Original title: How does India decide the direction of the world epidemic?
India is also at a critical stage of the epidemic.
World Health Organization (WHO) Emergency Planning Director Mike Ryan said on March 23 that in a sense, can humans fight against the new crown epidemic The decisive victory will depend largely on India ’s ability to control the virus.
Zeng Guang, a high-level expert group member of the National Health and Health Commission and the chief epidemiologist of the Chinese Center for Disease Control and Prevention, also told the media recently, “Developing countries including India, Bangladesh and Nigeria are the next stage of epidemic prevention and control The key point. ”
As of 10 a.m. on April 5, a total of 3,076 people were diagnosed in India, 77 died, and 237 were cured. Compared with its population of 1.37 billion, the cumulative number of confirmed cases is not high. But many experts pointed out that India’s figures are underestimated. In an interview with the media, Dr. Ashish Jha, director of Harvard ’s Global Health Institute, pointed out that the number of confirmed cases in India is wrong, more cases have not been confirmed, and a large number of community transmissions have not been realized.
If the trend of the next phase of the world’s epidemic depends on India, then India is already at a critical stage of the epidemic. How effective is its epidemic prevention? Can the healthcare system withstand the impact of the epidemic?
From imported cases to community transmission
India’s alarm sounded very early. On January 25, the Indian government issued a travel warning asking the public to avoid unnecessary travel to China, and anyone who comes to India from China must be forced or segregated for 14 days.
Five days later, on January 30, the first confirmed case occurred in India. An Indian student studying in Wuhan, China was diagnosed with a new crown infection when returning to his hometown in India during the vacation. Within four days, two more students who returned to India from China were diagnosed, and a total of more than 3,400 suspected contacts were observed in isolation.
On February 2, India announced that the visa service for Chinese passport holders was suspended, and the Indian visas already obtained by Chinese passport holders are no longer valid. At this time, 21 airports in India have conducted entry quarantine for passengers from China. As of January 31, a total of 234 flights and 43,346 passengers have been inspected.
Lin Minwang, assistant dean and researcher of the Institute of International Studies at Fudan University, told China News Weekly that after the closure of Wuhan, India ’s response was very decisive. On the one hand, they know that their medical and health systems are relatively fragile; on the other hand, they also come from India ’s experience and lessons from the past few disease outbreaks.
Ashish Jha, director of the Harvard Institute of Global Health, pointed out that when the Ebola virus attacked West Africa in 2014, India established some good testing centers and testing programs. In 2018, when Nipah virus (a virus with a mortality rate of about 95%) attacked Kerala, although 17 people died, the human-to-human situation was brought under control.
At the end of January and early February, India had no new cases for nearly a month after the three cases were confirmed, and all three confirmed cases have been discharged. Until March 2, two people with a history of travel in Europe and the United States were diagnosed, and since then, the confirmed cases in India began to climb slowly.
The founder and head of the public health organization CDDEP, and senior research scholar at Princeton University, Ramanan Laxminarayan pointed out that the spread of the Indian epidemic at this time did not come from the Chinese because they have been isolated. It is possible that they came from Italians who came to travel.
According to the WHO ’s India report, it was not until early March that India issued a comprehensive medical examination of all international passengers. On March 13, India announced that passengers who entered the country afterwards and visited China, Italy, Iran, South Korea, France, Spain and Germany after February 15 will be quarantined for at least 14 days. In addition, except for special visas, all Indian visas will be suspended.
At this time, the cumulative number of diagnoses in India has just exceeded 50. Ten days later, on March 20, the cumulative number of diagnoses tripled to 196. Since then, new cases in India have continued to climb. This is because the new crown epidemic is indeed spreading in India; on the other hand, it is also because of the expansion of the testing population.
According to Lin Minwang, in the early days, India only conducted dozens of nucleic acid tests per day, conducted in 52 laboratories approved by the state, and only tested people with overseas travel records. According to foreign media reports, as of March 18, only 11,500 subjects had been tested, and the detection rate was very low compared to their population base. In mid-to-late March, several experts pointed out that India ’s diagnosis data is incorrect, and a large number of community transmissions have not been detected.
The Indian government has repeatedly stated that there is no community transmission in India. The head of the Medical Research Council of India (CMR), Barram Bargava, stated on March 14 that India is in the “second phase” of the new crown epidemic prevention and control. Contacting people has not yet entered the third stage, which is the stage of community communication.
