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Friday, 10 April 2020

THE CORONA COMBAT – THE THIRD REVIEW BY LT GEN P R SHANKAR (R)-ex DG ARTY




Please pass it on to your fiends. They will feel proud to be Indians. 
Others will wake up to India. We are ahead of the curve. We will stay that way.



General

It is Day 15 of the lock down. 3/4th of Phase 1 done.  Phase 2 fast approaching.  That stupid Chinese Virus has not made much head way in India. We are ahead of the curve. India battles bravely and resolutely. The world is starting to look at us and say – hey , what are these Indians doing right? Even WHO has praised us. The PM has spoken to all the CMs, Cabinet, Past PMs, Past Presidents and the Opposition. That is good. There is no politics in Corona. All states are in full swing. We are in it together – all for one and one for all. All communities can sink or swim together – no choice baby.  

The Corona Virus has done some good also. Pollution levels are low. CO2 emissions are down by more than 25%. Climate change negotiations could not achieve this. Do not say this loudly. The Chinese will say it is because of their global leadership! Incidentally there were reports that people in Jalandhar were able to see Himalayas .  A few days more and all the Sardars there will start seeing Rockies! Then you will have to wonder which Corona effect they were talking of? The Virus or the Beer?

The government has taken very stringent action as per the data put out by Oxford COVID 19 Government Response Tracker. That is clear from the map above and graphic below. It is indeed commendable. The worlds most populous democracy with such a high rate of success in implementation. Sure there have been blips. That is to be expected. The economic stimulus response may seem low. However businesses can wait. The needy need to be attended to. That is being done. I am also sure that the Government has kept its powder dry and has some reserves left. In this battle, the reserves, their deployment and recreation will matter. Take it from a salty old Gunner. The least cost approach will do well ultimately. We must be proud of what we have achieved so far. We need to just do more.  

                                                     

 Enemy

The enemy has not mutated as yet but has clearly  revealed it’s a slow festering fuse which attains critical mass and erupts with a fission rate of 2.5 if left unchecked. It has not yet surfaced fully in India. It has started spreading through asymptomatic people also. Stealthy. In China, Singapore and Japan it is re-appearing in a second wave. Singapore has gone into a 30 day lockdown. Japan has declared Emergency.  

Overall Assessment. We have to kill it or it will hit us hard in multiple waves. Its either the Chinese virus or us. Take your pick. However till we get a vaccine we have to live with it. It will be an endemic disease till we attain herd immunity either naturally or by design.

Own Forces

Current Status

Climate.  The temparature are varying between 29-36 deg C with night time temps around 21-24 degs.

Cases . The current status state wise is as below 
STATE/UT
CONFIRMED
ACTIVE
RECOVERED
DECEASED
WEST BENGAL
91
75
13
3
UTTARAKHAND
31
27
4
-
UTTAR PRADESH
332
308
21
3
TRIPURA
1
1
-
-
TELANGANA
404
348
45
11
TAMIL NADU
690
664
19
7
RAJASTHAN
348
321
25
2
PUNJAB
99
77
14
8
PUDUCHERRY
5
4
1
-
ODISHA
42
39
2
1
MIZORAM
1
1
-
-
MANIPUR
2
1
1
-
MAHARASHTRA
1018
875
79
64
MADHYA PRADESH
290
248
21
21
LADAKH
14
4
10
-
KERALA
336
263
71
2
KARNATAKA
175
146
25
4
JHARKHAND
4
4
-
-
JAMMU AND KASHMIR
125
118
4
3
HIMACHAL PRADESH
27
24
1
2
HARYANA
143
110
31
2
GUJARAT
175
136
25
14
GOA
7
7
-
-
DELHI
576
547
20
9
DADRA AND NAGAR HAVELI
1
1
-
-
CHHATTISGARH
10
1
9
-
CHANDIGARH
18
11
7
-
BIHAR
38
22
15
1
ASSAM
28
28
-
-
ARUNACHAL PRADESH
1
1
-
-
ANDHRA PRADESH
314
306
5
3
ANDAMAN AND NICOBAR ISLANDS
10
10
-
-
TOTAL
5356
4728
468
160

Hot Spots . 20 hot spots and 22 likely hot spots have been identified by the Government. These are increasing. 

Outlier Events . There are a few outlier events which have occurred which have an overall bearing on the overall situation.

