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India should stop flying blind: John Hopkins COVID report

The report suggests that health care workers safety be prioritised and surveys on immunity building be conducted for better visibility

Sanchita Kadam 27 Mar 2020

corona in india
Image: PTI
 

The John Hopkins University through its Centre for Disease Dynamic, Economics and Policy released a report called “COVID19 for India updates” on march 24.

It has predicted infections from COVID-19 in India


It predicts that curve will be at its peak in April-May, this year, and will further flatten in July. Each colored curve has a different significance. The blue curve is a trajectory with current lockdowns but insufficient physical or compliance. The red curve which suggests peak in May, is a stage of moderate to full compliance but no change in virulence or temperature or humidity sensitivity. The orange curve represents an optimistic scenario with decreased virulence and temperature/humidity sensitivity.

It has also predicted the graph of hospitalisations:

 

While this is on national level, it has also made similar graphs for each state in India. Some highly affected states such as Maharashtra and Kerala are shown below:

These state-wise graphs have been driven by date of seeding of the epidemic, major metro cities where initial transmission is rapid, flight connections to COVID affected countries as well as age and demographic variables.
 

Takeaways

The key takeaways are that social distancing focused on the elderly population is essential, the longer this period, the more the infections will be delayed in the post July period. It also warns of hospital transmissions. The report says, “Model is sensitive to hospital outbreaks of COVID19 induced by admission of infected patients into hospitals. Need for large, temporary hospitals to handle this load over the next three-month period. Secondary, hospital-based transmission fuels the epidemic.”

On testing, the report states, “Testing, particularly of those coming in with respiratory symptoms is essential to separate those in hospitals.”

The report also emphasised on serological surveys in order to monitor the stage of the epidemic instead of “flying blind” which is what India is doing currently. Serological surveys provide the most direct measurement to define the immunity landscape for many infectious diseases. These surveys are the most direct and informative technique available to infer the dynamics of a population’s susceptibility and level of immunity.

It is estimated that ventilator demand will be about a million. Current availability in India is estimated to be between 30,000 and 50,000 ventilators. The focus also needs to be on the safety of health care workers since if they start getting infected the health care system will be strained for capacity. The report says, “Mortality in healthcare workers could further increase deaths in the general population.   Healthcare workers need personal protective equipment (i.e., masks and gowns) to protect themselves.”
 

Key policy suggestions

1. Delays in testing are seriously reducing the ability of the population to protect itself.  This is the most important way in which we can contain the epidemic. An increase in the official number of detected cases in the short term could encourage the population to take distancing more seriously and will reduce panic compared to a big spike later.

2. Border closures at this stage have little to no impact and add further economic disruption and panic. While international transmission was important in the first stage, domestic transmission is now far more relevant.

3. A national lockdown is not productive and could cause serious economic damage, increase hunger and reduce the population resilience for handling the infection peak. Some states may see transmission increase only after another 2 weeks and lockdowns should be optimized for when they could maximize the effect on the epidemic but minimize economic damage. State level lockdowns in the most affected states could change the trajectory of the epidemic and should commence immediately. Any delay allows for more secondary cases to emerge. Lockdowns should be guided by testing and serological survey data and should be planned on a rolling basis. We will expand these recommendations shortly. 

4. Preparedness for case load should be the highest priority at this time. We will be issuing guidance based on the model for state level needs for bed capacity, oxygen flow masks and tanks and ventilators.

5. Temperature and humidity increases should help us in reducing case load. Although the evidence is limited, it is plausible.

6. We need to focus on both children under the age of five and the elderly. Early testing and healthcare in this population could help significantly reduce the mortality toll of the epidemic. 

7. We should be prepared for multiple peaks in the model (we have only shown what happens in July) and we should be prepared for more cases and deaths later in the year.

Current scenario

The experience from China suggests that by the time cases are recognised, the transmission has already been going on for weeks. It is possible that India will fare better than other countries due to its demographic advantage of a younger population and the seasonality (of humidity) which could delay infections, albeit in the later part of the year. On the hand, it could do worse due to nutrition challenges in young population and the difficulty in maintaining social distancing in the long run.

Disease parameters

There is also a comparison drawn between South Korea and Italy. While Italy has not been able to contain the disease, South Korea has only been testing, as has also been suggested by the WHO. South Korea thus has a mortality of 0.7% with about 12,000 to 15,000 tests carried out every day.

It is probably time that India picks a page out of the South Korea model and gets as many tests done as possible, especially in the most highly affected states.

