This presentation shall sensitize the hospital management and program staff towards a very elementary understanding of the evolving epidemiology of the Pandemic of COVID-19. It would try and throw some light on the short-term effect on the functioning of the eye hospitals in the country and region as well as longer term impact of this pandemic in days to come. The presentation would also point out to preparedness issues that would be needed in the light of such outbreaks by healthcare institutions.
Lecturer: Prof. B.R. Shamanna, School of Medical Sciences, University of Hyderabad
B.R. Shamanna: So, what I’m going to be speaking in the next 40/45 minutes is basically trying to look at how this pandemic called COVID-19 has evolved and how has it actually impacted health care services as well as eye care services. And this is basically being the crux of my talk in the next 40/45 minutes.
Before I actually want to start, I want to dedicate this talk of mine to an eminent man, Dr. Pararajasegaram whom we lost just a few days ago. I think, you know, for all of us who have been associated with eye care and with me and with the programs related to blindness prevention, he’s been like an universal mentor for all of us. And, you know, notwithstanding that an extremely warm human being, an academic doyen, a teacher par excellence. Whatever we are today probably has to be, sort of, we have to acknowledge the contribution of Para to our lives and to our day-to-day living. And I think from him, I learned the aspect of what evaluation is.
He used to say, “Evaluation is fact-finding not fault-finding.” I think that’s a very strong statement and that’s something which I always mentioned when I go on these evaluation missions. He also used to say, “To measure is to know, if you don’t measure it you will not know it.” And that’s very true when we’re talking of something called as a epidemiology. And I think the sentence which used to hit me hard was when he used to say that, especially to the ophthalmologist, he says, “If ophthalmology is your profession then prevention of blindness is your blooming business.” And that’s something which I want to attribute this presentation of mine to this wonderful human being. I become a little emotional.
Before I continue I think this disclaimer which is on the screen is something which I want to propose and say that I think the data becomes outdated very quickly with all the evolution which is happening with respect to this pandemic. And more recent information if you would like to get from your own regions and from your own countries, I think or from your local authorities, please do contact the concerned people.
A lot of people who have helped me in this presentation or I have borrowed a lot of ideas, slides, information from this presentation, I wouldn’t be doing justice if I just, you know, if I mention all the names. But I will acknowledge all my peers, seniors, teachers for sharing their information for this presentation. And let me tell you that the sources quoted and represented are all verified. Most of them coming from a peer-reviewed publications and definitely authenticated and I can assure you they’re not from the University of WhatsApp, which all of us are probably, you know, bombarded with more than the pandemic. I think we’re faced with what’s called as an infodemic and we don’t know what to believe and what not to believe.
So, what I would do is basically set out these two learning objectives to our hospital managers, program personnel and Orbis and their partner organizations and especially tell them about what the epidemiology so far has been or the understanding so far has been with respect to COVID-19. Then, highlight the short- and long-term impact of COVID-19 on general health care and most specifically on eye health services.
So, I would structure my presentation in terms of the epidemiology of COVID-19: the definition, the magnitude, the causes and the transmission, then the prevention control and something which all of us are familiar with today is what is called as flattening the curve. Let’s look at what this flattening of the curve means. And then I’ll flag some issues with respect to the impact of COVID-19 generally on health and eye care services. And I’m definitely not very qualified to speak on COVID-19 and eyes and the subsequent doyens and subsequent, sort of, seniors and other people who follow this webinar series are more suited to talk about COVID-19 and eyes. So, I will just flag a couple of issues and leave it there.
Just to jog people’s memory or just to tell you what epidemiology is for the benefit of those people who are exposed to this concept or this discipline for the first time, the best definition probably or the simplest definition comes from the dictionary of epidemiology and this is by John M. Last. Last defines epidemiology as “The study of distribution and determinants of health-related states or events.” When I say health-related states and events, health-related states and even maybe what keeps us healthy. That is also equally important when we’re talking of things like, you know, preventive care.
So, health-related states could also be diseases, deformities, disabilities, you know, all the, you know, these which we say with respect to the health-related states or even like for instance, just day before yesterday we had an event where there was a gas leak. It’s a point, sort of, an event which happened in Visakhapatnam. So, there’s also come under – we need to study the epidemiology and to look at how it is distributed or where it is distributed and what has led to this particular event in specified populations and then look at applying this science to control of the health problems which we are worried about. And in this case, we’re looking at COVID-19 as the, you know, core problem.
So, basically, epidemiology is based on answering these four key questions. What are these four key questions? They are: what is the issue I am looking for, which is the case definition. Now, how do we I define blindness, how do I define visual impairment, how do I define red eye, how do I define COVID-19? So, the first and foremost thing in epidemiology is to understand the case definition. Once you understand the case definition, the next question we need to answer is, how big is this problem and where is the problem? And that is where I think you talk about the magnitude of the problem and its distribution.
So, what is the issue, which is the case definition, how big and where is the problem is the magnitude and distribution. And then you look at what caused this particular problem or what are the reasons for this particular problem, which are the causes and the determinants. And last but not the least, we complete the cycle of answering the questions in epidemiology by looking at what should we be doing about it since we know the case, since we know the magnitude and distribution, since we know the causes and the other determinants. Now, what do we do about it, which is where we talk about prevention and control.
