Thursday, May 28, 2020

CMAAO CORONA FACTS and MYTH BUSTER 107 Strategic Lessons

CMAAO CORONA FACTS and MYTH BUSTER 107 Strategic Lessons

929:  Lessons learnt from coronavirus strategies
Dr K K Aggarwal
President CMAAO

With inputs from Dr Monica Vasudev

1.     Italy reached nearly 100,000 Covid-19 cases and more than 10,000 deaths by March 29, becoming the deadliest epicentre in the pandemic. They were slow to implement strict social distancing measures and, even once officials began to institute social distancing as Covid-19 cases began to spike, the public did not seem to respond to government directives with urgency. Italy suffered from “a systematic failure to absorb and act upon existing information rapidly and effectively rather than a complete lack of knowledge of what ought to be done.”

2.     In early days it was common to see officials sceptical of the Covid-19 threat pointing to low fatality numbers and asking why there was panic, given how many people die of the seasonal flu every year. But the coronavirus spreads stealthily, with those who contract it not showing symptoms for days, and the full gravity of their illness not becoming clear until a week or two after infection.

Most political leaders of the world who have not faced the taste of SARS and MERS earlier did not act pre-emptively despite evidence suggesting such delays could increase the number of cases. State-of-emergency declarations were shrugged off by the public and political leaders.

3.     Threats such as pandemics that evolve in a non-linear fashion (they start small but exponentially intensify) are especially tricky to confront because of the challenges of rapidly interpreting what is happening in real time. The most effective time to take strong action is extremely early, when the threat appears to be small — or even before there are any cases. But if the intervention actually works, it will appear in retrospect as if the strong actions were an overreaction. This is a game many politicians don’t want to play. The first step to a better pandemic response is acknowledging the current situation.

When three cases appeared in Kerala India between 31st January and 2nd February, even India did not close the International boarders thinking it to be a Kerala local [problem. They only acted on 22nd March.

4.     Ignoring and not anticipating the problem of migrants: Italy started small with its coronavirus containment and only expanded it as the scale of the problem revealed itself. The country started with a targeted strategy: Certain areas with a lot of infections were designated as “red zones.” Within the red zones, there were progressive lockdowns depending on the severity of the outbreak in the area. The restrictions were only broadened to the whole country when these measures did not stop the virus’s spread.

In fact, these limited lockdowns made it worse. Because the coronavirus transmits so silently, the “facts on the ground” (number of cases, deaths, etc.) didn’t actually capture the full scale of the problem. Once partial lockdowns went into effect, people fled to less restricted parts of the country — and they may have unwittingly taken the virus with them.

The selective approach might have inadvertently facilitated the spread of the virus. Consider the decision to initially lock down some regions but not others. When the decree announcing the closing of northern Italy became public, it touched off a massive exodus to southern Italy, undoubtedly spreading the virus to regions where it had not been present.

Even in India after the 3rd lock down was partially lifted the migrants caused a surge in the cases.  Between 3.5 to 7% of them became positive and carried the infection to other states.

5.     There will be a surge after the lockdown is lifted: The disease will continue to spread with no lockdown, social distancing, or other intervention with no change in transmission rate. R0= 2.66

If there is moderate lockdown, it will reduce transmission to R0 of 2 during lockdown period, then transmission will resume at R0 of 2.4.

In Hard Lockdown, there will be reduced to R0 of 1.5 during lockdown period, then transmission will resume at R0 of 2.4.

And with Hard Lockdown and Continued Social Distancing/Isolating Cases there will be reduced transmission to R0 of 1.5 during lockdown period, then, through social distancing regulations and isolation of symptomatic individuals will resume at R0 of 2.

6.     Uniform national policy vs state policies: Both India and USA did not declare a public health national emergency and had asked states to take care of the problem. Trump did issue his recommendation that people stay home for 15 days to stop the Covid-19 spread, but he did not renew the call. States took different approaches: some, like New York, California, and Washington locked down completely. Others, like Florida, were reluctant to take the same step.

7.     Lockdown will only postpone the worse: Italy’s experience indicates that truncated social distancing periods and a mishmash of social distancing policies across different interlocked areas only prolonged and deepened the problem.

8.     Public ignorance: The message that personal social distancing and masking will never be lifted for the next few years has not been understood by the masses as yet.

9.     Having two strategies in the same country: The experiences of Lombardy and Veneto, two neighbouring Italian regions that took two different strategies for their coronavirus response and saw two different results, are instructive. Lombardy has 10 million people, and it has endured 35,000 Covid-19 cases and about 5,000 deaths; Veneto is home to 5 million people, but it has seen just 7,000 cases and fewer than 300 deaths. Its outbreak is a fraction the size of its neighbour’s.

This is what Veneto did to successfully control the outbreak:
Extensive testing: People with symptoms and people who were asymptomatic were tested whenever possible.

