Mumbai: The capital city of India, New Delhi, seems to be heading towards becoming the coronavirus capital as well, as many people are saying. The number of cases in Delhi is much less than in Mumbai, but the rate of growth in this city has been high, given that the early number of cases was much lower. What exactly is happening in Delhi? What has caused the sudden increase in cases? What is the medical response? How is the infrastructure prepared to cope with it?

We speak with Arvind Kumar, chairperson of the Centre for Chest Surgery and Lung Transplantation at Sir Ganga Ram Hospital, Delhi, and founder of the Lung Care Foundation.

Edited excerpts:

As someone on the frontlines of this battle, why do you think the number of cases is increasing? What do you see, from your patients, in terms of the changing symptoms that might give you some clues?

I think one of the main reasons why the numbers are increasing is that people have developed a feeling that everything is good, and that the crisis period is over. I see--including in my colony and elsewhere, when I drive to the hospital--as much traffic on the roads as I used to, maybe a little less, before the lockdown. With the large number of people coming out, working together, going to the market, and with the general feeling that everything is good, people are not taking the precautions as they were during the lockdown. I think [this] increased people-to-people interaction is leading to an increase in the number of cases. 

As you know, every infected case has the potential to infect 2.7 more cases in a day. And when you have more cases, the whole thing increases by geometric progression--something on which our initial decision to lock down was based. Those dynamics apply as much today as they applied at that time. But people were very responsive to lockdown restrictions at that time, whereas now there is a general feeling that things are back [to normal], and that we should worry about business and everything.

The projections by the health minister of Delhi estimated about 550,000 cases and a requirement for 80,000 beds by the end of July. That is really a frightening scenario and as a doctor, my first response will not be to prepare the infrastructure for that--because I do not think any system can prepare infrastructure adequate for that. My first response will be to go out and do everything to break this cycle of transmission and not let that mathematical model come true. That is the best thing we can do for ourselves.

Why is it, you feel, that the transmission did not break in almost 75 days of lockdown--if you were to look at Delhi and the cases you have been seeing? 

There were a couple of problems that occurred during the lockdown. Our lockdown was complete from one angle--a large number of people did follow the lockdown rules. 

But you are aware there were a couple of instances because of which there was a spread of infected cases to pockets across the city and also across the country. After that, there was this problem of migrant labour, which also led to movement of millions of people--some of them infected--from one part of the country to another. On the one hand, we had 95% of the population staying indoors. But we also had these huge numbers [of people] who were outdoors. So, there was a lot of infection carried from one point to another. 

The lockdown was never intended to eradicate the infection; it was only intended to break the chain of transmission. Now, that was to have continued for some more time. We lifted these measures at a time when the cases were still rising. I had been repeatedly saying that the time to lift the lockdown is when you have crossed the peak and you are on a downward trend. We were not on the downward trend, but the lockdown was lifted; a general impression was given to people that everything is hunky-dory, and we are seeing the consequences now.

What are you seeing in the hospital now, in terms of the patients coming in, the progression of the disease, and the complexity? How has that changed in the last eight weeks, if so?

There are problems at multiple levels. 

With a large number of infected people coming to the hospital and more and more health workers directly involved in their care, the overall volume of people in the hospital is much more than it was at the beginning of the lockdown. There is that much more exposure for the healthcare worker. An increasing number of healthcare workers--doctors, nurses and other people--are becoming ill, and they are now going out. So, there is an increasing requirement of healthcare workers because of the increasing cases, but there is a dwindling number of those people available (because a lot of them are being quarantined). This is a very explosive combination.

Number two, more and more cases are now reporting to the hospitals. Despite 20% of the beds assigned for COVID-19, there is a situation where most private hospitals are chock-a-block and do not have beds for patients. As the numbers increase, we will have a situation where patients will find it difficult to get a bed.

Number three, we are also seeing more numbers of young people getting affected; some of them with serious disease. To say that young people never have a problem [or severe COVID-19] is not true; sometimes even young people can have a problem.

Everything that needs to be done to decrease the number of cases is the need of the hour, while we continue to take care of those who are already infected and will get infected.

Any insights on the potency of the disease between the first week of April and today?

I do not think there is any change in the potency of the infection pre-lockdown versus post lockdown. But there is definitely a difference in the potency or the lethality of the virus in India compared to the US and Europe: The lethality is less in India, and that has been attributed to various factors.

What could those factors be, from your own experience?

Various theories have been propounded to explain the lower death rate. BCG vaccination [Bacille Calmette-Guérin, against tuberculosis] is routinely practised in India, and a lot of researchers have attributed this less lethality to this. Secondly, we have a high prevalence of malaria in our country, and all of us have antibodies against that, so that could also be acting against [more lethal COVID-19] as a protective measure. Thirdly, we already have a huge number of infections that all of us face, and we do have some antibodies against all that. And the fourth speculation is that maybe the virus strain that we have in India is a little less lethal than the strain which is there in Europe. 

You talked about how, particularly post-lockdown, the cases have shot up because people are interacting. Does that not mean there is community transmission? I know medically and in official terminology, it may not match.

There has been a lot of discussion around community transmission. The ICMR [Indian Council of Medical Research] has released data of its sero-survey of 83 districts, in which they have reported 0.73% prevalence of the antibodies, which means that there is not a major transmission or asymptomatic transmission in the community. So, going by the ICMR definition, there is no community transmission yet. 

However, at the same time, it is also true that we are seeing pockets or areas where there is a lot of intra-community transmission. And I am sure if they do testing in those pockets--which they are, and the results are expected in a week or 10 days later--there the seroprevalence will turn out to be much higher. So, we do have pockets of community transmission but definitely there is no country-wide community transmission.

Tell us about infrastructure. Delhi has about 8,200 beds for COVID right now. You said that the projections can trigger the need for 80,000 beds by July end, which is not physically possible. How do you see the management and logistics of cases today? Are they any solutions in logistics management and the way patients are distributed that can ease the load?

While talking of solutions, even at the cost of repetition, the first thing I would say is each one of us needs to make serious efforts to break the chain of transmission. If we have the same rate of spread, trust me, no infrastructure will be able to handle that load and we are heading for a serious situation. Let us pray that we do not reach that situation. I would repeat that please, all of us, let us have a self-imposed lockdown and minimise people-to-people interaction, so that we are able to break the cycle and not let those numbers come true. 

Number two, there is a concerted effort going on to convert more beds in government and private hospitals into COVID beds. For example, in our Kolmet and City hospital [of Sir Ganga Ram Hospital], 50 and 140 beds were given to COVID. Then 20% of the beds in the main hospital were also given to COVID. Now, they are being increased to 40%. The same thing is happening in other private hospitals.

Converting a non-COVID bed to a COVID bed takes time. There is a fundamental difference in the room of a COVID patient and a non-COVID patient. Typically, all hospitals have positive pressure air-conditioning, which is meant to make the air move away from the patient area so that the infection does not come towards the patient. In the case of COVID, where the patient is the source of infection, you have to do reverse engineering and have negative-pressure air-conditioning. This means you have to retrofit your air conditioning system; and have a minimum of 12 air exchanges every hour, install viral filters in your input-output areas, and change the pattern of the airflow. Now, this needs time. Similarly, the nursing counter, the food and medicine, the entry [need to be separate], the isolation—there is a huge retrofitting that needs to be done for which the facilities need time. 

There is also the precarious situation that a lot of workers who were on daily wages or outsourced are just disappearing. This is a serious problem that we cannot overlook, because all hospitals have a lesser and lesser number of these people reporting. This means your available manpower is decreasing while your requirement is increasing. 

So, these are real practical problems that healthcare facilities are facing, but we are trying to overcome it and have maximum beds. There is also a provision now that hotels are being attached to each hospital, to accommodate mild symptomatic cases (moderate and severe cases will come to the main hospital), and the respective hospital will provide medical care in the hotels. But this also needs some time to arrange.

You said, as have others, that we are heading to the peak, and at some point this will peak and then start ebbing. Could you explain to us what does peaking exactly mean, from a layperson’s point of view? And why is it that things will be a little safer once this virus or disease has peaked?

Today, one infected person infects about three people. Tomorrow, you have four infected people who will infect 12 people. This increases in a geometric progression and goes on for a certain amount of time, when you have what is called “herd immunity”; where a big percentage (60-70%) of people have had this infection and they develop innate immunity from acquiring more infection. 

So, if an infected person goes out, there are three people [who can potentially get infected]. But two of them are immune because of herd immunity. So only one person will get infected. This is how the infection rate, which was spiraling in a geometric progression, reaches its end and starts coming down. 

The number of cases who are improving starts going up and the number of new infections starts coming down. And as the new infections decrease, the new infections that will occur from them will also decrease. So, the negative growth also occurs now in a geometric progression and you have a rapid decline in the number of cases. 

So, our expectation is, the earlier we have a good number of people developing asymptomatic infection without any problem, developing immunity, and thereby becoming immune to fresh infection, that is when we will peak and our numbers will start decreasing. 

