Cases: 1M April 2, 2M April 15, 3M April 27, 4M May 8, 5M May 20, 6M May 30, 7M June 7, 8M June 15, 9M June 22, 10M June 29th, 11M July 4, 12M July 8, 13M July 13, 14M July 17, 15M July 23, 16M July 25, 17M July 29, 18M August 1, 19M August 6

Ground Zero: Wuhan - in live animal market or cafeteria for animal pathogens: 10^th January; Total cases are based on RT PCR, 67% sensitivity

Coronavirus Cases: 19,238,021

Deaths: 716,548

Recovered: 12,346,089

ACTIVE CASES: 6,175,384

Currently Infected Patients 6,110,197 (99%) in Mild Condition

65,187 (1%) Serious or Critical

CLOSED CASES: 13,062,637

Cases which had an outcome: 12,346,089 (95%) Recovered/Discharged

716,548 (5%) Deaths

India races with Brazil

Doubling Time

India predictions

1. Death rate is deaths today vs number of cases today.
2. Corrected death rate is deaths today vs number of cases 14 days back.
3. For one symptomatic test positive case, there are 10-30 asymptomatic cases and 20 untested cases.
4. Estimated number of deaths = Reported deaths x 2.
5. Number of deaths today should be 15% of the serious patients present 14 days back.
6. Undocumented cases for each documented case - Iceland: 1: 2; Germany: 1: 5; New York City grocery store shoppers: 1: 10;California: 1.5%.
7. Amongst active cases, 2.37% are serious, 1.82% need oxygen, and 0.41% need ventilator support.

Facts

1. India: In states with average population density of 1185/sq km, the average number of cases were 2048. On the contrary, in states with population density of 909/sq km, the number of cases were 56. When Chandigarh and Pondicherry were taken out from this group, the Average Density of other states were 217 and the average number of cases were 35. [HCFI]
2. COVID Sutras:It’s a COVID-19 pandemic due to SARS 2 Beta-coronaviruses (different from SARS 1 where spread was only in serious cases); with over eleven virus sequences floating; has affected up to 22.8% of Delhi population, Causes Mild or Atypical Illness in 82%, Moderate to Severe Illness in 15%, Critical Illness in 3% and Death in 2.3% cases (15% of admitted serious cases, 71% with comorbidity< Male > Females); affects all but Predominantly Males (56%, 87% aged 30-79, 10% Aged < 20, 3% aged > 80); with Variable Incubation Period days (2-14; mean 5.2 days);  Mean Time to Symptoms 5 days;  Mean Time to Pneumonia 9 days, Mean Time to Death 14 days,  Mean Time to CT changes 4 Days, Reproductive Number R0 1.5 to 3 (Flu 1.2 and SARS 2), Epidemic Doubling Time 7.5 days; Origin Possibly from Bats (Mammal); Spreads via Human to Human Transmission via Large and Small Droplets and Surface to Human Transmission via Viruses on Surfaces for up to three days. Enters through MM of eyes, nose or mouth and the spike protein gets attached to the ACE2 receptors. ACE2 receptors make a great target because they are found in organs throughout our bodies (heart muscle, CNS, kidneys, blood vessels, liver). Once the virus enters, it turns the cell into a factory, making millions of copies of itself, which are then breathed or coughed out and infect others.
3. Prevalence: New York: 13.9%; New York City at 21.2%; S Korea: 5.7%; World: 5%; Ohio prison: 73% of inmates; New York: 21% mortality [April 22 in JAMA].
4. Viral particles seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.
5. Thrombosis: University of Pennsylvania reports that clots are seen in patients even on blood thinners.
6. Other human beta-coronaviruses have immunity lasting only for one year with no IMMUNITY PASSPORT.
7. In absence of interventions, prolonged or intermittent social distancing (till 2022-24) is the key.
8. Low levels of cross immunity from the other beta-coronaviruses against SARS-CoV-2 could make SARS-CoV-2 appear to fade away, only to return after a few years. Surveillance till 2024.
9. During peak, trace and treat, and after the peak, trace and treat the close contacts.
10. Increased spread: close environment, crowded place with close physical contacts with no ventilation.
11. Strategies: From community mitigation to individual containment; broader good over individual autonomy; perfect cannot be the enemy of the good; pandemics are fought on the grounds and not the hospitals. Treat the patient and not the test report; Consider every surface and every asymptomatic person as virus carrier
12. HCW: Direct patient exposure time < 30 minutes; 7 days work and 7 days holidays.
13. Italy: mortality reduced when they were short of ventilators.
14. Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract infections.
15. Great Imitator (protean manifestation).
16. IgM can be false positive in pregnancy, immunological diseases; Pooled tests (< 5, 20 Kerala, 64 Singapore RTPCR) when seroprevalence is < 2%.
17. Early treatment, day 3-5, to reduce the viral load and prevent cytokine storm using hydroxychloroquine with azithromycin or ivermectin with doxycycline with IV remdesivir and IV single dose tocilizumab (IL-6 receptor inhibitor) if very high D-dimer and IL-6; convalescent plasma therapy (given early, donor 14 days symptoms free, between day 28-40, single donation can help 4 patients), Lopinavir-ritonavir and Favipiravir if very low CD4 counts.
18. Hypoxia: Low flow oxygen < 6l/mt, titrated to high flow oxygen using non rebreathing mask, Venturi mask, HFNC and helmet CPAP, NIV in supine or prone position.
19. Early intubation with prone ventilation only if progressive. Hypoxia (walking dead) have capillary problem and not alveoli.

Formulas

1. Deaths in symptomatic cases: Less than one percent (best of the care)

Therefore, Deaths X 100= expected number of symptomatic cases

2. Cases after seven days: Cases today x 2 (based on doubling time 7 days, will change as per doubling time of the country)
3. Cases expected in the community

Get number of deaths occurring in a five-day period

Estimate the number of infections required to generate these deaths based on the country or area case fatality rate

Compare that to the number of new cases actually detected in the five-day period.

This can then give us an estimate of the total number of cases, confirmed and unconfirmed

4. Lock down effect = Reduction in cases after average incubation period (5 days)
5. Lock down effect in reduction in deaths: Reduction in number of deaths on day 14 (average time to death of that country)
6. Requirement of ventilators on day 9: 1-3% of number of new cases detected
7. Requirement of future oxygen on day seven: 10% of total cases detected today
8. Number of people which can be managed at home care: 90% of number of cases today
9. Requirement of ventilators: 1-3% of number of cases admitted 7-9 days back
10. Requirement of oxygen beds today: 10% of total cases admitted seven days back
11. Case fatality rate: Number of total deaths as on date/number of total RTPCR positive cases as on today
12. Infection fatality rate: Number of total deaths as on date/number of total calculated cases as on today
13. Number of reported deaths = Number of confirmed deaths x 2
14. Number of unreported or untested cases = Number of reported cases x 10-30 (depending on the country, New York 10, Delhi 23.8, Pakistan 30)
15. Number of asymptomatic cases: For 6 symptomatic cases, 200 asymptomatic cases 
16. Oxygen requirement on that day in the hospital at 6am: Number of cases detected to have hypoxia on six minutes walk test.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA