Categories
Public Health

India and COVID19 – The Story So Far and the Road Ahead

Late January, a medical student fleeing from Wuhan became the first confirmed cases of SARS-Cov-2 in India.1 Couple of her classmates also contracted the virus and India made its initial entry into a leader board no country wants to lead. The three students largely remained asymptomatic and recovered with a month, ending India’s first tryst with the virus.

The second wave started at the end of February. By now, SARS-Cov-2 had spread to 64 countries / regions across the world, with South Korea and Italy reporting over 1,000 confirmed cases. But it is quite possible there were cases in India long before that. It was only in in May that we found that the virus had already reached France in late December itself.2 It is quite possible that the virus had reached India from Europe long before we started screening the flights coming from Europe.

Nevertheless, as confirmed cases started gradually increasing in India, the Central Government took a bold step in locking the country down for three weeks to prevent the spread of the virus. Many countries were opting for lockdown to tackle the virus, but the step by India was a bold one for two reasons:

  1. Lockdown is a strategy for the rich. It meant many will have to live off their savings and those who can’t will have to be protected by the government. US alone has provided for over 3 million via unemployment benefits.3 India, with perhaps the largest number of poor people in the world, would have struggled to provide for those getting unemployed due to lockdown.
  2. It would have taken a phenomenal effort to enforce the lockdown given the size of the country and population density in certain parts. The only comparable country is China, which can rely on heavier surveillance than India could enforce.

By 14th April, Goa, the North East and East India excluding West Bengal were largely unaffected by the virus and had limited the number of cases to less than 100. States like Haryana, Karnataka and Kerala had managed to control the spread as well and showcasing more than one-fourth recoveries.

But it was already evident by then that many places in the country where the infection had reached the community.

Though India officially denied community reach of the virus, on 10th April, Indian Council of Medical Research (ICMR), which was coordinating India’s Covid19 response (Which in itself was odd since there was already another organization fitted for it – Integrated Diseases Surveillance Programme (IDSP) 4) had recommended 36 districts be prioritized to target Covid-19 containment activities. This was based on the Sentinel Surveillance study done till 2nd April.5

By 3rd April, India recorded a little over 3,000 cases of SARS-Cov-2. This was spread across 255 districts in 30 states and union territories. Incidentally, only 66 districts had reported more than 10 SARS-Cov-2 cases then.

And ICMR was recommending stricter containment in 36 districts.

As the economic cost of the lockdown became more apparent, India went on a period of staggered release of lockdown after 14th April. But as expected from a country with community transmission of a virus, India showed a consistent increase in cases as norms got relaxed. What was 104 districts on 24th March, when lockdown started, it became 379 on 14th April, 489 on 4th May, 564 on 17th May and with the last release on 31st May – 654 districts have seen confirmed cases of SARS-Cov-2 across the country.

The Road Ahead

Image 1 – Italy

Image 2 – India

After a long three month struggle, Europe is finally starting to hope they can move beyond Covid. While most of the European countries peaked in cases late March, they have seen a gradual decline in cases over two months.

This long tail foreshadows what we may see in India. But for that, we have to reach the peak first. So, we can expect considerable pain, both from Covid and the economy, for at least the next two months before things start to get better.

The 66 districts that saw more than 10 cases on 3rd April, now account for 66% of the SARS-Cov-2 cases in the country.

As cases increase, hospitals get stressed and treatment gets delayed. This leads to an increase in fatality rate. While India is doing remarkably well with around 7,500 dead from 267,000 SARS-Cov-2 cases (2.8%), there are over 100 districts with a fatality rate of 3.7% and above. The ones to watch out for over the coming weeks:

Jalgaon (Maharashtra), Dhule (Maharashtra), Kolkata (West Bengal), Solapur (Maharashtra), Aligarh (Uttar Pradesh), Meerut (Uttar Pradesh), Dewas (Madhya Pradesh), Patan (Gujarat), Khargone (Madhya Pradesh), Amravati (Maharashtra), Nashik (Maharashtra), Mathura (Uttar Pradesh), Gorakhpur (Uttar Pradesh), Sagar (Madhya Pradesh) and North 24 Parganas (West Bengal).

All these districts have shown consistent growth the past week and has high fatality rate. With more testing, it may be possible to weed out the SARS-Cov-2 carriers and catch patients early, although districts like Kolkata and Nashik may already be stressed, given the high number of cases there.

Ujjain (Madhya Pradesh), Anand (Gujarat) and Panchmahal (Gujarat) have seen low growth in cases recently, but has an overall high fatality rate. Increasing testing in such places may reveal the extent of the spread, since high fatality rate may be due to late stage discovery of the disease.

On a positive note, there are 48 districts that show a high growth rate in cases with a less than 1% fatality rate. This would indicate better testing and good potential to keep a check on the virus. These include Chennai (Tamil Nadu), Chengalpattu (Tamil Nadu) and Gurugram (Haryana). All of the three districts have recorded over 1,000 SARS-Cov-2 cases

Among the 25 districts that have over 1,000 cases, Indore (Madhya Pradesh) and Jaipur (Rajasthan) have shown the slowest growth rate the past week, indicating a positive road ahead.

