NovelCovid 19 viral vaccines, B 1.1.7 UK, B.1.351 South Africa, P1 Brazil

Dr KK Aggarwal, PresidentCMAAO, HCFI, and Past National President IMA

Cases:1M: April2, 2 M April 15, 3 M: April 27, 4 M May 8; 5 M May 20, 6 M May 30, 7 M June 7,8M by June 15, 9 M June 22, 10 M June 29. 11 M July 4, 16 M, 17 M July 29, 18 MAugust 1, 21.8 M August 16, 25 M August 30, 28 M September 10,

Ground Zero:Wuhan in the live animal market or cafeteria for animal pathogens: January 10; Total casesare based on RT PCR, 67% sensitivity

B.1.1.7lineage (a.k.a. 20I/501Y.V1 Variant of Concern (VOC) 202012/01): 23mutations:  This variant has a mutation in the receptor-binding domain (RBD) of thespike protein at position 501, where the amino acid asparagine (N) has beenreplaced with tyrosine (Y). The shorthand for this mutation is N501Y. Thisvariant also has several other mutations, including 69/70 deletion, whichoccurred spontaneously and likely leads to a conformational change in the spikeprotein; P681H: near the S1/S2 furin cleavage site, a site with highvariability in coronaviruses. This mutation has also emerged spontaneouslymultiple times; the variant is associated with increased transmissibility(i.e., more efficient and rapid transmission); In January 2021, scientists fromthe UK reported evidence^[1] that suggests the B.1.1.7 variantmay be associated with an increased risk of death compared with other variants;Early reports found no evidence to suggest that the variant has any impact onthe severity of disease or vaccine efficacy.

B.1.351lineage (a.k.a. 20H/501Y.V2): This variant has multiple mutations in the spikeprotein, including K417N, E484K, N501Y. Unlike the B.1.1.7 lineage detected inthe UK, this variant does not contain the deletion at 69/70. This variant wasfirst identified in Nelson Mandela Bay, South Africa, in samples dating back tothe beginning of October 2020, and cases have since been detected outside ofSouth Africa, including the United States. There is some evidence to indicatethat one of the spike protein mutations, E484K, may affect neutralization bysome polyclonal and monoclonal antibodies.

P.1lineage (a.k.a. 20J/501Y.V3): 17 Mutations, The P.1 variant is a branch off theB.1.1.28 lineage that was first reported by the National Institute ofInfectious Diseases (NIID) in Japan in four travellers from Brazil, sampledduring routine screening at Haneda airport outside Tokyo. The P.1 lineagecontains three mutations in the spike protein receptor-binding domain: K417T,E484K, and N501Y. There is evidence to suggest that some of the mutations inthe P.1 variant may affect its transmissibility and antigenic profile, whichmay affect the ability of antibodies generated through previous naturalinfection or through vaccination to recognize and neutralize the virus.

Some ofthe potential consequences of emerging variants are the following:

·                    Ability to spread more quickly in people: D614G confers increased ability tospread more quickly than the wild-type SARS-CoV-2. 614G variants propagatemore quickly in human respiratory epithelial cells in the laboratory,outcompeting 614D viruses. There also is epidemiologic evidence that the 614Gvariant spreads more quickly than viruses without the mutation.

·                    Ability to cause either milder or more severe disease inpeople: B.1.1.7variant may be associated with an increased risk of death than other variants.

·                    Ability to evade detection by specific viral diagnostic tests:B.1.1.7 has S gene target failure.

·                    Decreased susceptibility to therapeutic agents such as monoclonalantibodies. B.1.1.28

·                    Ability to evade natural or vaccine-induced immunity: B.1.1.28

Ability to evade vaccine-inducedimmunity: Oncea large population is vaccinated, there will be immune pressure that could favourand accelerate the emergence of such variants by selecting for "escapemutants." There is no evidence that this is occurring, and most expertsbelieve escape mutants are unlikely to emerge because of the nature of thevirus.

        "Wild-type" refers to the strain of the virus– or background strain – containing no major mutations.

Coronavirus Cases:

116,271,005

Deaths:

2,582,776

Recovered:

91,934,743

ACTIVE CASES

21,753,796

Currently Infected Patients

21, 663,686 (99.6%)

in Mild Condition

89, 800 (0.4%)

Serious or Critical

CLOSED CASES

94, 515, 172

Cases which had an outcome:

91,934,743 (97%)

Recovered / Discharged

2,582,776 (3%)

Deaths

India

March 5:New cases 189, Total Cases 11173761, Total Deaths 157584, Active Cases 176283

March 4: New Cases 16824, New Deaths113, Total Cases 11173572, Total Deaths 157584, Active Cases 177967

March 3: New Cases 17425, New Deaths 86, Total Cases 11156748, TotalDeaths 157471, Active Cases 175044

March 2: New Cases 15704, New Deaths 110, Total Cases 11139323, TotalDeaths 157385, Active Cases 171776

March 1: New Cases 11563, New Deaths 80, Total Cases 11123619,Total Deaths 157275, Active Cases 169786

February 28: New Cases 15616, New Deaths 108, Total Cases 11112056,Total Deaths 157195, Active Cases 170293

February 27: New Cases 17346, New Deaths 117, Total Cases 11096440,Total Deaths 157087, Active Cases 166079

February 26: New cases 16056, New Deaths 109, Total Cases 11079094,Total Deaths 156970, Active Cases 160985

February 25: New Cases 16568, New deaths 119, Total Cases 11063038,Total Deaths 156861, Active Cases 157418

February 24: New Cases 17144, New Deaths 144, Total Cases 11046470,Total Deaths 156742, Active Cases 153257

February 23: New Cases 13463, New Deaths 100, Total Cases 11029326,Total Deaths 156598, Active Cases 148584

February 22: New Cases 10792, New Deaths 80, Total Cases 11015863, TotalDeaths 156498, Active Cases 148882

February 21: New Cases 13980, New Deaths 79, Total Cases 11005071, TotalDeaths 156418, Active Cases 151639

February 20: New Cases 14315, New Deaths 99, Total Cases 10991091, TotalDeaths 156339, Active Cases 147214

February 19: New Cases 14587, New Deaths 117, Total Cases 10976776,Total Deaths 156240,

February 18: New cases 12643, NewDeaths 85, Total Cases 10962189, Total Deaths 156123, Active Cases 140998

February 17: New Cases 12440, NewDeaths 89, Total Cases 10949546, Total Deaths 156038, Active Cases 138802

February 16: New Cases 11795, NewDeaths 109, Total Cases 10937106, Total Deaths 155949, Active Cases 138254

February 15: New Cases 9139, New Deaths76, Total Cases 10925311, Total Deaths 155840, Active Cases 138579

February 14: New Cases 11434, NewDeaths 91, Total Cases 10916172, Total Deaths 155764, Active Cases 141325

February 13: New Cases 12188, NewDeaths 85, Total Cases 10904738, Total Deaths 155673, Active Cases 139277

February 12: New Cases 12137, NewDeaths 104, Total Cases 10892550, Total Deaths 155588, Active Cases 138253

February 11: New Cases 9353, New Deaths85, Total Cases 10880413, Total Deaths 155484, Active Cases 137578

February 10: New Cases 12760, NewDeaths 119, Total Cases 10871060, Total Deaths 155399, Active Cases 144032

February 9: New Cases 10510, New Deaths85, Total Cases 10858300, Total Deaths 155280, Active Cases 143416

February 8: New Cases 8947, New Deaths81, Total Cases 10847790, Total Deaths 155195, Active Cases 145690

February 7: New Cases 11673, New Deaths86, Total Cases 10838843, Total Deaths 155114, Active Cases 150653

February 6: New Cases 11948, New Deaths72, Total Cases 10827170, Total Deaths 155028, Active Cases 150733

February 5: New cases 11689, New Deaths94, Total Cases 10815222, Total Deaths 154956, Active Cases 150476

February 4: New Cases 12410, New Deaths120, Total Cases 10803533, Total Deaths 154862, Active Cases 153270

February 3: New Cases 12917, New Deaths107, Total Cases 10791123, Total Deaths 154742, Active Cases 156873

February 2: New Cases 11000, New Deaths113, Total Cases 10778206, Total Deaths 154635, Active Cases 161865

