We have been hearing this advice from many sources for the management of Covid19 effectively. For understanding more about Covid19, I went on to check for a simple metric i.e. percentage of confirmed Covid19 cases vis-a-vis a total number of tests conducted by various countries affected with Covid19. My data sources are shared at the end of the article. I have used a different data source for the month of May; the reason being comparable dataset was not available with the earlier source.
Total Confirmed Cases
Mar 18, 2020
Mar 20, 2020
Mar 14, 2020
Mar 19, 2020
Mar 20, 2020
Total Confirmed Cases
May 24, 2020
May 24, 2020
May 24, 2020
May 24, 2020
May 24, 2020
Just to mention, the source which I used earlier did not have the data for China so I could not include the same. Apart from China, I have shown the data for the countries which have got the maximum number of confirmed cases to date (in March) for illustration purpose and I also included our own country to put this in perspective. Now, if we compare the data for two instances; it shows different positivity rate (i.e. percentage of total confirmed cases / total test)
As we all know that lockdown was imposed in our country for preparing ourselves for fighting this long battle against Covid19 and a very important aspect in this battle is to increase our daily testing capacity as it’s the only way available to us to understand the spread of the virus in any particular community.
We have come close to daily testing capacity of 1 lakh+ tests a day which is almost 100 times increase from the initial days but still we are way behind when we see tests per million vis-à-vis other developed countries. Just to put this in perspective; India is doing 2135 tests / million population whereas Iran which has almost similar number of confirmed cases has been doing 9544 tests/ million population. And if we compare this with developed countries this number is in the range of 20000 – 75000 tests/ million population.
At the same time; we should not forget that various studies world over suggest that actual number of infected individuals are always higher than number of confirmed cases the reason being each country depending upon their testing strategies are able to identify the confirmed cases. Also, we should not forget that number of confirmed cases is a lagging indicator to understand the spread as the symptoms start to emerge only after 2 to 14 days from the day an individual got infected with the virus.
I am writing this article at a time when we are in lockdown 4.0 and have got relaxation in many parts of the country. This would be the real test of our healthcare infrastructure which we have managed to build during the national lockdown.
Positivity rate for India is less vis-à-vis other nations which also got impacted with Covid19 (which is a good sign)
We need to improve our testing capabilities to understand the level of community spread (as it is done in other countries); the reason being based on the historical evidence and current developments globally pandemic strikes in waves so we should not discard the possibility in our case as well.
We should also increase the use of rapid antibody test to ascertain the level of community spread.
We should be more concerned about deaths happening due to Covid19 as it is believed that 80% of the cases would be mild in nature; 15% would need hospital support and 5% would need ventilator support.
In our country, one can also debate the number of deaths happening because many of deaths happening in our country are not certified medically. But that is something we should discuss separately.
Again as always, questions and clarifications are welcome.
About the author
Yatindra Jha is a healthcare consultant with a focus on public health policy.
Charles Darwin in 19th century, proposed an interesting theory of evolution, and three of his theories have been validated time and again and become the law of natural selection.
The three laws of Darwin are
Prodigality of Production
Struggle for Existence
Survival of the fittest.
When we see the evolutionary aspect specific to human beings, man seems to be nurtured nature to a great extent through social and technological innovations that he brought to live a domesticated or tamed life far from wildness of nature.
Man seems to have tamed first law- prodigality of production by balancing with economic viability of nurturing child, that lead to the direction of minimizing birth rates , innovations in medicine aided this to minimize urge for having more children over centuries, defeating first law.
Man seems to have taken upper hand with his innovations and technological discoveries and minimizing the struggle for existence, in fact comforting himself to great extent to protect from vagaries of nature.
Survival of the fittest: This is the natural law, where how so ever the innovations at onestage or the other Man has to yield to the power of nature, still man is not able to win over to help the weakest of human being to survive over nature’s power.
