India races to number 5 position in the world for COVID-19 cases
Reproductive number
Well, this position (in the number of COVID cases) is one that we could do without. But are we going there? I think so. The way cases have been increasing and unfortunately it is likely thing to happen. Looking to the sheer number of people in India and absolute lack of social distancing and lack of proper usage of masks coupled with density and illiteracy, COVID cases have been multiplying. As we know the R0 (pronounced R zero or R naught) or reproductive number is the average or expected number of people that an infected person could spread the virus when infected. If R0 is greater than 1, then the outbreak will progress to an epidemic. The R0 value of the 1918 pandemic of Spanish flu was estimated to be between 1.4 and 2.8. And for swine flu, or H1N1 virus, in 2009, its R0 value was between 1.4 and 1.6.Because of the availability of specific drug and early availability of vaccines, it was comparatively easily contained. The R0 for COVID-19 is a median of 5.7, as per the study published online in journal “Emerging Infectious Diseases”. So one person infected with COVID can transmit it to 5–6 persons. So the doubling time will be 2–3 days. This situation arises when no measures are taken but due to effect of lock down it improved greatly in India.
Number of infected cases
Unfortunately, we are not in a position to know how many persons are really infected for several reasons: First, the ICMR guidelines states that only hospitalized patients will be tested, which is correct also to avoid unnecessary panic. It is the same situation in many other countries. I have come across so many individuals calling us that they have mild symptoms and they would like the test but it is not possible to do so on an outdoor basis at present. Secondly there will be many asymptomatic individuals moving around in the society who will be positive and capable of spreading the disease, but not tested as they will not go to hospitals. Thirdly, persons in our country are very scared to get admitted in COVID hospitals as everyone knows that they are required to stay alone for 10–14 days and Indians are used to being cared for by a relative when sick. Many are also scared due to all these. I know for a fact that many individuals with mild symptoms stay at home as they know that no specific treatment will be available in hospitals either. They opt to take widely publicized drugs like HCQ and Azithromycin, and also Vitamin C, Zinc and Ayurvedic or homeopathic drugs.
Availability of hospital beds
It is also a fact that vacancy is a major issue in COVID hospitals all across the world. As people don’t know where to go they will move around in different hospitals for admission for moderate symptomatic patients or they will wait outside the hospital for some hours in the hope that some patient may be discharged and their turn will come. Private hospitals have limited beds as compared to the cases occurring in the cities now. The Government is trying very hard to get more beds.I know of patients, even doctors, with COVID symptoms staying at home mainly due to fear of staying in hospitals. This is a worrying trend as some patients will deteriorate, and they may not be aware of progression of the disease. COVID-19 patients develop hypoxia (decreased oxygen saturation in blood) which is also called happy hypoxia, because patients do not become symptomatic till their oxygen saturation drops down to almost 50 % which is quite low. By the time this occurs, they are already in the advanced stage of illness. The cases are still increasing and we hope that the medical facilities will be available to needy patients .
Effect of lock down
The 3 lock downs were very well thought through and executed, but somehow cases are still increasing. They were intended to strengthen the infrastructure and build up medical facilities, and for the breathing space before the sudden increase in cases. It was to flatten the curve. The explosion which we wanted to avoid and which we were worried about should not happen now. But India has already reached to number five position in the world as far as COVID cases are concerned leaving Spain behind. In spite of best effort of government, people still don't maintain social distancing. It is the duty of public to wear masks and to maintain social distancing and frequent hand washing otherwise community transmission will occur in a big way. We are now seeing many cases in doctors and in people known to us. Initially it was the area that was known to hit but now it is the people everywhere getting affected.
Is Prevention feasible now?
The question is how can you prevent it happening to you? If you stay home and don’t meet anyone from outside, and have no communication with anyone at all, maybe you can still prevent it. But if you go to work, go to buy essential things or take a walk on the road or allow domestic help, you will be vulnerable. So the next question is how long can we do all of the protective measures? We don’t know. May be we have to continue for 6 months, or a year or even more. Is it possible to continue life style like that? I don’t know. At least, it is not possible for majority of people.
Case fatality rate
More and more people in India will become infected but thankfully somehow deaths are less in India as compared to the rest of the world. CFR or Case Fatality Rate is around 3.2% in India as compared to around 6% in US, 10 % in Spain, 13% in Italy or 15% in UK. Why? Neither we nor the world know the answer. The relatively younger population in India ( India has only 6% of population above 65 years, The virulence of the virus or the effect of heat (Both of which appears unlikely as not proven scientifically), deaths occurring at home (which does happen in India but which would not go unnoticed if it is in large numbers but as per data, only 22% deaths are medically certified in India), BCG vaccinations or previous Corona infections which causes common cold, (both of which does not have conclusive scientific data), early implementation of lock down which was responsible for the low % of deaths and deaths may rise after unlock which is a possibility. There is also some research regarding host susceptibility, either genetic or other basis which may also be the contributing factor but again this is not proven though there are some studies showing chances of development of respiratory failure or progression of severity may be associated with certain genetic factors. There are also studies on molecular or receptor level basis as COVID binds to ACE receptors in lung and there might be effect of certain drugs acting on these receptors. Many studies are going on and reliability of the studies is also to be assessed.
There are also cases where the report is negative as it has the sensitivity of 70% only, or sometimes it may not have yielded virus due to improper technique in collecting the samples. All these cases, if they have typical symptoms or have pneumonia on imaging studies, they are still very likely to be positive and they may not be counted so. I think there is one possibility that no one has yet thought is the role of intestinal worms in immunity and if at all it has some effect as scientists have shown that the worm infestation may be associated with immunity boosting and people living in slums or low socioeconomic conditions, there are increased incidences of warm infestations. There might also be a role of gut microbiota as a lot of diseases like diabetes have some influence due to them. We don’t know many things as it is a new disease.
In conclusion we have not reached the peak in India, as cases are still increasing. The recovery of cases does not give exact idea in the figurative way. Epidemiologically significant will be reduction in number of cases. We have seen how so many variables are existing in this scenario. When exact theory is not known for one particular situation, many of them are hypothesized. COVID beats them all. Starting from the origin to the spread and pattern of spread to mortality associated factors are all ambiguous. Like a true mystery, we may not get all the answers to the problem but let us hope that we all survive to tell the story.
