Situation today (updated 10-May-20 12:20 IST):
Many CoVid-19
vaccine trials are underway across the world. However, it is unlikely we will
have one which is widely available before March 2021. There is no known therapeutic cure. The antivral drug Remedivisir has the promise of reducing about four days from the total recovery time of two to eight weeks - this is no big deal! Without testing everyone in the community we have no way of spotting the infected person because of long incubation period of this virus during which the infected persons remain asymptomatic for 5 days (median). Many remain asymptomatic for longer periods and some even throughout the period of recovery! As the infected person sheds virus and infects others it is very important to quarantine him/her. If a community does not have the means of testing for the presence of infection then it must resort to a "social distancing style of living" or a complete lockdown, unless of course it has sufficient healthcare capacity to deal with infected patients in distress - which is experienced by only about 20% of the cases; community may mean one or more persons living in a building, zone, district, State or a Country. Sweden is practicing "voluntary social distancing" without any sort of lockdown and so far its healthcare capacity has not got overwhelmed. Seniors are more susceptible to getting infection and more likely to experience distress, therefore, they are advised to not intermingle with others. Most of the other countries found that their healthcare capacities were getting overwhelmed and they have had to impose a lockdown and force social distancing.
Over the next 12 to 18 months, or until a cure is found, TESTING which is quick, reliable and cheap is of great importance. If Governments donot realise its importance, they will not spend enough on developing and implementing such tests. Without knowing who is positive or negative, Governments will be forced to ask communities to observe "social distancing styles" or lockdowns and this will cause many businesses and economic activities to cease; massive unemployment followed by starvation of the poor, or social disorder, is inevitable in less developed and emerging economies of the world.
At present the Govt of India is not picking up the full cost of lockdown - it has almost outsourced the care of the poor and marginalised people to the States, NGOs and good samaritans. GOI has also neglected relief to MSME units and instead issued an unimplementable diktat to all employers to pay full wages to their workers. GOI seems to be unaware that many workers, including 87% of about 70 million construction workers, are daily wagers and they have no employers! Were GOI to pick up the full cost of sustenance of all poor people, it would perhaps realise the urgency of freeing people and employers to get on with their business. Government must force quarantine of only those that need to be - i.e. identify infected or susceptible or vulnerable people and arrange adequate protection or isolation. Requisite identification cannot happen without having extensive TESTS, or testing capabilities.
Over the next 12 to 18 months, or until a cure is found, TESTING which is quick, reliable and cheap is of great importance. If Governments donot realise its importance, they will not spend enough on developing and implementing such tests. Without knowing who is positive or negative, Governments will be forced to ask communities to observe "social distancing styles" or lockdowns and this will cause many businesses and economic activities to cease; massive unemployment followed by starvation of the poor, or social disorder, is inevitable in less developed and emerging economies of the world.
At present the Govt of India is not picking up the full cost of lockdown - it has almost outsourced the care of the poor and marginalised people to the States, NGOs and good samaritans. GOI has also neglected relief to MSME units and instead issued an unimplementable diktat to all employers to pay full wages to their workers. GOI seems to be unaware that many workers, including 87% of about 70 million construction workers, are daily wagers and they have no employers! Were GOI to pick up the full cost of sustenance of all poor people, it would perhaps realise the urgency of freeing people and employers to get on with their business. Government must force quarantine of only those that need to be - i.e. identify infected or susceptible or vulnerable people and arrange adequate protection or isolation. Requisite identification cannot happen without having extensive TESTS, or testing capabilities.
Many
people are working on developing a faster and a cheaper CoVid-19 test that
detects the infection. The prevalent PCR test costs Rs.4.5K (in India it is free for only those who show ID of Ayush scheme for the poor) and takes days to get
results (testing is done on an imported machine that costs about Rs.20 lacs, testing process takes a batch of multiple samples, say 90, and after a preparatory step of amplification, completes the process of detection in 4 hours - the rest of the delay is in bureaucratic rules - at present ICMR must review the positive cases before the patient can be informed!). rRT-PCR explanation video.