So, basically in epidemiology we actually have methods where we describe, we analyze, and if necessary, we experiment, like for instance, should we be experimenting with a vaccine versus no vaccine, should we be giving one kind of medication as prophylaxis, like for instance hydroxychloroquine or should we be giving ivermectin. So, these are things which come from experimental methods.
To summarize, basically, epidemiology is a quantitative science. When I say quantitative science you look at counts, you look at measures, you look at counting everything or you look at numbers. Basically, that is what epidemiology is all about. So, epidemiology is about distribution, determinants and ways and means of controlling a particular event or a health problem within populations and it’s a quantitative science.
Now, let’s look at the definitions going forward. So, if I’m talking about, say for instance, an outbreak. What is an outbreak and how does it differ from something which is called as an epidemic and how does an epidemic differ from something called as a pandemic? Please concentrate on the words which are marked in the red font. So, outbreak is whenever there is a condition which is already existing and by chance when you find more number of cases in that particular population, in a confined area, that constitutes a outbreak. Like, for instance, a sudden outbreak of diarrheal disease, ARS.
You know, those kind of issues where the diarrhea is always present but suddenly you find the numbers much more than what existed in that particular confined area. That’s an outbreak. When this outbreak starts becoming bigger, when it involves a population in a region, say for instance, the epidemic of cholera which spread from Indonesia to other parts in Southeast Asian region. Then we call it an epidemic which is nothing but a sudden often increase in the number of cases of a disease about what is normally expected in a population in a particular region. So, that’s called as an epidemic.
And you call it an epidemic when this epidemic involves many countries or continents, when the epidemic actually spreads to involve many countries or continents across continents then it is called as a pandemic. Here, large number of people are basically, sort of, affected. So, if you look at these pandemics in the recent past we had one with respect to what was called as the swine flu pandemic. The swine flu pandemic, swine spread from, you know, pigs and those kinds of animals into human beings.
We had one in 2009 and 2010 where you can see the areas which had the cases. It spread from different parts. Again, it’s something which originated in countries like China. Whereas the ongoing pandemic on your right side of the slide if you see, it’s the COVID pandemic which is ongoing with respect to involving many countries. You can see the deck the red bubbles there. Almost involving all the continents and almost all the countries. So, this is what a pandemic is. When you’re looking at an outbreak of epidemic proportions across different continents and countries, then it becomes a pandemic.
In epidemiology, one of the things which we do with respect to the definition is understanding what is called as the natural history. Now, for instance, once I define what COVID-19 is which I’ll come to a little later, then we study what is called as a natural history. A natural history is from the time you are exposed till the time of its logical conclusion without any intervention in an uninterrupted study.
So, there are issues with respect to ethics when you’re looking at natural history, but just to tell you, if you look at the right side of your slide, you’ll find that we have the susceptible host who’s exposed, then you have some people developing infection, some people withstanding this or not developing the infection. The period from which the exposure happens to the onset of clinical signs and symptoms or clinical disease is called as the incubation period.
And within the incubation period, you have a latent phase and an infectious phase meaning people are not infectious in the latent phase, like for instance, today we seem to have a lot of people who have the virus but are asymptomatic or pre-asymptomatic. And that is the reason we have a lot of issues with respect to not knowing whether they’re silently carrying the disease unlikely to spread the disease to everybody. So, that’s one aspect related to what is called as the exposure to onset, the latent and/or called as the incubation period.
And once after the clinical phase is reached, then you have the phase two, either the death or recovery, which is again after a certain period of time, when the signs and symptoms completely sort of as, you know, it is exhibited then you have what is called as a non-infectious phase again, going to its logical end point. So, if you don’t interrupt, you study from the biological onset to the pathological evidence to science and symptoms to – where the point, where you actually become – it becomes evident and you seek medical care and then look at diagnosis and treatment. That’s when you call it the natural history of the particular disease.
So, how did or what is the natural history so far of the COVID-19 pandemic? You can see that there is a first phase, the darker blue which is the second phase, and a much darker blue which is the third phase. So, we know that for all practical purposes it evolved or we need to believe that it evolved from the wet market in Wuhan in the Hubei Province of China.
Then, over a period of time it spread. And once it’s spread, it spread to a time when – it spread from, you know, sort of the wet market or from bats to the intermediate hosts called pangolins to humans and then from humans to humans and over a period of time you can see then till, you know, from somewhere during the late time of December to February, before the WHO described, you know, actually labeled it as a public health emergency of international concern, I thought that was what they said and it was called as a global pandemic. This is the evolution of the COVID-19 pandemic.
As I speak, I guess these numbers are little, you know, it’s still – the more the numbers till today morning across the globe with respect to the corona disease 19, you have close to 4 million or 40 lakh people who are confirmed, about 280,000 or 2,80,000 people who have the con – who are confirmed or who died because of coronavirus disease and this disease has spread over 215 countries which means it hasn’t spared even the islands and small countries. It has spread to almost all the countries.