One mathematical model by ministry officials has predicted that will happen by mid-September. They have done a Bailey’s analysis and predicted that by mid-September, the novel coronavirus will disappear from our country. I hope and pray that it happens much before that.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Mumbai: The capital city of India, New Delhi, seems to be heading towards becoming the coronavirus capital as well, as many people are saying. The number of cases in Delhi is much less than in Mumbai, but the rate of growth in this city has been high, given that the early number of cases was much lower. What exactly is happening in Delhi? What has caused the sudden increase in cases? What is the medical response? How is the infrastructure prepared to cope with it?

We speak with Arvind Kumar, chairperson of the Centre for Chest Surgery and Lung Transplantation at Sir Ganga Ram Hospital, Delhi, and founder of the Lung Care Foundation.

Edited excerpts:

As someone on the frontlines of this battle, why do you think the number of cases is increasing? What do you see, from your patients, in terms of the changing symptoms that might give you some clues?

I think one of the main reasons why the numbers are increasing is that people have developed a feeling that everything is good, and that the crisis period is over. I see--including in my colony and elsewhere, when I drive to the hospital--as much traffic on the roads as I used to, maybe a little less, before the lockdown. With the large number of people coming out, working together, going to the market, and with the general feeling that everything is good, people are not taking the precautions as they were during the lockdown. I think [this] increased people-to-people interaction is leading to an increase in the number of cases. 

As you know, every infected case has the potential to infect 2.7 more cases in a day. And when you have more cases, the whole thing increases by geometric progression--something on which our initial decision to lock down was based. Those dynamics apply as much today as they applied at that time. But people were very responsive to lockdown restrictions at that time, whereas now there is a general feeling that things are back [to normal], and that we should worry about business and everything.

The projections by the health minister of Delhi estimated about 550,000 cases and a requirement for 80,000 beds by the end of July. That is really a frightening scenario and as a doctor, my first response will not be to prepare the infrastructure for that--because I do not think any system can prepare infrastructure adequate for that. My first response will be to go out and do everything to break this cycle of transmission and not let that mathematical model come true. That is the best thing we can do for ourselves.

Why is it, you feel, that the transmission did not break in almost 75 days of lockdown--if you were to look at Delhi and the cases you have been seeing? 

There were a couple of problems that occurred during the lockdown. Our lockdown was complete from one angle--a large number of people did follow the lockdown rules. 

But you are aware there were a couple of instances because of which there was a spread of infected cases to pockets across the city and also across the country. After that, there was this problem of migrant labour, which also led to movement of millions of people--some of them infected--from one part of the country to another. On the one hand, we had 95% of the population staying indoors. But we also had these huge numbers [of people] who were outdoors. So, there was a lot of infection carried from one point to another. 

The lockdown was never intended to eradicate the infection; it was only intended to break the chain of transmission. Now, that was to have continued for some more time. We lifted these measures at a time when the cases were still rising. I had been repeatedly saying that the time to lift the lockdown is when you have crossed the peak and you are on a downward trend. We were not on the downward trend, but the lockdown was lifted; a general impression was given to people that everything is hunky-dory, and we are seeing the consequences now.

What are you seeing in the hospital now, in terms of the patients coming in, the progression of the disease, and the complexity? How has that changed in the last eight weeks, if so?

There are problems at multiple levels. 

With a large number of infected people coming to the hospital and more and more health workers directly involved in their care, the overall volume of people in the hospital is much more than it was at the beginning of the lockdown. There is that much more exposure for the healthcare worker. An increasing number of healthcare workers--doctors, nurses and other people--are becoming ill, and they are now going out. So, there is an increasing requirement of healthcare workers because of the increasing cases, but there is a dwindling number of those people available (because a lot of them are being quarantined). This is a very explosive combination.

Number two, more and more cases are now reporting to the hospitals. Despite 20% of the beds assigned for COVID-19, there is a situation where most private hospitals are chock-a-block and do not have beds for patients. As the numbers increase, we will have a situation where patients will find it difficult to get a bed.

Number three, we are also seeing more numbers of young people getting affected; some of them with serious disease. To say that young people never have a problem [or severe COVID-19] is not true; sometimes even young people can have a problem.

Everything that needs to be done to decrease the number of cases is the need of the hour, while we continue to take care of those who are already infected and will get infected.

Any insights on the potency of the disease between the first week of April and today?

I do not think there is any change in the potency of the infection pre-lockdown versus post lockdown. But there is definitely a difference in the potency or the lethality of the virus in India compared to the US and Europe: The lethality is less in India, and that has been attributed to various factors.

What could those factors be, from your own experience?

