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

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 –

Strictly following precautions and giving up occasionally
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

I don’t think you can live with the guilt of being responsible for the death of near or dear one.
Presuming you will survive, what is the guarantee that your organs will not be compromised for a long time?
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, outsiders wonder what is causing this 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

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?

Strict Social Distancing is not enough, we will be inhaling the bug via several routes.
You all need to suspend all strolls, shopping, and other errands. Let us minimize exposure as much as we can. Can we buy online?
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.

Herd Immunity

Anthony Fauci, the well-known face of CDC, says that it is unlikely the coronavirus will ever be eradicated, though nations can bring the level of infection down to “low levels.”

According to Dr. Fauci, a combination of three-pronged strategy will provide a cautiously optimistic to control the COVID-19 menace. The three-pronged collective strategy should consist of

1. Good public health measures,
2. Degree of global herd immunity and
3. Good vaccine

What are the failures? Well, those are intrinsic inabilities. It is the collective callousness that is resulting in a raging fire of COVID-19. Faultlines differ, however, our ineptitude and complacency are primarily the cause. We are thoroughly bored in the confines of our homes, or for some, it is personal freedom, and for others, the virus is a hoax and far less believe, they are invincible, not realizing that they are the source of transmission (Carrier) of infection to unsuspecting innocents who face the morbid consequences or mortal end.

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 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.”

Excerpts from CNBC August 2020 –

“According to epidemiologists, herd immunity is necessary to contain a virus and is reached when enough of the population is either vaccinated or survive infection and build antibodies to ward of new infections. The virus then doesn’t have enough hosts to infect.

Most scientists think 60% to 80% of the population needs to be vaccinated or have natural antibodies to achieve herd immunity, Dr. Mike Ryan, executive director of the World Health Organization’s health emergencies program, said last month. ” from CNBC August 11, 2020.

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

https://www.sciencedirect.com/science/article/pii/S1074761320301709

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.

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

Why is the incidence of Coronovirus so high in the US?
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 –

Our needs for Essentials
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