Look at India, we have something like 66,000 cases, about 2200 deaths, about, you know, 66, about, you know, 70% of those who are still active cases and 30% who are the recovered or the cured cases. And with the darker blue, you know, areas of the Indian map showing where the disease is more pronounced, the western part of our country, Rajasthan, you know, Maharashtra, Gujarat and then Tamil Nadu, et cetera., which have this particular problem. This is where we stand with respect to the global as well as the Indian magnitude of this COVID virus condition.
So, I told you the first thing within epidemiology apart from looking at the natural history which we have done so far is to really understand what this, the case or what is the definition or what caused this particular condition. So, the name of the virus is called SARS-CoV-2 which means, SARS stands for Severe Acute Respiratory Syndrome and the coronavirus is coronavirus type 2. So, it’s called SARS-CoV-2 and the disease it causes is called as coronavirus disease, which is, or the novel coronavirus disease or novel coronavirus or, you know, earlier it was called some other name. But for all practical purposes it’s labeled now as the coronavirus disease and the year is 2019. Hence, it’s given a name, COVID-19.
Among the coronaviruses, there are about seven corona viruses, the structure of which you can see on top. It’s called the coronavirus because it resembles the corona of the sun. So, this coronavirus is the seventh one which has infected human beings. And it has evolved from the natural hosts which are bats or pangolins and crossed from animals to human beings. So, it’s called as zoonotic disease, meaning it spread from animals to human beings.
As of today, we know that this is a natural virus which has occurred and which has been, you know, probably it has mutated among the different host before it has passed on to the human being. There is no evidence to say that it is a biological weapon or it’s been manufactured in a lab as there are conspiracy theories which are floating around. Let’s assume for all practical purposes as of today, it’s something which is there for us in terms of a natural occurrence.
Illustratively, I think this is something which the people who are big, you know, the managers, the program people and the, you know, administrators will understand. The transmission of cycle, of course, of SARS-CoV-2 is from the bats to the intermediate, you know, funny looking animals called as these pangolins or like the anteaters which come into contact either, you know, people eat them or people stay with them or, you know, some of them have them as pets also. So, when they come into contact with these human beings, the human being becomes an incidental host and from the human beings it spreads via either, what is called as a droplet spread or a direct contact. And this is the human to human spread.
On the right side of your slide just look at the incubation period, which means the period during which the organism or the virus has entered into our body and the time when we start showing about signs and symptoms. On an average for SARS-CoV-2, it’s about two to seven days as compared to the Middle Eastern Respiratory Syndrome which is also caused by another, you know, coronavirus. If you look at it, it’s about two to seven days on an average but their last, it’s been known that even up to 36 to 40 days people have developed the particular disease, which means that it can harbor within somebody without causing signs of symptoms, you know, on even to the extent it may be an outlier or it may be an extreme circumstance but you have to understand on an average it’s about two to seven days.
What’s worrying for all of us if you look at this particular coronavirus disease is the fact that the period of contagiousness which means the time when you can actually start infecting others where without knowing you have the disease you already spread the disease and that is what is called as the period of contagiousness. Within SARS and COVID, the SARS-CoV-2 virus, actually the contagiousness period starts from about two to three days before the clinical signs and symptoms begins, which means you may not show any clinical signs and symptoms but you’re still spreading this particular virus. That’s the most unfortunate thing with respect to SARS CoV 2.
And that is where today all of us talk about 80% to 85% of people being asymptomatic and some of them with that being pre-symptomatic and only few people showing a florid sort of occurrence of this. And very few end up being severe or critical sort of coronavirus disease. This is a problem with respect to its contagiousness where you may be spreading the virus without knowing that you harbor that particular virus.
So, how does it spread from person to person? Eighty five to 90% of the time, it spreads through what are called as these droplets. How are these droplets generated? They’re generated when person coughs or sneezes. The little drops which come out when you don’t protect yourself or when you don’t practice cough etiquette, et cetera. That’s when these droplets and larger droplets actually are able to fall at a further distance and that is where you call today, we talk about something called a social or physical or safe distance.
The reason for that is to make sure that you don’t fall within the vicinity of this droplet. And some of these droplets which are small are also liable to actually be floating within the air and they become what is called as airborne transmission. And these bigger droplets may fall on the ground or maybe actually fall on certain surfaces and these surfaces are called as or inanimate surfaces. The surfaces which do not have life, which are called as formites and these formites actually are you know surfaces like metal or plastic, et cetera.
You know you’re told that it survives for 48 hours, 72 hours, up to seven days, et cetera. on these particular surfaces and that’s why it’s very important for us to have hand hygiene, cleaning the surfaces, et cetera, et cetera. So, the COVID virus or coronavirus disease is spread from person to person through majorly, the droplet infection, the formites or from surfaces and very little from airborne.
We also know that there are other modes which are under research and slowly being confirmed. As of today, we don’t know whether it spreads from mother to child or through the, you know, what we call it as through the, you know, pregnancy and delivery, et cetera. It doesn’t happen but feco-oral is known. Reproductive fluids, especially semen. People have said that it may spread but that is still under research. But do understand that majorly this disease spreads through droplets.
This is an interesting sort of an illustration for you to understand. If you get or if somebody gets this coronavirus disease or harbors the SARS-CoV-2, how many people can they infect? And this is called as a basic reproduction number or sometimes it is also designated as R zero or R nought.