At the end of March, the Indian Minister of Health stated that there has been limited community communication in India. The reason for the Indian government to change its rhetoric is the large-scale spread of a local religious organization in India.
According to the British “Guardian” report, on March 13th, the Indian Islamic religious group Tablighi Jamaat held a two-day annual meeting at the headquarters, 3500 people from all over India and overseas gathered in Nizamuddin, New Delhi. They arrived many days in advance and participated in various activities. Since then, nearly 2,000 people have stayed in the area for a few days. According to a student interviewed by Reuters, the headquarters is a six-story building with a prayer and sermon hall. At night, it becomes a dormitory with 200 to 300 people per floor.
These gatherings returned to various Indian states, triggering the spread of the epidemic throughout India, and the government began to track and search for these people. According to a Reuters report on April 3, Indian authorities have discovered and isolated 9,000 people associated with the headquarters or its close contacts. There are more than 450 confirmed cases of the new crown epidemic and at least 8 deaths related to the sect, which accounted for one fifth of the cumulative confirmed cases in India at that time.
The organization also held a rally in Malaysia at the end of February and early March. According to data from Lianhe Zaobao, this resulted in more than 500 people in Malaysia and other countries infected with the new coronavirus.
India’s anti-epidemic measures entered a “strict intervention stage” in mid-to-late March. The policy was escalated again on the evening of March 24. Modi delivered a televised speech announcing that India will implement a comprehensive blockade from midnight that day for a period of 21 days. During the blockade period, all shops, commercial establishments, factories, workshops, offices, markets and places of worship will be closed, interstate buses and subways will be suspended, and construction activities will also be suspended. Modi explained that this is to save India, “If we cannot control the outbreak in the next 21 days, our country and family will go backwards for 21 years.”
Temperature factors and slum environment
Assistant of the Johns Hopkins University School of Public Health Professor Debashree Ray and his team predict that in the absence of any intervention measures, by mid-May, the number of confirmed cases in India will reach 2.2 million, and if the strictest intervention policy is adopted, the number of cases can be controlled at 13,800.
Another set of forecast data comes from CDDEP and the joint prediction of some scholars at Johns Hopkins University and Princeton University. If no intervention measures are taken, there will be 300 to 400 million cumulative cases diagnosed by July, but most of them are mild disease. The peak period will come in April and May, and there may be 100 million confirmed cases, including 10 million serious cases, and 2 to 4 million need to be hospitalized. Scholars also said that in theory, strict isolation can reduce peak data by 75%.
In addition to strict anti-epidemic policies, there are many factors that affect the future situation of the Indian epidemic.
The first is the impact of temperature discussed by international scholars. In 2003, SARS gradually disappeared in summer, so many scholars explored the effect of high temperature on the new coronavirus. India has gradually entered high temperature weather after April. The current maximum temperature can reach 35 degrees. Will the high temperature weather affect the spread of the new coronavirus in India?
Both the CDDEP team and the Debashree Ray team pointed out in the research report that the effects of temperature are still being explored. The latter bluntly stated that at present, public health actions of an intervening nature should still be the focus rather than relying on hypothetical prevention controlled by meteorological factors without solid evidence.
At present, what is more concerned by the world is that India announced the first confirmed case from a slum at the end of March, and the patient died soon after. Lin Minwang said that this will be the biggest challenge facing India.
India ’s slums are densely populated, poorly ventilated, without even clean water, and have extremely poor sanitary conditions. It can be said to be a hotbed of new coronavirus. The first confirmed case of a new crown in an Indian slum is from the Dharavi slum, one of the largest slums in Asia, located in Mumbai. Within the range of three to five square kilometers, there are between 700,000 and 1 million people.
An official in Mumbai said that the 56-year-old patient had no history of travel, and seven others who lived in the same house as him had been isolated.
Today, there have been 3 confirmed cases in the slum, and the other two cases were a 52-year-old disinfection worker and a 35-year-old doctor practicing medicine near the slum. Their close contacts have also been isolated.
Some public health experts pointed out that if the virus spreads in slums like Dharavi, the outbreak will be difficult to control, because Dharavi usually has 8 to 10 people living in a room. According to the British “Guardian” quoted the first comprehensive census of India’s slum population, one-sixth of Indian urban residents, that is, 64 million Indians live in slums.