February 1: New Cases 8587, New Deaths 94,Total Cases 10767206, Total Deaths 154522, Active Cases 165234

January 31: New Cases 11528, New Deaths116, Total Cases 10758619, Total Deaths 152428, Active Cases 170203

January 30: New Cases 13065,New Deaths 128, Total cases 10747091, Total Deaths 154312, Active Cases 170670

January 29: New cases 13055, Newdeaths 137, Total Cases 10734026, Total Deaths 154184, Active cases 171968

January 28: New Cases 18940, New Deaths162, Total Cases 10720971, Total Deaths 154047, Active Cases 173762

January 27: New Cases 11752, New Deaths134, Total Cases 10702031, Total Deaths 153885, Active Cases 175328

January 26: New Cases 12569, New Deaths127, Total Cases 10690279, Total Deaths 153751, Active Cases 178200

January 25:  New Cases 9036, NewDeaths 116, Total Cases 10677710, Total Deaths 153624, Active Cases 178808

January 24: New Cases 13239, Newdeaths 132, Total Cases 10668674, Total Deaths 153508, Active Cases 185992

January 23: New cases 14891, New deaths155, Total Cases 10655435, Total Deaths 153376, Active Cases 185963

January 22: New Cases 14344, New Deaths154, Total Cases 10640544, Total Deaths 153221, Active Cases 187260

January 21: New cases 14481, NewDeaths 161, Total Cases 10626200, Total Deaths 153067, Active Cases 190976

January 20: New Cases 15277, New Deaths152, Total Cases 10611719, Total Deaths 152906, Active Cases 193650

January 19: New Cases 13795, NewDeaths 161, Total Cases 10596442, Total Deaths 152754, Active Cases 198596

January 18: New Cases 9975, New Deaths137, Total Cases 10582647, Total Deaths 152593, Active Cases 202202

January 17: New Cases 13962, New Deaths145, Total Cases 10572672, Total Deaths 152456, Active Cases 209519

January 16: New Cases 15051, New Deaths181, Total Cases 10558710, Total Deaths 152311, Active Cases 210215

January 15: New cases 15151, New Deaths176, Total Cases 10543659, Total Deaths 152130, Active Cases 212646

January 14: New Cases 15677,New Deaths 189, Total Cases 10528508, Total Deaths 151954, ActiveCases 214472

January 13: New Cases 17015, New Deaths201, Total cases 10512831, Total Deaths 151765, Active Cases 214812

January 12: New cases 15903,New Deaths 200, Total Cases 10495816, Total Deaths 151564, ActiveCases 217839

January 11: New cases 12482,New Deaths 166, Total Cases 10479913, Total Deaths 151364, Active Cases217881

January 10: New cases 16085, New Deaths150, Total cases 10467431, Total Deaths 151198, Active Cases 224103

January 9: New Cases 18820, New Deaths213, Total Cases 10451346, Total Deaths 151048, Active Cases 224903

January 8: New cases 18482, New deaths229, Total Cases 10432526, Total Deaths 150835, Active Cases 225756

January 7: New cases 18106, New Deaths234, Total Cases 10414044, Total Deaths 150606, Active Cases 226716

January 6: New Cases 20460, New Deaths221, Total Cases 10395938, Total Deaths 150372, Active Cases 229403

January 5: New cases 17909,New Deaths 265, Total Cases 10375478, Total Deaths 150151, Active Cases228833

January 4: New Cases 16278, New Deaths200, Total Cases 10357569, Total Deaths 149886, Active Cases 232343

January 3: New Cases 16660, New Deaths215, Total Cases 10341291, Total Deaths 149686, Active Cases 245474

January 2: New Cases 21222, NewDeaths 266, Total Cases 10324631, Total Deaths 149471, Active Cases248633

January 1: New Cases 17080, New Deaths187, Total Cases 10303409, Total Deaths 149205, Active Cases 252275

December 31: New Cases 19046, Newdeaths 244, Total Cases 10286329, Total Deaths 149018, Active Cases 255525

December 30: New cases 21957, Newdeaths 299, Total Cases 10267283, Total Deaths 148774, Active Cases 258747

