Mumbai’s experience can be considered for flattening the curve and the Kerala model for reducing the death rate
After almost 16 months into the Covid-19 global pandemic, with almost three months in its second wave, Covid cases are increasing leaps and bound pan India. In April alone, India recorded 7 million, which is more than a third cases since the beginning of the pandemic with 402,110 on the last day of April, 414,280 on 6 May and this is going to grow further as the peak isn’t near. Within a week we will breach the half-million mark, but may not go beyond, as our testing capacity isn’t more than daily 2 million tests. Currently, we are reporting more than half of the global Covid cases and a third of global deaths for the last 10 days. The sudden spurt in cases has resulted in unprecedented pressure on the already over-burdened healthcare system, with Covid-infected patients dying in large numbers, not due to Covid-19 infection alone, but due to delay in getting medical care including that of oxygen support. This has been manifested through the increase in the Case Fatality Rate (CFR) during the last week of April 2021, by a staggering 50%, over its figures of 1.2% three weeks before. CFR for Covid-19 infections is calculated as the number of deaths occurring from the number of infections recorded two weeks prior (and not from today’s infected cases). By far, Kerala is the model state for the record low CSR maintained consistently at 0.3% throughout the course of the pandemic. For last several weeks we had been saying that the current strains of the Coronavirus including double mutants or triple mutants namely—E484Q, L452R, B 1.617, B 1.618 and the UK variant B 1.1.7 are highly infectious but less virulent and less lethal. We believed that like the cases during the first wave, 85% are asymptomatic or mild symptomatic. Realising that proportionately high number of infected people are reporting with symptoms, we deleted the terminology “asymptomatic” and started saying these strains are more infectious and more virulent but less lethal, with 85% of the patients being mild symptomatic, continued saying that the CFR is low, around 0.7%. There was also a belief that as a lot of senior citizens and people with co-morbidities have been vaccinated, that could be contributing to the lower number of deaths in the current wave. Added to this is a new variant N440K, first isolated from Kurnool district of Andhra Pradesh, and found to be at least 10 times more infectious, in the laboratories at Centre for Cellular and Molecular Biology (CCMB), Hyderabad and Innovative Research (AcSIR), Ghaziabad. More so, this strain is found in 5 to 9% of new Covid patients from AP, Chhattisgarh, Karnataka and Maharashtra during last four months. That explains high numbers in these four states.
However, during the last couple of weeks things have taken an ugly turn. We realised that a higher number of infected people were becoming hypoxic, requiring oxygen support, bed support, ICU support and ventilator support. Deaths were increasing—both recorded as well as unrecorded. There was a clear disconnect between recorded deaths with that of the ones at crematoria and funeral grounds. Disturbing visuals ruled last fortnight sending shockwaves not only in different parts of India but globally. The analysis of data of Covid infections during the last six weeks and Covid-related deaths during the last four weeks is revealing. Our initial euphoria based on all those analogies was short-lived. What it shows is that the CFR in India has escalated from 1.2% to 1.8% and then now settled at 1.4% as oxygen supply has been eased.
Similarly, though almost at the peak of the second wave, Maharashtra’s CFR has jumped by 30% in three weeks, from 1% to 1.3%, and more shockingly 44% in the last two weeks, from 0.9% to 1.3% till yesterday. This shows even a so-called wealthy and relatively better prepared state did see higher deaths. It has now settled at 1.2% this week. What have been analysed are only official recorded deaths and not those who have died before reaching healthcare facilities. In these analyses, mere coronavirus or its newer strains cannot be blamed for increased mortality leading to higher CFR in the current wave. A sizeable contribution could have been the want of proper triaging of medical help-seekers—in getting timely medical care including the allocation of bed, oxygen support, ICU and ventilators where triaging has failed.
Triage is a well-documented, effective strategy of staggered degree of medical care, when we face the huge challenges of sudden nature on the healthcare system—be it a man-made, natural catastrophe or a pandemic situation of this proportion. When a large number of people require urgent care with limited resources at disposal, the management decides, classifies and divides patients into multiple categories based on the severity of disease. This could be based on objective as well as subjective criteria but based purely on medical conditions without other factors like rich-poor, influential or commoner etc. It is now standard practice globally and is used effectively during the Covid pandemic. However, barring a few states or cities, it is not used optimally in most places in India. When hospital beds aren’t available home-triage has to be tried and here comes the institutional quarantine as well as Covid Care Centres (CCC) in picture.
