The Tsunami (Wave) of Covid – What can we do?

The Tsunami Wave of Covid – What can we do?

I am in touch with all the different corners of the country. The unsurmountable fire of Covid has engulfed every nook and corner. The stories of death and desperation are so common that not a single call is devoid of the deep realization of the country’s anguish and pathos.

I realize two distinct sets of institutions, and I see a distinct dynamic response from both these institutions. First, the Government as an institution and second and foremost, ‘WE the People’.

Let us talk about the Government since we so much believe in our sense of entitlement. I am taking a neutral position and not siding or opposing with intent by design.

There was a sense of complacency and pragmatism in diverting the vaccines as well as the medications such as Remdesivir or Favipiravir to other countries that were suffering. In today’s integrated and dynamic world, national interests are subserved by commending global leadership. After Indira, we have an astute leader in Modi who understands this and has the knack and panache to drive that.

The age of vaccine diplomacy

During this age of vaccine nationalism, when most western powers huddled into vaccine nationalism, Modi took a moral stand of supporting the global cause. We have to understand, I did not see a sense of abandonment but a vision to expand and extend the national cause.

Corona – A global Slayer

SARS CoV2 has the enigma for a surprise attack and ambush. It’s different, and it has caught all by surprise the advanced nations and the advancing nations with the same level of temerity. Estimation models, intelligence, and expert instincts have all failed across the spectrum – from advanced, advancing, to those making attempts at advancing their nation.

India’s story is very distinct and different, and a significant onus lies with us as ‘We the People.’ First, it’s a massive country with a population of over 1.3 billion people. Next, it’s a free democratic country, where an extra sense of entitlement prevails. To add to this, it’s highly diverse, geographically, culturally, ethnically, ideologically, and politically and economically. With such a melting cauldron of diversity, it becomes incredibly challenging to provide a standardization of care across all strata.

We the People

Why are we hoarding? Why are we preemptively reserving resources when those are not indicated? Why are we black marketing resources despite knowing the crisis hours? Where is our faith in equitable and fair distribution when we break the queue and create pandemonium to grab necessities? Barring a few, have we ever shown trust, and confidence in the processes rather than bypassing those?

In a country where the rights belong to us and where I have bequeathed morals as someone else responsibilities, how can we expect our Government to function orderly and deliver?

These are pandemic times, and these are times of pandemonium, but definitely not armageddon. Hope and faith are the foremost things during a tempest. Let’s ride through this in an orderly way. Let’s trust and activate our inner moral compass that follows that will guide us with our responsibilities and our rights. Let’s follow an equitable process and trust fair practices, and most importantly, let’s pray and practice patience and activate our inner endurance to bear this calamity with courage and patience. Let us focus on us as the prime object of change, and a change in the system will follow.

I wish an early recovery through these tormenting and tortuous times.

Shashank Heda, MD
Dallas, Texas

https://pib.gov.in/PressReleasePage.aspx?PRID=1712710

CovidRxExchange – A year into the Journey

As I take this moment to recap our one year journey with CovidRxExchange, with all humility I wish to honor and pay our gratitude to our Patrons, Mentors and SPOCs, Executive and our various teams who helped evolve CovidRxExchange as an initiative to reckon with –

Patrons –

Dr. Vikas Mahatme, Ophthalmologist, Padmashree, and Rajya Sabha Member
Dr. Sunil Deshmukh, Radiologist and Former, Minister, Govt. of Maharashtra.
Wing Commander Babu, Formerly IAF
Mr. I. S. Chahal, Commissioner, Mumbai
Dr. Zodpey, VP, PHFI, Delhi,

Mentors:

We are deeply humbled and honored to have mentors like –
Prof. Emeritus Dr. Manbar Rawat, a Prof. of great respect and repute across multiple generations.
Prof. Emeritus Dr. Vilas Jahagirdhar, Formerly, Prof Microbiology and Dean
Prof. Uday Bodhankar, Formerly, IAP President, VP COMHAD, UK
Prof. Vrinda Sahasrabhojaney, Retd. Prof. Medicine.
Dr. Naveen Thacker, Director, IAP

Intent and Objective:

CovidRxExchange, a global nonprofit initiative, started in March 2020 to disseminate expertise, insight, and experience in managing Covid for the doctors, Health Care policymakers, and policy planners, and administrators. The intent is to enable doctors across borders to leverage the expertise they have honed in Covid patients’ care.

In March 2020 (exactly a year back), our initial foray was to disseminate knowledge and expertise from the US to the experts at Mumbai. We arranged our first call between Dr. Toraskar, Chief of Critical Care at Wockhardt and HOD of Cardiology at Nair Hospital, and two experts from the US, who had by then gained significant experience managing critical cases of Covid. From that experience, we realized, it is best to institutionalize the knowledge transfer and make it global. After that, we started panel discussions on the practical care of Covid in HDU and ICU.

Over a period of time, as Covid kept raging across countries, economies, globally, nationally, and regionally, we realized the needs got more specific, and we differentiated our nonprofit services to include more services under our gamut of CovidRxExchange.

Scope and Out of Scope: We are aggregators and disseminators of expertise, insight, and experience. We occasionally conduct our own research. We are a global organization.

Our Ethical Values

CovidRxExchange adheres to strict ethical guidelines. Nondiscrimination and noncommercial form the backbone of our services. We are an inclusive organization devoid of leaning towards any political ideology or any faith-based ideology. We are committed to translating academic evidence-based medicine to enable doctors, policymakers, and administrators. We are noncommercial and agnostic of vendor bais in providing our nonprofit services.

Activities and Accomplishments:

A. Our Initial Engagement – Panel Discussions and Second Consultations

After conducting several panel discussions, we were approached for several second consultations. Our next group was the second consult, and our global group of experts offered a second consult in several cases. Dr. Ajay Chaurasia (Cardiology, HOD, Nair Hospital), Dr. Nandita Divekar (UK), Dr. Rahul Sarkar (UK), Dr. Hettiarchi (UK) and Dr. Sandip Banerjee (UK),

B. Web-based Knowledge Repository (Lifecycle and Extended Lifecycle Approach)

Eventually, we created a web-based repository, a library with a Lifecycle approach to deal with Covid. Our lifecycle approach provides end-to-end case expertise of different aspects of covid from remote consult, first visit, admission (floor) to HDU, ICU, discharge, and bereavement.

As Long Haul disease became prevalent, we extended our Lifecycle Model to Extended Lifecycle Model, including Stress Management for Doctors and HCW and rehabilitation.

C. Risk Management: Extending Individual Care to Institutions, Cities, and Corporations.

Realizing that Covid was no more a patient condition, we created a 3×3 model. The 3×3 model extended the services to institutions, cities, and corporations. Thus the policy planners too came under the aegis of Covid Care. We helped the City of Coimbatore, An City (Anonymous) with significant Covid to identify and restructure their Covid, and did a post facto analysis for a metropolitan area for What best could have been done. Indore team (comprising of Dr. Nishant Khare, Dr. Sanjay Dhanuka, Dr. Anand Sanghi, and Dr. Gaurav Gupta), the UK Team (comprising of Dr. Divekar, Dr. Banerjee, Dr. Sarkar), the US Team (comprising of Dr. Lakshimi Sambathkumar, Dr. Arvind Virmani and I), and the Mumbai Team (comprising of Dr. Chaurasia, Dr. Ashok Anand, Dr. Hemant Bhandari, and Dr. Pankaj Maheshwari), worked along with the Coimbatore Commissioner, Deans, and Professors to provide a blueprint for Covid mitigation in the Corporation of Coimbatore. Dr. Rajamani and Ms. Kruthka Govindarajalu, Director, Smart City, Coimbatore, played a pivotal role.

D. Tribals and Areas of Deprived Resources: Eventually, as Covid made inroads into the tribal areas/interiors and understanding that 10% of India’s population lives in Tribal Areas, we developed our Tribal Covid Model. Dr. Ashish Satav, Dr. Sahasrabhojaney, Amod, and I, spearheaded this Tribal Covid Model. Realizing that the economically deprived areas and tribals areas have shared problems, we consolidated this capability under Tribal and Areas of Deprived Resources.

E. Holistic Health: Mindfulness, Sleep, Exercise, Nutrition, and Yoga, are crucial to achieving normal health. Ms. Gomathy Periatheruvadi, an Entrepreneur and Executive from the US, is leading this capability.

