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, 20M August 10, 21M August 16, 22M August 19, 23M August 21, 24M August 27, 25M August 30, 26M September 3, 27M September 7, 28M September 10, 29M September 14, 30M September 18, 31M September 21, 32M September 23, 33M September 28, 34M October 1, 35M October 4, 36M October 8

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: 37,099,134

Deaths: 1,072,605

Recovered: 27,890,943

ACTIVE CASES 8,135,586

Currently Infected Patients 8,067,176 (99%) in Mild Condition

68,410 (1%) Serious or Critical

CLOSED CASES 28,963,548

Cases which had an outcome: 27,890,943 (96%) Recovered / Discharged

1,072,605 (4%) Deaths

India

India-USA New cases per day: 12638 difference

Total difference: 917470

Deaths Crossed 100,000 on 3^rd October

Doubling time 41 days

9^th October: New Cases 73196, New Deaths 929, Total Cases 6977008, Total Deaths 107450, Active Cases 884053

8^th October: New Cases 70824, New Deaths 967, Total Cases 6903812, Total Deaths 106521

7^th October: New Cases 78809, New Deaths 963, Total Cases 6832988, Total Deaths 105554, Active Cases 902972

6^th October: New Cases 72106, New Deaths 991, Total Cases 6754179, Total Deaths 104591, Active Cases 908335

5^th October: New cases 59893, New Deaths 886, Total cases 6682073, Total Deaths 103600, Active Cases 919363

4^th October: New cases 74767, New Deaths 902, Total Cases 6622180, Total Deaths 102714, Active cases 936013

3^rd October: New Cases 75479, New Deaths 937, Total cases 6547413, Total Deaths 101812

2^nd October: New cases 79974, New Deaths 1071, Total Cases 6471934, Total Deaths 100875

1^st October: New Cases 81693, New Deaths 1096, Total Cases 6391960, Total Deaths 99804

30^th September: New Cases 86748, New Deaths 1179, Total Cases 6310267, Total Deaths 98708

29^th September: New cases 97529, New Deaths 1178, Total Cases 6223519, Total Deaths 97529

28^th September: New cases 69671, New Deaths 777, Total Cases 6143019, Total Deaths 96351

27^th September: New Cases 82767, New Deaths 1040, Total Cases 6073348, Total Deaths 95574

26^th September: New cases 89010, New Deaths 1124, Total Cases 5990581, Total Deaths 94534

25^th September: New cases 85468, New Deaths 1093, Total Cases 5901571, Total Deaths 93410

24^th September: New Cases 85919, New Deaths 1144, Total cases 5816103, Total Deaths 92317

23^rd September: New cases 89688, New Deaths 1152, Total Cases 5730184, Total Deaths 91173

22^nd September: New cases 80391, New Deaths 1056, Total Cases 5640496, Total Deaths 90021

21^st September: New Cases 74493, New Deaths 1056, Total Cases 5560105, Total Deaths 88965

20^th September: New cases 87382, New deaths 1135, Total Cases 5485612, Total Deaths 87909

19^th September: New cases 92755, New deaths 1149, Total cases 5398230, Total Deaths 86774

18^th September: New cases 92789, New Deaths 122, Total Cases 5305475, Total Deaths 85625

17^th September: New cases 96793, New Deaths 1174, Total cases 5212686, Total Deaths 84404

16^th September: New cases 97859, New Deaths 1139, Total cases 5115893, Total Deaths 83230

15^th September: New cases 91120, New Deaths 1283, Total Cases 5018-34, Total Deaths 82091

14^th September: New cases 81911, New Deaths 1054, Total Cases 4926914, Total Deaths 80808

13^th September: New cases 93215, New Deaths 1140, Total Cases 4845003, Total Deaths 79754

12^th September: New cases 94409, New Deaths 1108, Total Cases 4751788, Total Deaths 78614

11^th September: New cases 97654, New Deaths 1202, Total Cases 4657379, Total Deaths 77506

10^th September: New cases 96760, New Deaths 1213, Total Cases 4559725, Total Deaths 76304

9^th September: New cases 95529, New Deaths 1168, Total Cases 4462965, Total Deaths 75091

8^th September: New cases 89852, New Deaths 1107, Total Cases 4367436, Total Deaths 73923