So, people who are now you know, forecasting or making epidemiological models in terms of saying, you know, how long will we take to reach the peak, when will it start coming down, when we should, you know, we think about something called as herd immunity through infection which is the natural outcome or does vaccine have a role, et cetera.
If you look at the left side of your slide, you’ll see that the coronavirus disease, the reproduction rate is, R zero is about between two and three, which means one person can infect about two to three people. So, if this goes on exponentially you know, at the end of a certain period of time that quite a lot of people who get infected if they’re not, if they are within the vicinity of this droplet spread or surfaces, if they touch and then touch their mouths and eyes, et cetera, et cetera.
So the COVID 2 has a basic reproduction number or R Zero of between two and three. Whenever you have anything about one, then you reach a stage of either an epidemic or a pandemic. Even 1.1 is an epidemic or a pandemic stage. Less than one is preferable. That’s when you actually it dies down. Equal to one is when you have adequate what is called as herd immunity. It’s brought down to such low levels that it is always there but it doesn’t cause a problem. But at this point in time we are talking of something called as the ability to actually infect two to three persons.
Just look at measles. Measles has a R Zero of 16 which means it’s a very, very contagious particular disease and that’s why we should be concerned. But the issue with measles is we have a vaccine. We can protect ourselves. It doesn’t, you know, just because we have a vaccine or vaccine coverages are very, very high, it doesn’t kill a lot of children. Although, that is one of the main reasons for under five mortality rates in many countries. At this point in time with Coronavirus disease, neither we have a treatment nor do we have a vaccine. And that is the reason all of us should be concerned with.
So basically, you’re looking at as I told you, the exposed time, the infectivity time and then, going on to either cause the ultimate outcome or the recovery. This is a very nice illustration which I borrowed from my senior colleague and my teacher Dr. Murthy which talks about the droplet spread. You know, how does it spread. One person spreading it to two person and that person spreading it to two more. And that person spreading it to four more and ultimately, it goes on to 16. It goes into exponential numbers. That is why it’s very important for us to make sure that the infection doesn’t spread.
So again, everybody exposed does not get infected. Everybody infected do not develop the disease. What’s important for us is how much is the inoculum. Inoculum means how much of the quantity of virus which gets into you and what is the duration of exposure. The inoculum plus the duration of the exposure has the potential to cause infection. And that is why when we study the model with respect to forecasting or with looking at the epidemiological model, we use what is called as a SIR model, which is a basic model, where S stands for susceptible. At this point in time because it’s a new virus. The first time it has occurred. It has occurred in December. Every one of us are susceptible, because none of us have developed any immunity, unless until you test for antibodies.
So, susceptible some of them will be based on the quantum of virus as well as the duration of exposure gets infected. And then some of them go on to or many of them, most of them, 90%, 95% of them recover completely. And only 5% of them as of today actually died, because of this particular condition. So, it’s a very important understanding for us. As you know, basic epidemiologist to say. What’s the susceptibility? What’s the infectiousness? What is the recovery potential?
These are, you know, I told you, you know, these are you know very verbose sort of statements with respect to the, what’s called as a suspect case, what’s called as a confirmed case and what’s called as a contact. I’ll just run you through that there’s four definitions of who is called as a suspect. But you have to understand, a patient with acute respiratory illness and a history of travel to a country which had this thing, reporting local transmission of Covid prior to 14 days, et cetera is a suspect case. Or somebody who’s been treating, somebody who’s also a health care worker also becomes a suspect case. And somebody requiring ET, or you know hospitalization with no other reasons explained but has all these signs and symptoms which I’ll come to in a minute is also called as a suspect.
All the test results are inconclusive. These are all called as Suspect COVID-19 disease. The reference is there which is from the National Center for Disease Control Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. You call it a COVID case or COVID-19 confirmed case only when there is confirmation by COVID testing. We’ll come to the COVID testing in a while. But only when it is confirmed by doing a test, then it is called as a laboratory confirmed test. Apart from that, you have categories of people who are called as contacts. Whether, you know, somebody who’s providing care without proper PPE or Personal Protective Equipment. Or staying in the close environment of somebody who has COVID-19 including workplace, classrooms, households and gatherings, travelling within the vicinity.
And you must have noticed on the Aarogya Setu app if you have downloaded. And this is one of the concerns of, it’s one of the things which it flags off. And within this, you have what are called as high risk contacts and low risk contacts. So, you have this as the case definition when it comes to COVID-19. So these illustration’s just to tell you that this COVID-19 disease, actually likes one of the receptors within our body which is present in almost all the organs. This is called as the Angiotensin-converting enzyme type two receptor. And these receptors are present in all organs of the body. That means, this COVID-19 disease actually can affect all organs of the body.
And, when you look at, the respiratory system, it can cause a sort of a sore throats, it can go on to leading to pneumonias. It can cause acute respiratory distress systematically just like any other viral disease, fever, cough, fatigue, you know sometimes, blood in the sputum, it can also affect the heart, it can cause cardiac injury, lead to severe sort of blood disorders or you know, breathlessness et cetera.