Proactive tracing: If somebody tested positive, everybody they live with was tested or, if tests weren’t available, they were required to self-quarantine.
Emphasis on home diagnosis and care: Health care providers would actually go to the homes of people with suspected Covid-19 cases to collect samples so they could be tested, keeping them from being exposed or exposing other people by visiting a hospital or doctor’s office.

Monitoring of medical personnel and other vulnerable workers: Doctors, nurses, caregivers at nursing homes, and even grocery store cashiers and pharmacists were monitored closely for possible infection and given ample protective gear to limit exposure.

Lombardy, on the other hand, was much less aggressive on all of those fronts: testing, proactive tracing, home care, and monitoring workers. Hospitals there were overwhelmed, while Veneto’s have been comparatively spared. And yet it took weeks upon weeks for Lombardy to adopt the same strategies that were already working next door in Veneto:

10.  Not reporting the proper data or underreporting the data for political gains: Importance of good data — the raw numbers themselves — which were lacking in the early days of Italy’s outbreak. These figures should focus on the important metrics like tests conducted and hospitalizations. The data is often downplayed by most countries. Every one wants gto show that they have the best results. .

Wuhan Update: In two weeks, the Chinese health authorities managed to administer 6.5 million tests for the coronavirus in Wuhan, the city where the pandemic began and where six new infections detected two weeks ago raised fears of a second wave of contagion.  200 cases were found, mostly people who showed no symptoms. This study demonstrates that for every, one symptomatic case there are 33 asymptomatic cases.

Actual Cases (1.7 million: 10 times the number of confirmed cases)
New York State conducted an antibody testing study
12.3% of the population COVID-19 antibodies as of May 1, 2020.
The survey developed a baseline infection rate by testing 15,103 people at grocery stores and community centers across the state over the preceding two weeks. The study provides a breakdown by county, race (White 7%, Asian 11.1%, multi/none/other 14.4%, Black 17.4%, Latino/Hispanic 25.4%), and age, among other variables. 
19.9% of the population of New York City had COVID-19 antibodies.
With a population of 8,398,748 people in NYC, this percentage would indicate that 1,671,351 people had been infected with SARS-CoV-2 and had recovered as of May 1 in New York City. The number of confirmed cases reported as of May 1 by New York City was 166,883, more than 10 times less.

11. Actual deaths are twice the number of reported deaths

As of May 1, New York City reported 13,156 confirmed deaths and 5,126 probable deaths (deaths with COVID-19 on the death certificate but no laboratory test performed), for a total of 18,282 deaths

The CDC on May 11 released its "Preliminary Estimate of Excess Mortality During the COVID-19 Outbreak — New York City, March 11–May 2, 2020" in which it calculated an estimate of actual COVID-19 deaths in NYC by analyzing the "excess deaths" (defined as "the number of deaths above expected seasonal baseline levels, regardless of the reported cause of death") and found that, in addition to the confirmed and probable deaths reported by the city, there were an estimated 5,293 more deaths to be attributed. After adjusting for the previous day (May 1), we get 5,148 additional deaths, for a total of actual deaths of 13,156 confirmed + 5,126 probable + 5,148 additional excess deaths calculated by CDC = 23,430 actual COVID-19 deaths as of May 1, 2020 in New York City.

Mortality Rate (23k / 8.4M = 0.28% CMR to date) and Probability of Dying

As of May 1, 23,430 people are estimated to have died out of a total population of 8,398,748 in New York City. This corresponds to a 0.28% crude mortality rate to date, or 279 deaths per 100,000 population, or 1 death every 358 people.

Infection Fatality Rate (23k / 1.7M = 1.4% IFR)

Actual Cases with an outcome as of May 1 = estimated actual recovered (1,671,351) + estimated actual deaths (23,430) = 1,694,781.
Infection Fatality Rate (IFR) = Deaths / Cases = 23,430 / 1,694,781 = 1.4% (1.4% of people infected with SARS-CoV-2 have a fatal outcome, while 98.6% recover).

12.  Admitting covid patients in non covid hospitals instead of managing them at home: Home admissions: Coronavirus can hit "like a tsunami". In one hospital in Italy more than 100 out of 120 people admitted with the virus developed pneumonia. Doctors became  patients. Opening separate COVID-19 blocks to admit and treat the infected patients made the hospital hot spots. Delhi is doing the same mistake that Italy made.

Do not allow hospitals becoming “the main” source of Covid-19 transmission. The related coronavirus illness MERS also has high transmission rates within hospitals, as did SARS during its 2003 epidemic.
Major hospitals in Italy such as Bergamo’s themselves became sources of [coronavirus] infection with Covid-19 patients indirectly transmitting infections to non-Covid-19 patients. Ambulances and infected personnel, especially those without symptoms, carry the contagion both to other patients and back into the community.

Covid-19 patients started arriving and the rate of infection in other patients soared. That is one thing that probably led to the disaster in Italy.
Western health care systems have been built around the concept of patient-cantered care. But a pandemic requires “community-cantered care.”. Broader good overrules over the individual good.

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