Figures: Truth Opinion and Challenge

Destroying Models

Opinion and truth, make a strange couple. Opinions, are created. It can even destroy truth.  Loud anchors and doctored visuals dish out facts distorted beyond recognition, tell-tale marks intact, persuading us to believe. As truth lie buried deep, opinions cloud our thoughts and dictate our actions. Welcome to the world of prime-time TV discussions!

The prime-time discussion one day was dedicated to the figures of seroprevalence in the country. Results of the fourth round of national sero-survey conducted by the ICMR had just become 'known'. Some participants seemed genuinely concerned. One, visibly upset, was breathing fire.  

“Look at the serosurveillance figures! Kerala is the lowest in the country! Their immunity is the lowest. One of the smallest states, the biggest contributor to covid cases in the country, more than half the country’s cases from there.”

In another outburst on a regional channel a self-depreciating participant lamented,

“The Kerala model, touted as the best was an illusion.”

A state, acknowledged for its efficiency in handling epidemics, was under intense criticism.

People with poor immunity? Super spreaders?

What is the Truth?

Speaking Figures

Yes; Kerala really has the lowest seroprevalence figures in the country.

State	Seroprevalence	State	Seroprevalence
MP	79.00%	Punjab	66.50%
Rajasthan	76.20%	Telangana	63.10%
Bihar	75.90%	Jammu & Kashmir	63.00%
Gujarat	75.30%	Himachal Pradesh	62.00%
Chhattisgarh	74.60%	Jharkhand	61.20%
Uttarakhand	73.10%	West Bengal	60.90%
UP	71.00%	Haryana	60.10%
Andhra Pradesh	70.20%	Maharashtra	58.00%
Karnataka	69.80%	Assam	50.30%
Tamil Nadu	69.20%	Kerala	44.40%
Odisha	68.10%

Kerala is also reporting large incidence of daily new Covid infections. Kerala component exerts significant influence on the national figures.

     * Figure corresponding to 23^rd Jul seems to have been clubbed with that of 24^th. [i]

On 3^rd Aug, of all the new cases reported in India, 55.54% was from Kerala alone, a huge jump from 45.78% the previous day.

In all fairness to seething anchors, most of them clearly with not-so hidden agenda, and party spokespersons, present solely for pushing political ends, every word of the facts placed were indisputably true. However, the inferences drawn and accusations being heaped were bordering the ridiculous. Claims of great work by spokespersons of parties in power and accusations of incompetence by others, both beg rebuttals. Commercial and political compulsions demand rhetoric. 

 

Implications of Seroprevalence

Seroprevalence indicates the population segment that has developed antibodies. People develop antibodies to novel coronavirus, either through infection or vaccination. One doesn’t necessarily have to fall sick with infection to acquire antibodies. Asymptomatic and unreported infections also produce antibodies.

According to the survey, 79% of the population in Madhya Pradesh, as against just 44.40% in Kerala, has already acquired the antibodies. As a corollary, it also means that above 65% of those in Kerala are still susceptible to covid infection. States with high seroprevalence are likely to have lesser cases of covid infections since they may be close to achieving herd immunity.

Why does Kerala have such low seroprevalence?

  

Complacency?

Initial days of infection clearly overwhelmed the infrastructure. There were countless heart wrenching stories of people dying without getting beds in hospitals. Many having managed beds, faced shortages of ventilators and even oxygen. Isolation of patients was the only way to control the wildfire-like spread. Thus came the National lockdown, followed by series of State controlled lockdowns. Everyone, everywhere was shouting “social distancing” to ‘flatten the curve’! The flat curve containment strategy aimed to slow down the rate of infection, preventing medical facilities from being overwhelmed.

Kerala was the first state to report covid infection. Given an estimated total population of 3,53,36,581as on 08 Aug 2021, it has cumulatively reported 34.9 lakh cases of covid, second only to Maharashtra, leaving all populous states behind! It means that only 9.88% of its population has contacted covid! What about seroprevalence numbers? There is a gap to be bridged!

The apparently low, 44.40% seroprevalence effectively means Kerala succeeded in restricting infection and keeping about 65% of its population away from infection even well into the second wave, no mean feat for the densely populated state. The state actually flattened the curve and successfully staggered the spread. By any standards, it is an amazing epidemic control activity. Political animosity, inability to read and understand figures should not diminish the sheen of a gigantic achievement.

Mortality and Infection

The numbers in the public domain are those which the states officially report. It is commonly believed that all states, despite vehement denials, underreported covid infection and mortality. Such reports with statistics are in the public domain, though not officially authenticated. Interestingly, even those reports reveal that Kerala has the least under-reporting!

Deaths, irreparable loss for those affected, do become statistics. Despite best efforts Kerala too reported many deaths.  

Deaths, when considered as a percentage of infection, Kerala seems to have controlled, despite rising figures of infection. Primary health centres and the medical fraternity deserve credit.

The state’s covid mortality rate is also well below the national average. 

Achievements aside, why is infection increasing?

Policy flaws? Implementation deficit? 

Is there something that we are missing out?

 

Price of Compliance?

Experts hold the aggressive delta variant responsible for the return and increase in infection world over. If the delta variant alone was responsible, then numbers would have shot up across India. That is apparently not happening.

Why is Kerala then different from others?

Wide spread underreporting aside, it is possible that the population in other states have already been exposed to the virus and have already acquired antibodies. Therefore, they now show lesser numbers. Kerala enforced masks amongst the population. Keralites who had taken instructions very seriously now find themselves most susceptible to the virus! Numbers certainly point to it.

With neighbours insisting on RTPCR tests each time, ignoring vaccination certificates, crossing over into Tamil Nadu and Karnataka has become a costly affair for Keralites.

Kerala seems to be paying a price for compliance.

 

Boundaries of Science

The scientific community has consistently changed its opinion about Covid and its spread. From ‘spread by physical contact’ that led to harsh ‘social distancing norms’, medical fraternity seems to have now settled for ‘aerial route’ as the favoured mode of spread. The society has moved a long way from patient victimization to home isolation and micro containment policies. 

Accept it or not, it is very clear, that Covid is here to stay for good and that we will have to live with it. Our survival so far, is less about our scientific and medical competencies but more about survival compulsions of the virus itself. Corona virus is mutating fast, not for acquiring more lethality, but with the aim of prolonging its own longevity, which can happen only if its human host is alive.

Hold our pride and arrogance back, it is the existential compulsions of the virus that grants us the mercy of survival. We need to augment our efforts in that direction. Hitting herd immunity at the earliest is our best escape route.

 

We, The Herd

Coronavirus is not bound by geographical, political or religious boundaries. It does not differentiate between caste, creed, colour, gender, and doesn't bother for any reservation schemes. Politicians can manage data and manipulate visibility. But the virus seems to deliberately ignore them and prove all divisive theories wrong. The only effective way forward is to consider all the people around as part of the same herd. Faster the herd attains immunity, better it is for each member of the herd. This is possible only through very aggressive vaccination programs and not by sustained isolation.

 

Vaccine Management

Vaccination may not prevent infection. but as of now we know, it protects. It hits even those vaccinated but with relatively less severity.

The most susceptible region as of now is Kerala. Authorities must move in quickly and vaccinate each one in Kerala. It’s a tall order considering the current process of vaccination. As on 08 Aug, only 62,69,657 people in Kerala have received both the doses. It makes just 17.74% of the population. That leaves the authorities a humongous 82% of the population to be protected.

In absolute numbers, considering the total requirement of 7,06,73,162 doses for 3,53,36,581 people, a total of only 2,13,03,626 doses (1,50,33,969 first & 62,69,657 second) have been administered till 6^th Aug. It leaves the administration with the burden of administering 4,93,69,536 doses more. Considering the state’s vaccination abilities, (5,06,397 doses on 24 Jul and 4.91 lakh doses on 24 Jul) the target is not difficult to achieve. If Kerala can earnestly adhere to four lakh shots a day, it will still take 124 days to cover the population.