December 29: New cases 20529, NewDeaths 285, Total Cases 10245326, Total Deaths 148475, Active Cases 263512

December 28: New Cases 16072, NewDeaths 250, Total Cases 10224797, Total Deaths 148190, Active Cases  269840

December 27: New Cases 20333, NewDeaths 281, Total Cases 10208725, Total Deaths 147940, Active Cases 278840

December 26: New Cases 18574, NewDeaths 280, Total Cases 10188392, Total Deaths 147659, Active Cases 279885

December 25: New cases 22350, NewDeaths 251, Total Cases 10169818, Total Deaths 147379, Active Cases 283057

December 24: New Cases 23924, NewDeaths 350, Total Cases 10147468, Total Deaths 147128, Active Cases 283142

December 23: New Cases 24236, NewDeaths 302, Total Cases 10123544, Total Deaths 146778, Active Cases 284705

December 22: New Cases 23886,New Deaths 331, Total Cases 10099308, Total Deaths 146476, Active Cases290130

December 21: New cases 19174, NewDeaths 302, Total Cases 10075422, Total Deaths 146145, Active Cases 293663

December 20: New cases 24589, NewDeaths 330, Total Cases 10056248, Total Deaths 145843, Active Cases 305015

December 19: New Cases 26834, NewDeaths 342, Total Cases 10031659, Total Deaths 145513, Active Cases 306465

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

December 17: New cases 26762, Newdeaths 342, Total Cases 9977834, Total Deaths 144829, Active Cases 312961

December 16: New Cases 18164,New Deaths 357, Total cases 9951072, Total Deaths 144487, Active Cases328922

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

December 14: New Cases 21791, Newdeaths 353, Total Cases 9906507, Total Deaths 143746, Active Cases 340929

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

December 12: New Cases 30354, Newdeaths 393, Total Cases 9857380, Total Deaths 143055, Active Cases 357446

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

December 10: New Cases 34666, Newdeaths 487, Total Cases 9796992, Total Deaths 142222, Active Cases 364582

December 9: New cases 26351, New Deaths337, Total Cases 9762326, Total Deaths 141735, Active Cases 376086

December 8: New Cases 32067, New deaths404, Total cases 9735975, Total Deaths 141398, Active Cases 379771

December 7: New Cases 27107, New deaths404, Total Cases 9703908, Total Deaths 140994, Active Cases 385269

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

December 5: New cases 36111, New Deaths480, Total Cases 9644529, Total Deaths 140216, Active Cases 404367

December 4: New Cases 36638, New Deaths509, Total Cases 9608418, Total Deaths 139736, Active Cases 410679

December 3: New Cases 38309, New Deaths570, Total Cases 9571780, Total Deaths 139227, Active Cases 416869

December 2: New Cases 33761, New Deaths498, Total Cases 9533471, Total Deaths 138657, Active Cases 424710

December 1: New Cases 36456, New deaths500, Total Cases 9499710, Total Deaths 138159, Active Cases 429753

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

November 29: New Cases 39036, Newdeaths 444, Total Cases 9432075, Total Deaths 137177, Active Cases 448585

November 28: NewCases 41815, New Deaths 495, Total Cases 9393039, TotalDeaths 136733, Active Cases 454837

November 27: New cases4135 3, New deaths 486, Total Cases 9351224, Total Deaths 136238, Active Cases456100

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

November 25: New Cases44699, New Deaths 518, Total Cases 9266697, Total Deaths 135261, ActiveCases 453450

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

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

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

November 21: New Cases 45295, Newdeaths 499, Total Deaths 9095908, Total Deaths 133263, Active Cases 442606

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

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

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

November 17: New Cases 38532, Newdeaths 472, Total Cases 8912704, Total Deaths 131031, Active Cases 448660

November 16: New Cases 28555, NewDeaths 450, Total Cases 8874172, Total Deaths 130559, Active Cases 455444,

November 15: New cases 30715, NewDeaths 435, Total Cases 8845617 (8.8. Million), Total Deaths 130109, ActiveCases 467558

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

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

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

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

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

November 9: New cases 37211, New Deaths451, Total Cases 8591075, Total Deaths 127104, Active Cases 506765