Nature vs Nurture dialogue
In the course of human history, infectious diseases have been among the most important causes of mortality and morbidity for humans, including plague, smallpox, and tuberculosis (TB), measles, and diarrheal infections. Studies of the origins and distribution of infectious diseases examine the geographic distribution, life stage, and evolution of the infectious agent [malaria parasites, TB mycobacteria, cholera bacteria, influenza, severe acute respiratory syndrome (SARS and HIV); the geographic distribution and life cycle of intermediate hosts (arthropod vectors for many diseases, birds for avian flu, bats for SARS, and deer and ticks for Lyme disease spirochetes); the geographic distribution of diseases they cause in humans and other species; and the key clues that some population subgroups are strikingly more or less susceptible than others. Infectious agents are also important factors in major “noninfectious” inflammatory diseases, like certain cancers, atherosclerosis, and arthritis
Inter species race to super power: Evolution in Action
Within the microbial world, there is remarkable interspecies competition and cooperation. Microbes exchange genetic material, even with different genera. They compete for space and food sources, adapting to selective pressures. Fungi have been particularly adept at producing antimicrobial chemicals that protect them against bacteria. Starting with Fleming’s use of the extract of Penicillium to kill Gram-positive bacteria, patients have benefited from these antibiotics from nature. These chemicals may be isolated and used directly, or they may serve as lead compounds for drug development. However, microbes are not passive agents. They respond promptly to negative natural selection in the form of antibiotics by developing genetically transmitted resistance to the action of individual antibiotics or sets of antibiotics. If these microbes are pathogenic to humans, our response is to create generations of antibiotics; hence, the “race to superpower.”
Man continues to evolve not only biologically but also through anthropological social means and tactics to make his life better. In the process nurtured a parallel evolution in his sphere called “Culture” leading to dynamic changes in food habits, living, and protection from nature. Organizing politically to streamline set of cultural patterns across the globe for the benefit and wellbeing of the species Homo sapiens.
Current Pandemic COVID19 and course of nurturing: Nature continued to keep checks and balances to the course of nurture by man. Famines, floods, cyclones etc. of geographical nature have changed the course of the human nurturing process. Human association with wild animal food habits has been tapered for a quite long time as man continued to be civilized, however, the famines lead man to go back to wild and survive the nature’s fury.
Living on animal meat wild is not new to humans, since hunter- gathers time, man is accustomed to live on animals wild or domesticated. In the course of human evolution as he evolves as social being, his biological capacities of disease resistance has taken back seat, thus man lost capacity to gel with powerful biome of the nature. Between 1958- 1961 China faced severe famine, and survival has become a challenge, then Man took the recourse and restarted sourcing food from wild, in large scale supported by policies and politics, wild animal meat has become source of food, that lead to 360 degree turnaround from domestication to wild way of feeding, living on wild meat.
This has taken economic scale and China is spread with Vet markets all around, where anything moving is commercialized and dined. The human incapacity to fight resistant biome (Microbes) in the wild off late lead to many epidemics in a course of 5 decades, we have Ebola, Zeta virus Sars, H1NI, and now Covid19, the origin may be China or Africa or any other place, the change in food habits nurtured by culture and rapid decrease in immunity of human beings due to nurturing, lead to the scale of pandemics we have been witnessing now. The frequency of epidemics increasing, as man power to wild is plummeting due to excessive nurturing and cultural domestication.
If we see Nature vs Nurture scenario in comparison of two contrary theories one Biological theory of Darwin on Natural selection vas Malthus sociological & statistical theory of Demographic transition, the direction of trajectory is evident
Darwin vs Malthus: Darwin’s law- 1. Prodigality of Production 2. Struggle for existence 3. Survival of the fittest. Malthusian demographic theory states stage1- High birth rates – High death rates stage 2- High birth rates – Low death rates 3. Low birth rates- Low death rates. With evolution of medicine and technology. Darwin’s 1st law becomes redundant, so Population is controlled. Human innovations minimized Man’s struggle for existence. Man’s penchant to reverse natural process of survival of the fittest is challenged by innovations and man said its “survival of the weakest”. This principle of evolved man is challenged again by COVID 19 and pandemics in the past. Man Vs Nature– struggle continues.