The Tablighi Markaz event has turned out to be a pan India problem with many infected members moving to and fro from many districts in the country. As result infection must have transmitted much beyond; despite the contact tracing efforts. They will surface after 15 Apr only when the incubation period is done. It has a bearing on the lock down period.

The Migration fracas must have taken infection into rural areas. Though there are reports that these migrants have been traced to their villages and put in isolation camps. The efficacy of such action is suspect. This time bomb is an unknown quantity and will go into fission mode only after 15 April.

It is very common that people disregard common cold and cough in the lower income groups, specially in heart land India. Hence many cases could go unreported. It has two facets. The young population of India, and many of them are migrants, will be able to/might come out of it without reporting. Simultaneously herd immunity is building. The problem is that there is undetected transmission going on at fission rates which will burst on us after two weeks when critical mass is achieved.  

All these indicate that the Chinese Virus must be pulled out of its hole like a cobra. Which means lock out has to continue.

Gearing Up. The entire country is gearing up for Phase 2 of the battle. We are now battle hardened.  

Assessment. The Chinese Virus is still in Stage 2 with limited community transmission in hotspots.

Harvest. Beyond 15 April is harvest time. This has to be factored in all calculations. It is unthinkable that harvest activities are curtailed.

Data Co-Relationship

Fatality Rates and Case Discovery Rates. Everyone says ‘Test, Test and Test’. The feeling is that we are not testing enough. Hence, data from countries badly affected in the temperate zone, tropical zone and an outlier (S/Korea) were analyzed. (base data from https://www.worldometers.info/coronavirus )The true indicator of prevalence of disease in the country is death and hospitalization; if you cannot test enough. Another indicator is - for the number of tests being conducted how many cases are being discovered or are surfacing? This analysis was done for 05 and 08 Apr and has been tabulated.  Focus on the fatality rates, and the case discovery rates columns. View it from any parameter, Indian rates and actual numbers are the least. An analysis of data from these tables indicates the following: -

COUNTRY
08 Apr 2020
CASES
CASES/Million
DEATHS
DEATHS/M
TESTS
TESTS/M 
FATALITY RATE /M (%)
FATALITY RATE /M (%)
(05 Apr)
CASE DISCOVERY RATES
CASEs/TESTs (%)
CASE DISCOVERY RATES=
CASEs/TESTs (%)(05 Apr)
Temperate Zone
USA
400412
1210
12854
39
2075739
6271
3.22
2.76
19.29
18.8
SPAIN
141942
3036
14045
300
9.88
9.48
ITALY
135586
2243
17127
283
755445
12495
12.61
12.32
17.9
18.9
GERMANY
107663
1285
2016
24
1.86
1.48
FRANCE
109069
1671
10328
158
9.45
8.41
IRAN
62589
745
3872
46
211136
2514
6.17
6.1
29.64
29.96
UK
55242
814
6159
91
266694
3929
11.17
10.3
20.71
22.8
NETHERLANDS
19580
1143
2101
123
86589
5053
7.96
9.89
22.61
22.04
Tropical Zone
INDIA
5351
4
160
0.1
140293
102
2.5
2.33
3.81
2.79
SAUDI ARABIA
2795
80
41
1
1.25
1.176
PAKISTAN
4035
18
57
0.3
39183
177
1.66
1.66
10.29
8.2
MEXICO
2785
22
141
1
25410
197
4.54
4
10.96
12.06
Outlier
S KOREA
10384
203
200
4
477304
8996
1.9
2
2.17
2.21

In all parameters India is at almost the lowest levels.

Temperate region countries are very badly off as compared to tropical countries. Hence it would be fair to say that we will not be so badly affected.

Deaths and number of cases are low in India. There is a similarity with Pakistan being in the same belt. This is crucial since India went into a stiff lock down whereas Pakistan did not.

Very interestingly the number of cases surfacing for the tests we have conducted is among the least. The testing rates are akin to S Korea! Even if we increase the cases by 20 % and decrease the tests by 20% , the case discovery rate stays below 6%. So what does this tell you? It tells you quite a few divergent things as under: -

The disease is not prevalent or transmitting at rates as seen elsewhere. It is far slower. The lock down is clearly working.

This could also be due to other factors like rising temperature, BCG vaccination factor, natural immunization due to exposure of Indians to multiple virus / Other endemic diseases.