November 8: New Cases 46661, New Deaths491, Total Cases 8553864, Total Deaths 126653, Active Cases 511551

November 7: New Cases 46318, New deaths557, Total cases 8507203, Total Deaths 126162, Active Cases 513750

November 6: New Cases 49851, New Deaths576, Total Cases 8460885, Total Deaths 125605

November 5: New Cases 47622, New Deaths675, Total Cases 8411034, Total Deaths 125029, Active Cases 3335730

November 4: New Cases 50465, New Deaths704, Total Cases 8363412, Total Deaths 124354, Active Cases 528428

November 3: New Cases 46033, New Deaths511, Total Cases 8312947, Total Deaths 123650, Active Cases 534540

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

November 1: New Cases 46441, New Deaths493, Total Cases 8229322, Total Deaths 122642, Active Cases 563775

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

October 30: New Cases 48120, New Deaths550, Total Cases 813666, Total Deaths 121681, Active Cases 583574

October 29: New Cases 49281, New Deaths568, Total Cases 8088046, Total Deaths 121131

October 28: New cases 49912, New Deaths509, Total cases 8038765, Total Deaths 120563, Active Cases 603251

October 27: New Cases 42965, New deaths519, Total Cases 7988853, Total Deaths 120054, Active Cases 611605

October 26: New Cases 36838, New deaths505, Total Cases 7945888, Total Deaths 119535, Active Cases 627638

October 25: New Cases 45158, New Deaths463, Total Cases 7909050, Total Deaths 119030, Active Cases 656026

October 24: New Cases 50224, New Deaths575, Total Cases 7863892, Total Deaths 118567, Active Cases 7075723

October 23: New Cases 54028, New Deaths656, Total Cases 7813668, Total Deaths 117992, Active Cases 682107

October 22: New Cases 54482, New Deaths683, Total Cases 7759640, Total Deaths 117336, Active Cases 695979

October 21: New cases 56000, New Deaths703, Total Cases 7705158, Total Deaths 116653, Active Cases 716610

October 20: New Cases 54422, New Deaths714, Total Cases 7649158, Total Deaths 115950, Active Cases 740658

October 19: New Cases 46498, New Death594, Total Cases 7594736, Total Deaths 115236, Active Cases 748883

October 18: New Cases 55511, New Deaths578, Total Cases 7548238, Total Deaths 114642, Active Cases 773701

October 17: New Cases 62092, New deaths1032, Total Cases 7492727, Total Deaths 114064, Active Cases 784264

October 16: New Cases 65126, New Deaths886, Total Cases 7430635, Total Deaths 113032, Active Cases 795969

India predictions

1.      Deathrate is deaths today vs. the number of cases today.

2.         Corrected death rate isdeaths today vs. the number of cases 14 days back.

3.         For one symptomatic testpositive case, there are 10-30 asymptomatic cases and 20 untested cases.

4.         Estimated number ofdeaths = Reported deaths x 2.

5.         Number of deaths todayshould be 15% of the severe patients present 14 days back.

6.         Undocumented cases foreach documented case - Iceland: 1: 2; Germany: 1: 5; New York City grocerystore shoppers: 1: 10; California: 1.5%.

7. Amongst active cases, 2.37% are severe, 1.82% need oxygen, and 0.41%need ventilator support. 

Facts

 DENSITY:India: In states with an average population density of1185/sq. km, the average number of cases was 2048. On the contrary, in stateswith a population density of 909/sq. km, the number of cases was 56. WhenChandigarh and Pondicherry were taken out from this group, the Average Densityof other states was 217, and the average number of cases was 35. [HCFI]