F. Rehabilitation and Long Haul: This is one area where we are still striving to expand our footprint. We are exploring to develop this capability, and Dr. Mariya Jiandani has shown interest and bandwidth to expand these services.

G. Vaccines – Developing a requisite immunity is based on critical success with Vaccine deployment. Vaccines emerged as a significant area that our doctors needed an incredible amount of support. Realizing this, we organized a series of panel discussions and one on one calls to address patient concerns.

H. Variants – Mutations and their aggregation into variants created a different challenge, both in transmission, infectivity, and the second/third/fourth surge across nations. We have set up a dedicated capability and integrated this under the vaccine capability. We are exploring the implications of the variants such as B1.1.7, B1.351, P.1, B1.521, and the recent variants found in India and other countries on the transmission, infectivity, morbidity, and mortality. Dr. Mukul Acharya (UK), Dr. Anand Kawade (India), Dr. Nitin Wairagkar (US), Dr. Kedar Toraskar (Mumbai), Dr. Naveen Thacker (India), Dr. Suhasini Balasubramiam (Chennai), Dr. Anita Mathew (Mumbai), Dr. Mala Kaneria (Mumbai), and Dr. Neetu Jain (Delhi) are working under the mentorship of Prof. Dr. Rawat and Prof. Jahagirdhar.

I. Dispelling Rumors: As rumors are flying rife; we are identifying SPOC’s to evaluate, analyze, and provide a scientific evidence-based rationale to dispel rumors

J. Socialization of scientific understanding into commonly understood language is important as we consider that if our nonmedical community is aware, they can be the necessary pivot to transgressing towards success. Thus dispelling ‘Rumors and Socialization’ are emerging as recent capabilities.

K. Liaison: Covid needs an adequate translation to policy and execution. We are currently working on establishing a capability to connect with the policymakers at different Govt. Machinery levels.

L. Awareness: Specifically for the nonmedical folks based in the US, we have created an Awareness Group to share information on awareness.

M. Strategy, Risk and Program: With my background in Strategy, Governance, and Risk Management made me realize that these should include these as independent capabilities. Thus, Strategy (Wing Commander Babu and I), Governance (Founders) and Risk (Amod and I) are maturing this capability. We reinvented the industry approach on Risk Management and tweaked it to align with Covid and Medical care. Concurrently, as capabilities were sprawling, we realized a common framework should encapsulate the entire initiative. Thus, we initiated program management (with a CMMI/ISO) capability to standardize for all the capabilities. Manish Singhal has taken the onus to develop this nascent capability.

N. Legal, Compliance, Finance: While some of these capabilities are a doctor (customer) facing, many capabilities are operational and happening on the backend: operations, Legal, Compliance, and Finance capabilities. Mr. Yogesh Vyas, Mr. Amod Manjrekar, and

O. Technology: Manish Singhal, Amod Manjrekar, Pankaj Bhakta, and Shriram Devata provide that support. This is still an incipient and nascent capability where we are expecting significant development.

P. CME: These capabilities are in embryonic stages. We are exploring global sponsors and accreditation for this capability.

Q. Editorial: We are upgrading our capability to provide updates (weekly, daily, and flash). Currently, we are scaling capability to include over 2000 of our users.

R. Emerging Technology: We are building an industry consortium to address medical problems leveraging technological advances. An example can be using Artificial Intelligence and Machine Learning to address predicting the utilization of beds, or developing a model to understand the emergence of a specific variant in a specific geography and the impact of these newer (hypothetical) variants on transmission, infectivity, and overall community-based impact.

S. Ombudsman:

We strongly encourage professional interaction and courtesies. We heavily lean on Evidence-based rationale, and we respect creativity. Our ethical values are foremost essential for us, and we cherish those with the highest order. We have identified Prof. Emeritus Dr. Manbar Rawat to resolve any residual issues if not resolved by the Founder.

All along, we have ensured that only hands-on experts are providing the knowledge transfer. We are not book-based academicians. Our experts have significant hands-on experience and expertise from their specialized domain. These experts’ work contributions are pro-bono, i.e., they do not charge us, and we do not reimburse them.

Funding: As of this writing, we the Founders, have funded all the initiatives. We have not received any funding from donations, advertisements, any pharmaceuticals, or any other industry. We have avoided all and any conflict of interest.

Scaling and Continuity: We will explore submission to foundations for support. If we secure funds for CovidRxExchange, we will announce that and develop Policies, Governance, Visibility, Transparency, and Audit/Accountability.

Slack: Slack is our global portal of Collaboration and Communication. However, WhatsUp is a transitory and stop-gap arrangement to support ease of communication.

Movers and Shakers: We will post the list of Several Movers and Shakers who make this initiative a throbbing success. Women, Budding Leaders, Technology Team and Operations team are few who make several things happen.

Our Founders (in alphabetical order of their first name):

Dr. Ajay Chaurasia, HOD Cardiology, Nair Hospital, Saifee Hospital, Mumbai Hospital, etc.
Dr. Anand Kawade, Pediatrician and Vaccine Authority, KEM Hospital, Pune and Vadu
Dr. Arvind Virmani, Molecular Scientist, Washinton DC.
Dr. Ashok Anand, Professor and Head, Gynecology and Obstetrics, GMC and JJ, Mumbai
Dr. Hemant Bhandari, Orthopedician, Mumbai Hospital, Mumbai
Dr. Pankaj Maheshwari, Chief of Urology, Fortis Hospital, Thane, Mumbai
Dr. Shashank Heda, Molecular Pathology and Technology Executive, North America

Humble Note: If inadvertently, we have missed a name, kindly bring it to our notice and we will credit them for their contribution. We request you to pardon for any of our omissions.

Rubber Meets the Road.

Let’s start where I want to end this topic, and I know you won’t like me saying this. The pandemic is likely to swagger around more than anticipated. If we anticipated it to end sooner, if not early 2021, it bores disappointment. It’s just not the delay in rolling out the vaccine. Let’s see the multitude of issues why the pandemic is likely to last longer.

Vaccine Nationalism is an integrated world is unlikely to protect a nationality unless the borders are strictly closed. Well, any isolationism and walls are unlikely to stop the Humboldt of global integration. If the rich or the have (those with technology), are planning to cover their nationals, the virus is likely to linger longer in those deprived.

What are the consequences?

Most of us are aware of the new mutations in the virus that imposed an immediate lockdown in the UK. This mutant variant is secondary to the virus gaining survival by mutating and escaping. Such mutants are like to hamper our interventions right from screening to vaccination.

Is it a global vaccine rollout?

Of course nor, the vaccine rollout has started in the EU, UK, US, Brazil, Mexico, Canada, Japan, China, and a select few countries. However, several countries are lagging behind either because they have no funds or no technology or logistics to deploy a complex vaccine delivery program. Add to that the regular protagonist of the ‘conspiracy theory’ school, and you compound the problem to a level of practical reality.

Surprise – Many doctors are evading vaccine

I was surprised to see practicing doctors avoiding vaccines. This is not an isolated but a pervasive phenomenon. There are still lingering doubts about the virus getting integrated into the human genome, which is unlikely to happen. Another misconception is heavy metal contamination of the vaccine. You and I are more exposed to the unknown quantity of heavy metals in our produce from Mexico or the disposable material we are exposed to. First, I may disagree if such contaminations are possible with the vaccines, and even if those were, it is unlikely that you get a significant dose to perturb your system. Another misconception that is going around – that the vaccine is made in cow or pig. I just piety these folks who work on churning the rumors mills devoid of research, reasoning, and rationale.

The cold chain and logistics

It is a formidable challenge to manage the cold chain in a diverse world like ours, even if we presume that vaccination will be adopted uniformly. Having worked as a molecular oncology fellow, I know that especially the RNA vaccines from Moderna and Pfizer need a distinct cold chain, and any disruption is likely to compromise the efficacy of the vaccine significantly. Now consider the vast and remote corners where the vaccines have to be carried out if we were to target complete eradication of the virus.

These are not easily surmountable challenges and devoid of a strategy and execution plan that is customized to individual locales (countries, regions, etc.), it is unlikely to achieve the desired goal of covering 60%-80% population. If the virus lingers, it will mutate and likely stay with humanity for longer than the expected period of time. It will evade our detection gold standard, such as RT PCR. It may create resistance to drugs such as Remdesevir, or worst, become more aggressive and, last, render our vaccines useless. That’s why we vaccinate ourselves annually for flu.

Let us hope for the best.

Hope is not the best strategy; instead, hope is the worst strategy. A thorough understanding of the global target population dynamics vis a vis the vaccination program is required. Strategies alone cannot help; execution of the plan will be the harbinger to success. Until then…

I wish you all a very safe 2021!

Shashank Heda,

Dallas, Texas

The Culpable Trend Continues

Of course, we saw during Covid how China suppressed the Covid investigation, manipulated the data and cleared the crime scene.

Recently, I saw news that China is targeting a GDP of 8 and above fir 2021. It is no news that China is under severe debt, industry is recuperating to gradual recovery, (and of course it will be, because its global customers are still reeling under recession), and it has quadrupled its expenses during a time depleted revenue flow and persistent pressure of aggressive spending on aggressive militarization.

Credits: John H Tuckers, The Riverfront Times

Now comes the real news

It has suspended the regulating agency which rates the progress. And why not? It has to, if it needs to pain all hunky dory, like the old style communist propaganda.

Eventually, we know, with one stroke of Perestroika, the entire communist castle came crumbling down. It’s just a matter of time, such artificial models have no sustenance, they glitter like a nighttime bugs, and lose the flare with the arrival of twilight.

Shashank Heda
Dallas, Texas

Chinese regulator suspends rating agency over Yongcheng default
https://asia.nikkei.com/Business/Markets/China-debt-crunch/Chinese-regulator-suspends-rating-agency-over-Yongcheng-default

Sleep Walking

Let’s scratch the surface

You all know how the bulls are raging on the stock markets globally. Most indices have skyrocketed while the economies of the world are reeling under covid.

Credits: Ben Carlson, https://fortune.com/2019/10/29/stock-market-rally-2019-christmas-eoy/

In a world full of non-ideal things, this one is no outlier, not because the markets display anomalous behavior but because the sentiments are so disconnected from the ground realities.

They say Covid is a disease of the affluent. Though I may disagree with that observation, however, stock market sentiments are the affluent’ sentiments. None of us want to see it lose, so we succumb to sentiments than the bottom line of individual companies comprising the index.

What’s so wrong if stocks are rising, especially in a sagging economy?

Absolutely a great question. Let’s understand the dichotomy and the disconnect. Presume my shares from a listed company shot up by 27% in the last nine months; obviously, I gained those. That offers a relative advantage over those struggling to survive and sustain.

However, let’s understand the stimulus bill. If only we have a great economy, ideally, we would not have the required stimulus. Interest rates would not have been low, millions would not have defaulted on their payments and mortgages, and unemployment would have been on the decline.

When the indicators are not connected with the ground reality, we are bound to land up in a ditch. Just imagine my leg is on the gas paddle, and I am pressing it hard; my car is cruising at astonishing speed, but the indicator says 22 mph.

When the indicators do not capture realities, we live in the castle, when the bourgeoisie falter, that revolutions are born. To douse the fire, we provide stimulus and subsidies. The vicious cycle keeps going endless while we churn a class of have-nots and increase the chasm with the have’s.

https://fortune.com/2019/10/29/stock-market-rally-2019-christmas-eoy/

Global stock markets form K-shape as investors search for growth
https://asia.nikkei.com/Spotlight/Datawatch/Global-stock-markets-form-K-shape-as-investors-search-for-growth

School Closure and Kids Infectivity?

Excerpts:

Are my kids susceptible?

Now that COVID has started raging once again across the US, it is very possible that the schools in your area may decide to close or remain open. Select states may choose to keep the schools open, whereas others may decide to close. Is there any data to support the spread of disease with the schools opting to remain open?

It is important to understand if the Kids are infectious? Are they likely to be an asymptomatic carrier? Are they more susceptible? Do they have enough antibody response? A map of the US with states mandated school closure is provided in this blog. (Word count 795, reading time 3-4 minutes).

Are kids “Briefly Infectious”?

Now that some states have mandated the schools to reopen, and though the kids have the option to physically attend or participate remotely, it is important to understand the implications for the family.

3% or 9% Threshold? What’s Right?

NY Mayor Bill D Blasio imposed a 3% moratorium on the case positivity rate to keep the school system open. You may see your state or local officials changing their decision to keep the schools closed if they see a rising number. The debate of 3% or 5% is seemingly not important. These numbers are related to the incidence of test positivity on a daily basis. Presume, you have 100 people visiting for testing, and 9 are positive (9%). Now presume, you have 500 people visiting for testing, and 3 per 100 are positive (3% but a total of 15 cases). Obviously, the absolute number matters most. However, New York Governor Andrew Cuomo or Iowa, Gov. Kim Reynolds has set the state’s closure threshold at 9 percent and 15 percent respectively. Why is the difference?

Hospital Beds influence the policy decision

The absolute numbers posted above make it clear that the more the number of the population infected, the more the number of beds required to treat the population. In fact, if the severity of the cases rises, another parameter that frequently influences the decision is the total number of ICU beds. If the system is inundated, these beds become significantly crunched and so lockdowns are enforced.

These exact sentiments were communicated by Dr. Celine Gounder, Adviser to President Elect Joe Biden, when she said, “there may come a tipping point where you do need to go back to virtual schooling. But I think the priority is to try to keep schools open as much as possible, and to provide the resources for that to happen”.

Impact of Lockdown

Lockdowns have a significant impact on the daily lives and economic health of a nation or state. It has been observed that Lockdown has rendered a significant portion of working women to discontinue work and focus on the kids. This almost significantly reduces household income and increases stress and unhappiness due to an inability to meet family needs. Across the globe, educational planners are concerned about the pandemic inflicting an indelible harm to the academic development to the kids.

Are kids more susceptible?

Recent research points to the Type 1 IFN that offers protection with the innate and adaptive immune response. As we age, the functioning is likely to get compromised and make us vulnerable. That is the reason, kids are less affected, whereas the elderly are more likely affected due to COVID. Second, children, have powerful innate immunity that mounts a severe and rapid response to the viruses, thus not allowing the viruses to gain a foothold, thus sparing them from severe disease.

Do Children have a less protective response?

Research from Karolinska Institute in Stockholm has demonstrated that the antibodies produced by kids are IgG type whereas, those produced by adults are of several types. The IgG antibodies bind to the S protein, whereas the diverse range of antibodies produced by adults bind to various proteins and help better neutralization of the virus.

The range of antibodies that children produced differed from those of adults. Children primarily made one type of antibody, called IgG, that binds to the spike protein on the surface of the virus. Adults, by contrast, made several types of antibodies that bind to the spike protein and other viral proteins, and these antibodies were more powerful than IgG at neutralizing the virus. Adult COVID-19 cohorts had anti-spike (S) IgG, IgM, and IgA antibodies, as well as anti-nucleocapsid (N) IgG antibodies, while children with and without MIS-C had reduced breadth of anti-SARS-CoV-2-specific antibodies, predominantly generating IgG antibodies specific for the S protein but not the N protein.

Are Schools the Superspreaders?

According to a report from Ney York Times, very little transmission happened in schools. The latest data shows that random testing since October has produced a positivity rate of just 0.17 percent. Please visit an article cited below from the Journal of Pediatrics, an official journal of the American Academy of Pediatrics.

Take-Home Message:

Kids may have better immunity burst to deal with SARS CoV2 but they may not have a complete armamentarium of antibodies to deal with every aspect of the virus.
Kids may be less susceptible to the virus, but that does not rule out a possibility of MIS-C.
Elderly parents at home are susceptible to infections from the kids, even if you presume, the kids are likely to have less probability of the disease. Grandparents and other senior elderly family members should be segregated from the kids to provide adequate protection.

https://www.edweek.org/ew/section/multimedia/map-coronavirus-and-school-closures.html

https://www.nature.com/articles/s41590-020-00826-9

Compiled on behalf of COVIDRxExchange, a Nonprofit initiative

Note: This is not a medical advice or recommendations. Please consult your doctor or local policy planner while making a decision. This is author’s personal Opinion and readers are strictly advised to consult medical professionals. Follow your local official advice and guidelines while trying to prevent the spread of coronavirus.

Visit Vaccine and Drones (https://mymilieu.org/2020/11/16/vaccines-and-drones/) to learn more about the effectiveness of the vaccines.

Click to access peds.2020-031971.full.pdf

https://pediatrics.aappublications.org/content/pediatrics/early/2020/10/16/peds.2020-031971.full.pdf.

https://www.edweek.org/ew/articles/2020/03/20/when-americas-schools-shut-down-we-all.html

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

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.

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

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:

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.
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.
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.
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.

Synthetic nature of sars-cov-2-genome Download

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