COVID & Spanish Flu – Comparison and Contrast

102 Not out – Approximately 102 years back, the world was ravaged by Spanish Flu (a misnomer) and today, we are reeling under COVID-19. Both pandemics caused significant pandemonium, and share a common pattern. While it is understandable to see an intermittent new ‘human – microbe’ interaction, going awry, the current pandemic has exposed our fault lines and our preparedness after 102 years. It is not about microbes and our immunity, it is a testimony of our (un)evolved human journey or rather stagnation of evolution in the last 102 years.

102 Not Out, provides a succinct comparison and contrast between the Spanish Flu and COVID-19 and a poignant story of our collective failure.

Background

1918-19 – That period must be the one coinciding with your grandparents or great parent’s birth. So, memories are only through archival records. The global toll was almost 50-100 million, whereas the US lost some 685000 people (a very high percentage for the population at that time). India had 5% mortality with over 12 million succumbing to Spanish Flu.

Spanish Flu – What is that?

Is it truly Spanish flu? It started in France and England. However, they both were at war and wanted to keep this covered. However, Spain being neutral, and news being public, it was reported transparently. It is a misnomer to call it Spanish flu. That is derisive, as Spain was neutral during WW I. It was World War I and soldiers were living in overcrowded barracks. It started in Etaples, France in 1916. It will similarly be wrong to construe that it was an element of French warfare because a similar disease was also observed in 1917 at Aldershot, England. Then too, it was commonly thought to have jumped the animal-human borders as pigs and poultry were a mainstay at these hospitals.

It never occurred to them that they would take the Influenza bug along with them while traveling back home. A disease that once was restricted to specific geography quickly became ubiquitous and spread out indiscriminately. As John Barry said, in New York Times, “None alone provides great protection, but the hope was that if most people followed most of the advice most of the time, the interventions could significantly reduce the spread of the disease, or “flatten the curve,” a phrase now all too familiar. This may sound simple, but it is not. As with a diet, people know what to eat but often stray; here straying can kill”.

3D_Influenza_transparent_key_pieslice_med

(Picture Credit – CDC illustration on influenza virus. Influenza A viruses are classified by subtypes based on the properties of their hemagglutinin (H) and neuraminidase (N) surface proteins. There are 18 different HA subtypes and 11 different NA subtypes. Subtypes are named by combining the H and N numbers – e.g., A(H1N1), A(H3N2). Click on the image to enlarge the picture).

It almost engulfed an entire then connected globe. However, the definition of connectedness, which was ignored then and which is ignored now too, is common to both the Spanish Flu and COVID-19. An estimated 500 million people worldwide were affected. It was a rudimentary period in the evolution of medicine and of course, there were no vaccines or medicines to treat the patients. The findings were, as usual, generally, healthy young adults succumbed to the illness, contrary to most diseases that took the life of the young and old. Today, we call this onslaught of infection against those with a mature immune system as Cytokine Storm. Then, we only knew it killed the young. Then too, people used hand washing, isolation, masks, avoiding public places, and quarantining those ill/suspected ill. It ravaged the economy and disrupted public life, basic civic services like garbage clean up, and postal delivery government services etc. were compromised. There was no one to cremate dead bodies; garbage was flying astray across the streets, no one to light neither lamp posts nor sufficient people to deliver the mail. City offices started digging mass graves, closed schools, public places including theaters. The truth was not transparent, trust in authorities deprecated. Then too, there was a lurking fear that ““civilization could easily disappear from the face of the earth.” Reopening then was marked by a rebound in cases.

Rebound after Reopening

Spanish Flu Rebound

In its intense and acute form, the malady lasted for almost 15 months, from the spring of 1918 to the summer of 1919. It is said that this pandemic Flu almost killed 50-100 million people. Today, we call that Influenza A or H1N1 flu. H1N1 kept lingering, again due to mutations, for 38 years until it was controlled with specific therapies.