Inference: The struggle of man to tame the nature continues, man continues to takerecourse to duck nature fury through pandemics, resistant biomes and changing natural process which are unknown and stronger. The only ammunition is to build, develop robust public health structures, functions and processes along with rapid innovation in medicine to tame unknown natural enemies like resistant biomes, whether its viral, bacterial, protozoans, helminths etc. and remain vigilant to natural transitions and transformations. Human might of nurturing through technology, medicine, culture appears to be miniscule in the larger scheme of nature’s innovations.
About the author
Bhaskara Venkatesh is a master’s in Anthropology and works as a senior manager with the technology industry.
On 15th March 2020, India had just crossed 100 cases. Italy was at 24.7k cases, US at 3.6k cases, Brazil had just gone past 200 cases, Germany had crossed 5.8k cases and Russia at just 63 cases. In the last two months even with varying amount of restrictions, COVID19 has still wrecked havoc in these countries and the world.
With India now sitting at the threshold of 100K cases, we look at the effect various lockdowns has had on the Covid19 situation in India. We also take a look at how the countries continue to recover from COVID19.
We dig further in to our classification of Indian States with a new methodology that scores the states basis various parameters.
Note: We have removed Korea and Sweden from the study to Include Brazil and Russia. This gives us a better representation of the top countries with respect to no of cases reported
India and The world
On the 62nd day after crossing 100 cases India has the second highest daily growth rate (7 Day Rolling Average). If we look at the table only Brazil is ahead of India
India has had 3 Lockdowns and we will start Lockdown 4.0 from tomorrow. These lockdowns have ensured that we have done much better in the number of reported cases than other countries in the study. But has the curve really flattened out? When we look at the other countries, we see that most of the countries have nearly managed to flatten the curve albeit at a very high number of reported cases. Currently on a logarithmic scale India, Russia and Brazil are showing strong signs of growing while other countries have a flat curve.USA, Italy and Iran have all flattened their curve. (Spain and France also show a flat curve though not included in the below graph)
For India, the lockdown has ensured that we miss the steep growth path of other countries but we are still poised to hit a huge number, albeit at a slower rate. This means we have just prolonged our battle with the disease.
Although, India may seem to be trending towards a higher number of cases all may not be lost. India is doing well in terms of its recovery rate and outcome percentage.
Recovery Rate, i.e. no of people recovered by total outcomes continues to improve for the world and for India. India’s recovery rate has now crossed 90%. For the world it stands at 85%. The other countries in the study have also improved their recovery rate
Recovery rate should be studied along with the outcome curve, i.e. how many cases have had an outcome with respect to active cases. For e.g Russia has a 96% recovery rate but 76% of the cases still await an outcome. Similarly Iran has a 93% recovery rate at a 85% outcome rate which more or less signifies the actual recovery rate for the country.
India has a good recovery rate with a decent outcome%.
Net Active Cases
Net Active Cases = Total Cases – (Cases Recovered+Total Deaths)
India’s Net Active cases are at just a little above 53K. Except for Iran and Germany, all the other countries are much ahead of India. With India’s high recovery rate, it clearly shows that India is also recovering at a much higher pace than the other countries.
India has also seen a declining trend in the net active case added each day. In the past seven days we have added around 1700 net active cases per day compared to higher than 1900 net active cases in the week before.
This is a positive sign for the Indian Medical Fraternity as the reducing number of new active cases added does prevent the medical system from getting overwhelmed.
Lockdown Effect on India
When we take a look at the effect lockdown had on our growth rates, it can be observed that lockdown 1 certainly slowed us down, but lockdown 2 and lockdown 3 failed to have the desired effect of flattening the curve.
If we look at the Indian States, Maharashtra has had no effect in the lockdown. Its contribution to the cases in fact has grown during the three lockdowns.
Similarly Delhi is another state that has been contributing heavily during the lockdowns showing minimal effect of the lockdown.
We have changed the methodology of classification of states (Good, States to be Watched and Worry States) from May onwards. We were classifying the states on the basis of their 7DAGR only. Now we have also included the following to arrive at a weighted score
Total Cases Reported
Basis these parameters we have arrived at a group of
States to be Watched
The Good States
As on 16th May 2020, the following states qualify as the Good States. These states are characterized by low growth rates, low cases/million, higher Outcome% and high recovery rates.