Kerala was looked at separately since it is one of the earliest affected states due to a high level of overseas traffic and migrants. It has 275 cases and has tested 11232 persons. Its case discovery is 2.44%. it approximates to the national average (http://dhs.kerala.gov.in/wp-content/uploads/2020/04/Daily-Bulletin-HFWD-English-April-7-1.pdf).

We might be testing the wrong persons. Possible. However the probability is low.

Cases are not being reported even for testing. Hence transmission is taking place unchecked without our knowledge.  

Even if there are a lot of unreported cases, hospitalization and death would have spiked. That has not happened. However it would be prudent to monitor deaths due to other diseases. If this is true, it might burst on us one fine day in the next week or so.
  
It is also possible that unreported cases have recovered or in self-recovery mode due to the youth factor. In which case two things are happening. The youth dividend is paying off and herd immunity is increasing.  
The disease is increasing in spread in India. In other countries it might have peaked. However for us, it is on the upswing. The worst is ahead of us.
   
WE HAVE SLOWED DOWN THE FISSION RATE. WE HAVE BOUGHT TIME. WE SHOULD UTILIZE IT. WE HAVE THE OPPORTUNITY TO LOCALIZE IT AND BOTTLE IT.

Spatial Distribution Granulation

The number of cases in the country needs to be granulated to district level. The data for all districts of TN and Punjab are given below. Data for the rest is also freely available. A look at the granulated data tells you quite a few things: -

TAMIL NADU
690
ARIYALUR
1
PERAMBALUR
1
KALLAKURICHI
2
RAMANATHAPURAM
2
THE NILGIRIS
4
SIVAGANGA
5
TIRUVANNAMALAI
5
KANNIYAKUMARI
6
VELLORE
6
KANCHEEPURAM
7
NAGAPATTINAM
11
THANJAVUR
11
TIRUPATHUR
11
VIRUDHUNAGAR
11
SALEM
12
THIRUVALLUR
12
THIRUVARUR
12
CUDDALORE
13
THOOTHUKKUDI
17
CHENGALPATTU
20
TIRUPPUR
20
VILUPPURAM
20
KARUR
22
MADURAI
24
THENI
24
RANIPET
26
ERODE
27
NAMAKKAL
28
TIRUCHIRAPPALLI
31
TIRUNELVELI
38
DINDIGUL
45
COIMBATORE
64
CHENNAI
152
PUNJAB
99
BARNALA
1
FARIDKOT
1
KAPURTHALA
1
PATIALA
1
RUPNAGAR
3
MOGA
4
MANSA
5
JALANDHAR
6
LUDHIANA
6
HOSHIARPUR
7
PATHANKOT
7
AMRITSAR
10
SHAHID BHAGAT SINGH NAGAR
19
S.A.S. NAGAR
26
FATEHGARH SAHIB
2

The spread is from urban areas to rural areas. The rural areas are not yet affected as much as urban areas.

However we need to watch for outbreaks. We should be able to free up the rural belt first.

The number of hot spots in the country which need to be focused upon emerge very clearly, if one sees all districts

Many districts have few cases. Districts/cities which need bottling, and those which can be freed out comes out from this granulation. After all if a district has a few cases only, it can be opened with precautions.

Districts which are lowly affected are our reserve capacities.

A fatality rate and case discovery rate analysis along with the demographics of the districts will tell us how to handle each district individually and a state collectively.

This Chinese virus needs to be handled at district level by district-based local systems.   


Herd Immunity. A virus is defeated only if herd immunity is built. Herd immunity is built either through vaccination or exposure. Vaccination is 18 -24 months away. Exposure means huge amount of people infected and diseased. Limited experience suggests immediate exposure means an overwhelming load on the health care system beyond India. Lock down only postpones the problem to buy us time. Hence we need to go into a controlled herd immunity program through staggered and planned exposure. Even that is possible only if we know that a person who has been infected does not get back the disease. We need to work on this very seriously since this is a long haul enterprise as said by the PM. Moreover, many of our people may also be acquiring herd immunity without our-knowing it. Trap this data and mainstream it. 