Antigenic Shift versus Antigenic Drift

Influenza A and B, each has 8 genes and a variation keeps happening to make a combination each year. As investigations reveal, the 1918 pandemic started with an H1N1 strain, that kept mutating. At this moment, it is wise to understand the meaning of H and N, H stands for those proteins which are required to latch on the cell (inside) and release themselves (N proteins) when mature to infect other cells. This protein structure keeps changing slightly, called antigenic drift. Sometimes, the virus mutates significantly with major changes in the structure of the H and N proteins, called an Antigenic shift.

fcimb-08-00343-g0001

Fast Forward 2019-20 – Comparison and Contrast

It is commonly accepted believe that SARS CoV2 jumped the animal-human barrier. It too spread out from densely populated places. Like COVID-19, it took the world by surprise. No one anticipated that the global burden of death would be over 250, 000 in just 4 months. Then, there was no medicine and here again, we have no specific remedy. The mechanism of death was the same, cytokine storm prevailed then and it is reigning now. It took away the young healthy adults then, however, it is incapacitating for those young adults now, though the mortality is very high in the elderly. Then too, we used masks, isolation, and barrier protection, which we see as the mainstay of stopping the virus within the communities. We call it social distancing, back then, they called it crowding control.

What have we learned?

We see a commonality in the pattern. The biological behavior of the bugs is not changeable. The human response was almost the same. We respond exactly the same way how we responded then. We distanced from each other, we realized, it was spreading through our breath and mouth, so we used masks in 1918 and again, we are using masks. Is there anything wrong with this?

Quotable quotes from Christopher Nichols, Associate Professor of History at Oregon State University –

“The questions they asked then are the questions being asked now,”

“And while it’s very rare that history provides a simple straightforward lesson for the present, this is one of those instances. The Spanish flu tells us that social distancing works. And it works best if we act early, act fast and stick together — and base our decisions not on social or economic concerns, but on science and data and facts.”

References:

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1997248/
https://www.nytimes.com/2020/03/17/opinion/coronavirus-1918-spanish-flu.html
https://www.webmd.com/lung/news/20200420/four-lessons-from-the-1918-spanish-flu-pandemic#4
https://www.cdc.gov/flu/about/viruses/types.htm
https://www.cdc.gov/flu/about/viruses/change.htm

 

https://interactives.nejm.org/iv/playlist/index.html?media_id=siCcYW3U&pcs=sidebar

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1997248/https://www.nytimes.com/2020/03/17/opinion/coronavirus-1918-spanish-flu.htmlhttps://www.webmd.com/lung/news/20200420/four-lessons-from-the-1918-spanish-flu-pandemic#4https://www.cdc.gov/flu/about/viruses/types.htm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1997248/https://www.nytimes.com/2020/03/17/opinion/coronavirus-1918-spanish-flu.htmlhttps://www.webmd.com/lung/news/20200420/four-lessons-from-the-1918-spanish-flu-pandemic#4https://www.cdc.gov/flu/about/viruses/types.htm

COVID Rx Exchange

We created this group for doctors managing COVID patients. While those on the ground are managing clinical challenges, practice guidelines are being developed, enriched, and enhanced daily. This group is focused on sharing realtime expertise across boundaries during these crises. It is nonprofit & non-commercial.

We are very optimistic about a professional discussion. Please invite your colleagues managing Covid patients. For a complete description please visit https://wp.me/p7XEWW-1hj

Welcome to all those who joined recently using the group’s invite.

We started this collaborative initiative to cross-pollinate experiences and expertise with COVID-19 across the borders. As is obvious, the EU and the US have a maximum toll from COVID-19 and obviously, the body of experience is significant. We wish to transfer the insight gained from these experiences to those where COVID is now on the rise, especially in India, South East Asia, and the Middle East.

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Scope of this initiative:

To provide realtime information on –

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A key need is to have a realtime dialog with those on the ground on either side of the COVID Wave, both the receding and the rising. The intent is to share actionable and supporting ancillary information. SARS CoV2 is a new virus to humanity, is constantly mutating while humanity is unraveling the multitudes of mechanisms involved in the pathophysiology of COVID. This pandemic has driven several intelligent folks across the globe to research and refine the management guidelines regularly.

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Convalescent Serum and COVID-19

The convalescent serum has been used for several diseases since 1890 by Behring initial experiment with Diphtheria. Eventually, the convalescent serum has been used bacterial infections, pertussis, measles, Argentine hemorrhagic fever, influenza, chickenpox, infections by cytomegalovirus, parvovirus B19 and, more recently, Middle East respiratory syndrome coronavirus (MERS-CoV), H1N1 and H5N1 avian flu, and severe acute respiratory infections (SARI) viruses. Suffice it to say, it is as older as vaccination.

Compiled by

Shashank Heda, MD., Dallas, Texas.

Question: The serum could actually be a virus as there have been cases (documented of course) were even recovered patients were spreading the virus.

Answer: You raised a very interesting question. I appreciate your raising this. However, kindly get the references.

The convalescent serum has been used for several diseases since 1890 by Behring initial experiment with Diphtheria. Eventually, the convalescent serum has been used bacterial infections, pertussis, measles, Argentine hemorrhagic fever, influenza, chickenpox, infections by cytomegalovirus, parvovirus B19 and, more recently, Middle East respiratory syndrome coronavirus (MERS-CoV), H1N1 and H5N1 avian flu, and severe acute respiratory infections (SARI) viruses. Suffice it to say, it is as older as vaccination.

Keeping with the intent of dispelling myth and provide confidence to the community, I am making every attempt to provide transparency based on the existing scientific research. Below, I am attaching two excerpts along with their references.

Convalescent blood products (CBP), obtained by collecting whole blood or plasma from a patient who has survived a previous infection and developed humoral immunity against the pathogen responsible for the disease in question, are a possible source of specific antibodies of human origin. The transfusion of CBP is able to neutralize the pathogen and eventually leads to its eradication from the blood circulation. Different CBP has been used to achieve artificially acquired passive immunity:  (i) convalescent whole blood (CWB), convalescent plasma (CP) or convalescent serum (CS); (ii) pooled human immunoglobulin (Ig) for intravenous or intramuscular administration; (iii) high-titer human Ig; and (iv) polyclonal or monoclonal antibodies.

==           ==

Convalescent Plasma:

In the absence of specific antiviral agents and vaccines for COVID-19, clinical trials have been conducted aimed at investigating the efficacy of convalescent plasma in treating COVID-19. A very recently published study by Chinese researchers confirmed the efficacy of convalescent plasma in controlling SARS-CoV-2 (Table 1) (Roback and Guarner, 2020). The report suggested that COVID-19 patients showed signs of improvement approximately 1 week after convalescent plasma transfusion. Another clinical study involved 10 critically ill patients infected with COVID-19 from 3 different hospitals in Wuhan suggested high-titer convalescent plasma transfusion can effectively neutralize SARS-CoV-2, leading to impeded inflammatory responses and improved symptom conditions without severe adverse events. All 10 patients receiving convalescent plasma transfusion showed improvement of clinical outcomes or were cured and discharged from the hospital (Duan et al., 2020). Given the clinical effectiveness of convalescent plasma, the FDA has granted clinical permission for applying convalescent plasma to the treatment of critically ill COVID-19 patients (FDA, 2020).

Convalescent plasma collected from donors who have survived an infectious disease by producing protective antibodies is considered to provide a great degree of protection for recipients affected by the emerging virus (Dodd, 2012). Convalescent plasma has been successfully employed to treat numerous infectious diseases, including the 2003 SARS-CoV-1 epidemic, 2009-2010 H1N1 influenza virus pandemic, and 2012 MERS-CoV epidemic (Dodd, 2012, Hung et al., 2011, Mair-Jenkins et al., 2015), for which modern medicine has no specific effective treatment.

Mayo Clinic named national site for Convalescent Plasma Expanded Access Program

https://www.sciencedirect.com/science/article/pii/S0889159120305894?via%3Dihub.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175848/

https://jamanetwork.com/journals/jama/fullarticle/2763983

Mayo Clinic named national site for Convalescent Plasma Expanded Access Program

https://jamanetwork.com/journals/jama/fullarticle/2763983

 

Civic Liberty and Public Health

The US is the most affected country bearing 32% of global (COVID-19) disease burden. A prominent influencing factor is the fundamental percept of individual freedom, as enshrined in the constitution and supported with the first amendment. Across the US, people are protesting about the compromise of personal freedom with the Stay at Home orders. Coronavirus has challenged all frontiers of humanity, its evolution and exposed our fault lines, irrespective of the countries, economies, ethnicities, ideologies, and our model of governance.

Civic liberty or public health – How do we achieve the right balance? Finally, balance also has a context and background. While there is a tendency on part of the state to erode individual freedom, the situation with Coronavirus is obvious. The inability to impose restrictions will definitely compromise the health of the society and ultimately the individual. In fact, not doing so will abrogate the state’s duties of providing safety for the individual. The scientific principle that underlines the “flatten the Curve” is provided along with a link to the international tracker of individual freedom across the globe. Also, expert opinion from Human Rights Experts and Legal Expert from Brooking, Harvard, University of Chicago, and Columbia University is cited in my blog. Realtime R(not) factor can be tracked for your county from the link provided herein.

What is compromised? What is indispensable?

COVID has opened a dialectical discussion on individual freedom and individual freedom that can harm the wider community. Freedom of movement is enshrined in the first amendment. To a few, these are considered at odds with each other. However, it’s a matter of perception. In the case of COVID-19, the common good outweigh individual freedoms.

When can we consider individual freedom compromised?

Ideally, we can consider that individual freedom is compromised if it results in (1) enhanced surveillance powers that compromise privacy (as in China, drones, cameras, and Bluetooth trackers) (2) suspension of rights, (3) control over information; and (4) delayed elections.

None of these are used here in the US. So, it is wrong to construe that freedom is compromised. More so, the federal government has declared an emergency. Nancy Gertner, a senior lecturer on law and a retired federal judge, says that the types of surveillance measures lately used in South Korea might even be feasible here, if somewhat less likely. “The issue is whether the measures are proportionate with the purpose. Since this is a public health emergency, we’re not dealing with the usual rules and regulations.”

Testing and stepwise removal of the restriction to movement

Therefore, restrictions could ease once widespread testing for the virus becomes available. Once the Govt. ramps up the testing, then you can dovetail the precautions according to who’s vulnerable. If you’ve got no idea, you quarantine everybody. But if you can test widely you can also titrate the response. However, it worth noting that, RNA testing and not testing the antibodies, is important. Thus sensitivity and specificity of a test become important. Sensitivity is used for screening, whereas, specificity is used for diagnosis. in case of Corona, we can’t wait for the antibodies to develop since those take time to develop after the infection and before the antibodies become evident, the person is infective (even if asymptomatic) and can potentially shed the viruses. Thus, personally, I am averse to antibody testing for screening, though the opposite is currently practiced.

Lesser restrictions in favor of more fundamental freedoms is more a policy concern rather than a matter of law. Temporarily accepting lesser freedoms for the good of the country and the wider population, in general, is acceptable in order to regain fundamental freedoms of movement more quickly and permanently our, to earn a living, and to attend events and gatherings. Protests such as these are uncalled for since we don’t need proof to weigh the cost versus benefits.

How best to mitigate the concern?

Freedom of movement, due to Lockdown secondary to COVID-19, should be tied to the growing, declining curve of the infection and or testing. It cannot be blanket freedom for the entire nations. States, Counties, and Cities are displaying a distinct pattern. Those which are on the rising side of the curve, also called hotspots, should definitely have “Stay at Home” Order. Those on the declining part of the curve should be tallied with the R(not) factor (explained later). and if the R(not) is declining below one, then we should consider the removal of restrictions.

While the outcry for compromise of individual freedom is healthy, a governance and policy framework to monitor and remove the temporary restrictions on individual freedom should be tracked, monitored, and reported to provide transparency.

Citations

https://jamanetwork.com/journals/jama/fullarticle/2761556?widget=personalizedcontent&previousarticle=2764283

New restrictions on civil liberties during coronavirus

Freedom and privacy in the time of coronavirus

COVID-19 Civic Freedom Tracker: https://www.icnl.org/covid19tracker/

https://news.uchicago.edu/story/fight-against-covid-19-how-much-freedom-are-you-willing-give

https://www.cjr.org/analysis/coronavirus-press-freedom-crackdown.php

Tracking Realtime R(not) factor https://rt.live/

Facts will unravel the truth

Facts alone pave the way for unraveling the truth

The US alone contributes to 29% of the global burden of COVID-19 positive cases. As against, the US, India has a paltry 0.5%. I liked PM Modi’s lockdown, despite the criticism. Any crisis moment is likely to have its collateral damage. However, a leader has to weigh the big picture and make the right decisions at the right moment. I am not a great fan of PM Modi but let us not be partisan at such critical times. Figures talk, and they talk a lot. You cannot hide those in a country like India. If the lockdown persists for another 3 weeks, India would have controlled the giant virus adorably!

Various schools of thought are rife with speculation. Some think Indians have a healthy immunity, while data from the UK points towards a specific predilection for the Asian Indian population. From the get-go, I (Shashank Heda) have been holding a grouse against China (not the Chinese ethnicity) that they have tried a more diminutive and (an unknowingly an attenuated strain) against India. Given India’s porous borders and the uncontrolled travel and social interaction, it is possible that India was already infected with a milder version sometimes back, and now Indians have an immune response to some of those Spike proteins or possibly the hemagglutinins. Time alone will reveal the telltale genetic fingerprinting and the genesis of this virus.

In the interim, it is definitely not the time to drop the guards. Let us educate our folks for –

  • Social distancing (no social/community/outdoor activities)
  • Isolation and shelter at home
  • Masks and decontamination precautions

Most important, they need to remember to

  • destress themselves,
  • implement a balanced life,
  • keep active and connected and
  • sleep well.

They need to be reminded that, they are not alone, 40% of the global population is going through the same routine.

Excerpts from BBC below –

“Our [infection] growth rate is highly contained although we are actively chasing the fire,” she told me. “Almost all of our testing has been driven by protocol, starting with people with travel history, contact tracing of people in touch with them and so on. The probability of getting more positive cases [from this cohort] would have been much higher.” Many are also pointing to the lack of reports about any surge in hospital admissions with influenza like illness and Covid-19 patients, which would hint at a rapid community transmission.

https://www.bbc.com/news/world-asia-india-52265061

Herd Immunity

A raging debate is ongoing on Herd Immunity versus isolation. While herd immunity has been a de-facto nature’s standard for protecting the masses or herd, (not necessarily human alone), Coronavirus (SARS CoV2) has thrown this natural principle into question for several reasons – 1) it is new and has high mortality and morbidity due to its properties 2) we have no innate defense against it 3) Even the most highly industrialized nations have no capacity to accommodate the sick patients. Let us review the factors why we should not YET resort to Herd Immunity.

 

Before getting started, let us see a live example of herd immunity being practiced to counter Covid-19. Let’s visit Sweden (Updated May 4, 2020).

“herd immunity,” in which a critical mass of infection occurs in lower-risk populations that ultimately thwarts transmission. “relies more on calibrated precautions and isolating only the most vulnerable than on imposing a full lockdown.”

I am strongly convinced for Herd Immunity because that’s the only mechanism for mass protection at the lowest cost (understanding the collateral damage). Herd Immunity, should not be construed with the development of commensals, or symbiosis between the bugs and the host. Of note, let us understand the process of herd immunity and commensal development from an evolutionary basis. For these bugs (those existing in GI tract) the external environment is harsh and toxic. They cannot exist outside and so have taken refuge inside the host. Eventually, the host and the bugs take a symbiotic relationship or often, at least don’t harm the host unless in rare circumstances. Summarize to say that there is no evolutionary angle to this novel coronavirus. It is de-novo, not an adaptive organism.

Herd Immunity and Vaccination

Second, from the perspective of spreading immunity – understand that the collateral damage it may cause is irrespective of the value of the individual. At a theosophical and spiritual level, who are we to decide a 78-year-old should die or survive? We only have to create a judicious system to protect if we know the risk is higher in this population.

Biologically and from the perspective of Epidemiology, Herd Immunity, especially as it plays from a vaccine perspective, offers lesser chance unless a vaccine is introduced. It provides better protection when a vaccine is introduced in the population. They both have a synergistic effect. In fact, the lesser a population is vaccinated, the lesser the herd immunity phenomenon.

Despite, not knowing this Coronavirus ever existed, I strongly feel that Herd Immunity is best for general mass protection if the morbidity, as well as the mortality, are low and this is considering the varying Rho factors for various bugs.

UK and Sweden tried Herd Immunity and failed. In a partial sense, the US unknowingly imposed the principle of herd immunity (by not imposing the lockdown) and paid the cost. Today, the UK, the US, and Scandinavian countries all are reversing their stand on herd immunity. This is because of the grim reality of 20000 plus deaths in the US and several thousand deaths in the UK. Those sticking to Herd Immunity have taken a heavy toll because –

  • This is a new virus (as against the others which evolve) whose least quantity infects (S protein configuration, antiviral suppression, and cytokine storm)
  • There mortality and morbidity significantly high for the state to prepare and manage this huge tide.

Excerpts from Kevin Kavanaugh from the link cited below –

“Mitigation strategies can decrease a contagion’s R0. To decrease the total number of individuals with active infections, the R0 will have to be less than one. So, on average, each infected person spreads the virus to less than one person. When this happens, the epidemic will eventually burn out.

Herd immunity strategies rely on a significant portion of the population to become immune to stop the spread of the virus. The higher the R0, the larger the percentage of the population who must become immune before the total number of those with active infections decreases and the epidemic burns out. An R0 of 5 to 7 will require 80% to 85% of the population to become immune before the number of infected will start to decrease. Thus, it can be argued that without mitigation, the R0 will be far too high to be able to stop this epidemic with herd immunity. Almost all of the population would have to contract the infection before the epidemic would stop, which probably will not happen. The availability of a vaccine to prevent infections with pathogens having a high R0 is of utmost importance.

Other concerns are that immunity to coronaviruses which cause the common cold only lasts between 1 to 2 years and there is mounting evidence that cats and dogs may become infected, giving concerns of an animal host.

Thus, without a vaccine, this virus will be with us for some time. Herd immunity may slow the expanse of the epidemic, but it is not likely to meaningfully stop it without mitigation strategies. And there is significant concern that those who currently recover could be re-infected in the near future. Strategies of social distancing, not gathering in large crowds, wearing masks and protecting those at increased risk are required to manage this epidemic.Returning to life as usual with the dependence on herd immunity in a non-vaccinated population to control spread is almost certainly a false narrative”.

Thus, I feel, our ultimate recourse is our own defense – innate and adaptive complimented by herd immunity. The only reason, we are not resorting to herd immunity exclusively is because of the morbidity and mortality associated with this virus.

CItations:

https://www.nationalreview.com/2020/05/coronavirus-crisis-sweden-refused-lockdown-other-countries-following/ (Updated May 4, 2020)

https://www.infectioncontroltoday.com/covid-19/viewpoint-have-you-heard-about-herd-its-covid-19-fallacy (Kevin Kavanagh)

https://www.historyofvaccines.org/content/herd-immunity-0 (Animation)

https://www.aap.org/en-us/aap-voices/Pages/It-Takes-a-Herd.aspx (A simple scientific version)

https://www.technologyreview.com/2020/03/17/905244/what-is-herd-immunity-and-can-it-stop-the-coronavirus/

https://watermark.silverchair.com/cir007.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAlIwggJOBgkqhkiG9w0BBwagggI_MIICOwIBADCCAjQGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM2OVG8xg2pfYzNM-QAgEQgIICBSi7ifrpZhiYGndgs3xVawidKzRobUyILH54jTeTTCVvKXxKjfGTstEXY_TVc27do_oKohDgo0nlz3sEmDDDyXdf08bkvBxpUii7mooK0y4Cuonz8aMhK7uIcSVRndSJMKxsIbyrpXVSlgjnaCC387cZvR4qtxWfBcQqadTp1SmLZjw2qFgFm-w6W5Z6lzhNeAo9T4z-I9fVbPBPIlHS5ja0OrR19tlb7-bqbhxSlHujS0BnE5vGEjkB3yukP_2fTAR-2tir3Kje3j0Ae8jjDw2jV2AcCxjCxI6d-AdHTOKaB0JDka3AtdPccwhK-aHmteNLQCqnf9LAPbKHp075g79itw-qyLDc2ymz3IQg5lAWgKu1KO_vMkbCwkdr0Mx196-Rta8ssMWA7BxYySK2_hzcXcNicgsyy63sjXK6VHTy5UZNgSOw_F80rslfOgrCeP_yU-lFkMXB0Ll_2PRTXV5npNHbi0CwP0C-2oaGBpAUKeLycCOIDphV7F7bKQSlaKW4kgRf-XH3bqtsjnezQWGk2NllH4l_ErIujEUBev0hTMAaTPTIEMXc6OO429S6zwpF8JHpzdsmPLDXypaadLjseQk3Goikt2WmOKQB50WdqkYMYSWlcO2SUxMDA7_HZi_SkZhRPIigFE9Ocgo23y5UxAjHk3C6k5HRTbN0mQSmmKEA4Ag

 

Click to access f26ca43be04880eaf4ad046a1f9408cb2e11.pdf

Absolute Isolation Works Absolutely

As of this writing the total deaths in the US have mounted to 10,335. Never before mankind had seen such a fast moving, swiping infection. We knew Ebola, we knew Marburg viruses, and a few Prion diseases but collectively, we had never faced such a dreaded disease with high mortality. We were caught almost unprepared or at least we ignored with complacency. I have shared my thought on why isolation is important to contain this disease and how countries like Singapore, South Korea and japan are dealing planning isolation and intelligence in dealing with this crisis.

Absolute Isolation Works Absolutely

As noted in my earlier blog, viruses are obligate parasites that need (MUST) a host cell to survive. They go through their phases of replication and eventually, after not getting proper host cells to infect, die a natural death.

Strict Isolation Social Distancing

I have had many folks across the geographies asking me a few questions?

  1. Why is the incidence of Coronovirus so high in the US?
  2. Are certain ethnicities (such as Indians) immune to the Coronavirus?

I will emphasize the control of Coronavirus based on the viruses’ obligate dependence on live cells for survival. We all know that if we practice Isolation absolutely, we should be assured of not having the disease.

Two situations preclude our ability for Isolation –

  1. Our needs for Essentials
  2. Fundamental Sense of Liberty

I owe you all a clear and concise write up on the best practices and pragmatic guidelines on “How to Manage Essentials” giving an end to end perspective, that provides the best way to avoid getting the virus inside your home. Give me until later this late evening to fulfill that commitment.

Let us talk about the “Sense of Liberty”. The US, the EU, and most developed nations have an enshrined fundamental Right of liberty to move.  Isolation or ‘Shelter in Place’ equals to ‘House Arrest’ for them. The later nullifies isolation and thus provides a continuation of the propagation of the virus by allowing it to jump from people to people (aerosol, airborne, contact and fomites).

Special intervention in community level

So after the rise of an emerging disease, goverments have a special responsibility to balance between civil liberties and special measures for protecting susceptible populations. However, three components of “scientific“, “voluntary” and civil liberty should be considered as guiding principles for decision-making and operating each special protective measure at the community level (cited).

Aerosols Airborne Fomites

I see a dichotomy based on the above two practical limitations that are increasing the spread of Coronavirus in the US. Select countries like India and Japan are strongly considering the imposition of emergency. Whereas, many have implemented strict isolation even if the idea of isolation has emerged from behind the Iron Curtain of China.

The Bhilwara Model

The Bhilwara Model for containment of COVID-19 refers to imposing a curfew in the district including suspension of essential services, extensive screening, and house-to-house surveys to check for possible cases, and detailed contact tracing of each positive case so as to create a dossier on everybody they met ever since they got infected. A similar model was followed in Singapore, South Korea, and Taiwan. Singapore had gone a step ahead and deployed its intelligence sleuths to extract the contact tracing, whereas, the draconian Chinese Govt deployed Bluetooth tracing abandoning the privacy laws (they do not exist in China, except while the couple is conjugating, I believe!).

The success of the Bhilwara model is attributed to controlling an outbreak within the first four days of the initial incidence (remember the Rho factor.

Absolute isolation works absolutely. Yes, it does but can we forego our sense of liberty? Can we minimize our needs and limit our consumption? Please visit my next blog on “Managing the Essentials”.

 

Also read – Support your service folks (maids, handyman, lawnmowers etc.) https://mymilieu.org/2020/04/02/supporting-service-folks-during-crisis/

Why is Coronavirus highly infective? https://wp.me/p7XEWW-1go

Additional Reading:

How do I know if I have a Coronavirus infection? Before reading further, I strongly advise and recommend that this should not be construed as advice. Your best recourse is your doctor or health care professional.

Doctors in China used a triage system for fast screening. This was published in the Lancet. Below flowchart from the Lancet.

COVID Symptoms Flowchart Lancet JPEG

 

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7117787/

. 2020; 8(1): e41.
Published online 2020 Apr 1.
PMCID: PMC7117787

Epidemiological and Clinical Aspects of COVID-19; a Narrative Review