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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