7^th September: New Cases 75022, New Deaths 1129, Total cases 4277584, Total Deaths 72816

6^th September: New cases 91723, New Deaths 1008, Total Cases 4202562, Total Deaths 71687

5^th September: New cases 90600, New deaths 1044, Total Cases 4110839, Total Deaths 70679

4^th September: New cases 87115, New deaths 1066, Total Cases 4020239, Total Deaths 69635

3^rd September: New Cases 84156, New Deaths 1083, Total Cases 3933124, Total Deaths 68569

2^nd September: New Cases 82860, New Deaths 1026, Total cases 3848968 Total Deaths 67486

1^st September: New cases 78169, New Deaths 1025, Total cases 3766108, Total deaths 66460

31^st August: New cases 68770, New Deaths 818, Total cases 3687939, Total deaths 65435

30^th August: New cases 79457, New Deaths 960, Total cases 3619169, Total deaths 64617

29^th August: New Cases 78472 New Deaths 944 Total cases 3539712 Total deaths 63657

28^th August: New Cases 76665, New Deaths 1019, Total cases 3461240, Total deaths 62713

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

DENSITY: 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]

COVID Sutra: COVID-19 pandemic is 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.

The most important

1. Masking is THE prevention
2. RT PCR Ct is THE test for diagnosis
3. Zinc is THE Vitamin
4. Day 5 is THE day in COVID phase for mortality prevention
5. Day 90 is THE day after which the word COVID ends
6. Home Isolation is THE modality of Treatment
7. 12 years is THE age when the mortality starts
8. CRP is THE lab test for seriousness
9. Loss of Smell is THE symptom equal to RT PCR test
10. 15 minutes is THE time to get the infection

Numbers to remember

1. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770945: RDW at admission 14.5%

Other Sutras

1. 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].
2. Viral particles are seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.
3. Thrombosis: University of Pennsylvania has reported that clots are seen in patients even on blood thinners.
4. Other human beta-coronaviruses have immunity lasting only for one year with no IMMUNITY PASSPORT.
5. In absence of interventions, prolonged or intermittent social distancing (till 2022-24) is the key.
6. Low levels of cross immunity from other beta-coronaviruses against SARS-CoV-2 could make SARS-CoV-2 appear to fade away, only to show resurgence after a few years. Surveillance till 2024.
7. During peak, trace and treat, and after the peak, trace and treat the close contacts.
8. Increased spread: close environment, crowded place with close physical contacts with no ventilation.
9. 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.
10. HCW: Direct patient exposure time < 30 minutes; 7 days work and 7 days holidays.
11. Italy: mortality reduced when they were short of ventilators.
12. Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract infections.
13. Great Imitator (protean manifestation).
14. IgM can be false positive in pregnancy, immunological diseases; Pooled tests (< 5, 20 Kerala, 64 Singapore RTPCR) when seroprevalence is <2%.
15. 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 CD 4 counts.
16. 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.
17. Early intubation with prone ventilation only if progressive. Hypoxia (walking dead) have capillary problem and not alveoli.

Formulas and Predictions

Deaths

1. The goal is to save lives. Monitoring deaths is important, especially when testing is limited. 
2. Daily deaths are the best indicator of the progression of the pandemic, although there is generally a 17- to 21-day lag between infection and deaths.
3. Deaths in symptomatic cases: Less than one percent (best of the care).
4. Therefore, Deaths X 100 = expected number of symptomatic cases
5. Some may count "probable" or "presumptive" COVID-19 deaths when cases are not confirmed with a positive test but are based on symptoms and medical history. New York added 3,700 presumptive deaths in one day in April when testing was more limited.
6. Case fatality rate: Number of total deaths as on date/number of total RT PCR positive cases as on today
7. Infection fatality rate: Number of total deaths as on date/number of total calculated cases as on today
8. Number of reported deaths: Number of confirmed deaths x 2

Prediction Metrics

1. The University of Washingtons Institute for Health Metrics and Evaluation (IHME):

Is based on what is known about a disease and how peoples actions may affect that.

