The COVID-19 Conundrum: Between Scylla of losing lives and Charybdis of losing livelihoods
Manipur’s situation is not yet alarming, but there is also no room for complacency.
This new pandemic called Covid-19 has ravaged nearly all countries of the world and yet this alarming global scourge is still not showing any signs of slowing down. As of this writing, there are about 30.7 million cases of infections globally, with over 9.5 lakh deaths. India is the second worst affected country, with more than 53 lakh (5.3 million) cases of infection, and about 85,000 deaths. The situation in our country is quite alarming as daily rises have been in the range of 70,000 to nearly 1 lakh cases for the past several days!
Manipur’s situation is not yet alarming, but there is also no room for complacency. The government is taking all possible steps, I believe, to contain the disease. However, if the public doesn’t strictly abide by the recommended control and preventive measures such as use of masks, social distancing, hand hygiene, regular use of soaps and hand sanitizers and religious maintenance of quarantine/isolation SOPs, the outbreak may go out of control! Till date, the number of cases in Manipur have shot up to 8,723 cases with 6,723 recoveries and the number of deaths stand currently at 55.
In this column, I would like to review the status of the Covid-19 pandemic and the conundrum of negotiating the razor's edge between opening up to save dwindling livelihoods and imposing limited/intermittent/localized lockdowns to stem the surge in infections and save precious lives. Across the globe, nobody knows how to navigate the precarious journey between Scylla of lockdowns and charybdis of unlocking. Yet, our lives must go own treading the narrow path between pandemic-caused restrictions and gradual resumptions of normal times as it used to be!
Status of Covid-19
Till date, SARS-CoV-2 has infected over 30 million people globally, of which more than 5 million are in India. India’s contribution to the global tally is nearly 20%. Nearly 1 million have died globally, of which about 85,000 deaths occurred in India. India accounts for about 9% of Covid deaths. Yet the curve continues to rise across mainstream cities, towns and villages, and even border areas of India!
Orchestrating the symphony: Lockdown and Unlocking, how?
Unless the wily virus soon develops, some small mercies for humankind in the form of reduced contagiousness (falling R 0 -basic reproduction number), decreased morbidity and mortality, or a safe, durable, equitable, and efficacious vaccine or a “silver bullet” in the form of a drug or cure arrives on the scene; we’re indeed faced with an inscrutable conundrum. If you impose strict lockdowns further, many hapless individuals will lose livelihoods. Conversely, if you relax and fully unlock the various sectors of the economy, there’s the sure likelihood of losing more lives to the pandemic. Fortunately or unfortunately, there can only be medical endings to a pandemic, and not political ones, through pronouncements or circulars. In this case, a medical ending can be achieved only through an effective vaccine or cure, painstakingly worked out in the laboratory by thousands of usually unsung scientific soldiers. But we have to still wait for the first vaccine or drug to arrive. Meanwhile, what are the options we have?
Non-pharmaceutical interventions to fight Covid-19
All of us are now familiar with the oft-mentioned “test-trace-treat strategy”. Test the suspected people, trace their contacts rigorously (isolate/quarantine them so that they don’t transmit the virus to susceptible people), and treat severe/critical cases properly.
Let’s now focus our attention on testing strategies that may help check transmission of SARS-CoV-2. A utopian scenario is that we test the entire population of a town/city/state/country, isolate all positive cases till they “recover” to protect the rest of the population. As this isn’t feasible, we need to ascertain who to test, when, and how to trace their contacts. In this context, the timing of Covid-19 transmission is critical.
Timing of Covid-19 transmission
Ferretti et al. have done a crucial study regarding the timing of Covid-19 transmission. This work has now been published as a preprint at the medRxiv server (Sept. 16, 2020; doi.org/10.1101/2020.09.04.20188516). Their focus is on transmission by early-symptomatic individuals and their contribution to the total surge in infections. (We shall discuss asymptomatic and pre-symptomatic transmissions in upcoming columns.)
The major findings are:
1. The peak of transmission occurs on the day of onset of symptoms (20% of transmissions).
2. The day after onset of symptoms accounts for 16 per cent of transmissions.
3. So, the first two days of symptom onset (days 1 and 2) account for over 1/3rds of total transmissions.
Seventy five percent (75%) of transmission events occur in window period ranging from 2-3 days before to 2-3 days after the onset of symptoms. Pre-symptomatic transmission accounts for about 41% of the events and early-symptomatic transmissions account for about 35% of the events.
Implications for the standard SOPs:The implications of this critical study are manifold.
1. There is the prime importance of isolation of early-symptomatic cases, however mild the symptoms may be.
2. There must be aggressive testing in and around hotspots of infection.
3. There is urgent need for rapid and, if feasible, at-home testing kits. Fourth, contact tracing of symptomatic individuals must be done at war footing.
4. The time between sample collection and obtaining of test results must be short, preferably much less than 24 hours.
In addition to the above mass testing, rigorous isolation and seroprevalence antibody screening would go a long way in stemming the disease. We must trust the science and we must crunch numbers to control this pandemic. We need to draw weekly graphs of the rise and fall of infections, and rigorously calculate the R 0 values regularly, to decide where we must impose restrictions and where there can be relaxations.
There is as yet no approved cure or vaccine for COVID-19. Meanwhile, it’s likely that the number of morbidities and mortalities would continue to soar across most parts of the world, including India (and Manipur). What then should we do meanwhile before the development of an approved cure or vaccine.
The government must strictly enforce the standard SOPs for tracing, testing, and treating potential infection cases. Within the limits of the available budget, testing must be scaled up to catch more of potential infections including asymptomatic cases. If feasible, antibody based screening (serosurveillance) may be done in infection hotspots to monitor the spread of the infection and percentage of population who has developed immunity against the Covid-19 virus.
Three kinds of hospitals or treatment facilities need to be set up: first, to treat critical Covid patients; second, to address non-Covid cases, and third, to manage long Covid “recovered” individuals. The general public must also religiously abide by the necessary control and prevention measures (use of masks, social distancing & hand hygiene etc.); we need to be a tad altruistic: please remember that you’re sacrificing a little bit of your creature comforts not just to save your own life but also others’ lives!