Soon many organisations are going to come out with better tests (faster & cheaper). Self-testing will likely become possible using cheap kits, e.g. Mologic of UK . Others who have announced testing solutions include MyLab, Pune, CSIR's Paper-strip test, Rajiv Gandhi Centre for Biotechnology in Kerala,
If Governments realise the importance of mass testing, they could scale up the present methods but none of them seem to be doing so. USA has an empowering law - Defence Production Act under which the Government can force a private enterprise to produce the needed items or it could take over available capacities to produce needed items. USA has sanctioned 25 Billion dollars for amping up testing. No one knows how much fund has been allocated to develop and deploy testing in India!
Soon many organisations are going to come out with better tests (faster & cheaper). Self-testing will likely become possible using cheap kits, e.g. Mologic of UK . Others who have announced testing solutions include MyLab, Pune, CSIR's Paper-strip test, Rajiv Gandhi Centre for Biotechnology in Kerala,
CRISPR–Cas12-based detection of SARS-CoV-2 and Abbott's Solution.
Second type of tests, called Serological (blood) tests for detecting antibodies are quite quick (five minutes) and cheap (few hundred rupees - less than $10) - the presence of antibodies indicates the patient has recovered from the infection fully or partly - his/her quarantine must continue for two weeks.
Second type of tests, called Serological (blood) tests for detecting antibodies are quite quick (five minutes) and cheap (few hundred rupees - less than $10) - the presence of antibodies indicates the patient has recovered from the infection fully or partly - his/her quarantine must continue for two weeks.
If Governments realise the importance of mass testing, they could scale up the present methods but none of them seem to be doing so. USA has an empowering law - Defence Production Act under which the Government can force a private enterprise to produce the needed items or it could take over available capacities to produce needed items. USA has sanctioned 25 Billion dollars for amping up testing. No one knows how much fund has been allocated to develop and deploy testing in India!
Most
countries, including very affluent regions, have healthcare capacities that are woefully inadequate to deal with
the flood of CoVid-19 patients being encountered - forcing doctors in few places into a triage situation (in which
doctors must select who gets treatment and who is left to die).
The healthcare
system capacities getting busted are of ventilators, PPE, hospital beds and
even number of medics and doctors – everything is in short-supply and no amount
of money can make good the shortage in time to save lives. Cities with best healthcare
facilities are facing a crisis – Lombardy, Madrid, NYC – the CoVid-19 fatalities
in such crisis situations can be unpredictable – definitely many times higher
than the world average of 2%.
In absence of universal, i.e. easily accessible, testing capabilities, inevitably every country has come around to the view that SOCIAL DISTANCING is the ONLY
method to flatten the peak (i.e. reducing the numbers infected per period of
time – or stretching the doubling rate – for e.g. in 3.5 days the number of
infected doubles in NYC). We must control Ro (R naught is the Reproductive number
- refers to the numbers an infected person will infect - 3.37 in Denmark and
1.7 in India in the last week of March'20). Ro has to be brought down below 1 before
the epidemic will die down. ICMR study shows one person leads to 403 people getting infected, in a chain, in one month without social distancing whereas that number drops to 2.5 even with 75% compliance.
LOCKDOWN of a district, state or country, is a very blunt method (conversely, a high precision method would be one that immobilises, i.e. quarantines, ONLY the susceptible or exposed or infected people). Lockdown serves to immediately force down the value of Ro and get a breathing
time to get prepared for the peak infection rates and also flatten the peak. As
a total countrywide lockdown hits the economy which in turn can kill many vulnerable people, each country is soon going to be confronted with having to trade off deaths due to CoVid-19 versus deaths due to massive unemployment and clobbering the economy.
What is the solution?
SOLUTION
to minimise the fatalities and get maximum people to get back to work as early
as possible requires that we identify "relatively safe" people and allow them to
work or play or attend schools and confine others, in a quarantine at home or
some administered facility or in hospitalised isolation in severely symptomatic cases.