 

The Challenge

The Health Minster has a challenge on her hands. The real challenge is vaccine availability. That rests with the Central Government. It will be prudent for the central government to push the maximum quantum of vaccines to Kerala, with lowest seroprevalence.  With an efficient network of primary health centers and medical workers at par with the best in the world, the task can be considered accomplished.

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[i] All figures used for the graphs here have been culled from the government site in the public domain. The figures against 23^rd Jul have been shown as zero. However, the figures of 24^th show substantial spike indicating likelihood of the two days figures getting added.

RIDING THE THIRD COVID WAVE

Ant and The Grasshopper

The story of the ant and the grasshopper must have been narrated countless times in our childhood. The ant survived the famine and the famished grasshopper perished! Most of us, forced to by our kids or grandchildren would have re-narrated the story with all the sound and action to make it captivating. The last line is often about the moral of the story! They say all these childhood stories convey some profound message, which we conveniently forget as we grow up. 

Let us recall the story in another setting!! The 'covidian' setting!

Did it evolve naturally or was it synthesised for weaponisation? Even as debates rage, accusations denials and counters fly, covid continues to wreak havoc across the world. The second wave was deadlier than the first and everyone is now talking of a third. 

Will there be a third wave? Will it be deadlier? Then what do we do?

What Numbers Say

A distinct rise, a fall and the relative calm thereafter is referred to as a pandemic wave. Lethality dictating intensity of affliction and virulence dictating spread, differ from region to region. India weathered the first wave without much damage compared to others. Mistaking the calm before the storm as the end, we declared victory. But the storm struck again.

A comparison of figures available in public domain in respect of the top ten covid affected[1] countries throw light into the magnitude of affliction.

	Country	Total Population	Total Cases	Total Deaths
1	USA	33,27,70,250.00	3,40,43,068.00	6,09,544.00
2	India	1,39,23,45,967.00	2,80,47,534.00	3,29,127.00
3	Brazil	21,39,34,926.00	1,65,15,120.00	4,62,092.00
4	France	6,54,05,173.00	56,66,113.00	1,09,402.00
5	Turkey	8,51,64,357.00	52,42,911.00	47,405.00
6	Russia	14,59,91,530.00	50,71,917.00	1,21,501.00
7	UK	6,82,10,816.00	44,84,056.00	1,27,781.00
8	Italy	6,03,80,707.00	42,16,003.00	1,26,046.00
9	Argentina	4,55,73,096.00	37,53,609.00	77,456.00
10	Germany	8,40,28,088.00	36,87,715.00	89,051.00

 

In terms of infection rate, Andorra, a tiny European country with a population of 77,378 leads the table with infection rate of 17.74 % that translates to 13,727 in absolute terms. The USA, with 10.23%, at 13^th spot of rate of infection leads the list in absolute numbers with 3,40,43,068. India with infection rate of 2.01%, stands 105^th but comes second[2], in absolute numbers.

In absolute numbers of covid deaths, India stands third. However, with a fatality rate of 1.17% amongst the infected, it stands 139^th. Compared to many advanced countries, COVID has been kind to India. Percentages are dangerously innocuous. Increase in percentages impacts countries depending on the population size. For a large population base, even one point increase can mean colossal numbers. One percent for India, translates to a humongous 1,39,23,459 infections. At the current fatality rate of 1.17%, it means 1,62,904 people more dead. While the numbers are large by themselves, the economic and social cost of losing citizens especially young would be huge.

The second wave was characterised by increased fatality. How the third wave would impact whom remains a speculation. If bravado of the grasshopper about doing better than other countries in competitive covidian statistics consumes anyone, it may tempt them to let guards down. It can be a terrible mistake. Only ant-like single-mindedness can prepare countries adequately enough to face the third wave. With a huge population to take care of India has a lot to do.

Combat Strategy

A two-pronged strategy of ‘Prevention’ and ‘Intervention’ is required to tackle the third wave. Prevention is the best weapon against COVID. Quantum of beds, oxygen, doctors and medicine etc required will be inversely proportional to the success of the preventive measures. More successful the preventive measures, lesser required the medical intervention. With one new variant being called an “absolute beast”, it is wise to be the ant and be prepared for the worst.

Prevention The Remedy

The primary focus of the government and citizens in the war against covid, must be prevention. Prevention has many facets.

