Cases: 1M April 2, 2M April 15, 3M April 27, 4M May 8; 5M May 20 Ground Zero: Wuhan - in live animal market or cafeteria for animal pathogens: 10th January; Total cases are based on RT PCR, 67% sensitivityDoubling time India 13.5 days, USA 33 days, Brazil 13 days, Russia 18 days, Spain 47 days, UK 35 days, Italy 55 days, France 49 days, Turkey 37 days

Likely minimum deaths (362023 + 53975 x 15 = 8096) = 370119

Coronavirus Cases: 5,905,292; Deaths: 362,023; Recovered: 2,579,678; ACTIVE CASES 2,963,591; Currently Infected Patients 2,909,616 (98%) in Mild Condition; 53,975 (2%) Serious or Critical

CLOSED CASES 2,941,701; Cases which had an outcome: 2,579,678 (88%) Recovered/Discharged 362,023 (12%) Deaths,

742 cases per million population (India 115), 45.8 deaths per million population (India 3)

India Doubling time: 13.5 days. Will be in top 5 if social distancing not followed

28 Days

Top 9:   India will cross Germany and France

India predictions

1. Delhi cases - 0.04%, Maharashtra 0.02% and Gujarat 0.01% of the population
2. >90% of people are symptomatic within 2 weeks of infection
3. Death rates 3.20%; Corrected Death Rate 7.3% [China 5.58%]
4. Doubling time India 13.5 days, USA 27 days, UK 27 days, Spain 40 days, Russia 13 days, Italy 46 days, Brazil 11 days, France 41 days, Germany 44 days, Turkey 30 days
5. Estimated cases in India: Number of deaths x 85 (number of serious patients 14 days before): On May 4, with 175 new deaths, on 20^thApril, expected serious cases would have been 666; expected cases 4440 as against 1239 reported (Undiagnosed cases  >75%)
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. If we take New York as bench-mark, minimum mortality 0.75% (Number of cases on 20^th278900)
8. Death rates on 8^thMay - World: 6.9%; Europe: 9.6%; North America: 6%; Asia: 3.4%; South America: 5.1%; Africa: 3.8%; Oceania 1.4%
9. Deaths per Million Population: USA: 232; Spain: 558; World: 34; India: 2
10. 10^thMay: % of tests positive - USA 15%, Italy 8.7%, UK 12.4%, Spain 10.4%, India 3.9%
11. Mortality on 11^thMay - Delhi 1%; Maharashtra 3.7%; Gujarat 6%; MP 5.9%; Kerala 0.78%; Rajasthan 2.8%; Andhra Pradesh 2.3%; Bihar 0.9%; West Bengal 9.5%; UP 2.3%
12. Test Positive - West Bengal 4.4%; Gujarat 7.2%; MP: 5%; Delhi 7.3%; Kerala 1.3%; Maharashtra 9.8%; Rajasthan 2.3%; UP 2.7%
13. 3^rdLock down effect: May 3 Number of cases 3062; till 9^th May all cases are prior to lock down 3.0 effect; 10^th May onwards extra cases post lock down 3.0 effect
14. Amongst active, 2.37% are serious, 1.82% need oxygen, and 0.41% need ventilator support.
15. As on date, India has conducted over 2.27 M tests, out of which 4.29% of the samples have tested positive.
16. Among 10 most affected Indian states, Rajasthan has the highest percentage of recoveries (57%), followed by Maharashtra (29%); Punjab stands at 9%.

Extra Reading Background Material

1. China: Captured tiny droplets of viral genetic markers in 2 hospitals in Wuhan floating for > 2 hours. Infectivity? [Journal Nature]
2. 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]
3. Revised 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 three virus sequences floating (one similar to Wuhan, second similar to Iran and the third strain similar to USA – UK); has affected up to 10% (5.7%  S Korea) of the population; Causes Mild or Asymptomatic 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 ages, 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 be breathed or coughed out and infect others.
4. 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].
5. Viral particles seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.
6. Thrombosis: University of Pennsylvania reports that clots are seen in patients even on blood thinners.
7. Other human beta-coronaviruses have immunity lasting only for one year with no IMMUNITY PASSPORT.
8. In absence of interventions, prolonged or intermittent social distancing (till 2022-24) is key.
9. 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 is needed till 2024.
10. During peak - trace and treat - and after the peak - trace and treat the close contacts.
11. Increased spread: close environment, crowded place with close physical contacts with no ventilation
12. 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
13. HCW: Direct patient exposure time < 30 minutes; 7 days work and 7 days holidays.
14. Italy: mortality reduced when they were short of ventilators.
15. Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract infections.
16. Great Imitator (protean manifestation)
17. IgM can be false positive in pregnancy, immunological diseases; Pooled tests (< 5) when seroprevalence is < 2%.
18. Early treatment is needed to reduce the viral load and prevent cytokine storm with off label use of drugs like hydroxychloroquine with azithromycin; ivermectin, remdesivir; Tocilizumab interleukin (IL)-6 receptor inhibitor; convalescent plasma therapy (given early; bridge compassionate therapy, donor 14 days symptoms free, single donation can help 4 patients), Lopinavir-ritonavir and Favipiravir.
19. Hypoxia: Low flow oxygen < 6l/mt, titrated to high flow oxygen using non rebreathing mask, Venti mask, HFNC and helmet CPAP, NAV in supine or prone position.
20. Early intubation with prone ventilation only if progressive. Hypoxia (walking dead) have capillary problem and not alveoli.
21. Formulas: Deaths in symptomatic cases 1; Deaths X 100= expected number of symptomatic cases; Cases after seven days: Cases today x 2 (doubling time 7 days); Cases expected in the community: Number of deaths occurring in a five-day period and estimate the number of infections required to generate these deaths based on a 6.91% 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); Lock down effect in reduction in deaths: On day 14 (time to death); Requirements of ventilators on day 9: 3% of number of new cases detected;  Requirement of future oxygen on day seven: 15% of total cases detected today;  Number of people which can be managed at home care: 80% of number of cases today;  Requirements of ventilators: 3% of Number of cases today;  Requirement of oxygen beds today: 15% of total cases today.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA