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On The Line of Fire?

What went wrong with Padmashri, Padmabhushan Mr. S. P. Balasubramanyam, the legendary singer from India? He was recovering and suddenly he deteriorated and succumbed to the illness.

COVID can surprise you anytime, even in the recovery period. I got another note from social media, of a young doctor, a father of a six-month child – obviously a young family. He succumbed to complications of COVID. He was waiting to be discharged and go home.

Well, these unusual stories are gradually becoming common, and I thought of sharing it with you since doctors are seeing such scenarios very often. What is going wrong? Can we truly control it? Understanding these 10 points may possibly help prevent COVID-19. (Reading time 5 – 6 minutes; Scientific perspective).

(Note: We are planning to conduct a cross cutting expert global advisory session to clarify all relevant questions. We are planning to conduct this half day session before the start of the SECOND WAVE. Please share your questions to me in person or on this page as we are crowd sourcing questions from all).

Well, these unusual stories are gradually becoming common, and I thought of sharing it since doctors are seeing such scenarios very often (Please scroll to the bottom of the blog to see the detailed note). 

I had another gentleman who went to a Salon. He argued that he should support the local economy, a lame excuse. Well, even if he wants to support the local economy, he can donate bigger amounts and support the local economy, like many others who have supported their dependent workforce.  Time and again, I have been sharing rejoinders on awareness and precautions, and I am summarizing those below – 

1. A Constantly Mutating Virus:

The virus is constantly changing. It has a gene called RDRP (RNA-dependent RNA Polymerase) that encodes for an enzyme that makes a template for the RNA’s to produce in copies in billions. RDRP has a vulnerable to mutations and this results in the constantly changing nature of the virus. It is this enzyme that makes a (defective) template resulting in mutations. Every time, RDRP makes a template, it ends up producing an erroneous copy that results in mutant copies with every generation of the virus reproduction. 

2. Comorbidities and Unknown Risk:

Selective comorbidities and risk factors are known,however many are yet unknown. We all now know that diabetes, hypertension, smoking, cardiac problems, asthma, immune-compromised, and other respiratory illnesses predispose to COVID. However, we are seeing several youngsters without any of these comorbidities who are suffering and sometimes succumbing to COVID. 

3. Incomplete understanding of the Impact:

Also, we see that some have comorbidities and dies of COVID, whereas others with similar comorbidities survive despite having COVID. Knowing your comorbidities, science still cannot say if your disease will be asymptomatic, mild, moderate, or severe. 

4. Clean recovery or Long Haul Disease:

Despite the recovery, Science cannot predict if you will be ‘long hauler’, i.e. those have long term consequences. According to few reports, almost 10% to 1/3 recovered patients land up with Long Haul disease. The legendary singer, mentioned above, started showing signs of recovery, including light speech and physical activities. He deteriorated due to post COVID complication and eventually died of post recovery complications. 

5. Status of Vaccines:

Vaccines are in pipeline and serious efforts are being made to develop and durable vaccines but we don’t have one that we can rely upon. 

6. Repurposed drugs but No Specific Drugs:

We have supportive drugs but no specific drugs to remove the virus. We know it very well that HCQ was the mainstay at the beginning of the pandemic. Later, it fell into disrepute. Steroids were questioned and only after the ‘Recovery Trial’ substantiated the use of steroids with a randomized controlled trial, that changed the management of COVID. Tocilizumab similarly came in and had an ignominious walkout after the COVECTA trial. Just a few days back, the Japanese FDA approved Favipiravir. the later drug, with its RNA-dependent RNA polymerase activity, has anecdotal evidence of effectiveness since it’s a proofreading enzyme that renders the removal of nucleoside analog (drug molecule) and despite continue inducing mutations. Changes to the use of these guidelines may be anticipated as well. 

Different modalities of therapy for treating COVID-19.

7. Reinfections:

Several are indeed recovering but several reports of reinfections are emerging. It is a fact that several people are recovering from COVID, however, it is equally true that many lands up with severe disease, and those recovering are having long-term debility and need rehabilitation? 

8. Asymptomatic Spreader:

Are you sure, if you will just get the mild form of COVID or remain asymptomatic? Even if you remain asymptomatic, are you sure, you will not pass it on to your family members and if they get COVID, are you sure, like you, they too will be unscathed?   

9. Herd Immunity:

It is like playing with fire. Some insist that we should expose ourselves to build our innate resistance. Remember, this is not a natural virus, also, it evokes severe inflammatory and immune reactions within the body. It is structured or has been structured to keep changing. Our immune systems are built to remember, called immune memory. The changing nature of the virus renders the previously learned immune phenomenon useless. So even if we expose ourselves, our immunity will not last long. It is similar to Influenza. We see a different strain at least every year. With COVID, we see a different strain every few weeks. 

10. Convalescent Plasma and Antibodies:

Plasma from patients having recovered from COVID-19 has antibodies to SARS CoV2. Plasma, thus drawn from recovered patients helps treat and or contain COVID in infected patients. The earliest experiment was done by Edward Jenner in 1796 when he scratched the fluid from the blisters of a cow suffering from smallpox into the skin of a normal healthy man and induced protection. As we now know, Smal Pox is completely irradicated. Convalescent plasma (CP) uses the same principle, of tapping into existing antibodies for treating existing COVID-19 patients. 

However, there is a catch. CP is nonspecific, ie. it has other unrequired antibodies that may trigger untoward reactions. Also, if the virus itself is changing, those antibodies are ineffective. More so, the antibody levels drop after a certain period. Thus monoclonal antibodies become relevant. Placebo controlled randomized trials are being underway (as of this writing) that will offer solace to the treatment of COVID-19. Antibodies have to be targeting specific proteins called epitopes. In the presence of changing epitopes, it is fluid to understand the reliance on monoclonal antibodies. 

Myriad Complexity –

a) Cytokine and Bradykinin Storm: For the common men, the difference is nimble, it does, however, matter for the doctors though. Cytokine storms – processes in which the immune system overreacts to an infection. Ideally, cytokines disappear once the virus copies reach a threshold. COVID, however, puts the body into an overdrive mode and produces cytokines that ultimately result in damage to the organs. (drives the body to produce the immune system keeps producing them and the organs take the brunt from these excess cytokines). Cytokines are associated with myeloid differentiation and disease severity, concurrently the T cells are reduced as is evident from the reduced numbers of CD4+ and CD8+ T cells in patients with COVID-19. 

b) Kallikrein–kinin system: Irrespective of the pathognomic phenomenon (mechanism of the disease), COVID unleashes vast reaction from your own body to damage itself. Think, of this like a natural defense which is supposed to protect you, has turned up against you, causing a perfect storm to disrupt and incapacitate you.

Remember the fluid build up around the lungs, which is primarily caused by bradykinins. Bradykinins causes the blood vessels leaky and result in edema (swelling) around vital organs such as the lungs (short of breath), muscle (body aches), gastrointestinal tract (diarrhea), kidneys (congestion and rising serum creatinine), and a multitude other clinical features.    

c) Endothelial Nitric Oxide System: Endothelial nitric oxide synthase (eNOS) becomes a potential therapeutic target. Hypercholesterolemia, diabetes mellitus, arterial hypertension, and smoking are associated both to nitric oxide synthesis reduction or degradation increase. This nitric oxide bioavailability reduction is followed by endothelial dysfunction

A Picture is Worth 1000 Words:

A review of the work – A great deal of work has been done in the treatment and or containment of COVID-19 in the last 9 months. LitCOV provides an exclusive insight on the amount of scientific literature exclusively within the field of COVID-19. Based on the data from Milken Institute, select treatment modalities have been captured in the pie chart below (cumulative progress in the treatment of COVID).

Reflections On Human Urge to Move Freely

Our fundamental human urge to move and intermingle has been severely constrained, however, historical evidence shows that no calamities remain constant. If you recollect, no rains, volcanoes, earthquakes, or twisters (andhi) remains forever. One day it wanes and so will this virus, it is nature’s law and this virus too will follow those laws. 

Remember, humanity has a significant resilience built-in and as the history of human evolution shows, it has never been subdued nor will it ever let any event subdue its spirit and independence. However, events have always taken a huge toll and we never know if we are on the line of fire. 

Death of COVID Treating Doctor:

A 38 yrs old male doctor gen practitioner was admitted to our hosp with COVID on the 6th day of illness with 60% lung involvement, SpO2 borderline with mild dyspnoea. He became critical in the next 2 -3 days with a typical cytokine storm. We shifted him to ICU and on NIV. He was quite tachypneic, tocilizumab 2 doses were given and his NIV requirements decreased ..and eventually, after 5 days of ICU stay, he was weaned off from NIV and stable on nasal prongs 4-5 L o2. Later, he was shifted to the ward with oxygen. On the previous day of his discharge, he developed abdominal distension and severe abdominal pain, and constipation. A Ryles tube was passed and was kept NBM, X-ray abdomen showed dilated bowel loops but no air-fluid levels. GI doc advised enema, a CT abdomen was advised, radiologist suspected some bowel ischemia, so the patient was shifted to Ruby Hospital, Pune. After struggling with the consequences of ischemic bowel complications, the patient succumbed due to Sepsis and multi-organ failure.

It is now a routine, to see notes such as the one below, on social media. 

Do you want to be on the line of Fire?

COVID-19 cytokine storm: The anger of inflammation; Cytokine. 2020 Sep; 133: 155151. Published online 2020 May 30. doi: 10.1016/j.cyto.2020.155151 PMCID: PMC7260598; PMID: 32544563

https://www.bio.org/policy/human-health/vaccines-biodefense/coronavirus/pipeline-tracker

https://covid-19tracker.milkeninstitute.org/#vaccines_intro

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Boosting the State of Indian Economy

GDP trend indicates the health of any economy. The economic slowdown is often cyclic and a fact of life. However, the economic woes are all-pervasive and understanding the root causes help in providing insight on how best to fix. Individual countries have different problems, comprising different patterns. Thus the root causes can be broadly categorized into a pattern and individual factors specific for the country and its economy. Often, there is a shared thread between the integrated global market place. Identifying the patterns and the specific individual factors will help in putting up a strategy for revival.

This article articulates the need for a solution within broader problem space for India, which has fluctuated economically from ‘at risk’ (2013), ‘expansion’ (2016) and now again ‘at risk’ (2019). This blog is not exhaustive and does not go into a detailed root cause analysis or detailed solution building exercise. In this article, the author has provided a select set of solutions that would boost the economy, provide opportunities across multiple sectors and ameliorate the problem of the continuing slowdown.

Word Count 2294; reading time 8 – 11 min.

Economic slow down is often cyclic and a fact of life. Slowing down or crash landing of the Indian Economy is an increasing chatter on the internet. However, a closer look will reveal that the recessionary phenomenon encompasses most major economies including the US, China, Japan, Germany, the UK, France, Russia, South East Asia (the so-called ‘Tiger Economies’ of the 2000s), Brazil, Turkey, and oil-rich Gulf Nations. Latin American countries such as Venezuela, Brazil, and Argentina are acutely going through this recessionary distress with revolts and change of ruling Governments. Venezuela is undergoing severe inflation called stagflation that is spreading the contagion across the borders. Poland and Canada are amongst the only few countries that are showing flying colors despite the adverse global economic headwind.

Nations such as Pakistan, Sri Lanka, and many African countries, especially those who have subscribed to the String of Pearls (SOP), Belt and Road Initiatives (BRI), Regional Comprehensive Economic Partner (RCEP) and the 54 nations of the Africa Continent Free Trade Agreement (AfCFTA) will face a massive financial challenge while servicing the burgeoning Chinese loans. Countries such as Pakistan, are on the precipice of falling into bankruptcy. No wonder India quit the Regional Comprehensive Economic Partnership (RCEP) regional trade consortium. 

The economic woes are all-pervasive and the root cause commonly follows select patterns. Individual countries have different problems. However, there is a common shared thread and select individual factors. Identifying the patterns for a specific country will help in putting up a strategy for revival. I have focused on articulating the need for a solution within broad problem areas. This blog is not exhaustive and does not go into a detailed root cause analysis or detailed solution building exercise.

Ignored Global Comparison:

In India, private debt in 2017 was 54.5 percent of the GDP and the general government debt was 70.4 percent of the GDP, total debt of about 125 of the GDP, according to the latest IMF figures. In comparison, the debt of China was 247 percent of the GDP. As of October 2018, it stands at approximately CN¥ 36 trillion (US$ 5.2 trillion), equivalent to about 47.6% of GDP. A key gauge of China’s debt has topped 300% of gross domestic product, according to the Institute of International Finance (IIF), as Beijing steps up support for the cooling economy while trying to contain financial risks. China’s total corporate, household and government debt rose to 303% of GDP in the first quarter of 2019, from 297% in the same period a year earlier, the IIF said in a report this week which highlighted rising debt levels worldwide.

In the United States, total non-financial private debt is $27 trillion and public debt is $19 trillion. More telling, since 1950, U.S. private debt has almost tripled from 55 percent of GDP to 150 percent of GDP, and most other major economies have shown a similar trend. Cumulative debt stands at 40 trillion dollars. Comparative figures from the US reveal that India is not badly hit, considering the numbers released by the Indian Government are trustworthy and credible.

Let us review select Key Performance Indices (KPI’s) of India’s financial health. Here are a few interesting figures from the State Of Indian Economy –

  • GDP growth is at a 15-year low
  • Unemployment is at a 45-year high
  • Household consumption is at a four-decade low
  • Bad loans in banks are at an all-time high
  • Growth in electricity generation is at a 15-year low

The list of highs and lows is long and distressing. But the state of the economy is worrying not because of these disturbing statistics. These are mere manifestations of a deeper underlying malaise that plagues the nation’s economy today. These figures were published in the Hindu, a very reputed and respected daily. When I share independent data from foreign outlets, those are immediately ridiculed as being ‘biased to damage the growing stature of India’.

I was talking with a building contractor friend of mine who has a meaningful business.  When prodded on his state of business, he said, everything is so dry and no new constructions are taking place. This is not my isolated discussion. Every now and then, I do probe these questions to people across the globe and India happens to be on the top. Below is a list of industry verticals that are not just sluggish but in recession (more than 2 quarters of slow down beyond certain percent points).

 

India Economic Slow Down

Industries Impacted: 

  • Manufacturing
  • Farming
  • Auto
  • Construction
  • Airlines
  • Service industry

Impact Equivalence: 

If you factor in the total percent affected, you will notice a major chunk of the population that forms the base of the pyramid, is affected because of the slowdown.

What happens now?

Well, families and business entities are at least losing 34-57% of their revenue. That’s a significant number. Spending goes down and tax collection goes down, tax at the POS (point of sales), tax from earning and tax from the business.

    1. Quantitative Easing
    2. Bad Loans or Risk prone leveraged industry
    3. Global slowdown
    4. China – A special mention
  • Quantitative Easing:

Well, let us borrow now at a cheaper rate from the Govt, or blow up what is saved in RBI (exit RBI Governors), a loan or from outside or print currency.

  • Bad Loans or Risk prone leveraged industry:

We can’t let this to catapult to a state of anarchy. We have to loan where the potential for defaults are high. Banking, Airlines, Telecom ate common examples. These were bankrupt overnight? The most common folks (shareholders) lost the most. Millions of crores of national treasure disappeared in just a fraction of time.

I disagree with “the Hindu” here. Let us understand, corruption was not just prevalent but endemic and all-pervasive. Nothing wrong, if Modi tightened the levers. At least he had guts to do that. No one including the system had shown responsible behavior and if Modi has tightened the noose, nothing wrong about it.

I will elaborate on the reasons where we are going wrong, needless and pointless to blame Modi for all the ills. Devaluation and GST came at a wrong time that confluence along with a Global slowdown, on which Modi had little control.

  • Global slowdown:

India is not alone. China, UK, Germany, Japan, the US, France, Gulf, Russia, Brazil, and many Tiger economies (remember the term for ASEAN economies used in 2000) are significantly slowed down.

  • China deserves a special mention:

China is the worst affected with 100s of ‘Ghost Cities’, flailing international trade pacts (CPEC, ASEAN and The revival of the Silk Road) and the flight of money compounded by the increasing cost of labor. It is gaining a notorious reputation of creating and exploiting poor nation’s solvency, squashing neighbors and selling obsolescence across the globe (recollect how your electrical and other goods specifically made is China have become durable and short-lasting).

India WEF

What should be done?

First and foremost, Modi has to move beyond strongman to strategist. A nation survives on vision and not just statesmanship. I have identified a few areas that will help boost productivity at the individual level, jump start the GDP and improve the health of the economy.

    1. Foundational Infrastructure
    2. Roads and Railways
    3. Satellite Cities and Telecom
    4. Innovation in Farming
    5. Revamp Agricultural Supply Chain
    6. Environment and Pollution
    7. Sewage and Containment
    8. Social Re-Engineering

India Vision and Strategy Continue reading “Boosting the State of Indian Economy”

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Community Cameras Vs Home (Perimeter) Cameras

For Emerald Valley Only. Please forward to residents of Emerald Valley Only.

In general, holiday season in itself is a sufficient reason to see a spike in security related issues. Recently, we saw few security related incidences such as the cone placement or specific homes being targeted. Community cameras are definitely a great option. Several complex issues make the decision making difficult.

I talked about the top ten things that need to be considered while choosing community cameras. As against community cameras, Home (Perimeter) cameras offer an easy cost effective decision. In addition, it is available anywhere (where connectivity is available) on your smart phone. In addition to having cameras, we can supplement those with Neighborhood Watch Sign with Smart Alert. All these will act as deterrence.

Understand, this is deterrence, crime will not stop or be reduced to zero with any of the above efforts. Please visit the link to share your opinion. http://wp.me/p7XEWW-pj

Community cameras are definitely a great option. Choosing a right technology, placing the cameras at vantage points, monitoring those (in real time and historical), archiving, retrieval the saved information and policies on retrieval (viewing data) bear down the decision on proceeding with the cameras. All these activities need resources and we can either explore mobilizing our own home owners doing that or hire outside resources ($125, 000 for five years, a costly option). Thus funding also becomes a critical issue for the success of this initiative.

While we resolve the complex decisions around community cameras, I had suggested earlier using “Dummy Cameras”. The design of those dummy cameras can be made to retrofit, if we decide to proceed with permanent community cameras, once we choose a permanent option. Dummy cameras backed up with signs such as “Neighborhood Watch with Smart Phone Alert” can dissuade or discourage many. Thus, reactivating Neighborhood watch and repainting those signs indicating Neighborhood Watch with Smart Phone Alert will provide an interim workable option.

Below, I have reactivated the polls to collect the community opinion.  Please forward this to anyone within the community. These polls will end on Dec 26, 2016. Please visit the link on http://wp.me/p7XEWW-pj. I have called out the Top Ten Things to consider while placing the community cameras.

Several factors are important while choosing and placing the cameras. Eg. Fixed focal length lenses are available in various fields of views: wide, medium, and narrow. A lens that provides a “normal” focal length creates a picture that approximates the field of view of the human eye. A wide-angle lens has a short focal length, and a telephoto lens has a long focal length.

Top Ten Things to Consider while Placing Community Cameras

  1. Location of the cameras – unobstructed view, redundancy (if one fails or obstructed by a vehicle, alternate place for capturing). Away from Vandalism. Mounting Electric poles or homes where cameras can be
  2. Types of cameras (depth of field) – narrow angle, wide angle regular, pan tilt zoom (PTZ) etc. Wide angle is required at the entrance and exit, where as a narrow angle will be required while focusing on the alley or narrow street. Zooming will help if there is active monitoring. Tilt and pan will serve a similar purpose.
  3. Frame per second – remember, intruders will be very fast and agile in completing their tasks. Higher number of frames per second helps in gathering precise information
  4. Night vision enabled cameras are a must obviously since thefts are like to occur while it is dark.
  5. Cloud storage and safety of the data is critical. While dealing with a cloud solution, you may want to explore if that is from the manufacturer or service provider.
  6. Power option – solar powered are best preferred.
  7. Integrating all the cameras into single dashboard is not a difficulty thing but you need folks with sound knowledge in networking.
  8. Monitoring (do we want real time monitoring?). Who will be responsible for retrieving older information, how long do we save that information etc.)
  9. Policies and Access to Saved data needs an adequate understanding from the users. This is one key aspect that will cause a lot less heartburn if resolved early on.
  10. CCTV and cabling

Don’t forget to account for – 

  1. Installation cost (not the purchase cost)
  2. Maintenance (include services, repair or replacement)

Overall, you need Governance on all these aspects. A group of dedicated folks with experience and or understanding on the different aspects need to handle all issues related with cameras. I know, you might have just thought that I made it so difficult. However, it is easy to install and very difficult to maintain unless you have given an adequate thought to all these aspects.

How about Residential Cameras?

Home perimeter cameras are still a good option. Cheaper, no hassle decision, and monitoring under home owners control (on the Smart Phone). In addition, they provide granular information right until where the incidence is happening (in this case your home). My personal experience has been exceedingly good since the time of placing (Perimeter) Home Cameras. Dummy Cameras on my farm have provided me a lot of safety too.

Use the same 10 principles mentioned above while installing home perimeter cameras.

To conclude  

Multiple layers of security are required to secure our community. Each has its place, advantages and disadvantages. Also, just in case one fails, we have other layers of security. While a decision of installing community cameras is not an easy one, community should explore interim options, such as dummy camera, that are easy to deploy.

Not sure why we wait in closing decisions on issues that matter us universally? Do you think you don’t need this because you will never be affected? Are we waiting for someone to take an initiative? Are we opposed to installing cameras? Simply voice your opinion. It stays anonymous.

Please share your opinion –

To see additional opinion from community members on security related issues or for additional links on below topics, visit documents or links on –

http://wp.me/p7XEWW-8E

The blog mentioned above offers hyperlinks to topics or documents addressing concerns on – 

  1. GUIDELINES FOR PUBLIC VIDEO SURVEILLANCE: A guide to protecting communities and preserving civil liberties
  2. An example of Camera Policies from University of Wisconsin at Green Bay
  3. Code of practice: A guide to the 12 principles (This does not apply to US scenario but it offers good understanding of issues to consider)
  4. Camera Types from Brick House Security (Offers an understanding of different types of cameras)
  5. Principles of Design for Operational Risk Reduction

 

 

Second Surge and COVID-19 prevention

The risk of infection is the same for everyone in that environment, but the consequences of infection are different depending on age, ethnicity, and comorbidities. Are there any formulae to calculate that? Possibly, emperical estimates can be made using known facts. However, remember, humanity is still in the discovery phase of COVID. We have identofied few risks factors, eg. Comobidities. However, a complete risk stratification is not yet available. Neither do we know who will have mild, moderate or severe disease. (On Behalf of COVIDRxExchange)

Now that aerosols are established as factors disseminating COVID, it is important to realize that COVID is persistent in the air. A few days back, I had a gentleman eating food in a restaurant or the patio of the restaurant. As usual, my relationship made me ask a few questions about his understanding of the disease. He said if we can eat outside food at home, why can’t we eat outside food in the restaurant.

Let us understand and analyze the situation. COVID is not foodborne, COVID is not water-borne, COVID is an airborne infection. The air around you will determine if you are likely to get COVID. In a setting such as a restaurant, this gentleman has a high probability of acquiring COVID. Factors that need to be considered while understanding your chances of getting COVID are the estimated prevalence of infection in that space, contact time and distance, and the degree of aerosolization.

The risk of infection is the same for everyone in that environment, but the consequences of infection are different depending on age, ethnicity, and comorbidities. I often cite an example – of inside and outside risk. Presume, it is snowing and the roads are all icy and slippery. Driving under such inclement conditions is fraught with severe risk. If during such times, you have an emergency at home, you still have to venture out and take care of that. However, if I say I just want to drive and see the fun, obviously it is stupidity.

Thus risk assessment becomes an important factor. Outside risk versus your own vulnerability. That also means that despite the outside risk is high, if you have a critical/essential function that needs immediate attention, you may want to consider doing that. However, if the vulnerability is high, ie. the impact is high, it also means that you want to seriously consider the probability of getting the disease. Thus likelihood and impact are important aspects that you want to consider.

Mitigation depends upon several aspects, face shields, masks (quality is important), and the time of exposure and the (presumably) pre & post-exposure mitigation you perform.

A simple approach to estimate your exposure can be shown in the below formula –

Exposure estimation = (Prevalence of the virus in the air) X (contact time) X (Distance of separation) X (inversely related to your protection mechanisms) X (your internal vulnerability).

The most significant aspect of COVID is that, as of now, SCIENCE DOES NOT HAVE A COMPLETE UNDERSTANDING OF AN INDIVIDUAL’S INTRINSIC RISK.

This is an opinion, not an advisory and you should consult your doctor to seek any advice. The author is not responsible or liable if you use this piece without consultation and advice from your doctor.

https://www.bmj.com/content/370/bmj.m3616

Let us not play God

It is not about China. It is about the human intrigue and opportunity to produce a new organism that unleashes vast implications for us as humanity. The day we start playing nature (God) that day, we should consider as doomsday, because we now know COVID very well and we are seeing how it erupted and further fractured our fault-lines and exposed us – logically, scientifically, politically, ideologically and just the very way we are organized and evolved as humanity.

Interesting repudiation. This is exactly what I was discussing in the first quarter of this year. The introduction is very intuitive and logically engaging. The policy makers across the world are turning a blind eye towards this synthetic source of the virus. However, it shows the power of how human can go wrong in trying to second guess the nature and remix and refactor its native form.

Again, it is not about China. It is about the human intrigue and opportunity to produce a new organism that unleashes vast implications for us as humanity. The day we start playing nature (God) that day, we should consider as doomsday, because we now know COVID very well and we are seeing how it erupted and further fractured our fault-lines and exposed us – logically, scientifically, politically, ideologically and just the very way we are organized and evolved as humanity.

  1. Has SARS-CoV-2 been subjected to in vitro manipulation?

1.1 Genomic sequence analysis reveals that ZC45, or a closely related bat coronavirus, should be the backbone used for the creation of SARS-CoV-2
1.2 The receptor-binding motif of SARS-CoV-2 Spike cannot be born from nature and should have been created through genetic engineering
1.3 An unusual furin-cleavage site is present in the Spike protein of SARS-CoV-2 and is associated with the augmented virulence of the virus

  1. Delineation of a synthetic route of SARS-CoV-2
    2.1 Possible scheme in designing the laboratory-creation of the novel coronavirus
    2.2 A postulated synthetic route for the creation of SARS-CoV-2

Step 1: Engineering the RBM of the Spike for hACE2-binding (1.5 months)
Step 2: Engineering a furin-cleavage site at the S1/S2 junction (0.5 month)
Step 3: Obtain an ORF1b gene that contains the sequence of the short RdRp segment from RaBtCoV/4991 (1 month, yet can be carried out concurrently with Steps 1 and 2)
Step 4: Produce the designed viral genome using reverse genetics and recover live viruses (0.5 month)
Step 5: Optimize the virus for fitness and improve its hACE2-binding affinity in vivo (2.5-3 months)

It is noteworthy that, based on the work done on SARS-CoV, the hACE2-mice, although suitable for SARS-CoV-2 adaptation, is not a good model to reflect the virus’ transmissibility and associated clinical symptoms in humans.

We also speculate that the extensive laboratory-adaptation, which is oriented toward enhanced transmissibility and lethality, may have driven the virus too far. As a result, SARS-CoV-2 might have lost the capacity to attenuate on both transmissibility and lethality during its current adaptation in the human population.

Serial passage is a quick and intensive process, where the adaptation of the virus is accelerated. Although intended to mimic natural evolution, serial passage is much more limited in both time and scale.

The following facts about SARS-CoV-2 are well-supported:

  1. If it was a laboratory product, the most critical element in its creation, the backbone/template virus (ZC45/ZXC21), is owned by military research laboratories in China.
  2. The genome sequence of SARS-CoV-2 has likely undergone genetic engineering, through which the virus has gained the ability to target humans with enhanced virulence and infectivity.
  3. The characteristics and pathogenic effects of SARS-CoV-2 are unprecedented. The virus is highly transmissible, onset-hidden, multi-organ targeting, sequelae-unclear, lethal, and associated with various symptoms and complications.
  4. SARS-CoV-2 caused a world-wide pandemic, taking hundreds of thousands of lives and shutting down the global economy. It has a destructive power like no other.

On point 2 above, I would like to add that, it is possible the military labs never realized the virulence of the new virus since most of the experiments were done on cell lines and animal models, such as laboratory rats and monkeys.

Bleach or Alcohol Based Disinfectant

With rapidly diminishing availability of commercial cleaning supplies, simply diluted bleach, which is readily available, can effectively disinfect homes, offices, and environment to prevent sustained transmission from inanimate objects. Bleach, when used in right dilution, can serve as an alternate option for Alcohol Based Disinfectant. However, the dilutions are important so are the adverse effects from exposure.

SARS-CoV-2 suggests that COVID-19 may remain viable for hours to days, on inanimate surfaces, such as metal, glass, or plastic, for up to 9 days. With exponentially rising COVID-19 cases in the United States, commercial disinfect supplies are in high demand and will unquestionably be limited in the near future. We will have to get creative with available resources, all the while taking safety precautions to ensure our efforts improve and not worsen the ongoing situation.

While the exact viral load on inanimate surfaces is unknown during an outbreak, it is critical to disinfect frequently touched surfaces. With rapidly diminishing availability of commercial cleaning supplies, simply diluted bleach, which is readily available, can effectively disinfect homes, offices, and environment to prevent sustained transmission from inanimate objects. As with many disinfectants, minimizing long-term skin contact and ensuring good ventilation can minimize clinical toxicity.

The virus can efficiently be inactivated by 62% to 71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 minute. Dilutions of ∼0.1% sodium hypochlorite are clinically effective with minimal irritation or sensitization.5 One should be mindful that corrosive injury on mucous membrane/skin contact is possible with excess volumes or mishandling, so appropriate caution and moderation are necessary. This solution should ideally be used within 1 month of preparation and stored in a closed, opaque container at room temperature.

∼0.1% sodium hypochlorite can be made by a roughly 1:50 dilution of household bleach (∼5.25% to 6% sodium hypochlorite) in tap water. The proposed formulation is shown to disinfect surfaces of the novel coronavirus. The Centers for Disease Control and Prevention (CDC) also recommends an approximately 1:50 dilution to disinfect COVID-19, explicitly noting 5 tablespoons (one-third cup) bleach per gallon of water or 4 teaspoons bleach per quart of water.

https://www.sciencedirect.com/science/article/pii/S0190962220306095

Am I Culpable for Spreading Virus?

This is a classic example of invincibility and complacency – that nothing will happen to me even while the entire world is suffering from COVID.

Passengers went on a cruise while COVID was raging, presuming that COVID won’t infect their isolation on the ship (in deep water!) never realizing that asymptomatics are the core carrier rather than those who are actively infected.

Exactly this is what happens around us. Yesterday, I was talking with a friend and I realized, he was not using a mask despite the incidence being very high in their state.

That’s pathetic, I understand coronavirus is not seen and leave behind a trail of fragrance but understand, every time an asymptomatic exhales or sneezes, they blow approximately 54 million copies of the virus in the air. It is now known that these copies stay for at least 3-6 hours in the air. That air may drift in your direction and not having a mask while exposed to the potentially infectious airborne virus is culpable negligence, especially knowing that it may make you another asymptomatic carrier.

This pandemic is replete with examples where the asymptomatic have infected the gullible and innocent unexposed. It is the later who has taken the brunt from SARS CoV2.

Shashank Heda, MD
Dallas, Texas, US

Coronavirus: Dozens test positive for Covid-19 on Norwegian cruise ship
https://www.bbc.co.uk/news/world-europe-53636854

The ‘Good and Not So Good’ of COVID-19

While COVID-19 is taking a huge toll across the globe, humanity is displaying a polar reaction – a not so invincible risk taking attitude and a scared, vulnerability. The answer lies in between these two polar extremes. A balanced approach will help to prevent COVID at the individual and family level, which will eventually also be reflected as a social index for measuring our progress while preventing SARS CoV2 and treating COVID-19 patients.

I discussed the ‘good and not so good’ aspects associated with the prevention of COVID-19 and our own vulnerabilities. The initial battle with COVID is in our mind, where we either think we are vulnerable or invincible.

Let us visit the “Not So Good” part early. 

The spike of COVID-19 is huge across the sunbelt of the US. Several southern states are massively infected due to the COVID-19. The virus is seeing a massive resurgence in the UK, EU, and Australia. It is still in its ascendancy in India, Pakistan, Sri Lanka, and several southeast Asian countries. The Middle East is just catching the fever. Brazil and Latin America (currently in their winter) are seeing a heavy toll. 

While COVID-19 is still raging across the globe, humanity is displaying a polar reaction. On one side, we feel strong and ready to take risk, on the other side we are scared and vulnerable. Can we balance our approach and fight this virus? The answer is a definite yes. How do we do that?
The Good and Not so Good of COVID-19

Intrinsic Vulnerabilities are in our mind

You may be thinking, our body is vulnerable and weak and so we catch the infection. While, most amongst us are following precautions., precautions are not enough. We see at least two major vulnerabilities despite following precautions – 

  1. Strictly following precautions and giving up occasionally
  2. Not understanding the innate immunity and how that helps

Let us talk about the occasional vulnerability that we create and expose. 

Restless Inside Home

Several amongst you are restless inside the confines of your home. You are frustrated, bored and some are just angry enough to throw those precautions to disdain. You want to step outside, you are thinking the risk is not what it sounds like, you may be thinking you are young and have a very low probability of acquiring the viral infection. You may be thinking some socialization is ok, more is not good, so let us go for a walk, maybe pub, may have a blast with a limited circle of friends, maybe shopping, etc. etc. 

Are you Alone? 

Think like this – 

1. If the risk is low, why do we see the resurgence or ascendancy of COVID across the globe? 

2. If you are young, have no risk factors, why are young people succumbing to illness?

3. If you say, your ethnicity provides protection? Can you check the mortality data for those exposed within your ethnicity? 

You may be thinking little social interactions are good (walks, pubs, dinners, outings, little shopping, little business, etc.). It is exactly these vulnerabilities that are perpetuating the spread of viruses. 

Do you know?

For every symptomatic patient, we have anywhere from 5 to 10 asymptomatic patients. Are you sure you are interacting with someone asymptomatic (carrier) and have no virus? I have seen several cases where the person stepping out got the asymptomatic carrier, infected those innocent parents/kids/spouse/family members and the later died. Consider these scenarios

  1. I don’t think you can live with the guilt of being responsible for the death of near or dear one. 
  2. Presuming you will survive, what is the guarantee that your organs will not be compromised for a long time? 
  3. Let us presume, you die from illness, have you thought of the implications of your loss on those surviving? Please read surviving with COVID stories and make your choice. 

How do you protect yourself?

CDC has given guidelines for protecting yourself. Every Government has made the best attempts in guiding their citizen from COVID-19. Following those is the utmost while undertaking any activities for your local area. 

Activate your Internal Resilience 

First and foremost, please decrease your exposure and risk. However, boosting your immune system with Yoga, Physical Activities, Sleep, Balanced Diet (and avoid refined diet), and meditation are great ways of doing so. I also saw some interesting read on Mayo Clinics. However, several educational institutions are providing a wealth of knowledge on those. However, reaching out to your doctor at the first instance of suspicion is best. 

The Good News

In its July 7, 2020 issue, Nature Immunology carried an interesting article on why the disease burden varies differently across regions. Simultaneously, the same paper has speculated that previous infection from Common Cold Coronaviruses (CCC) exposure also provides protection, against SARS CoV2. Excerpts from the article below

‘Pre-existing T cell immunity is related to CCC exposure, it will become important to better understand the patterns of CCC exposure in space and time. It is well established that the four main CCCs are cyclical in their prevalence, following multiyear cycles, which can differ across geographical locations. This leads to the speculative hypothesis that differences in CCC geo-distribution might correlate with the burden of COVID-19 disease severity. Furthermore, highly speculative hypotheses related to pre-existing memory T cells can be proposed regarding COVID-19 and age. Children are less susceptible to COVID-19 clinical symptoms. Older people are much more susceptible to fatal COVID-19. The reasons for both are unclear’. 

If these speculations are proven, it can rightly be said that T Cells have a lasting memory towards previous CCC that may be reactivated during a SARS CoV2 infection and offer protection. 

https://www.nature.com/articles/s41577-020-0389-z

Shashank Heda,

Dallas, Texas

(On behalf of CovidRxExchange) 

a nonprofit initiative to help global doctors fight Covid-19

Visit – https://www.covid-19rxexchange.org/)

A dubious distinction

The US has reached a dubious distinction of being a global leader in having 4 million cases of Coronavirus. What leads to this grim scenario? Often, that outside wonder where is the vulnerability. I shared a different perspective on the factors contributing to this grim scenario. In my opinion, there are several factors that contribute to these dismal figures. Understanding the failure is as important as understanding the success, it is through failures that we get a glimpse of success as it offers us an understanding of modeling success and our collective behavior. In this article, I have made attempts to capture aspects across major democracies that offer an insight into success and failure.

The US – then 4 million coronavirus cases. The US is the global leader in Covid-19 cases, followed by Brazil, India, Russia, and South Africa. The statistics run like this –

99 days to reach 1 million
43 days to reach 2 million
28 days to reach 3 million
15 days to reach 4 million
… days to reach 5 million

https://ourworldindata.org/coronavirus-data?country=USA~BRA~IND~RUS~GBR~OWID_WRL

A global leader again (pun intended), how could a country reach such epic proportions of the disease in just 180 days. At least 143,820 people have died across the country. Where is the indiscretion? Is it that the population is vulnerable? Or are we following flawed models of prevention?

Let me cite an example – my HOA asked me to fix the turf, stating it is an essential service. Of course, I responded saying why it is not but this is a reflection of a flawed model being followed.

A confusion between essential and non-essential is the major factor. Another aspect that is scientific activism by gullible people called ‘Corona Mixer’. It is akin to a flawed model of Herd Immunity followed in the UK, Sweden, and few other countries, where COVID-19 eventually exploded.

Third, fatigue from indoor has wrongly motivated several families to stride outside. Of course, a gullible common man cannot see the 54 million viruses that were just sprayed by an unexpected asymptomatic person in the vicinity that followed that infects other innocent bystanders as it drifts along the path of air currents.

There are more factors to the proliferation of the disease. Another complex issue is Political liberalism and assertion for a cause. Subversion or a feeling of being subverted is causing people to rebel and aggregate. Incorrect policies and guidance by WHO and other policy-making bodies is another contributing aspect factor.

Policies – a bedrock for containment: Policies offer a solid fabric for control and on the converse is equally true that not having consistent machinery to execute policies is an equal deterrent. I will shy to quote an example from a major city from central India where a breakdown of communication amongst the policy executioners resulted in a flare-up of COVID across the town. Remember, if only the infected (symptomatic and asymptomatic) can strictly isolate, we can contain the virus.

Indore a success story

We have several success stories from around the globe but visit CovidRxExchange to learn about, Indore – A Success Story. You will see how a metropolitan city controlled the disease at the outset with a well-executed policy and a diligent team of doctors.

Can we change this? Possibly that’s the Midas touch that would delay and possibly deter further infection.

Shashank Heda, MD
Dallas, Texas

References:

https://ourworldindata.org/coronavirus-data?country=USA~BRA~IND~RUS~GBR~OWID_WRL

https://www.ncbi.nlm.nih.gov/research/coronavirus/publication/32691016

R(0) & The Real Numbers

The daily cases of positive SARS-CoV2 are rising in several states. Newspapers and Govt. channels are providing the total positive cases detected daily. However, a visibility on the total burden of positive cases is not available despite knowing the daily stats. Often, it is erroneously thought that the cumulative numbers are less.

In this blog, I have talked about the incidence and prevalence of the persons affected that are shedding the viruses in the community, both from the symptomatic and asymptomatic perspective. The average number a symptomatic patient sheds virus and the average number an asymptomatic person sheds the virus is based on the the referenced scientific data. The details are mentioned in this blog.

This blog provides us a perspective on the cumulative cases within a community as well as how long should we continue lock down amidst the airborne nature of the virus.

Let me explain the concept of incidence and prevalence.

Incidence is the new cases occurring in that period, whereas prevalence is the cumulative cases existing during that period. If I presume the incidence at the time of collection of the swab is 10,000, and the asymptomatic is 5x to 10x (let us call it A), the total burden of positive cases is in that proportion.

If we are to presume the disease persists for 14 -21 days in its mild form, then the prevalence now is 14x-21x the multiple of A. If I go by some researchers, the asymptomatic shed the virus for 21-28 days.

That’s the total burden of test-positive cases.

Airborne precautions are likely to be scaled up on the risk stratification. All those risk color charts floating around are likely unreliable for this simple reason. To make it simple, I will just make two categories –

Essential
Non-essential

Non-essential are all those without which we can survive.

You may naturally ask, until when should we live like this? It’s not too long, vaccines and drugs are on the horizon. Also, though the virus is still aggressive, it will likely become less aggressive in the future. So, let’s wait before taking an unrequired risk.

Shashank Heda
Dallas, Texas

Shades of Gray

Interrelated phenomenon Shades of Gray – Gene Manipulation to establish hegemony, Drug Hoarding and Vaccine Nationalism,

It is understandable, the US started vaccine and drug hoarding, contrary to the principles of humanitarian values and ethics. Hegemony and lack of transparency from China and other power are adding towards a heady mix. This initiated a sense of self.

However, scientific pursuit falls within the realms of humanitarian traits, it is not nation-specific, or unique to any ethnicity, and definitely not the fiefdom or expertise of any ideology or religion.

Having said this, despite the attitude of select countries, we should keep humanity and altruism as our highest pursuits and avoid getting muddled in the politics of nationalism, ethnicity, ideology, or religion.

Every country should attempt in advancing science, however, we should not succumb to vaccine nation, drug hoarding, or manipulating the genome of the wild viruses and or bacteria for usurping our hegemony to advance our nationalistic endeavors. We all know, Science is a double-edged sword, used rightly will lead to evolution, and unlikely use to destruction.

Dr. Shashank Heda,
Dallas, Texas

Stay Safe! It’s a cliche!

The tidal second wave of Coronavirus is surging across the globe. What went wrong? Was easing the lockdown a wrong decision? or was it our inadequacy to understand the virus behavior? Can we understand what went wrong? We each define the microcosm of the society and we contribute towards the spread via our Social Bubble or contain the Spread with our responsible behavior.

I have captured all the risks factors and how to fix our own behavior during this tidal surge of COVID wave.

Stay safe has become a cliche, like Good morning, bye etc.

Friends, this week has been extremely bothersome as the second wave has been not just huge, not just a tidal wave but a seismic wave, and a tsunami that may overwhelm our healthcare system. Not just in Texas alone, it is across the US mainland, the UK, the EU, China, India, Brazil, Mexico, etc. It is extremely scary.

What went wrong?

First – let us understand some principles of transmission of the virus. Second, let us understand our fallacies. Next, let us understand our social dynamics.

A) Virus Transmission –

A virus multiplies in 100,000 copies in one single day. Almost, one bout of coughing produces 54 million copies, that fly as aerosol and also settle as fomites. Being a tough virus, it survives in the air for almost 3 -5 hours, depending upon the ambient conditions. The warm and humid environment makes it hang around longer. It drifts with the air current or stays suspended without a drifting, with no wind current. The peak is 14 days, thereafter the virus gets neutralized in the patient.

Symptomatic patients are not the only bug spreaders, for every symptomatic patient, we have 10 asymptomatic patients who are spreading the virus. However, for asymptomatic patients, the virus cycle continues for almost 28 days. Unfortunately for us and fortunately for the virus, it is colorless and invisible and since it is invisible, we feel pseudo confidence that we are invincible.

B) Our fallacies –

We presume the virus is not there. That and given our boredom of staying inside makes us extremely prone to catching the infection. We are frustrated staying secluded, within the confines of our four walls. But you are not alone, almost over two billion people on this planet earth are secluded and claustrophobic within the confines of their home. We all know social distancing but I see several families taking a stroll without masks, not knowing that they may be inhaling the virus.

Somewhere, we presume, it is a disease of the elderly. I have seen several case reports of a death within the young and healthy. I have seen case reports of kids suffering immensely from COVID. I have seen elderly parents escaping death. This all points towards one thing – that Science has not yet definitely identified risk factors for mortality and morbidity. Thus the virus behavior remains elusive and erratic. You may get the bug, harbor it and unknowingly, you become a super spreader. I see school kids interacting with each other. How can we ensure that those they are playing with have no disease (asymptomatic carrier)?

Social Bubble – Exactly, this small social network connects us with other tiny bubbles, and this is becoming the route of spread. New Zealand is the first country to realize this and they broke the vicious cycle and almost eradicated the virus. They will, however, get reinjected, once they start air travel though.

Work Bubble – We think, we are acutely dependent on running our family for a livelihood, not realizing that those who are working can become asymptomatic carriers and transmit to vulnerable parents staying with us. Are we so careless? (@Dr. Shashank Heda, for COVIDRxExchange.Org). If we have to essentially step outside for a living, let us live under a different roof, not with those family members who are vulnerable.

What Do We Do?

  1. Strict Social Distancing is not enough, we will be inhaling the bug via several routes.
  2. You all need to suspend all strolls, shopping, and other errands. Let us minimize exposure as much as we can. Can we buy online?
  3. Fomite transmission is deprecated. That means fomites do not pose as much risk as was considered previously. Please visit CDC for the guidance.

Summary: If you have let your guards down, a “new high probability” risk factor that will determine your chance of getting the infection. You can make your choices.