SOCIAL DISTANCING IS NOT A SUSTAINABLE SOLUTION. IT WILL CAUSE COLLAPSE OF MANY BUSINESSES AND ACTIVITIES.
SOCIAL DISTANCING IS NOT A SUSTAINABLE SOLUTION. IT WILL CAUSE COLLAPSE OF MANY BUSINESSES AND ACTIVITIES.
Specifically,
this is what every country must do with varying degrees of urgency:
1) Step up testing drastically - prioritise and privatise - let large employers share responsibilities; unfortunately not a single country has announced commitments at a level that is even close to what is required to find smart testing - PCR type tests of different confidence levels are required - cheaper ones (lower confidence level) can be given to households or smaller clinics and the more reliable expensive ones at certified labs which will test the cases filtered by the lower cost tests.
Develop cost-efficient and quick testing solution and do massive testing .. ultimately test everyone - for now, prioritise - start with testing of healthcare workers, as they are exposed to highest viral load;
tests needed for detecting CoVid-19 infection and another serological (blood) test needed to detect anti-bodies in a person who has recovered (or is rapidly recovering) from the infection - because such persons can go to work and they can be relatively safely deployed as healthcare workers where medics are in shortage.
tests needed for detecting CoVid-19 infection and another serological (blood) test needed to detect anti-bodies in a person who has recovered (or is rapidly recovering) from the infection - because such persons can go to work and they can be relatively safely deployed as healthcare workers where medics are in shortage.
To accelerate testing, "group tests"
could be tried - sample of a whole group of 10 or 100 people may be tested in one
go, and if found negative, released as safe; from the positive group half
and half split tests done to release "negatives" - the process
repeated till all the positives are identified. Group testing is a
decades old method - half-and-half method proposed here is the innovation and
it will be quick and cost-efficient until incidence of infection is low (less than 1%) or until tests become really quick and cheap -
- the group sampling method: groupsamples making effort will increase but the testing time will reduce as thenumber of testing devices is the constraint and not the sample taking process
- even a very poor quality test (with a high false negative) is whole lot better than no test.. Prof. Paul Romer (a Nobel Laureate of Economics at NY University) has shown that even 80% false negative calls will reduce by half the numbers needed to be really quarantined or isolated in contrast to a policy in which everyone is immobilised - like in a lockdown. See Links in Medical News below and Paul Romer's interview on MSNBC where he recommends 20 to 30 million tests DAILY in USA.
Privatise: Allow large employers or key sectors' employers to conduct tests of their staff and those found negative, may be issued green code - read about the CoVidApp and coding system below. There is no need to force lockdown on everyone!
Privatise: Allow large employers or key sectors' employers to conduct tests of their staff and those found negative, may be issued green code - read about the CoVidApp and coding system below. There is no need to force lockdown on everyone!
2)
Build capacities of equipment & Personal Protective Equipment (PPE) and build a reserve of trained medics through
a) rapid design - production – approval cycles for ventilators and also plan for rapid redeployment of same ventilators across geographies according to need; provide enough oximeters, oxygen cylinders and masks at local healthcare centres
b) procure PPE from across the world and
c) rapid enrollment of medics and appropriate training for those students nearing completion of their courses
3) Implement an AI - BIG DATA
application called CoVidApp:
- Legislative support needed - implementation to be sanctioned by the Government under a specific legislation
- to be used for the limited purpose of contact tracing of CoVid cases, their contacts to be alerted and providing assistance in enforcement of quarantine and isolation rules; in India, Aadhaar - will serve as the unique identifier for any "resident Indian" (as even foreigners can have one)
- Mandate every individual to wear a GPS tracker band / ring (its removal to be treated as a punishable offense) - we know some people don't care losing their lives but we can reasonably assume most people don't want to die of the CoVid-19 disease
- the unique part number of the tracker device would be mapped to the wearer's id in a central database (the part id could be encoded in an embedded RFID)
- designate authorised Testing Labs to update test results in a central CoVid database
– every individual will have a record in this database which will have Aadhaar number as the identifier with attributes that include - special classification: healthcare worker or law enforcer - essential services provider, current address - last test date - test type (PCR / Serological) - test result - test lab id - co-morbidity..
