proper data or underreporting the data for political gains: Good data was lacking in the early days of Italy’s outbreak. These figures should focus on the important metrics like tests conducted and hospitalizations. Most countries usually deemphasize the data. Everyone wants to show that they have the best results.
Wuhan Update: In two weeks, the health authorities in China have administered 6.5 million tests for the coronavirus in Wuhan, the city of origin of the pandemic, where six new infections detected two weeks ago raised concerns of a second wave of contagion. Two hundred cases were found, mostly people who showed no symptoms. This study demonstrates that for every symptomatic case there are 33 asymptomatic cases.
Actual Cases (1.7 million; which is 10 times the number of confirmed cases)
New York State conducted an antibody testing study that showed 12.3% of the population had COVID-19 antibodies as of May 1, 2020.
A baseline infection rate was developed by testing 15,103 people at grocery stores and community centers across the state over the previous two weeks. The study yields a breakdown by county, race (White 7%, Asian 11.1%, multi/none/other 14.4%, Black 17.4%, Latino/Hispanic 25.4%), and age, among other variables.
About 19.9% of the population of New York City was shown to have COVID-19 antibodies.
Having a population of 8,398,748 people in NYC, this percentage would suggest that 1,671,351 people had been infected and had recovered as of May 1 in NYC. The number of confirmed cases reported as of May 1 by New York City was 166,883, which is over 10 times less.
- Actual deaths are twice the number of reported deaths
As of May 1, NYC recorded 13,156 confirmed deaths and 5,126 probable deaths (deaths with COVID-19 on the death certificate but no laboratory test performed), for a total of 18,282 deaths.
The CDC on May 11 released "Preliminary Estimate of Excess Mortality During the COVID-19 Outbreak — New York City, March 11–May 2, 2020" in which an estimate of actual COVID-19 deaths in NYC was calculated by analyzing the "excess deaths" (the number of deaths above expected seasonal baseline levels, regardless of the reported cause of death). It was noted that, besides the confirmed and probable deaths reported by the city, there were an estimated 5,293 more deaths to be attributed. Once adjustment was done for the previous day (May 1), there were 5,148 additional deaths, for a total of actual deaths of 13,156 confirmed + 5,126 probable + 5,148 additional excess deaths calculated by CDC = 23,430 actual COVID-19 deaths as of May 1, 2020 in New York City.
Mortality Rate (23k/8.4M = 0.28% CMR to date) and Probability of Dying
As of May 1, 23,430 people are estimated to have died from a total population of 8,398,748 in New York City. This corresponds to a crude mortality rate of 0.28% to date, or 279 deaths per 100,000 population, or 1 death every 358 people.
Infection Fatality Rate (23k/1.7M = 1.4% IFR)
Actual cases with an outcome as of May 1 = estimated actual recovered (1,671,351) + estimated actual deaths (23,430) = 1,694,781.
Infection Fatality Rate (IFR) = Deaths/Cases = 23,430/1,694,781 = 1.4% which means that 1.4% of people infected with SARS-CoV-2 have a fatal outcome, while 98.6% recover.
- Admitting COVID patients in non-COVID hospitals instead of managing them at home: Home admissions: Coronavirus can hit "like a tsunami". In one hospital in Italy more than 100 out of 120 people admitted with the virus developed pneumonia. Doctors became patients. Opening separate COVID-19 blocks to admit and treat the infected patients made the hospitals hot spots. Delhi is doing the same mistake that Italy made.
Do not allow hospitals to become “the main” source of COVID-19 transmission. MERS, a related coronavirus illness, also has high transmission rates within hospitals, as it was for SARS during the 2003 epidemic.
Major hospitals in Italy became sources of coronavirus infection with COVID-19 patients indirectly transmitting it to non-COVID-19 patients. Ambulances and infected personnel, particularly those without symptoms, carry the contagion both to other patients and back into the community.
COVID-19 patients started arriving and the rate of infection in other patients increased. This is one of the things that probably led to the disaster in Italy.
Western health care systems work around the concept of patient-centered care. A pandemic; however, requires “community-centered care.” Broader good overrules individual good.
[Sources: vox.com; https://www.worldometers.info/coronavirus/coronavirus-death-rate/; statnews.com]
Dr KK Aggarwal
President CMAAO, HCFI and Past National President IMA