Key Lines of Operation

We are in it for the long haul. The key lines of operation which started in Phase 1 have to be practiced and reinforced all the way through. These are reiterated in point form below :-
Intensify testing, tracing, treatment, teamwork, and tracking and monitoring.. Break the transmission chain. 
Increase surveillance, vigilance and monitoring social, political and communal disruption.
Continue to build up capacities in medical and health care equipment.
Institute public and private behavior norms of social distancing, isolation, mask wearing, spitting, public urination. Make violations a punishable offence.
Carry out extensive door to door surveys and build data.
Carry out public hygiene activities scrupulously including disinfectant sprays, garbage disposal anti malaria spray
Put out norms for protection of the aged above 60 years. Separate queues, entry, counters etc.
Put in place crowd sourced apps for local resourcing and amenities.
Institute population control measures. Reverse migration should be expected.
Plan for de-congestion of overcrowded facilities through railways so that patients are moved from overwhelmed hospitals into neighboring ones even if out of the city/ district/ state. Inter state / inter district coordination must be instituted.
Security of health care workers is still a concern, mobilize local help and provide security to them. This is of paramount importance.
MLAs, MLC, MPs and all-party leaders must move into their constituencies and mobilize local resources to fight the Chinese Virus. They should provide leadership. They cannot appear only at elections to ask for votes. Mobilise community leaders, celebrities, local thinkers to assist and guide the overall effort. 
Testing. Testing capability and execution in the country has been ramped up. Additionally the Rapid Antibody Based Blood Test has been approved for use and will go into effect any time now. The strategy for this is in the graphic below. Taking into consideration the way the virus is panning out in India; the testing capability is presently ok. The only danger is that there could be a sudden explosion of the Chinese Virus due to the outlier events that could put things totally out of gear.   

Containment and Hotspot Management

Going forward it is important that all Governments, center as well as state, have a robust containment and hotspot management capability. This will be needed well into the future till such time a vaccine comes up. Already 20 hotspots are being tackled and 22 are under surveillance. We have had experience at state and district levels. These need to be built upon. Some important issues are highlighted in succeeding paras.

Kerala and Bhilwara Models.

Kerala was one of the states hit early and had lot of cases since many Keralites have extensive foreign contact. However despite the spurt in cases things are under control. They are a model as to how a state has put things under control.

Bhilwara in Rajasthan was an early hotspot put under lock down on 20 Mar, even before the nation went into lockdown. They have undertaken steps to ruthlessly contain the Chinese Virus. Today there are no new cases in the district.  This model has been adopted as the base model for the national containment plan.

An amalgamation of these two successful models and suitable adoption in various states, districts and cities as per local conditions will pave way for eradication of this disease.   
  
Government Policy. The government has quickly put together policies and procedures for various issues. The website https://www.mohfw.gov.in/ is very useful. Visit it once a day. Latest policies include Containment for large out breaks( https://www.mohfw.gov.in/pdf/3ContainmentPlanforLargeOutbreaksofCOVID19Final.pdf), Guidelines for quarantining ( https://www.mohfw.gov.in/pdf/90542653311584546120quartineguidelines.pdf), various training schemes for medical staff and Strategy for use of Rapid Antibody Blood Test for detection of cases.

Decentralization.  This battle must be fought in villages, cities, townships, districts, municipal corporations and states. It can and must be enabled, facilitated and coordinated at the center. It cannot be fought from the PMO or the CAB SECs office. Decentralization is the order of the day. Very significantly, that is being done.

Lock Down Options

Many options are available for lifting the lock down. Kerala Government has come out with a three-stage plan. In the previous review a five-stage plan was outlined. Whichever way one looks at it. The lockdown must be lifted in a staggered manner as per local conditions. The response must be flexible, differentiated and reversible. Whatever the option chosen – prepare the people for it. Give some time for preparation – mental and physical. For example summer is approaching. Water security and provisioning is an issue especially in water scarce areas and cities. local administration needs physical response time to act.  Similarly harvest activities must commence and norms must be put in place. Think through and anticipate. Each one of us has to put his/her hand up and make it count.  


WE HAVE A LONG HAUL AHEAD
NEED TO STAY PATIENT , DETERMINED AND RESOLUTE
SO FAR ALL INDIANS HAVE HEAVED TOGETHER
THERE IS NO REASON TO FEEL PESSIMISTIC
IN FACT THERE IS LOT OF OPTIMISM
WE HAVE EVERYTHING TO GAIN
IF
WE ARE TOGETHER 
WE WILL KICK THIS CHINESE VIRUS BACK TO WHERE IT CAME FROM

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