Haryana – Haryana has seen a recent spike in cases most of which are related to Delhi. Haryana, despite being surrounded by Delhi, UP, Punjab and Rajasthan (All these states have high number of cases) has done very well in terms of new cases. The Growth rate is below 4% and with aggressive testing it has maintained a low positive percentage also.
Jammu And Kashmir – This state saw a huge spurt in cases during the first lockdown. Most of the cases here were either linked to the religious event in Delhi or pilgrims returning from Iran. The state was once a worry state and now has come in the good states
Karnataka – There has been spurts seen in state but overall the state has maintained its low positive percentage and cases/million. The recovery rate is a bit lower compared to its peers but with outcome% also below 50%, the recovery rate may go up.
Kerala – This state was on its way to 100% recovery but with the return of Migrant Populations and Expats, there has been a minor spurt of cases. It will be interesting to see whether Kerala is able to control its cases as it had done previously.
Punjab – Punjab had more or less weathered the COVID19 storm in the first two lockdowns, but a sudden upsurge of cases from the last week of April saw Punjab come in the “Emerging Bad” category in my last article. But it has been an aberration due to infected pilgrims returning from Nanded and Punjab has controlled the situation well, to move in to the good states.
Jharkand – Less number of tests, but lesser cases and growth rate puts this state among the good states.
States to be watched
These states are those states that have either started showing a positive trend i.e. moving from a Worry State to a Good State or a negative trend i.e. moving from a Good State to a Worry State.
Andhra Pradesh – This state is on the way down and will probably move towards the good states in a day or two if the trend continues.
Madhya Pradesh – Another state on the way down. This state was showing alarming trends during the month of April and was a worry state. It has still not completely slowed down but is definitely on its way down
Odisha – This was an encouraging state but recent trends show a very huge growth rate and will probably move to a Worry State soon.
Rajashtan – Another state that was showing huge growth numbers in April has slowed down very well. It had moved down to a good state but another spurt of cases moved it back to States to be watched
Telangana – We are not sure of the numbers for this state as they have stopped reporting number of tests done. Hence we are keeping this state as a state to watch
Uttar Pradesh – Like Rajashtan, UP was also supposed to burst with cases. But UP has maintained its trend, although a lot more testing needs to still happen in UP.
The Worry States
The States that add most to the growth of the Indian cases have been categorized as the worry states. These states have high number of cases, a higher penetration of cases in the population, a high positive% and low outcome%.
Bihar – We had categorized this as an “Emerging Bad” State in our last article. It has now turned as a worry state. It has poor testing, a high growth rate and a low outcome%. This state may become a major problem especially with the migrant population traveling back.
Delhi – Delhi has tested a lot but it still has a high positive% and a high penetration rate. Delhi had slowed very well but with opening up of the wholesale market, cases have started zooming up again.
Gujarat – Gujarat was showing signs of slow down but still has a long way to go before it comes into a good state. high number of cases, poor recovery rate along with a sub 5% growth rate is making this state a huge worry for India.
Maharashtra – The state that refuses to slow down. Even after 54 days of crossing 100 cases the states growth rate of cases is still above 6%. This state has not slowed down once and daily number of cases have just shown an increasing trend. This is the most worrisome state in India, more so because of poor recovery rate also.
Tamil Nadu – A Covid19 explosion in one of its market turned this good state in to a huge worry state for India. This state is seeing a resurgence in cases after it was able to contain very well the effect of the religious event in Delhi, surge. The good part is that recovery rate is very high but still outcome% is very low.
West Bengal – Poor testing, High Growth Rate, very bad recovery rate along with questionable data sharing makes this state a time bomb. This state may explode or already has but we do not have the data for it.
In all, these worry states have to slow down. If they slow down and go below 4% India will see a reduction in cases. Also we should hope that in the coming days the list of Good States increases and worry states keeps going down.
CPM19 – The Road Ahead
On 2nd May, we predicted 75K cases for India by 17th May. There was another projection that the model made which showed more than 100K cases which was rejected as we were quite hopeful that growth trend would stabilize and we will not cross 3000 cases added per day.