– the individual will be assigned a colour code dynamically, determined by the CoVidApp:
– Red means PCR tested and found positive (CoVid-19) infected (must be isolated)
- to be used for the limited purpose of contact tracing of CoVid cases, their contacts to be alerted and providing assistance in enforcement of quarantine and isolation rules; in India, Aadhaar - will serve as the unique identifier for any "resident Indian" (as even foreigners can have one)
- Mandate every individual to wear a GPS tracker band / ring (its removal to be treated as a punishable offense) - we know some people don't care losing their lives but we can reasonably assume most people don't want to die of the CoVid-19 disease
- the unique part number of the tracker device would be mapped to the wearer's id in a central database (the part id could be encoded in an embedded RFID)
- designate authorised Testing Labs to update test results in a central CoVid database
– every individual will have a record in this database which will have Aadhaar number as the identifier with attributes that include - special classification: healthcare worker or law enforcer - essential services provider, current address - last test date - test type (PCR / Serological) - test result - test lab id - co-morbidity..
– the individual will be assigned a colour code dynamically, determined by the CoVidApp:
– Red means PCR tested and found positive (CoVid-19) infected (must be isolated)
- Yellow means
– suspect as s/he has been exposed to a +ive case or is partly recovered post-infection (requires to be quarantined); initially, on the day of roll out of the App everyone who has not got a test done, will be assigned Yellow code, i.e. s/he must get a test done ASAP
- Green
means – PCR tested and found negative, CoVid-19 free, (can move about)
-
Blue means
– two weeks elapsed since serelogical test showed presence of anti-bodies (that develop post-infection); least likely to get infected due to certain degree of immunity (can move about)
Based on experience and analytics (using AI), the colour codes will change - a Green Code will change to Yellow if it is found that a repeat test is called for after certain number of days or certain intensity of infection in a hot spot. The user will be warned that his/her status may change and that s/he requires a retest!
Based on experience and analytics (using AI), the colour codes will change - a Green Code will change to Yellow if it is found that a repeat test is called for after certain number of days or certain intensity of infection in a hot spot. The user will be warned that his/her status may change and that s/he requires a retest!
The CoVidApp will trace all
contacts, of a "positive", who will be ordered to be tested and they will be assigned
yellow code until test is done; CoVidApp will send SMS alerts to concerned people - including enforcement authorities
The CoVidApp will report to police and other authorities, truant behaviour of a "positive" person (red) or a
suspect (yellow) – such people cannot freely move about as they would be asked
to get quarantined or isolated;
Only those who are tested and found negative will be allowed to move about (assigned green or blue codes).
The CoVidApp will respond with the colour code when a query is made using Aadhaar number - of course the user would have to authenticate his/her Aadhaar through bio-metric (fingerprint scan, iris scan or facial recognition). The CoVidApp could send the user a text answer - Green Code or send a QR code in appropriate colour - the QR Code could contain information of aforementioned attributes and the quarantine or isolation location registered by the user.
China has been doing something similar... the technology and infrastructure exists in India too (in 90% area) - cost of "GPS band" will
have to funded - by the Govt.
If the Government plans to do hundreds of millions of test per month, the cost of rRT-PCR could drop to perhaps hundred rupees per test. 1.3 billion people if tested TEN times over one year, the cost would add upto Rs.1.3 trillion. If we quadruple it, the cost would be Rs.5.2 trillion - India's GDP of over Rs.200 trillion will otherwise take a hit of Rs.20 trillion or more (10% dent is assured due to both lockdowns and "social distancing").
Read Prof. Paul Romer's notes here.. https://paulromer.net/ or watch his 6-minute interview here..MSNBC interview of Prof Paul Romer His Q&A published in The New Yorker: https://bit.ly/3biSZmw
The cost of implementing the above solution is small when compared to the hit GDP will take by immobilising all the workers of the county for weeks on end or running the risk of a second or third wave of CoVid-19 - at present no one is sure of the development of "herd immunity" after a significant proportion of the population gets infected. UK went down that path and retracted its policy at considerable cost and grief; soon UK will become the worst managed case in Europe.
