Cases: 1M April 2, 2M April 15, 3M April 27, 4M May 8; 5M May 20, 6M May 30

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

Doubling time India 14.5 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 (382227 + 54551 x 15 = 8182) = 390409    

Deaths will cross 400K in one week

Coronavirus Cases: 6,479,836

Deaths: 382,227

Recovered: 3,009,732

ACTIVE CASES 3,087,877

Currently Infected Patients 3,033,326 (98%) in Mild Condition

54,551 (2%) Serious or Critical

CLOSED CASES 3,391,959

Cases which had an outcome: 3,009,732 (89%) Recovered /Discharged

382,227 (11%) Deaths

830.6 cases per million population (India 150) 

49 deaths per million population (India 4)

India Doubling Time: 14.5 Days. India crosses 200K and Delhi 20K

28 Days

India in top 7, will be in top six and cross Italy by end of 5^th June

India predictions

1. >90% of people are symptomatic within 2 weeks of infection.
2. Death rate is deaths today vs. number of cases today.
3. Corrected death rate is deaths today vs. number of cases 14 days back.
4. For one symptomatic test positive case, there are 10-30 asymptomatic cases.
5. Number of deaths = Reported deaths x 2.
6. Number of deaths today should be 15% of the serious patients present 14 days back.
7. Undocumented cases for each documented case - Iceland: 1: 2; Germany: 1: 5; New York City grocery store shoppers: 1: 10;California 1.5%.
8. Amongst active 2.37% are serious, 1.82% need oxygen, and 0.41% need ventilator support.

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 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.
4.  Prevalence:New York: 13.9%; 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 will be 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 using 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