This has not really happened and India has infact overshot our number by at least 18k cases. Nevertheless we will still try to predict the number for 31st May using this model.
We have used the CPM model to predict the growth trend for the states basis their classification as The Good State, States to be Watched and The Worry States. The prediction shows that by end of May we may very well be close to 150K cases. That’s another 60K cases in the next 15 days. The good news is that we may start showing a slow down in new cases reported after reaching a peak of close to 4900 cases per day. This may mean that we might start flattening the curve by end of this month.
If our prediction holds true we may see a step towards the end of this pandemic in India although as we said before the road to recovery is a very long one. Also as India continues to ease the lockdown the road ahead may still be very bumpy.
About the Author
Sanjeev Prakash is an Analytics and Marketing professional with more than 12 years of experience in Analytics, Data Management, Sales, Brand Management, Corporate Communications, Market Research and Customer Relationship Management. Sanjeev has an MBA from IMT Ghaziabad and a degree in economics.
Today we are in the midst of one of the largest epidemics that the modern world has seen. As we write this India has been under lockdown for the last 60 days. Covid19 has put healthcare back on the main agenda for most public policymakers. While doctors and hospitals being recognized in this fight, the real soldiers in this war are the nurses. In any healthcare set up, its the nurses who are in the trenches, fighting day in and day out against known and unknown elements. Some time ago we had written about how the nursing services were at the cusp of change. Today we focus on how the role of nurses evolves during pandemics.
Nurses today are leading from front. They are the managers at forefront at bedside of the patients, keeping them on the path to recovery. Therefore it is importatn that we keep nurses motivated and inspired to stay on with enthusiasm in the Covid Era. On this international Nurses Days, we spoke to Col Binu Sharma, Vice President for Nursing Services at Columbia Asia Hospital. Col Sharma entered the nursing profession almost 40 years ago in 1977. She has been in charge of nursing at Columbia Asia since 2007. Today her organization has more than 2000 nurses and technicians in hospitals across the country. Below are some excerpts from the interview
Healthcare India: Nurses are the backbone for our healthcare system, how does their day to day role change during epidemics?
Col Binu Sharma: Articulating the changes in the nurses’ role during a global health crisis is helpful for communicating a plan to decrease the spread of disease and for implementing improved policies, procedures, and supplies. The nurses are not only the backbone of the health care team but they are the most important link in the health care delivery system.
During epidemics, the nurses become the “role models “rather than merely playing various day to day roles. The role of the nurse changes to adapt to the needs of the patient, their families, the hospital, and the community. During such crises nurses take up leadership roles at the forefront like this time in the fight against Covid19. They not only add to the development of policies to fight epidemics or pandemics but they also prepare for, identify, respond to, and direct recovery efforts from global epidemics that require an informed, coordinated response.
Healthcare India: What kind of training is provided by the nursing colleges to handle these situations as part of the curriculum?
Col Binu Sharma: In the revised basic nursing curriculum the Indian Nursing Council has included 100 hours of theory & 160 hours of practical to teach budding nurses on the various aspects of epidemiology & standard treatment protocols. For community health practical the nurses are put in clinical areas in the remotest villages & they are introduced to nursing care services in resource limited setting and they are given ample opportunities to link theory to practice in these sort of situations.
In fact the entire nursing curriculum and training is about learning to face the most complex and adverse situation with positivity & humility.
Healthcare India: What measures and steps have you initiated in your career to help nurses deal with epidemics?
Col Binu Sharma: We have initiated many steps including
· Improved engagement and networking
· Providing job security and reassurance, Flexi hours, psychological counseling and support to relieve anxiety
· Encouraging fun activities, quiz and other relaxation measures
· Focus on their health screening, regular meals, hydration, power breaks, resting zones in hospital. Transport to pick up and drop
· Provided with digital platforms, webinars to connect for training, live demos and team communication
· Provided scope for continual training & development. Formulate revised SOPs based on protocols from various authorized national and international resources. Training on Infection control procedures, employee safety, and patient-related revised disease protocols
· Supporting with adequate resources, manpower, medical disposables. Ensuring quality and quantity of personal protective equipment and other safety attire
· Encouraging team spirit by listening to their needs, regularly talking to them, helping them, guiding & mentoring them and most importantly leading the way
Healthcare India: What are your recommendations that we are better prepared for the future?