On the right side, you can see all the organs at least some of the major organs which I have highlighted there. It can also cause conjunctivitis and that’s very important for us to understand. You can have conjunctivitis due to coronavirus disease. And as Eye care professionals I think, we should be looking at you know, cases of conjunctivitis also very closely. So, who are the people, who are at high risk, some of the people who are very high risk, especially older people. People which already having diseases like diabetes, heart disease, kidney disease, et cetera. Or what are called as co morbidity, people who are immunocompromised like HIV et cetera.
Even people with asthma, those people with liver disease, et cetera. Vulnerable populations like those who are disabled pregnancy and breastfeeding pregnancy per se, are not an issue. But you know, when you stay in an environment of when you stay in close contact with somebody having Covid, you become a vulnerable population. Those people who are experiencing homelessness, a rational racial and ethnic minority groups again, this needs to be studied in a little more detail.
This is something which all of you should be aware, I think once you cough the very next moment, I think you start thinking whether you are harboring this COVID-19 disease. Please don’t get worried. I’ve just put on a slide to show you the difference between COVID-19, the common cold, which we have very regularly. The flus which usually happens during the winter times, and also the allergies. So if you really look at these conditions and compare it with Covid, you see that fever, dry sensation within the throat or sore throat or dry cough and body aches, headaches, which is, you know, non-specific which occurs mostly in most of the viral diseases, and at a latest stage feeling difficulty in breathing or what is called a shortness of breath, are the main complaints or the main signs and symptoms which you can elicit from somebody having a COVID-19 disease.
When they have at least two of this, I think should go and get yourself tested or you should report yourself. As compared to common cold, where you’re looking at, you know, running nose and sneezing which is very common. Flu instance for that matter, you don’t have shortness of breath, you don’t have too much of body et cetera. Allergies definitely, when you have very commonly sneezing and running nose and some sort of sensations, especially with respect to you know, feeling of sneezing all the time within your nose et cetera, that’s when you have allergies. So, this slide is to give you a sort of differential between various other condition.
So how do we diagnose, I told you, a lab confirmed case of COVID-19 disease is confirmed. When you do a test, which tells you, whether the virus is there and that test as you can see in the blue boxes which I have outlined is, whether you have a current infection. And the test on the right side is called as RTPCR which stands for Reverse Transcriptase Polymerase Chain Reaction. Don’t worry. It means that it is like a photocopying machine.
As soon as the virus gets in and you take the swap and you process this test through what is called as a polymerase reaction it, it’s a RNA virus which is a single stand. This gets converted into a double strand by using this technique and these double stands make multiple copies of them, which is called as a Polymerase Chain Reaction and Amplification. And by looking at this number of photocopies, you can actually make out whether somebody has or somebody sampled nasal swap or ortho swap has this particular active COVID-19 or the SARS Covid II virus.
After a certain period of time, when the infection subsides and recover, you start getting what is called as these soldiers within your body, and this soldier are called as antibodies. The earliest soldier is the, what is called as mIgM type of antibodies which stays for a very short time. But the most pathognomonic antibody, which is a long time which you get is what is called as IgG antibodies. And for these IgG antibodies, you have tests which are called as the enzyme linked immuno sorbent SA or what is called as, ELISA test. I think yesterday our health minister talked about kids being available from India from Pune, where you have these ELISA kits already available and these kids will start testing people for antibodies.
There are other points of care tests, which are called as, which will come up which is like your pregnancy test. Basically, a drop of blood et cetera on this, think we’ll show you whether you have these antibodies whether it is IgM or IgG or no antibodies. And will tell you whether you have already developed immunities. This is the testing for coronavirus disease.
This is a very interesting slide and a slide which are lay a lot of your apprehensions. What it means is, if you really look at it, it says, there are a lot of cases who fall in the category of mild or moderate disease, when it comes to COVID-19. And majority of this mild or moderate disease, completely recover. The mild recover completely, the moderate almost all of them recovered. The very few people in the mild or moderate category, who actually go on to have a very, very bad outcome, which is the death in this particular case.
The severe and critical again, within the COVID-19 themselves are very few. So if you take a proportion out of 100, 90 people are going to have mild and moderate. About seven people will have severe, and only two or three people will have critical. The critical and the severe proportions will increase when you have more number of vulnerable population. Like for instance you must have seen in Europe, especially Italy, Spain et cetera. Which has majority of the people are pro a certain particular age, and their immunity is quite low.
So, to cut a long story short, COVID-19, 90 to 95% recover. You know 5% out of the 5%, 4% to 5% required supportive treatment, you know and the recover over a period of time. The only very few people who actually going to ultimately getting, ICU care, and ventilators et cetera, et cetera. You know, if you had looked at, today’s data within our country, we have about the lakh and 35,000 beds for COVID. How, what percentage of these beds are occupied by these critical people or require ventilation, less than 1%. 1% of these beds only have been occupied so far, in terms of the real essence of this severe and criticalities. Again, to re-assure all of you, majority of the people will recover on their own, probably will build our herd immunity by ourselves.
So, in summary this is what it is, it’s a Novel Coronavirus. These are the symptoms, these are the prevention, and this is the transmission rates. Now, let me go on to something which is critical. So when we are planning for our control and, you know management strategies, this becomes very important. What do we do before the disease occurs, which is called as the, you know, primordial, a primary prevention, what do you do to early identify this particular disease by testing et cetera, or screening which is called as the secondary prevention, and what do you do wants to develop the disease, where it is called as a risk prevention, where you actually limit the disability or rehabilitate people?
Based on this, you can take actions at the general population level, the susceptible population level, the asymptomatic population level and symptomatic population level. And this forms the sort of framework, for all of us, when we’re looking at our control and management strategies. So, this is just to tell you that there is the introduction or emergence of this disease, local transmission, then cluster transmission, then community transmission, as the disease amplifies and then slowly the disease goes off on its own, that is the natural history. Based on which stage of the disease we are. At this point in time in India, people are saying that, you know, we’ve been having community transmission, but the government is not ready to accept it. It doesn’t matter. You have cluster transmission or you have community transmission, the very fact that we have enforced two sessions of lockdowns for the last 40, 42 days.
Say’s that, we have accepted the fact that, we have community transmission. But such a large country, even districts within our country or within our states resemble countries on their own. You have two million people in a district, you know, a country like Bhutan is about 800,000 people, so which means our district is bigger than a country. So if you really look at it, when you have divided them into green, orange or red zones or containment zones, basically you’re saying that the disease is there in the community but it is clustered around certain areas. So, based on that you kick measures in terms of what you do.
So, this is what is that you know sort of classifications of transmission scenarios. As I said we are between three and four, we know that we have clusters of cases and we will progress to community transmission which must be happening in places like Dharavi et cetera, which there where it’s spreading quite fast and wide.
So, this is what we will do as WHO strategy objectives but adopted the local situation. There is nothing called as one size which fits everything. If Sweden has done something, we can’t do what Sweden has done. If Telangana has done something, we can’t do like for instance, the number of tests done in Telangana state is relatively lower than the number of tests being done in places like say Tamil Nadu, or places like, you know, other states like Madhya Pradesh or Delhi, et cetera. But what have we done? We have done you know very, very active surveillance. We have gone and looked at syndrome approach. We approach each and every household and asked for signs and symptoms of COVID and when somebody fails the test, or when somebody says, yes, I have the sign of symptom then we test them. That is the reason we’re in a position. But you have to understand that is something which we need to do with respect to what allows us to do but everything, the ultimate final common denominator is how do we control this particular problem.
Word about flattening the curve, I think all of you must be very familiar with this sort of the curve where if you don’t do any intervention the cases will rise up. We’ll go reach a peak and then we’ll come down. But if you take interventions at the personal level like for instance hygiene, at the community level like for instance with safe distancing at the environmental level by keeping our surfaces clean and supporting all our COVID warriors and, you know, dedicated health care professionals and all the research. You are buying time. With this time, you are able to actually establish your health system. As all of us know in our public health system is not actually geared up to meet this kind of eventuality. But we now are very sure that we can meet this eventuality.
I’m very conscious of the time, let me take about five to 10 minutes to actually go through the next couple of slides, where I want to highlight to you what we’re looking at in terms of our impact. You know, to quote Dr. David Nabarro, I think I like him a lot personally, but also at the same time I think, he was tipped to become the Director General of the World Health Organization, couldn’t. But he talks about three very important things related to this COVID pandemic. What are they? First and foremost thing is to protect lives. Only when you can protect lives, you can get or you can start looking at your livelihood. As we speak I guess, today the Prime Minister has bean, you know, discussing with all the state Chief Ministers. I think it’s been a marathon meeting where they’re talking of, we’re so far what we have done is we have somehow managed to get the number of cases under our control or we have a handle on. You know, the seriousness or being able to manage our serious cases of critical cases.
Now how do we get back people to their livelihood. All of us are very, very sensitive to issues related to our migrants, our daily wage workers, the homeless people, the people who are actually living from how in hand to mouth et cetera. It’s very, very important for us to kick start our economy, and that is where we talked about getting back our livelihoods. And next, after the livelihoods comes leaving the new normal. I think, ah, after when the epidemic or when the pandemic comes down, all of us should get used to living what is called as the new normal. It’s not going to be the same again. So, there’s this funny thing about BC, AC and the DC. You know, AC stands for After Corona, DC stands for During Corona and BC stands for Before Corona. So, it’s very important to really look at this new normal.
So what’s the impact on COVID-19 on individuals? We all know that, it’s hindered access to health care, our daily living with routine have completely changed and this has happened extremely quickly. You know, it’s not given us any time for us to get adjusted to this, routine as well as all of us are finding a difficulty to access care. It’s caused a lot of problems for our vulnerable populations and especially those people with long standing health conditions. And also, those people who are financially not stable, do not have homes or living in very dense conditions, where the outcomes may be worse, we don’t know. It looks like the resilience is much better than these populations compared to those populations were living in Ivory task, I don’t know. I’m just making it. It’s led to a lot of mental and psychological issues and, you know, substance misuse et cetera, will become problems in the future.
You know, you look at health care systems, I think all our countries are now get towards, making sure that we have some sort of response to disasters. So, we have actually looked at country, you know, just concentrating on public health emergencies and setting up this disaster management plans which case all other services are actually, suffering. Community awareness towards hygiene is very good thing which has happened. And probably, what may happen is in the short term, it will also increase the numbers coming to, you know, primary health care facilities et cetera, et cetera, we have to be geared for that.