The GPS tracking devices are available for less than Rs.1K. Adaptation for wearable bands will not take any time and the cost could be knocked down to half or less due to economies of scale. The per head cost of implementing the above solution will be less than Rs.1K. Any other solution that will be sustainable until the whole world gets vaccinated is likely to be more expensive and riskier. In India, we have to budget only Rs.1 trillion for implementation of this solution!!
For those with data privacy concerns - the tracking and contact tracing measure is going to be temporary - the GPS band wearing mandate can be removed post vaccination of population. The data collected could be deleted after a specified lapse of time (of few months). The Government legislation will have to make this explicit - also who will be allowed to access this data.
GOI's NIC has released an app - Arogya Setu app which World Bank has acclaimed as smart. Arogya Setu tries to raise alerts based on owner's GPS coordinates and a Bluetooth handshake; the app needs user's permission to keep GPS and tracking and Bluetooth ON always. If a phone comes in close proximity with a known positive owner's phone the app will trigger alerts. The problem with this system - requires ALL users to have smartphones with the app loaded - less than half mobile subscribers have smartphones in India - and the users can cheat - they can leave the phone behind and roam around or carry someone else's phone. Arogya Setu could be enhanced to provide the CoVidApp functionality described above but the legislative enablement must precede.
Summary of prescription:
Invest in and fast-track: Testing Solutions, PPE - Ventilators
Legislate: Mandate wearing GPS tracker linked to AADHAAR and permission to track through CoVidApp and use the data for the limited purpose of combating pandemic and delete the data after vaccination of population is completed
Develop: CoVidApp & GPS tracker
Implement: On-board CoVidApp + GPS tracker and TTT (Trace - Test - Treat) and Quarantine, Isolate suspects & patients
Incarcerate: defaulters reported by CoVidApp to the police
Read Prof. Paul Romer's notes here.. https://paulromer.net/ or watch his 6-minute interview here..MSNBC interview of Prof Paul Romer His Q&A published in The New Yorker: https://bit.ly/3biSZmw
The cost of implementing the above solution is small when compared to the hit GDP will take by immobilising all the workers of the county for weeks on end or running the risk of a second or third wave of CoVid-19 - at present no one is sure of the development of "herd immunity" after a significant proportion of the population gets infected. UK went down that path and retracted its policy at considerable cost and grief; soon UK will become the worst managed case in Europe.
The GPS tracking devices are available for less than Rs.1K. Adaptation for wearable bands will not take any time and the cost could be knocked down to half or less due to economies of scale. The per head cost of implementing the above solution will be less than Rs.1K. Any other solution that will be sustainable until the whole world gets vaccinated is likely to be more expensive and riskier. In India, we have to budget only Rs.1 trillion for implementation of this solution!!
For those with data privacy concerns - the tracking and contact tracing measure is going to be temporary - the GPS band wearing mandate can be removed post vaccination of population. The data collected could be deleted after a specified lapse of time (of few months). The Government legislation will have to make this explicit - also who will be allowed to access this data.
GOI's NIC has released an app - Arogya Setu app which World Bank has acclaimed as smart. Arogya Setu tries to raise alerts based on owner's GPS coordinates and a Bluetooth handshake; the app needs user's permission to keep GPS and tracking and Bluetooth ON always. If a phone comes in close proximity with a known positive owner's phone the app will trigger alerts. The problem with this system - requires ALL users to have smartphones with the app loaded - less than half mobile subscribers have smartphones in India - and the users can cheat - they can leave the phone behind and roam around or carry someone else's phone. Arogya Setu could be enhanced to provide the CoVidApp functionality described above but the legislative enablement must precede.