Col Binu Sharma: No amount of preparedness can predict success or failure in the future but being prepared always helps us to develop a positive outlook.
Factors like creating awareness among the community, development of infrastructure of the health care system especially in rural areas , educating the population at the rural sectors, providing safety & security to health care workers may help us deal with future occurrences of epidemics & pandemics in a much more coordinated manner.
Keeping our nursing workforce well trained with mock drills on disaster preparedness
Keeping database of ready nurses to be hired in case of such emergencies
Developing mentors for taking higher responsibility
Engaging and education society in some of the recommended measures of hand washing, social distancing, respiratory hygiene, sharing right information with hospitals are some of the regular improved measures.
It’s good to see nurses leading the fight, but as Col Sharma says in her interview, a lot of care and thought has to be given to keep the nurses encouraged and prepared to deal with the ever-changing complex scenario that has become Healthcare in India.
In the last week of April 2020, a septuagenarian in the state of J&K who was a renal dialysis patient for 2 years, was asked to get his next round of dialysis from a private nursing home as the hospital where he normally went for treatment refused the dialysis procedure since the entire hospital was converted into a COVID care center. The nursing home neither had the apt infrastructure nor the skilled personnel to handle any kind of complications that is common during a dialysis. Unfortunately, the patient died in less than a week. Another dialysis patient in Mumbai had to wait for 7 hours for treatment as he was not carrying his covid test result report. Around 1,30,000 patients are on dialysis in India and most of them depend on private dialysis centers.
In another caustic case, last week, a 25 yr old pregnant woman in Delhi, visited 2 of the leading government hospitals in Delhi for antenatal care. Both the hospitals denied her admission as she was not Covid-19 positive. As a result, she visited 6 hospitals and maternity clinics in next 48hrs before giving birth outside AIIMS. Many hospitals and nursing homes are completely shut even if one case comes up in them.
There are a plethora of such cases rising across the country as our healthcare system is under stress from managing the contagion outbreak. This is despite the fact that the Government of India has asked state chief secretaries to ensure that hospitals and clinics do not ask for a Covid test report from every patient who requires medical treatment. This raises red-flags and serious questions on the local authorities and regulatory bodies who have also threatened to cancel the operating license of hospitals and clinics if they turn away any non-Covid patient. Patients also fear the escalated economic cost if their treatment cost is not claimed or reimbursed as not all nursing homes and clinics fall under health insurance policies.
Similar danger mounts on Cancer and TB patients. India has the world’s largest TB load of 25%. In Mumbai, due to COVID, lack of adherence to TB drug regimen has risen to 40% from 15%. A significant decrease in TB notification has been witnessed which indicated that access to a TB center and subsequent diagnosis and reporting has been severely hit. These are dangerous signs which are being ignored. A TB patient can infect 10-15 more, and such patient can become a breeding-ground of new Coronavirus cases as Covid hits hard on low immunity patients. Many senior oncologists have claimed that due to difficulty in travelling during lockdown, many hospitals not providing regular treatment, hospitals shutting down and fear of contracting covid, have resulted in a delayed diagnosis of cancer patients which can push them to an advanced stage of cancer.
There has to be clear and stringent guidelines by MoH to each state health authorities highlighting the delirious effect of not providing critical care to non-Covid cases. State should ensure that no patient is denied treatment for any ailment by a hospital (government or private). Instead of shutting down the entire hospital even for one covid case, a wiser approach of creating zones within the hospital can be implemented. Online, phone consultation and Tele-medicine modules should be made widespread thorough proper communication channels.
Our healthcare infrastructure is one of the weakest in the world with a lack of adequately qualified health care professionals adding to the woes. We certainly can’t afford to inflict more burden on the already fragile healthcare services by denying treatment to those who are in need.
About the author
Dr Sumeet Kad is a Healthcare and Artificial Intelligence Leader, focusing on leveraging technology to create a model for affordable care