Various theories have been propounded to explain the lower death rate. BCG vaccination [Bacille Calmette-Guérin, against tuberculosis] is routinely practised in India, and a lot of researchers have attributed this less lethality to this. Secondly, we have a high prevalence of malaria in our country, and all of us have antibodies against that, so that could also be acting against [more lethal COVID-19] as a protective measure. Thirdly, we already have a huge number of infections that all of us face, and we do have some antibodies against all that. And the fourth speculation is that maybe the virus strain that we have in India is a little less lethal than the strain which is there in Europe. 

You talked about how, particularly post-lockdown, the cases have shot up because people are interacting. Does that not mean there is community transmission? I know medically and in official terminology, it may not match.

There has been a lot of discussion around community transmission. The ICMR [Indian Council of Medical Research] has released data of its sero-survey of 83 districts, in which they have reported 0.73% prevalence of the antibodies, which means that there is not a major transmission or asymptomatic transmission in the community. So, going by the ICMR definition, there is no community transmission yet. 

However, at the same time, it is also true that we are seeing pockets or areas where there is a lot of intra-community transmission. And I am sure if they do testing in those pockets--which they are, and the results are expected in a week or 10 days later--there the seroprevalence will turn out to be much higher. So, we do have pockets of community transmission but definitely there is no country-wide community transmission.

Tell us about infrastructure. Delhi has about 8,200 beds for COVID right now. You said that the projections can trigger the need for 80,000 beds by July end, which is not physically possible. How do you see the management and logistics of cases today? Are they any solutions in logistics management and the way patients are distributed that can ease the load?

While talking of solutions, even at the cost of repetition, the first thing I would say is each one of us needs to make serious efforts to break the chain of transmission. If we have the same rate of spread, trust me, no infrastructure will be able to handle that load and we are heading for a serious situation. Let us pray that we do not reach that situation. I would repeat that please, all of us, let us have a self-imposed lockdown and minimise people-to-people interaction, so that we are able to break the cycle and not let those numbers come true. 

Number two, there is a concerted effort going on to convert more beds in government and private hospitals into COVID beds. For example, in our Kolmet and City hospital [of Sir Ganga Ram Hospital], 50 and 140 beds were given to COVID. Then 20% of the beds in the main hospital were also given to COVID. Now, they are being increased to 40%. The same thing is happening in other private hospitals.

Converting a non-COVID bed to a COVID bed takes time. There is a fundamental difference in the room of a COVID patient and a non-COVID patient. Typically, all hospitals have positive pressure air-conditioning, which is meant to make the air move away from the patient area so that the infection does not come towards the patient. In the case of COVID, where the patient is the source of infection, you have to do reverse engineering and have negative-pressure air-conditioning. This means you have to retrofit your air conditioning system; and have a minimum of 12 air exchanges every hour, install viral filters in your input-output areas, and change the pattern of the airflow. Now, this needs time. Similarly, the nursing counter, the food and medicine, the entry [need to be separate], the isolation—there is a huge retrofitting that needs to be done for which the facilities need time. 

There is also the precarious situation that a lot of workers who were on daily wages or outsourced are just disappearing. This is a serious problem that we cannot overlook, because all hospitals have a lesser and lesser number of these people reporting. This means your available manpower is decreasing while your requirement is increasing. 

So, these are real practical problems that healthcare facilities are facing, but we are trying to overcome it and have maximum beds. There is also a provision now that hotels are being attached to each hospital, to accommodate mild symptomatic cases (moderate and severe cases will come to the main hospital), and the respective hospital will provide medical care in the hotels. But this also needs some time to arrange.

You said, as have others, that we are heading to the peak, and at some point this will peak and then start ebbing. Could you explain to us what does peaking exactly mean, from a layperson’s point of view? And why is it that things will be a little safer once this virus or disease has peaked?

Today, one infected person infects about three people. Tomorrow, you have four infected people who will infect 12 people. This increases in a geometric progression and goes on for a certain amount of time, when you have what is called “herd immunity”; where a big percentage (60-70%) of people have had this infection and they develop innate immunity from acquiring more infection. 

So, if an infected person goes out, there are three people [who can potentially get infected]. But two of them are immune because of herd immunity. So only one person will get infected. This is how the infection rate, which was spiraling in a geometric progression, reaches its end and starts coming down. 

The number of cases who are improving starts going up and the number of new infections starts coming down. And as the new infections decrease, the new infections that will occur from them will also decrease. So, the negative growth also occurs now in a geometric progression and you have a rapid decline in the number of cases. 

So, our expectation is, the earlier we have a good number of people developing asymptomatic infection without any problem, developing immunity, and thereby becoming immune to fresh infection, that is when we will peak and our numbers will start decreasing. 

One mathematical model by ministry officials has predicted that will happen by mid-September. They have done a Bailey’s analysis and predicted that by mid-September, the novel coronavirus will disappear from our country. I hope and pray that it happens much before that.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.



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