India now has 31 cases of coronavirus, as of March 6. These cases are from many multiple different clusters including a recent introduction from Italy and the UAE. Cases now exist in Jaipur, Delhi, Gurugram and Hyderabad. As India’s Integrated Disease Surveillance Programme does contact tracing, around 25,738 people have been put under community surveillance in India.

As of March 5, the World Health Organisation has reported about 93,000 cases of COVID-19 and 3,200 deaths in about 77 countries. While the number of cases in China is subsiding, it’s rapidly surging in South Korea, Iran and Italy. As the number of affected countries increases, containment becomes increasingly difficult. Presymptomatic travellers are rapidly exporting the virus. China recently reported importing eight new COVID-19 cases from Italy.

Pandemic yet?

COVID-19 is caused by a recent outbreak of the SARS-CoV-2 virus that leads to respiratory distress and pneumonia-like symptoms in affected patients. It was first reported in Wuhan, China. SARS-CoV-2 is a spillover virus from bats and is known to be highly contagious.

The US, which has reported 108 cases so far, is facing heavy criticism for being underprepared. Faulty reagents in the test kits prepared by its Centers for Disease Control and Prevention severely restricted the initial screening. Preliminary analysis of genetic data indicates that the first case of transmission in the US started as early as January 17 and there are likely around 570 cases in the Washington cluster alone. Most of these are undetected and likely shedding the SARS-CoV-2 all along.

As this runaway virus is establishing its foothold outside China, many are wondering if it’s a pandemic yet.

An epidemic is a sudden unexpected rise in a disease incidence in a particular region. A pandemic is when such an outbreak is spread across the globe. While the WHO is still considering the use of the dreaded p-word, many experts believe that we are already in one. As the number of cases outside China surge, containment seems like a distant dream. In a hyperconnected world, porous boundaries protected by temperature guns are not enough to stop a pandemic.

With 31 cases, this is certainly the start of the India chapter of the coronavirus pandemic.

COVID-19 Datasheet

Patient demographics and symptoms

Most of the data about COVID-19 is based on the initial analysis of the outbreak in China. The median age of a patient is 51 years (n=55,942) and about 51 percent of the cases are male. While the disease is normally distributed, the severity and fatality are dependent on age and pre-existing diseases. So far, 93 percent of all deaths have occurred in patients above the age of 50, and 50 percent in patients above the age of 70.

We’ll come back to this.

Children are somehow protected from this outbreak. Despite being one of the most vulnerable populations, only 2.4 percent of all the cases are seen in patients under the age of 19, and only two percent of those cases end up becoming severe. The most likely reason for this is that children have prior immunity because of regular coronavirus (the milder cousins of SARS-CoV-2) infections in childhood. This immunity likely wanes in adulthood, leading to the sharp uptick in COVID-19 cases.

After infection, it usually takes five to six days for symptoms to appear, sometimes even 14 days. The most common symptoms are fever, dry cough, and flu-like symptoms.

About 80 percent of cases are mild and will show no or mild pneumonia. About 14 percent are severe. About six percent of COVID-19 patients end up becoming critically ill. All the deaths occurred in critical cases. Asymptomatic patients make up about one percent but end up developing symptoms within two days. The time taken for recovery varies from two weeks for mild cases to about 3-6 weeks for severe ones.

The WHO’s analysis from China suggests that from severe and critical patients (about 20 percent of all cases), about 25 percent of patients will require mechanical ventilation and the remaining 75 percent will require oxygen supplementation. This figure is concurrent with other data that suggests that around 10 percent of all cases will require ventilation support.

For a country like India with poor health infrastructure, COVID-19 has the potential to adversely affect an already overburdened system.

Death and case fatality rates

The most widely used and abused word in the course of this infection will be case fatality rate, or CFR. It indicates the percentage of patients who die because of the disease in the course of an outbreak.

The CFR for the Chinese epidemic was 2.3 percent, while the global CFR, according to WHO, is 3.4 percent. This means that for every 100 COVID-19 infections, around 3-4 people die.

But CFR is not a solid, constant number. It varies widely — even within a country. For instance, the CFR was 5.8 percent for Wuhan and 0.7 percent for the rest of China. It’s about 20 percent for patients above the age of 80, and 4.7 percent for males as compared to 2.8 percent for females.