Late March, George Gao of the Chinese Center for Disease Control spoke to Science Magazine about the road ahead with SARS-Cov-2 – Trace all SARS-Cov-2 carriers with mass testing, Isolate the carriers and trace out their close contacts, Quarantine and isolate the close contacts.6 As we officially start to slowly unlock our economy in June, despite the numbers on the rise, it will be a difficult road ahead for all of us in India.

A century ago, the Indian subcontinent was the biggest graveyard for the Spanish flu virus. In all probability, we are again headed there and the only way to have some form of control is to trace the infected early by mass testing and ensuring strict quarantine of the infected and their contacts. We also need a workable serological test7 to determine who have already been infected (and not initially traced) so that they can get back to work.

By Ranjith Kollanur

Bout the Author

Ranjith Kollanur is the Managing Parter with the Unseen Ink,

1https://www.outlookindia.com/magazine/story/india-news-wuhan-to-kochi-an-indian-medical-students-great-escape-from-epicentre-of-coronavirus/302922

https://www.bbc.com/news/world-europe-52526554

3https://www.marketwatch.com/story/a-staggering-number-of-laid-off-workers-are-receiving-more-money-from-unemployment-benefits-than-when-they-were-employed-2020-05-26?mod=article_inline

4https://idsp.nic.in/index1.php?lang=1&level=1&sublinkid=5778&lid=3707

5https://www.businesstoday.in/latest/trends/icmr-sentinal-surveillance-finds-39-percent-coronavirus-patients-without-travel-history/story/400629.html

6https://www.sciencemag.org/news/2020/03/not-wearing-masks-protect-against-coronavirus-big-mistake-top-chinese-scientist-says

7https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html

Categories
Mental Health

Is India facing Mental Wellness Crises ?

India has always been a spiritual nation. For the last 5000 years, we have believed that the source of our mental happiness and wellness is based on our spiritual way of life.

But the modern mechanical world has in a way disrupted that pattern and in the last 50 years, we have seen an increase in cases requiring mental wellness intervention. We also see an increase in cases where patients need counseling and therapy. While this is still an emerging trend it is believed that this year 2020, more than 20% of our po[ulation needs mental wellness interventions.

Covid19 has exposed the need for the same. It is believed that the number of people requiring treatment is almost 25% more than previously anticipated. Also, the infrastructure in terms of doctors, psychiatrists, and counselors is just not there. To discuss this and more Dr Sumeet Kad and I took up this issue in our third episode of India Health Talk. The link is below.

On the positive side, there is an increased awareness of the situation, also due to the rise of telemedicine, we would see an increase in the number of teleconsultations. However, the key is to increase awareness and not take your mental wellness for granted.

We would love to hear your feedback, as well.

Categories
Public Health

Covid19 Test. Trace. Treat… Are We Doing Enough?

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.

March Numbers

CountryDateTotal TestsTotal Confirmed Cases%Confirmed
SpainMar 18, 2020300001117837.26
ItalyMar 20, 20202068864103519.83
IranMar 14, 2020800001136414.21
United StatesMar 19, 202010394594159.06
IndiaMar 20, 2020145411911.32

May Numbers

CountryDateTotal TestsTotal Confirmed Cases%Confirmed
SpainMay 24, 202035565672823707.93
ItalyMay 24, 202033911882293276.76
IranMay 24, 202078128613352117.08
United StatesMay 24, 202014357969166682911.60
IndiaMay 24, 202029434211326744.50

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.

Key Points:

  1. Positivity rate for India is less vis-à-vis other nations which also got impacted with Covid19 (which is a good sign)
  2. 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.
  3. We should also increase the use of rapid antibody test to ascertain the level of community spread.
  4. 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.

Sources

Data Source: https://ourworldindata.org/covid-testing – March Data

Data Source: https://www.worldometers.info/coronavirus/ – May Data

Categories
Public Health Uncategorized

Privacy Concerns with the Aarogya Setu Application for Covid19

Just this week, we recorded the second episode for the India Health Talk, with Dr Sumeet Kad. During the recording we ended up discussing the privacy concerns around Aarogya Setu, the contact tracing application launched by the Government of India to track Covid19 cases in the country. Aarognya Setu today has more than 10 Crore downloads and is the largest contact tracing application in the world. How do we balance the privacy concerns with managing a pandemic like Covid19? Alo what can we learn about other applications across the world in this space?

While I understand the concerns, in my opinion, during a pandemic we may need to give up some control over our data and privacy for the greater good of society. Pandemic is a national emergency and Covid19 is probably the worst example of it. But using privacy to derail the efforts to combat Covid19 is not a good idea. In the long run this may be our downfall.

Below is the full recording of the episode. Do let me know your thoughts as well.

Categories
Public Health

Evolution, Natural Selection and Public health: A Covid19 Perspective

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

  1. Prodigality of Production
  2. Struggle for Existence
  3. 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

Natural course:

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.”

Nurture Course:

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.

Reference: https://www.pnas.org/content/107/suppl_1/1702

Note: The thoughts are a collation of various anthropological, biological snippets in a structured logical sequence by author.