There are gaps in care of patients of other elements especially chronic diseases or all of you can know and this is going to cause a big burden in terms of, you know, on the health care system. We’ll have to see that the government and private public, private partnership over the next few years or in the non-near term, we’ll have to see a major real alignment. The emphasis on internalization in terms of making our own supply chains or the making India with respect kits or vaccines or medical equipment is something good which is going to happen. Which may pros, also help the economy.
Medical tourism, will see a downward trend. I think with the international travel and these kind of issues and people a little skeptical about traveling. You’ll see issue with respect to medical tourism. All of us know and as I speak, I think I’m also using technology that is going to become a mainstay of even thing. You must have noticed that there are guidelines with respect to, how do you practice Telemedicine and Teleophthalmology et cetera.
The impact on eye health care, unimagined new normal. I think the recovery period, I’m not going to actually talk about it. You’ll hear more about it in the subsequent series. As I said, technology is going to play a very big role and this will also increase the reach. And also, look at impact in terms of saving, indirect costs et cetera. Handwashing, general consciousness for ophthalmology for eye health is very good. Because it can actually limit infections like Trachoma. We can get Trachoma within 2020 or the global elimination of Trachoma within 2020. Probably, you know, by our reduction and staring at these, you know, gadgets and screen. With and children, you know, all the online education and those kinds of things may be prone to more dryness, fatigue and short sightedness and myopia. Let’s see if we – things, so as eye help people, we should not be worried, we will not be out of our business, so don’t worry about it.
Chronic eye conditions and access to follow-up, especially with people with Glaucoma medications, diabetic, retinopathy and other things is going to be an issue. Lower funding for the eye health sector, definitely that’s something which we need to anticipate. I think managements will start looking at becoming leaner and efficient, I’m not somebody to judge. The relationship between eye health and sustainable development goals will become very relevant. I think more and more, it will cement the connect between eye health and SDGs.
We have no choice but to work in partnerships and collaborations, I think this is a very good thing. We’ll have staff, you know, safety and procurement challenges that’s something which will affect the eye health sector. Increased demand on the strength and the health systems, especially to, you know, to beat, sort of a cube to meet the demands of people and also populations and emergency. For us within this region and within this country, we have done very well with respect to many of the issues confronting eye health, sustaining those achievements in these periods are going to become problem not only to sustain them or continue, you know, doing what we were doing very well. But also make sure that we address the newer challenges.
The impact of COVID-19 on basic research as well, I think this is taking a hit. Overall, there’s been a slowdown, you know, cancelation, postponing of many conferences et cetera related to basic research. Research are also looking at virtual lab managements and left autonomous to face lockdown becoming a problem with respect to animal house and lab maintenance. Especially, for those people who are involved in basic eye care research, cell culture facilities. I think more and more informatics is going to take over how we’re going to manage basic research with virtual labs and those kinds of things are very interesting article, the reference of which I have quoted below.
This COVID has had impact on at least 13 of the 17 sustainable development goals. So, it’s very important for us to understand that on the right side of the box item, you can see where The Lancet published. That it has actually, impacted a lot of groups, a lot of policy decisions et cetera, which means on the left side you see that the COVID pandemic and its impact on the sustainable develop meant goals. I’m not going to go through everything, but just to let you know. It has a very big impact on development and health.
I think, you’ll hear more about it, you know. It can lead to all the problems. We’re now getting ourselves with development of protocols. We’re looking at, you know, the transmission or the I related aspect related to COVID II because COVID-19, because we have angiotensin-converting converting enzyme. But you have to be reassured that many of the eye complications as we have seen today is in those very serious patients. And actually, majority of them are on those people who developed severe disease.
These are all guidelines and certain indicators I think my subsequent because we’ll talk to you more about it. Very interesting survey which was published in the Indian Journal of Ophthalmology, AIOS members, you know, they ask questions like, are you currently seeing and operating patients? 3/4 of them said no, 1/4 of them said yes. With respect to seeing patients but only emergency and emergency surgeries. Web consultations, many of them have started Web consultations or telephone consultations, or social media or, you know, online consultations.
What are they going to start first after the lockdown has been released, I think it’s about, uh, restarting elective surgeries in a gradual or grated manner. Then, from the information about what kind of risk is there, I think majority agree that it is a lower risk. Then, what measures you will take I think this is this is something which gives an indication in respect of what we need to do . Thank you very much.
What are the epidemiological implications with respect to challenges and strategies of increase in the number of asymptomatic cases? The unfortunate thing is the asymptomatic cases probably are spreading this disease without knowing that they have this particular disease. And some of the asymptomatic actually become pre symptomatic and then symptomatic. But if there is somebody vulnerable and you spread this particular condition then you’re asymptomatic. They probably will, because they’re vulnerable. They will show more serious form of this particular disease or they may actually go on to becoming. That’s why it’s very important for us. I don’t know if you know today that there is what’s called as a strategy called shielding which is called in the West. Whereas in Kerala, they call it a reverse quarantine, where you make sure that you protect the people who are vulnerable. You don’t allow them to mingle with those people who are either contacts or risk of having this particular disease or who have COVID positive or who have symptoms.