Physical Distancing. It is proven that physical proximity greatly curtails spread. Physical distancing (NOT Social distancing) between people can drastically cut infection. This can be enforced by lawfully restricting movements of people and preventing congregation and maintaining stipulated interse distances between themselves. This can be successful only if citizens participate voluntarily and wholeheartedly. Such participation can come about only through building awareness. If physical distancing can be truly enforced, the third wave can definitely be defanged.

Masking. It is now confirmed that the disease spreads mostly through air. Though there are conflicting reports on the efficacy of masks in reducing spread of infection, it is widely believed that probability of infection can be greatly reduced if citizens use masks correctly. Pulling up a mask over one’s mouth and nose only to escape law enforcement doesn’t actually help. Use of mask must come voluntarily and correctly.

Vaccine Protection

The accepted practice to curb spread of a pandemic is universal vaccination. The probability of spread of epidemics considerably reduces in an immunised population. This should have been easy for India, the vaccine hub for the world. Analysis, of how we have done so far, done purely for administrative purposes and devoid of political aims, can help evolve strategy for future. 

                   https://dashboard.cowin.gov.in

The Numbers. As on 03 Jun, 21,98,43,531, doses have been administered through 33,996 (32878 Government & 1118 Private) centres. 17,56,89,202 were first doses and 4,41,54,329 second doses. 21,98,28,465 doses (19,48,14,503 Covishield & 2,50,13,962 Covaxin) have officially been given to 21,98,43,531 people, saving 15,066 precious doses through careful handling. 3.17 % of the population have been inoculated and 9.40% partially vaccinated. 

Citizens can legally receive vaccines only after registration on the government portal. As on 03, Jun only 25,73,76,403 citizens (only 18.49% of the 1,39,23,45,967 population) have registered for receiving vaccination. This low figure could be attributed to any one or more of contributing factors like vaccine hesitancy, access to portal or lack of awareness. This calls for serious policy thoughts and introducing incentives or penalties for registering.

The highest single day vaccination was 2,47,46,875 on 03 Apr. If the government pushes to maintain this figure it will take only 102 days more to immunize the country. But even those who have registered find getting slots for vaccination a challenge. This has come about due to vaccine shortage and the current policy.

Capacities.  According to available data, India has a total installed capacity of 8.2 billion doses per year. This includes capacities of “SII, Bharat Biotech, panacea Biotech, Sanofi’s Shanta Biotech, Biological E, Hester Biosciences, and Zydus Cadila”[1]. In addition, different vaccines are expected to be imported. Prima facie the entire population can be vaccinated twice over in one year. Unfortunately, things haven’t worked out this way. What then is holding India back?

Complexities. Underutilised capacities, pricing fiascos, and confusion over sourcing have added to the complexities. Introducing different types of vaccines to overcome shortages or provide flexibility have only added to the complexities. However, these can be surmounted even now. Three factors have to be ensured; vaccine willing people and the bridge between them. Here lies the visible challenge!

Medical Intervention

Despite the best of intentions and implementations virus will slip through and there would be infections. Since the infrastructure seemingly got overwhelmed, patients were advised to stay home till they developed serious complications. Left to non-medics and a combination of ignorance, aggravated by asymptomatic infection, high incidences of happy hypoxia and lack of access to emergency support, many succumbed. The high fatality rate of the second wave could have been different if all patients irrespective of their conditions were placed under medical supervision. That is the real challenge!

Covid has very serious and unpredictable pattern of attack. It needs medics and medicines. Faster the response better the treatment. Facilities have to me made as close to the population centres as possible to elicit credible results. A chain of treatment facilities, akin to evacuation and management of causalities in army, that takes cases depending on severity should be designed.

Kerala Model. Kerala steals a march over others in this regard. Rather than creating and operating unwieldy mega facilities it continues to micro managing. The primary health centres in each village or panchayat is the first line of defence against the attack. It is these facilities that continue to play stellar roles in curtailing fatalities. If the state had mandated even patients with mild symptoms to PHC care, Kerala could have seen very few fatalities.

First Line Treatment Centres (FTC)

The most effective way forward to handle the third wave is to open as many small centres, twenty to thirty bed capacity, as near to the people as possible. Every case reporting must be attended to and tested for covid.  In fact, it will do the community good to encourage people to report to the FTC at the slightest doubt. With antigen tests and such other tests becoming more available, covid can be detected early on.

Those confirmed positive must be taken in and kept under medical care. It will separate the patient from others, minimise community spread and ensure better survival rates. Those needing more support can be send up the chain for treatment.

Many railway coaches were ceremoniously converted into wards. How they have been utilised a cross the country is not known. Every railway station has space to park these coaches. Wherever there is scarcity of infrastructure local administration must be assigned a coach.  These, assigned with doctors and nurses and equipped with adequate medical equipment can become the first line facilities. Thousand bedded mega centres can grab eyeballs and headlines but smaller establishments give outstanding results. It also provides locals to contribute and even provides that many more opportunities to those hungry for media glare to satiate their desire

Medical Hands. The most cited reason for poor rural medical care is lack of doctors and nurses in the front-line treatment centres. Even in this sphere Kerala is a beacon for other states to follow. India has a huge bank of medical practitioners at the house surgency level. These qualified individuals under the guidance of a qualified doctor can handle the point of contact. They can evaluate the patient and send them up to the higher facility if the need so arises. Similarly, we also have a large number of nursing students across the country. They too under the guidance of qualified nurses can augment the fight against covid.

Costs

Covid is an extremely destructive phenomenon and once in a life time experience. It inflicts uncalculatable economic and social costs. Combating it also demands tremendous costs. Preventive measures essentially are disruptive and directly or indirectly impact many economic activities. Restructuring or reorienting existing processes involve costs. Many social functions, part of our culture, would be impaired or altered and they too have serious impact on micro economy. But all these combined could be minuscule compared to the cumulative costs of treating infection post infection activities and deaths.

Preventive measures disrupt life, citizens are used to, and therefore could evoke poor voluntary compliance. Making people see reason is a painfully slow process. It needs concerted efforts to create favourable awareness. It would also need coercive implementation and that could hold political costs. That is where strong and visionary leadership stands apart.

To-do List

Aware of the difficulties of implementing even the most well-intentioned programmes, a list of implementable steps is suggested.

·       Legally enforce physical distancing.

·       Enact and enforce a national policy restricting types of congregations and stipulating numbers needs to be. It may be good to remember that virus doesn’t differentiate or make concessions based on type of congregation.

·       Incentivise production and businesses centres to devise means to stagger staff presence and self-regulate.

·       Adopt and implement concept of micro containment zones where lockdowns are complete in all aspects.

·       Make wearing of masks compulsory by law. Impose hefty fines on anyone breaking masking law.

·       Allow manufacture, distribution and sale of only correct pattern of masks.

·       Regulate price and prevent profiteering.

·       Open at least one micro treatment centres in every village panchayat.

·       Use out of service railway coaches, if need be, to create infrastructure. Allocate them to panchayats/ villages / local governing bodies to manage.

·       Equip these with medical equipment to function as primary covid treatment wards

·       Deploy house surgeons and final year medical students to man these facilities.

·       Similarly deploy final year trainee nurses to meet the need for nurses.

·       All district headquarters to operationalise a control centre operating on common platform to bring about transparency and asset sharing.

 ·       Ensure truthful reporting.

Wisdom in Caution

When initially cautioned about the tenacity of the virus to stretch the human species beyond 2020, many were scorned those who sounded alarms. Declaring the ‘song and dance’ for new year 2021, many ridiculed those advising caution as alarmists and worse, driven by personal agendas. The bravado vanished and those who scorned slithered behind the shadows. The virus continues to test. To beat the virus, whether it was an evolutionary curse or the folly of careless weaponisation only fortitude of the ant can help. Others can be allowed the freedom of the grasshopper. 

[1] https://www.worldometers.info/coronavirus/#countries

[2] Contrary to the prevailing tendency of covid competition, comparison made here is purely with the aim of gauging how covid has impacted the population.

[3] Business Today 14 Apr 2021