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, 37M October 11, 38M October 14, 39M October 17, 40M October 19, 41M October 22, 42M October 24, 43M October 26, 44M October 28, 45M October 30, 46M November 2, 47M November 4, 48M November 6, 49M November 7, 50M November 8, 51M November 10, 52M November 12, 53M November 14, 54M November 15, 55M November 17, 56M November 19, 57M November 20, 58M November 22, 59M November 24, 60M November 25, 61M November 27, 62M November 29, 63M December 1, 64M December 2, 65M December 4, 66M December 6, 67M December 7, 68M December 9, 69M December 10, 70M December 12, 71M December 13, 72M December 14, 73M December 15, 74M December 17

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: 75,981,580

Deaths: 1,680,216

Recovered: 53,246,458

ACTIVE CASES 21,054,906

Currently Infected Patients

20,947,984 (99.5%) in Mild Condition

106,922 (0.5%) Serious or Critical

CLOSED CASES 54,926,674

Cases which had an outcome: 53,246,458 (97%) Recovered / Discharged

1,680,216 (3%) Deaths

India:

18^th December: New Cases 26991, New Deaths 342, Total Cases 10004825, Total Deaths 145171, Active Cases 309731

17^th December: New cases 26762, New deaths 342, Total Cases 9977834, Total Deaths 144829, Active Cases 312961

16^th December: New Cases 18164, New Deaths 357, Total cases 9951072, Total Deaths 144487, Active Cases 328922

15^th December: New cases 26401, New Deaths 384, Total Cases 9932908, Total Deaths 144130, Active Cases 332985

14^th December: New Cases 21791, New deaths 353, Total Cases 9906507, Total Deaths 143746, Active Cases 340929

13^th December: New Cases 27336, New Deaths 338, Total Cases 9884716, Total Deaths 143393, Active Cases  353715

12^th December: New Cases 30354, New deaths 393, Total Cases 9857380, Total Deaths 143055, Active Cases 357446

11^th December: New cases 30034, Total cases 9827026, New Deaths 440, Total Deaths 142662, Active Cases 360572

10^th December: New Cases 34666, New deaths 487, Total Cases 9796992, Total Deaths 142222, Active Cases 364582

9^th December: New cases 26351, New Deaths 337, Total Cases 9762326, Total Deaths 141735, Active Cases 376086

8^th December: New Cases 32067, New deaths 404, Total cases 9735975, Total Deaths 141398, Active Cases 379771

7^th December: New Cases 27107, New deaths 404, Total Cases 9703908, Total Deaths 140994, Active Cases 385269

6^th December: New Cases 32272, New Deaths 374, Total Cases 9676801, Total Deaths 140590, Active Cases 398040

5^th December: New cases 36111, New Deaths 480, Total Cases 9644529, Total Deaths 140216, Active Cases 404367

4^th December: New Cases 36638, New Deaths 509, Total Cases 9608418, Total Deaths 139736, Active Cases 410679

3^rd December: New Cases 38309, New Deaths 570, Total Cases 9571780, Total Deaths 139227, Active Cases 416869

2^nd December: New Cases 33761, New Deaths 498, Total Cases 9533471, Total Deaths 138657, Active Cases 424710

1^st December: New Cases 36456, New deaths 500, Total Cases 9499710, Total Deaths 138159, Active Cases 429753

30th November:  New Cases 31179, New Deaths 482, Total cases 9463254, Total Deaths 137659, Active Cases 437000

29^th November: New Cases 39036, New deaths 444, Total Cases 9432075, Total Deaths 137177, Active Cases 448585

28^th November: New Cases 41815, New Deaths 495, Total Cases 9393039, Total Deaths 136733, Active Cases 454837

27^th November: New cases 4135 3, New deaths 486, Total Cases 9351224, Total Deaths 136238, Active Cases 456100

26^th November: New Cases 43174, New Deaths 491, Total cases 9309871, Total Deaths 135752, Active Cases 456410

25^th November: New Cases 44699, New Deaths 518, Total Cases 9266697, Total Deaths 135261, Active Cases 453450

24^th November: New cases 44276, New Deaths 489, Total Cases 9221998, Total Deaths 134743, Active Cases 445851

23^rd November: New cases 37410, New Deaths  481, Total cases 9177722, Total Deaths 134254, Active Cases 439893

22^nd November: New cases 44404, New Deaths 510, Total Cases 9140312, Total Deaths 133773, Active Cases 445095

21^st November: New Cases 45295, New deaths 499, Total Deaths 9095908, Total Deaths 133263, Active Cases 442606

20^th November: New Cases 46288, New Deaths 562, Total Cases 9050613, Total Deaths 132764, Active Cases 441952

19^th November: New Cases 46182, New Deaths 584, Total Cases 9004325, Total Deaths 132202, Active Cases 445107

18^th November: New Cases 45439, New Deaths 587, Total Cases 8958143, Total Deaths 131618, Active Cases 444755

17^th November: New Cases 38532, New deaths 472, Total Cases 8912704, Total Deaths 131031, Active Cases 44866016^th November: New Cases 28555, New Deaths 450, Total Cases 8874172, Total Deaths 130559, Active Cases 455444,

15^th November: New cases 30715, New Deaths 435, Total Cases 8845617 (8.8. Million), Total Deaths 130109, Active Cases 467558