So, even those people who are asymptomatic, there are implications with respect to asymptomatic. But let me reassure you that majority of the people who are either pre symptomatic or asymptomatic have a mild disease and we’ll recover on their own. But if you make sure that you, you know, sort of maintain those kinds of strategies with respect to distancing and protecting our vulnerable, you’re in good shape.
Female Speaker: Sir, some countries, they’re developing herd immunity and some of course, having the lockdown and implemented….
B.R. Shamanna: I guess, ah, you know, in terms of Italy and the US, as I said I think herd immunity or is not actually a strategy. Herd Immunity is something which happens over a period of time. When you let the infection die on its own. When they are zero becomes less than one, then you’ve reached the stage of herd immunity whether disease actually stops. Ethically, it’s not right to expose people. Yeah, and what we can do is what my, another eminent teacher Dr. JP Muliyl talks of from CMC, Vellore. He says that if there are, you know, our majority of our population is below 35 years of age and likely, very likely that they will develop very mild disease or where they may be predominantly asymptomatic. All of them to actually go out, allow them to go and work and allow them to earn their livelihood.
And this is something which is something which we need to think about and that itself made to a large extent to build the capacity. Now what is the percentage of herd immunity by vaccines? It’s going to be 80% to 90%. But by herd immunity them itself, we have to reach at least 65% to 70% of the people being infected and generating antibodies within them. That’s the sort of guesstimate at the most not even an estimate.
Yeah, because as a question with respect to what is the incubation period asymptomatic individual with positive, how long can it carry the disease? Like I said the incubation period at this point in time is between two to seven days, but you can have the virus still about four weeks or more than four weeks et cetera. Which means that, you know, you can still be asymptomatic having the virus but and be spreading it to others but not demonstrating. Some of you can become pre symptomatic et cetera. So, the longest but then again, it’s an outlier.
One other thing which has come out our emerged very recently is because the RT-PCR test doesn’t tell you whether the virus is life or dead or anything. It just tells you whether there is that RNA. Even remnants of RNA is detected by this RT-PCR. So even like South Korea where they were talking about reemergence of a second peak or, you know, some people who were detected earlier than became negative and then developed positivity, probably is because of detection of this small fragments of the virus by amplification.
And unless until you can do testing with respect to detection of live virus you can’t, RT- PCR doesn’t do it. Cell cultures have to be done, or virus cultures had to be done. Janyianiji (phonetic) asked, “How safe it is to perform?” I wish I was a surgeon Janyianiji, you asked this question to the subsequent, you know, speakers. Pooja, yes, pre symptomatic and asymptomatic, I said pre symptomatic is when you start developing uh the overt signs of, you know, feeling uh fatigue, when you actually start having sore throat, when you start having a dry cough, fever et cetera. That’s when you actually start becoming pre symptomatic or think it’s very difficult to differentiate. It’s something which is subjective. You have to – I think you will know when you are feeling okay and when you’re feeling sick, that’s the feeling when you get when you have a pre symptomatic. Future of the pandemic, my goes, my guess is as good as yours.
Let’s hope for the best in terms of the pandemic subsiding. Thanks Ramesh, for your question with respect to what and how should we screen for COVID-19 patients, post up, post the pandemic? I guess as, we get to like, I think we have to be on our own. I think we have some guidelines and we have the thing from the All India Ophthalmic Society and what we should do. You know, for educational institutions we’re developing our own protocol. There are issues with respect to, you know, people warning up or people taking paracetamol when they’re traveling et cetera. All these also are very important things.
Yes, uh, I think we’ll have to – you asked about section 166 under D, you know, CRPC et cetera. You know, I’m not competent enough to answer that particular question. But yes, medical legal issues and, you know, protection especially for health care and other stuff is important. I think some direction and some things are you know happening with respect to, how do we, you know, really take care of our doctors and hospitals and health care professionals?
Yeah, incubation period, like I think I told you incubation period is when the organism or the virus has entered into your body until the time when you start become symptomatic. When you show signs and symptoms that period is called as an incubation period. Incubation period had to, you know, broadly one is called is a latent period, when you don’t have the capacity to actually transmit the disease. And then there is a period of what is called us infectiousness, when you will actually transmit this, without becoming symptomatic that is where it is called is the asymptomatic incubation period.
PLG (phonetic) has asked a question with respect to whether the peak will be in June and July. That is what Dr. Guleria has been saying, the Director of the All India Institute of Medical Sciences, New Delhi. I don’t think so, it’s a good idea to extend the lockdown. We have done enough with respect to making sure, the – no sort of trial run with respect to preparedness with respect to what we have achieved is – had done. It’s only a little, you know, it’s a dicey with respect to saying whether suddenly releasing the lockdown will lead to, you know, an epidemic of un measurable proportions.
Yes, we have to do grade it, you know, lifting off the lockdown, it will in terms of things. Excellent question Anuradha, I guess and you know model predictions, something which I’m not very sure about because there’s so many models. Anuradha has a very nice question with respect to changing people’s behavior. Yes, I think that’s something behavioral change always takes a lot of time unless until people participate. And unless until people understand that they have to change their behaviors. There’s very little health system or the providers can do. You have to look at changing behaviors, and that has to come from within, that’s has to come from within.