Summary of prescription:
Invest in and fast-track: Testing Solutions, PPE - Ventilators
Legislate: Mandate wearing GPS tracker linked to AADHAAR and permission to track through CoVidApp and use the data for the limited purpose of combating pandemic and delete the data after vaccination of population is completed
Develop: CoVidApp & GPS tracker
Implement: On-board CoVidApp + GPS tracker and TTT (Trace - Test - Treat) and Quarantine, Isolate suspects & patients
Incarcerate: defaulters reported by CoVidApp to the police
=====================================
What we already know about SARS CoV-2 virus:
It
mutates (article). It seems to do more damage to
the respiratory systems of older people (above 60 years old). It can create
mild sickness or it can create severe sickness. Younger people generally get
mild sickness.
For one
year, until a vaccine is found, SARS-CoV-2 will continue to infect people who
in turn will infect others unless they are identified and quarantined or
isolated – those who develop anti-bodies after having recovered from CoVid-19
may not get infected again – though few cases have been reported of recurrent
infection in Korea as well as China. This means repeated tests may be required
regularly on persons declared as disease (CoVid-19) free. Aforementioned CoVidApp will send message to a Green coded person to retest at the nearest location.
As of
date there is no cure for CoVid-19; only supportive care can be provided which includes
ventilator support for breathing in acute cases – many times ventilator support
has to be continued over 20 to 25 days. One afflicted with CoVid-19 can remain
asymptomatic and get cured even without him or her knowing. An asymptomatic
person can infect others who can suffer acutely, and unfortunately the
incubation period is of 2 to 14 days (the duration before which the symptoms
manifest).
Based on
largest datasets, mostly from hospitalised cases, China’s CDC reported:
about 81% of the cases are mild, 14% require hospitalization and 5% require
ventilator and critical care management. The deaths reported are mainly among
elderly population particularly those with co-morbidities.
One
infected person infects multiple persons if s/he is allowed to come in contact
with other people – the infection is carried through droplets discharged from
the mouth of the CoVid-19 infected person. The virus in the droplet can survive
for several hours to few days depending upon the type of surface and it enters
a new victim through the mouth or eyes. Until one is tested, one should assume
that s/he is an infected person, therefore, for the sake of others, each
individual must wear a face mask – any ordinary mask over the mouth will
prevent droplets with virus flying across and falling on another individual or settling
on surfaces which others may touch. So as a matter of routine, everyone who is
tested and found negative (green) is exempt from wearing a mask, all the rest
must wear one.
-------------------------------------
References:
17-Apr-20 The Economist - App based contact tracing
17-Apr-20 The New Yorker - Article by Max S. Kim: South Korea's bold experiment with an App - it alerts people who may have crossed the path of a person who tested positive. Users have conflicting views how much info to disclose - the patient's identity, place of residence, names of shops and restaurants visited?
Actually, the App need NOT disclose route or names at all. CoVid19App proposed above can just inform those likely to have been exposed - with the location and time when they were exposed. Such people's Colour Code ought to be made yellow, if it was green, (suspect - needs to be quarantined until tested and found negative):
CoVid-19 simulation models : https://www.evernote.com/l/AlewYomwslROlodqozgWqdtcHCaQ15wTalc/
Medical News, Research and tips on coping up with CoVid-19: https://www.evernote.com/l/Aldubgb4SbVN6IJ2LXjWWwkHtgeoUPwKwr0/
Corona Virus CoVid-19 - spread - tests - strategy to
minimise fatalities:
https://www.evernote.com/l/AleCSHb_kDhFF5JMA409OCdcZ5_BsxqaSSs/
https://www.evernote.com/l/AleCSHb_kDhFF5JMA409OCdcZ5_BsxqaSSs/
Corona carnage - good or bad for Globalization? For human
progress?
https://www.evernote.com/l/Alffc41npaZCJJjkHY2oW8xFXnuphJUOZ2s/
https://www.evernote.com/l/Alffc41npaZCJJjkHY2oW8xFXnuphJUOZ2s/
CoVid-19 is natural and not man made in a lab
https://www.evernote.com/l/Alc6DCudvFRMopK4LsQFka3WJj4JlGg7mlY/
https://www.evernote.com/l/Alc6DCudvFRMopK4LsQFka3WJj4JlGg7mlY/