The complete report can be read here

Related:

Covid-19 Lockdown: Migrant workers begin to leave city in a painfully long walk home

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India should stop flying blind: John Hopkins COVID report

The report suggests that health care workers safety be prioritised and surveys on immunity building be conducted for better visibility

corona in india
Image: PTI
 

The John Hopkins University through its Centre for Disease Dynamic, Economics and Policy released a report called “COVID19 for India updates” on march 24.

It has predicted infections from COVID-19 in India


It predicts that curve will be at its peak in April-May, this year, and will further flatten in July. Each colored curve has a different significance. The blue curve is a trajectory with current lockdowns but insufficient physical or compliance. The red curve which suggests peak in May, is a stage of moderate to full compliance but no change in virulence or temperature or humidity sensitivity. The orange curve represents an optimistic scenario with decreased virulence and temperature/humidity sensitivity.

It has also predicted the graph of hospitalisations:

 

While this is on national level, it has also made similar graphs for each state in India. Some highly affected states such as Maharashtra and Kerala are shown below:

These state-wise graphs have been driven by date of seeding of the epidemic, major metro cities where initial transmission is rapid, flight connections to COVID affected countries as well as age and demographic variables.
 

Takeaways

The key takeaways are that social distancing focused on the elderly population is essential, the longer this period, the more the infections will be delayed in the post July period. It also warns of hospital transmissions. The report says, “Model is sensitive to hospital outbreaks of COVID19 induced by admission of infected patients into hospitals. Need for large, temporary hospitals to handle this load over the next three-month period. Secondary, hospital-based transmission fuels the epidemic.”

On testing, the report states, “Testing, particularly of those coming in with respiratory symptoms is essential to separate those in hospitals.”

The report also emphasised on serological surveys in order to monitor the stage of the epidemic instead of “flying blind” which is what India is doing currently. Serological surveys provide the most direct measurement to define the immunity landscape for many infectious diseases. These surveys are the most direct and informative technique available to infer the dynamics of a population’s susceptibility and level of immunity.

It is estimated that ventilator demand will be about a million. Current availability in India is estimated to be between 30,000 and 50,000 ventilators. The focus also needs to be on the safety of health care workers since if they start getting infected the health care system will be strained for capacity. The report says, “Mortality in healthcare workers could further increase deaths in the general population.   Healthcare workers need personal protective equipment (i.e., masks and gowns) to protect themselves.”
 

Key policy suggestions

1. Delays in testing are seriously reducing the ability of the population to protect itself.  This is the most important way in which we can contain the epidemic. An increase in the official number of detected cases in the short term could encourage the population to take distancing more seriously and will reduce panic compared to a big spike later.

2. Border closures at this stage have little to no impact and add further economic disruption and panic. While international transmission was important in the first stage, domestic transmission is now far more relevant.

3. A national lockdown is not productive and could cause serious economic damage, increase hunger and reduce the population resilience for handling the infection peak. Some states may see transmission increase only after another 2 weeks and lockdowns should be optimized for when they could maximize the effect on the epidemic but minimize economic damage. State level lockdowns in the most affected states could change the trajectory of the epidemic and should commence immediately. Any delay allows for more secondary cases to emerge. Lockdowns should be guided by testing and serological survey data and should be planned on a rolling basis. We will expand these recommendations shortly. 

4. Preparedness for case load should be the highest priority at this time. We will be issuing guidance based on the model for state level needs for bed capacity, oxygen flow masks and tanks and ventilators.

5. Temperature and humidity increases should help us in reducing case load. Although the evidence is limited, it is plausible.

6. We need to focus on both children under the age of five and the elderly. Early testing and healthcare in this population could help significantly reduce the mortality toll of the epidemic. 

7. We should be prepared for multiple peaks in the model (we have only shown what happens in July) and we should be prepared for more cases and deaths later in the year.

Current scenario

The experience from China suggests that by the time cases are recognised, the transmission has already been going on for weeks. It is possible that India will fare better than other countries due to its demographic advantage of a younger population and the seasonality (of humidity) which could delay infections, albeit in the later part of the year. On the hand, it could do worse due to nutrition challenges in young population and the difficulty in maintaining social distancing in the long run.

Disease parameters

There is also a comparison drawn between South Korea and Italy. While Italy has not been able to contain the disease, South Korea has only been testing, as has also been suggested by the WHO. South Korea thus has a mortality of 0.7% with about 12,000 to 15,000 tests carried out every day.

It is probably time that India picks a page out of the South Korea model and gets as many tests done as possible, especially in the most highly affected states.

The complete report can be read here

Related:

Covid-19 Lockdown: Migrant workers begin to leave city in a painfully long walk home

Covid-19 stigma: Medical professionals ostracized and evicted from rented homes

Covid-19: Telemedicine, online counseling helps people tide over nationwide lockdown

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