Corona and India

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The following summary was prepared by the COV-IND-19 Study Group, an interdisciplinary group of scholars and data scientists (authors at end). An accompanying detailed report can be downloaded here. Images are courtesy of the COV-IND-19 Study Group

Four months since the first case of COVID-19 in Wuhan, China, the SARS-CoV-2 virus has engulfed the world and COVID-19 has been declared a global pandemic. The number of confirmed cases worldwide stands at a staggering 411,242 (as of 12:38 AM IST March 25, 2020, Microsoft bing coronavirus tracker). Of these, only 519 confirmed cases are from India (as of 12:38 AM IST March 25, 2020 ) (Figure 1), the world’s largest democracy with a population of 1.34 billion (compare China at 1.39 billion and USA at 325.7 million).

So far, the number of people tested in India has been relatively small. In the absence of widespread testing, it is impossible to quantify the magnitude of “community transmission”, in other words, estimate how many are infected outside hospitals and health care facilities. As we speak, those infected but not tested are infecting thousands of others. Currently all testing in India is being conducted under the jurisdiction of the government. People are queuing up at government hospitals to get tested, and potentially infecting each other. Allowing the private sector to test will boost the collector workforce, scale up operation, and reduce further person-to-person transmission. Currently, private labs are banned from conducting these tests after the government invoked an 1896 Act, which was designed and enacted to tackle the plague. [“India’s Handling of Coronavirus” – NDTV]

Below is a timeline of the actions taken in India

The latest action to be taken was of “Complete Lockdown” announcement by Prime Minister Narendra Modi, warning that “many families will be destroyed forever” if the country didn’t get to grips with its coronavirus outbreak in the next three weeks. Modi said the lockdown would start at midnight local time, would last for a minimum of 21 days, and would apply to all of India’s 36 states and territories. The lockdown starts from the midnight of 25th of March 2020.

Will the Lock Down have any effect?

The Travel Ban, social distancing and the lockdown can have major impacts on the number of cases in India.

The predicted number of cases by May 15 will be at 161 per 100,000 (i.e. 2.2 million cases nationwide) without any intervention and will drastically reduce to 1 per 100,000 (i.e. 13,800 cases nationwide) with the most severe form of intervention. Here, instead of adjusting the case counts for the total population of India, the researchers adjusted the estimates using the total population from major cities of the Indian states or union territories that are currently COVID-19 hotspots (namely, Kochi, Mumbai, Pune and Bengaluru).

This analysis shows the impact and necessity of interventions, and all people in India, regardless of their vulnerability to COVID-19, should adopt the public health guidelines issued by the Ministry of Health and Family Welfare in India.

We see that without enforcing the interventions, the predicted counts are going to exceed the estimated capacity of hospital beds in India (estimated at 0.7 per 1000). We should note that 70 hospital beds per 100,000 people is an upper bound on treatment capacity. Given an average occupancy rate of 75%, only a quarter of these are available. (Sindhu et al. 2019) Moreover, critically ill COVID-19 patients (about 5-10% of those infected) will require ICU beds, which constitute between 5 and 10% of bed capacity in Indian hospitals (Yeolekar & Mehta 2008) with very high occupancy rates. In short, if we do not take necessary precautions and follow the guidelines, we are in serious trouble

What can the Government of India do NOW?

The management of this COVID-19 crisis requires strong partnership of the government, the scientific community, the health care providers and all citizens of India (and all global citizens). Following are some recommendations some of which are based on what has been effective in other countries:

  • Drastically increase the number of tests administered daily as there are often asymptomatic cases that go on to infect others and so early diagnosis is extremely important. Government should join hands with the private sector to increase testing capacity.
  • Continue traffic ban, social distancing, quarantine and similar interventions to slow down the spread of the virus.
  • Provide free coverage for testing and treatment for COVID-19 for everyone in India.
  • Immediately prepare to protect the health care workers and first responders who are at the front line of this pandemic. This involves ensuring a steady supply chain of medical resources (masks, gloves, gowns, ventilators), and protecting our healthcare workers (physically and psychologically). Full gears (protective suit, medical goggle, cap, face shield, mask and gloves) are absolutely essential when seeing suspected cases. These protection strategies worked in China.
  • Reduce all non-essential medical care and expand number of beds and ICU beds.
  • Set up COVID-19 testing mobile labs, hospitals and mobile cabins (also called ‘Fangchang’) like South Korea and China (Huoshenshan hospital).
  • Ensure the healthcare facilities have adequate supply of medications that are currently being recommended. For instance, antiviral drugs “remdesivir and chloroquine are highly effective in the control of 2019-nCoV infection in vitro” indicating promise for treating COVID-19 patients [Wang et al. 2020]. WHO launched global trial (called SOLIDARITY) of 4 drugs/combinations: remdesivir, lopinavir and rotinavir, the two drugs plus interferon beta, and chloroquine.
  • Provide livelihood assistance over the quarantine period to those who test positive. This will incentivize people to get tested and comply with social isolation protocols. For many people in India, loss of several weeks of earnings can be economically devastating and since symptoms are mild for most infected people, it is unreasonable to expect that all sick people will tightly follow restrictions unless economically protected.
  • During periods of social distancing and lockdowns, there is grave livelihood threat to a lot of poor people even if they are uninfected — street hawkers, auto drivers, barbers and shopkeepers, etc. Provide a universal basic income (UBI), or some mildly means tested version of it, over the period of disruption.
  • To prevent shutdowns in badly affected sectors, the government may provide GST tax credit to firms based on the difference between past and current sales. Once the pandemic is over and normal business resumes, expansionary monetary and fiscal policy will be needed to revive macroeconomic health.

What can the people of India do NOW?

  • Adhere to the public health guidelines issued by the Ministry of Health and Family Welfare in India. Public awareness and co-operation are of utmost importance now.
  • Practice #SocialDistancing, which is maintaining physical distance and avoiding crowded places so we can be out of range of the respiratory droplets that are considered the principal source of the coronavirus spread. Continue to maintain social connections virtually with family, friends and people around you. We are in this together for the long haul and we need to watch out for one another. Empathy, resilience and solidarity are necessary for retaining our collective morale high.
  • Follow simple personal hygiene and sanitation practices, such as coughing/sneezing into your elbow, regularly washing hands with soap and water for at least 20 seconds or using an alcohol-based hand sanitizer containing 60–95% alcohol, avoiding touching nose, eyes and mouth with unwashed hands and disinfecting all ‘high touch’ surfaces such as counters, tabletops, doorknobs, toilets, keyboards and phones.
  • People suspected to be infected or to have been exposed to an infected person should follow quarantine protocols recommended by the Ministry of Health (e.g., isolate themselves in their homes and restrict outside activities, except for getting medical care).
  • People who employ and rely on domestic helpers, daily wage earners, etc. who come to work every day to their homes, have an active role to play now. We should consider allowing these workforce “paid leave” under these circumstances. It is for the benefit of both the employer and the employee families.
  • As we evaluate this situation with precaution, prudence and best possible prevention and treatment strategies, it is important to not panic. Recent studies show there have been additional mortality in Hubei province [Zhou et al. 2020] and China [Guan et al. 2020] during this time that can potentially be related to additional stress, anxiety and hypertension.
  • Hoarding food, medicines and other supplies have become an issue in many places. It is important to exercise control and be attentive to the community needs.
  • It is important to commit and adhere to good lifestyle choices: maintain a healthy diet, engage in physical activity and care for other existing co-morbidities in this period of confinement and systemic operational disruption.
  • Be mindful of the mental health challenges associated with this crisis at this moment and that are anticipated in the future [Xiang et al. 2020, CDC].

The COV-IND-19 Study Group is comprised of the following scholars and data scientists:

  • Debashree Ray — Departments of Epidemiology and Biostatistics, Johns Hopkins University
  • Rupam Bhattacharyya — Department of Biostatistics, University of Michigan
  • Lili Wang — Department of Biostatistics, University of Michigan
  • Maxwell Salvatore —Departments of Biostatistics and Epidemiology and Center for Precision Health Data Science, University of Michigan
  • Shariq Mohammed — Departments of Biostatistics and Computational Medicine and Bioinformatics, University of Michigan
  • Aritra Halder — Department of Statistics, University of Connecticut
  • Yiwang Zhou — Department of Biostatistics, University of Michigan
  • Peter Song — Department of Biostatistics, University of Michigan
  • Soumik Purkayastha — Department of Biostatistics, University of Michigan
  • Debraj Bose — Department of Biostatistics, University of Michigan
  • Mousumi Banerjee — Department of Biostatistics and Institute for Health Policy and Innovation, University of Michigan
  • Veera Baladandayuthapani — Department of Biostatistics, University of Michigan
  • Parikshit Ghosh — Delhi School of Economics
  • Bhramar Mukherjee — Departments of Biostatistics and Epidemiology and Center for Precision Health Data Science, University of Michigan

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