Mumbai has used the triage concept during the last several months and that helped staggering and augmenting medical care. Coronavirus has posed a war like situation and to respond to it, the Brihan-Mumbai Municipal Corporation (BMC) has set up ward-level war-rooms deploying teachers and administrative staff dealing with every single Covid report with alacrity—by calling them at home, inquiring after their well-being. Oxygen saturation level, symptomatology, if they have access to separate bathroom, if they have care-givers and then deciding to provide home-care through trained personnel including a doctor or shift them to CCC or hospital as needed by even providing an ambulance service. This has maintained Mumbai’s CFR at 0.7 throughout April 2021, not that Mumbai did not face any shortage of oxygen or beds or medicines or medical care-givers, but things were handled in a war-like situation. However, Mumbai’s CFR has escalated to 1% this week. After the declaration of a partial lockdown termed as “breaking the chain” in the state including Mumbai, came handy in reducing the new infections and flattening the curve. The Mumbai model has to be replicated elsewhere in the country albeit with required local modifications.
After bearing the worst brunt of the Covid pandemic, Maharashtra has finally achieved the first important goal—passing the peak. Whether or not any state has passed the peak can be judged only at least two weeks after the peak. The Covid-19 peak in Maharashtra including Mumbai, may have passed possibly during 11-25 April, could be on 18 April, considering different parameters. Maharashtra has done over 2.9 crore tests and recorded 4,996,758 Covid-19 infections till 7 May 2021 with a cumulative positivity yield (test positivity rate among tested samples) of 17% and has recorded 74,413 deaths due to Covid-19, with a cumulative Case Fatality Rate (CFR) of 1.5%. Whereas some districts in Maharashtra have been successful in flattening the curve, some 12 districts have still a challenging situation. For the matter of record, on the flipside, Nagpur district tops the country in Covid deaths per million population with 1,168 deaths per million and is second in Covid cases per million population with 98,194 cases per million.
Five of Maharashtra’s districts are among the top ten nationally in deaths per million population. Despite the claims of the National Covid Projection Council that India will peak this week, many states are still having severe surges by 50 to 300 times’ jump in the last eight weeks since 10 March 2021, considered as baseline, when the Covid graph of India was lying dormant barring Maharashtra and Kerala. As a matter of fact, Bihar has jumped from 44 daily cases on 10 March to 13,466 cases on 7 May (306 times); no reason than sheer neglect can be attributed to this. Whereas Uttarakhand, the host state of Kumbh Mela has jumped from reporting 36 cases on 10 March to 9,642 cases reported on 7 May (268 times). The election-bound state of Assam jumped from reporting 22 cases on 10 March to 5,626 cases on 7 May. The states of UP, Rajasthan, MP, West Bengal are all grappling with high daily reported infections as well as deaths. Hence, the other states may see the peak only after a few more weeks and till then burdening the already stretched healthcare system.
The parameters used for deciding the peak are:
1) DAILY RECORDED CASES: Maharashtra recorded 68,631 cases on 18 April 2021, which is the highest single-day number of Covid-19 infections in the state since the pandemic began. From 4 April to 17 April, Maharashtra’s recorded daily cases were between 47,000 and 67,000.
2) COVID-19 POSITIVITY YIELD: The downward trend is not linked to low testing numbers. In fact, the daily testing numbers have been on the higher side. Of the 2.5 crore total tests done, 51 lakh tests are done in the last 26 days, an average of 2 lakh daily and a record 289,535 tests on 25 April. The cumulative positivity yield was 14.4% on 2 April and 16.5% on 26 April. The positivity yield with 68,631 cases in 273,272 tests done on 18 April 2021 was 25% and came down to 20% on 7 May 2021.
3) ACTIVE CASES OF COVID-19 INFECTIONS: Looking at active cases’ parameter, the highest number of active cases of 699,858 was on 22 April, whereas it has been on a downward trend since then, with 654,758 on 7 May. The highest addition to active cases, 29,331 was on 4 April and the highest recovery of 74,075 cases was on 23 April.
4) DAILY DEATHS DUE TO COVID-19: Maharashtra recorded the highest number of daily deaths on 28 April 2021 at 1,035. The decline in deaths is seen two weeks later, as active cases at peak will keep on recovering and some will end up in some deaths at a gap of around two weeks.
Passing the peak is indeed the most important goal; however, subsequent surges can come, as seen in several countries of Europe. India being a vast country, some states may have different peaks. We cannot lower our guard. Mask remains the most important tool and prevents infections from any of the variants and mutants of the coronavirus, and the next being the vaccine; which has another historic day in its trajectory with the beginning of universal vaccination starting 1 May to cover even the 18-44 age group. Challenges are there, so also solutions and opportunities. Human work with admirable capacity during crisis was on display last fortnight. Let us hope that unitedly we can conquer the coronavirus sooner than later.
Dr Ishwar Gilada is Mumbai-based Consultant in HIV and Infectious Diseases, Secretary General Organised Medicine Academic Guild (OMAG), President, AIDS Society of India (ASI) & Governing Council Member, International AIDS Society (IAS).