COVID Sutra: COVID-19 pandemic is due to SARS2 Beta-coronavirus (different from SARS 1 where spread was only in severecases); with over eleven virus sequences floating; has affected up to 22.8% ofDelhi population, Causes Mild or Atypical Illness in 82%, Moderate to SevereIllness in 15%, Critical Illness in 3% and death in 2.3% cases (15% of admittedserious cases, 71% with comorbidity< Male > Females); affects all agesbut Predominantly Males (56%, 87% aged 30-79, 10% Aged < 20, 3% aged >80); with Variable Incubation Period days (2-14; mean 5.2 days);  MeanTime to Symptoms 5 days;  Mean Time to Pneumonia 9 days, Mean Time toDeath 14 days,  Mean Time to CT changes 4 Days, Reproductive Number R0 1.5to 3  (Flu 1.2 and SARS 2), Epidemic Doubling Time 7.5 days; OriginPossibly from Bats (Mammal); Spreads via Human to Human Transmission via Large andSmall Droplets and Surface to Human Transmission via Viruses on Surfaces for upto three days. It enters through MM of eyes, nose, or mouth, and the spikeprotein gets attached to the ACE2 receptors. ACE2 receptors make a greattarget because they are found in organs throughout our bodies (heart muscle,CNS, kidneys, blood vessels, liver). Once the virus enters, it turns the cellinto a factory, making millions of copies of itself, breathed or coughed out,and infecting others.

The most important

1.    Masking is THE prevention

2.    RTPCR Ct is THE test for diagnosis

3.    Zinc is THE Vitamin

4.    Day 5 is THE dayin the COVID phase for mortality prevention

5.    Day 90 is THE day after which the word COVID ends

6.    Home Isolation is THE modality ofTreatment

7.    12 years is THE age when mortalitystarts

8.    CRP is THE lab test for seriousness

9.    Loss of Smell is a symptom equivalentto the RT PCR test

10. 15 minutes is THE time to get theinfection.

Numbers to remember

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

Other Sutras

1.      Viral particles are seen in tears,stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.

2.      Thrombosis: the University ofPennsylvania has reported that clots are seen in patients even on bloodthinners.

3.      Other human beta-coronaviruseshave immunity lasting only for one year with no IMMUNITY PASSPORT.

4.      in the absence of interventions,prolonged or intermittent social distancing (till 2022-24) is the key.

5.      Due to low cross-immunity levelsfrom other beta-coronaviruses against SARS-CoV-2, the virus may appear to fadeaway, only to show resurgence after a few years. Surveillance till 2024.

6.      During the peak, trace and treat,and after the peak, trace and treat the close contacts.

7.      Increased spread: Closeenvironment, crowded place with close physical contacts with no ventilation.

8.      Strategies: From communitymitigation to individual containment; broader good over individual autonomy;perfect cannot be the enemy of the good; pandemics are fought on the groundsand not the hospitals. Treat the patient and not the test report; considerevery surface and every asymptomatic person as a virus carrier.

9.  HCW: Direct patient exposure time < 30 minutes; 7 dayswork and 7 days holidays.

10.  Italy: mortality reduced when they were short of ventilators.

11.  Hospital at HOME: CHF, mild pneumonia,exacerbations of asthma and COPD, cellulitis, and urinary tract infections.

12.  Great Imitator (protean manifestation).

13.  IgM can be falsely positive in pregnancy, immunologicaldiseases; Pooled tests (<5, 20 Kerala, 64 Singapore RT PCR) whenseroprevalence is <2%.

14.  Early treatment, days 3-5, reduces the viral load andprevents cytokine storm.

15.  Hypoxia: Low flow oxygen <6l/mt, titrated to high flowoxygen using non rebreathing mask, Venturi mask, HFNC and helmet CPAP, NIV insupine or prone position.

16.  Earlyintubation with prone ventilation only if progressive. Hypoxia (walking dead)has a capillary problem and not alveoli.

Formulas and Predictions

Deaths

1.     The goal is to save lives. Monitoringdeaths is essential, especially when testing is limited.

2.     Daily deaths are the best indicator ofthe progression of the pandemic, although there is generally a 17- to 21-daylag between infection and deaths.

3.     Deaths in symptomatic cases: Lessthan one percent (best of the care).

4.     Therefore, Deaths X 100 = expectednumber of symptomatic cases

5.     Some may count probable orpresumptive COVID-19 deaths when cases are not confirmed with a positive testbut based on symptoms and medical history. In New York, 3,700 presumptivedeaths were added in one day in April when testing was limited.

6.     Case fatality rate: Number of totaldeaths as on date/number of total RTPCR positive cases as of today

7.     Infection fatality rate: Number of totaldeaths as on date/number of total calculated cases as of today

8.     Number of reported deaths: Number ofconfirmed deaths x 2

Prediction Metrics

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

It is based on what is known about a disease andhow peoples actions may affect that.

Forecasts are not fixed but change depending onpublic behaviour. When people learn that new cases are rising, they startwearing masks and using social distancing again; and when they realize thatfresh cases are dropping, they tend to drop their guard.  IHME uses real-time infection data from JohnsHopkins Universitys Coronavirus Resource Centre to represent diseasetransmission and estimates how many Americans will die. The researchers thenestimate how many Americans are wearing masks or using social distancing, whichcan modulate the final model.

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

IHME found the "effective R over 1 inOklahoma. In all other states, the effective R was found to be less than 1."

2.     CDC:Relies on positive test results. CDCs report these as confirmed cases. Thepositivity rate suggests how tough or easy it is to find a case, which indicatesboth the spread of COVID-19 and how widespread testing is. If the rate ofpositive tests is 20%, one does not have to look hard to find a case, comparedto 1%, which means that one has to do many tests to get a positive one. Themore COVID-19 spreads, the higher the positivity rate. A 60% positivity ratemay suggest that testing is only being done in a nursing home during anoutbreak or a hospital where the most apparent cases are not the generalpopulation, where cases may be milder.

3.    Marylands COVID-19 dashboard: It reports the daily positivitypercentage (percentage of positive tests and total testing volume since March).While looking at testing, one wants to know how many tests were donehistorically with the ability to compare and understand if the number hasincreased or declined or is stable and the percentage that is positive.Maryland and Pennsylvania report a 7-day rolling average of the dailypositivity percentages. The 7-day average rate better indicates a trend ascompared to daily numbers.

4.      Thetesting numbers often fluctuate, depending on where testing is done and whenthe labs report test results. A sudden surge in testing numbers may point to alarge number of tests done in a group setting such as a nursing home or prisonon a single day. Laboratories and hospitals report test results on weekdays sothat the numbers can decline on weekends.

5.     Amajor goal during the coronavirus epidemic has been to flatten the curve tomaintain local hospital capacity. After expected COVID-19 surges, manyhospitals 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 patientsto prevent the hospital from being overwhelmed.

 2.    In order to plan for surges and increase capacity: It is required toknow the number of people who tested positive and were admitted to the hospitalwith symptoms of COVID-19.

3.     Pennsylvanias COVID-19 dashboard:  has a hospital preparedness page that showsthe number of hospitalized COVID-19 patients and the number and percentage ofavailable beds by unit, including intensive care, medical/surgical airborneisolation.

4.      Pennsylvania: Reports the number ofventilators COVID-19 patients and non-COVID-19 patients use every day.

5.     Illinois lists the recovery rate: InIllinois, the recovery rate of 95% is calculated as recovered cases divided byrecovered cases plus confirmed deaths. This indicates the quality of medicalcare and the severity of the disease. [WebMD]

6.     Caseswill double after the average doubling time of the country at that time

7.     Cases expected in the community: Get the number of deaths occurring in afive-day period.

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

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

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

8.     Lockdown effect: Reduction in cases after the average incubation period(5 days)

9.     Lockdown effect in a reduction in deaths: Reduction in number of deathson day 14 (average time to death of that country)

10.  Requirement of ventilatorson day 9: 1-3% of the number of new cases detected.

11. Requirement of future oxygen onday 7: 10% of total cases detected today

12. Number of people who can bemanaged at home care: 90% of the number of cases today.

13. Requirement of ventilators: 1-3%of the 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 untestedcases: Number of reported cases x 10-30 (depending on the country, New York 10,Delhi 23.8, Pakistan 30)

16. Number of asymptomatic cases: For6 symptomatic cases, 200 asymptomatic cases (CHINA); (1.78 M tests in HongKong, 32 asymptomatic cases, 10 symptomatic cases)

17.  Oxygen requirement on thatday in the hospital at 6am Number of cases detected to have hypoxia on six minutes’walk tests.

Dr KK Aggarwal

President CMAAO, HCFI and Past NationalPresident IMA