The latest forecasts state the U.S. will reach nearly 317,000 deaths by December 1, at the current rate of mask-wearing, which currently is slightly below 50% nationally and increasing mask wearing in public to 95% could save over 67,000 lives. Forecasts are not fixed but change depending on public behavior. When people learn that new cases are rising, they start wearing masks and using social distancing again; and when they realize that fresh cases are dropping, they tend to drop their guard.  IHME makes use of real-time infection data from Johns Hopkins Universitys Coronavirus Resource Center to represent disease transmission and estimate how many Americans will die. The researchers then estimate how many Americans are wearing masks or using social distancing, which can modulate the final model.

The rate of infection in a population is based on the "R0," or reproduction number. R0 represents the average number of people who will contract the infection from a single infected person, in a population thats never been witness to the disease before. If R0 is 3, it suggests that one case will create an average of three new cases. When that transmission rate of infection occurs at a specific time, its called an "effective R," or "Rt."  R0 less than 1 means the epidemic is under control; and when its higher than 1, it is still spreading.

IHME found the "effective R over 1 in Oklahoma. In all other states the effective R is less than 1.”

2. CDC: Relies on positive tests results. CDCs report these as confirmed cases. The positivity rate suggests how tough or easy it is to find a case, which is an indicator of both the spread of COVID-19 and how widespread testing is. If the rate of positive tests is 20%, one doesn’t have to look hard to find a case, compared to 1%, which means that one has to do a lot of tests to get a positive one. The more COVID-19 spreads, the higher the positivity rate. A 60% positivity rate may suggest that testing is only being done in a nursing home during an outbreak or a hospital where the most apparent cases are and not the general population where cases may be milder.
3. Marylands COVID-19 dashboard:It reports the daily positivity percentage (percentage of positive tests and total testing volume since March). While looking at testing, one wants to know how many tests were done historically with the ability to compare and understand if the number has increased or declined or is stable and the percentage that comes back positive. Maryland and Pennsylvania report a 7-day rolling average of the daily positivity percentages. The 7-day average rate smooths out fluctuations during the week and is better indicates a trend as compared to daily numbers.
4. The testing numbers often fluctuate, depending on where testing is done and when the labs report test results. A sudden surge in testing numbers may point to a large number of tests done in a group setting such as a nursing home or prison on a single day. Laboratories and hospitals report test results on weekdays, so the numbers can decline on weekends.
5. A major goal during the coronavirus epidemic has been to flatten the curve to maintain local hospital capacity. After expected COVID-19 surges, many hospitals limited surgeries and admissions to preserve their resources, including hospital beds, ventilators, and healthcare personnel.  [WebMD]

 Infrastructure Capacity

1. If hospital capacity reaches 80%, we may have to stop admitting patients to prevent the hospital from being overwhelmed.
2. In order to plan for surges and increase capacity: It is required to know the number of people who tested positive and were admitted to the hospital with symptoms of COVID-19.
3. Pennsylvanias COVID-19 dashboard:  has a hospital preparedness page that shows the number of hospitalized COVID-19 patients and the number and percentage of available beds by unit, including intensive care, medical/surgical, and airborne isolation.
4. Pennsylvania: Reports the number of ventilators COVID-19 patients and non-COVID-19 patients use every day.
5. Illinois lists the recovery rate: In Illinois, the recovery rate of 95% is calculated as recovered cases divided by recovered cases plus confirmed deaths. This indicates the quality of medical care and the severity of disease. [WebMD]
6. Cases will double after the average doubling time of the country at that time
7. 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

8. Lock down effect: Reduction in cases after average incubation period (5 days)
9. Lock down effect in reduction in deaths: Reduction in number of deaths on day 14 (average time to death of that country)
10. Requirement of ventilators on day 9: 1-3% of number of new cases detected
11. Requirement of future oxygen on day 7: 10% of total cases detected today
12. Number of people which can be managed at home care: 90% of number of cases today
13. Requirement of ventilators: 1-3% of number of cases admitted 7-9 days back
14. Requirement of oxygen beds today: 10% of total cases admitted seven days back
15. 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)
16. Number of asymptomatic cases: For 6 symptomatic cases, 200 asymptomatic cases (1.78 M tests in Hong Kong, 32 asymptomatic cases, 10 symptomatic cases)
17. Delhi: Sero positivity 33%, 30% positive had no antibodies
18. India 700 MPS, 30 positive
19. 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