However, the head of CDDEP, Ramanan Laxminarayan, believes that many of the residents in the slums are young people, and India ’s population over 65 is much smaller than that of Italy or China. “This may have a little protective effect.” It
is not yet possible to determine how the epidemic in India’s slums will spread, but it has already aroused the world’s attention.
Another influencing factor is the number of patients suffering from hypertension and diabetes in India. Ramanan Laxminarayan pointed out that about one-third of adults in India have high blood pressure and about one-tenth have diabetes. In the existing case studies of the new coronavirus, this group of people is very likely to be a susceptible group of new coronary pneumonia, and most of the serious patients also have such basic diseases.
Vulnerable medical resources The
above influencing factors ultimately point to a question. What is the level of India’s medical service system and can it withstand the large number of infections and severe cases that may come?
Senior researcher Shruti Rajagopalan and his team at George Mason University in the United States made a detailed analysis of this after the outbreak of the new crown. She pointed out that India’s medical service system is “fragile”, and its basic settings and staffing are not good. It should implement a comprehensive blockade policy longer than the original 21 days, so that India has time to build its basic medical facilities.
The Shruti Rajagopalan team pointed out that unlike China ’s medical and health system, India ’s private medical service system has more funds and personnel than the public medical service system. The latter is four times the medical capacity of the former. The private medical service system has 55 % Of beds, 90% of doctors, and 80% of ventilators.
According to data from the National Bureau of Statistics of India in 2019, only 30.1% of patients were seen in public hospitals, 65.8% were in private hospitals, and the remaining 4.1% went to charity hospitals and informal medical institutions.
According to 2018 data, the total number of beds in public hospitals in India is 739,024. There are currently no statistics on the total number of beds in private and charitable hospitals. The Shruti Rajagopalan team estimates that the total number of hospital beds in India is 1,759,580, and India has 1.31 beds per 1,000 people. This number is very low. According to World Bank data, France is 6.5, South Korea is 11.5, China is 4.2, Italy is 3.4, the United Kingdom is 2.9, the United States is 2.8, Iran is 1.5.
Because of the low number of hospital beds in India, the beds in India are always overcrowded. The researchers pointed out that people with other diseases usually occupy at least two-thirds of the beds at any time. In some public hospitals, The occupancy rate exceeds 100%. Therefore, they believe that in the new crown epidemic, the beds that can be provided to patients with new coronary pneumonia do not exceed 40% to 50% of the total.
Among them, ICU has fewer beds. According to 2008 statistics, ICU beds in public hospitals in India account for 5% of the total beds. According to estimates, there are 8779 ICU beds in India. Due to the high cost, ICU is usually operated at or near full capacity, and only a small portion of existing ICU beds are available for patients with new coronary pneumonia.
Judging from the number of medical staff, according to the 2019 data of the Central Health Intelligence Agency of India, there are 11.54 million registered doctors in India, with 86.32 doctors per 100,000 people. According to World Bank data, the world average is 150.5 and China is 178.55.
At present, the whole world is rushing for a ventilator that is extremely useful for patients with new coronary pneumonia, especially severe patients. Research shows that India currently has about 40,000 ventilators, and they need at least 700,000 or even 1 million ventilators.
The widespread shortage of hospital beds, medical staff and ventilators throughout India is more pronounced in some states, especially after India announced a comprehensive blockade.
The Shruti Rajagopalan team stated that there are huge differences in the number of registered doctors in each state. Uttar Pradesh, the largest state with nearly 200 million people, has only 38 doctors per 100,000 people, and Jharkhand has only 13 doctors per 100,000 people. States with a higher population density have fewer beds. They believe that India should pay special attention to the medical capabilities of densely populated areas in its next work.
At present, the new crown epidemic has hit the country’s fragile medical service system. On social networking sites, many doctors mentioned that hundreds of people come in line every day, and many people cough, sneeze or even have a fever. A doctor in Kolkata said: “We have had close contact with patients suspected of having new coronary pneumonia, but there is no due protective equipment … We can only take orders.” Some doctors said they were wearing plastic raincoats and motorcycle helmets Self-protection.
Ramanan Laxminarayan, head of CDDEP, pointed out that in West Africa, the measles vaccination rate has dropped significantly in the three or four years after the Ebola outbreak. India also faces the risk of other infectious or chronic diseases.
Ramanan Laxminarayan pointed out earlier that the outbreak in India is two weeks later than the United States and four weeks later than Italy. In this way, among the above uncertain factors, India has ushered in a critical moment for the epidemic.
Image source: Network screenshot