14^th November: New Cases 41659, New Deaths 449, Total Cases 8814902, Total Deaths 129674, Active Cases 481491

13^th November: New cases 45343, New Deaths 539, Total Cases 8773243, Total Deaths 129225, Active Cases 482551

12^th November: New Cases 43861, New Deaths 521, Total Cases 8727900, Total Deaths 128686

11^th November: New Cases 48285, New Deaths 549, Total Cases 10703056, Total Deaths 128164

10^th November: New Cases 44679, New Deaths 511, Total Cases 8635754, Total Deaths 127615

9^th November: New cases 37211, New Deaths 451, Total Cases 8591075, Total Deaths 127104, Active Cases 506765

8^th November: New Cases 46661, New Deaths 491, Total Cases 8553864, Total Deaths 126653, Active Cases 511551

7^th November: New Cases 46318, New deaths 557, Total cases 8507203, Total Deaths 126162, Active Cases 513750

6^th November: New Cases 49851, New Deaths 576, Total Cases 8460885, Total Deaths 125605

5^th November: New Cases 47622, New Deaths 675, Total Cases 8411034, Total Deaths 125029, Active Cases 3335730

4^th November: New Cases 50465, New Deaths 704, Total Cases 8363412, Total Deaths 124354, Active Cases 528428

3^rd November: New Cases 46033, New Deaths 511, Total Cases 8312947, Total Deaths 123650, Active Cases 534540

2^nd November: New Cases 37592, New Deaths  497, Total Cases 8266914, Total Deaths 123139, Active Cases 542346

1^st November: New Cases 46441, New Deaths 493, Total Cases 8229322, Total Deaths 122642, Active Cases 563775

31^st October: New Cases 46715, New Deaths 468, Total Cases 8136166, Total Deaths 122149, Active Cases 571529

30^th October: New Cases 48120, New Deaths 550, Total Cases 813666, Total Deaths 121681, Active Cases 583574

29^th October: New Cases 49281, New Deaths 568, Total Cases 8088046, Total Deaths 121131

28^th October: New cases 49912, New Deaths 509, Total cases 8038765, Total Deaths 120563, Active Cases 603251

27^th October: New Cases 42965, New deaths 519, Total Cases 7988853, Total Deaths 120054, Active Cases 611605

26^th October: New Cases 36838, New deaths 505, Total Cases 7945888, Total Deaths 119535, Active Cases 627638

25^th October: New Cases 45158, New Deaths 463, Total Cases 7909050, Total Deaths 119030, Active Cases 656026

24^th October: New Cases 50224, New Deaths 575, Total Cases 7863892, Total Deaths 118567, Active Cases 7075723

23^rd October: New Cases 54028, New Deaths 656, Total Cases 7813668, Total Deaths 117992, Active Cases 682107

22^nd October: New Cases 54482, New Deaths 683, Total Cases 7759640, Total Deaths 117336, Active Cases 695979

21^st October: New cases 56000, New Deaths 703, Total Cases 7705158, Total Deaths 116653, Active Cases 716610

20^th October: New Cases 54422, New Deaths 714, Total Cases 7649158, Total Deaths 115950, Active Cases 740658

19^th October: New Cases 46498, New Death 594, Total Cases 7594736, Total Deaths 115236, Active Cases 748883

18^th October: New Cases 55511, New Deaths 578, Total Cases 7548238, Total Deaths 114642, Active Cases 773701

17^th October: New Cases 62092, New deaths 1032, Total Cases 7492727, Total Deaths 114064, Active Cases 784264

16^th October: New Cases 65126, New Deaths 886, Total Cases 7430635, Total Deaths 113032, Active Cases 795969

15^th October: New Cases 60439, New Deaths 835, Total Cases 7365509, Total Deaths 112146, Active Cases 813303

14^th October: New cases 67988, New Deaths 694, Total Cases 7305070, Total Deaths 111311

13^th October: New cases 63517, New Deaths 723, Total Cases 7237082, Total Deaths 110617, Active Cases 827760

12^th October: New Cases 54265, New Deaths 710, Total Cases 7173565, Total Deaths 109894, Active Cases 938879

11^th October: New Cases 67757, New Deaths 813, Total Cases 7119300, Total Deaths 109184, Active Cases 868689

10^th October New Cases 74535, New Deaths 921, Total Cases 7051543, Total Deaths 108371, Active Cases 868309

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

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-coronavirus (different from SARS 1 where spread was only in serious cases); with over eleven virus sequences floating; 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. Due to low levels of cross immunity from other beta-coronaviruses against SARS-CoV-2, ARS-CoV-2 may 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 RT PCR) 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 RTPCR 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.

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. Lock down effect: Reduction in cases after average incubation period (5 days)

8. Lock down effect in reduction in deaths: Reduction in number of deaths on day 14 (average time to death of that country)
9. Requirement of ventilators on day 9: 1-3% of number of new cases detected
10. Requirement of future oxygen on day 7: 10% of total cases detected today
11. Number of people which can be managed at home care: 90% of number of cases today
12. Requirement of ventilators: 1-3% of number of cases admitted 7-9 days back
13. Requirement of oxygen beds today: 10% of total cases admitted seven days back
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 (CHINA); (1.78 M tests in Hong Kong, 32 asymptomatic cases, 10 symptomatic cases)
16. India 700 MPS, 30 positive
17. 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