CFR also increases with preexisting conditions: it stands at about 13.2 percent for those with cardiovascular disease, 9.2 percent for those with diabetes, 8.4 percent for hypertension, eight percent for chronic respiratory disease, and 7.6 percent for cancer patients. Thankfully, pregnant women don’t appear to be at higher risk, according to the data collected by WHO from China.

CFR suggests that COVID-19 is not existential or apocalyptic. But this doesn’t mean it's not serious. CFR is also a function of time and region. South Korea, for instance, has a CFR of 0.6 percent because it is doing 10,000 proactive tests, including drive-throughs. The CFR would certainly be high for a country like India with poor surveillance and health infrastructure. Relying on the 2-4 percent fatality figure adds complacency in containment efforts. Even a low CFR has the potential to blow if SARS-CoV-2 manages to infect thousands of people — not tough in a country like ours, where everyone is packed together like sardines.

Transmission and R0

The two main ways of transmission are through droplets and fomites. The former is through respiratory droplets produced when someone sneezes or coughs (within a distance of two metres) and the latter is when someone touches a virus-infected object (fomite) and then touches their nose, mouth or eyes. The WHO has ruled out an airborne route as a major mode of transmission.

Virus particles are found in the faecal samples of about 30 percent of COVID-19 patients. Culturing in some cases has ascertained that they were viable (not necessarily infectious). The role of the faecal-oral route in the transmission is, however, not clear yet.

Another important number in an outbreak is the R0 (read: “R nought”) or the reproduction number. It’s the number of secondary infections that a patient transmits in that period. The estimated R0 for the outbreak in China was about 2.2. This means that every patient will infect 2 other people. For an outbreak to subside, the R0 value should fall below 1. While R0 is an insightful number, it doesn’t capture all the complexities of a transmission.

Control and treatment

In the face of such a novel pathogen, the most efficient way of reducing infection is through non-pharmaceutical interventions like social distancing, quarantines, contact tracing, and hand hygiene. While these measures do not always aid in containing the virus, they help in buying time to prepare for mitigation and care.

Vaccines can be an incredible tool in arresting the spread of an outbreak. But for novel pathogens, vaccine development can take a couple of years. Currently, there are more than 20 potential vaccines under development for COVID-19. Many candidates — including inactivated whole virus, DNA, recombinant protein, and mRNA — are being tested but it would take about 12-18 months before one is finally approved. Even after one is approved, production will take time and it will be administered in multiple phases, starting with vulnerable elderly population and healthcare workers.

Early vaccines that are accelerated through trials are often experimental and can sometimes increase the risk of re/infection. The immunity conferred by a vaccine can often wane over time. Not to forget, the disinformation campaigns that have fanned the flames of vaccine hesitancy. While an important development, vaccines are not the defence we should bank on for now.

For infected patients, there is no cure currently available for COVID-19. Regular therapeutics used to manage pneumonia along with supportive care is the current recommended protocol for the disease. WHO has suggested 70 potential drugs, which should be tested for their efficacy against COVID-19.

Currently, hundreds of clinical trials are underway in China, investigating the potential of drugs and therapeutics like chloroquine, favipiravir, TCM, and convalescent plasma. Remdesivir, a promising drug that works well for RNA viruses like SARS-CoV-2, is currently under clinical trial in several hospitals.

While clinical trials are very long, if any of these potentials show significant improvement, the trial will be halted and immediately dispensed for use in other clinics and hospitals. Drugs that can be used as prophylaxis will take a longer time to be developed and will not have any valuable impact on the current outbreak.

Future and projections

In an early stage, an outbreak can still be controlled. But once it has independent self-sustaining clusters, it's very difficult to get hold of it.

Mathematical modelling of disease and air travellers has shown that without large-scale interventions, COVID-19 will likely spread all across the globalised world. In case the virus is not contained, which increasingly seems to be the case, scientists worry that COVID-19 may end up becoming endemic or native — infecting people seasonally, like influenza. Many experts, including an epidemiologist at Harvard University, Marc Lipsitch, think COVID-19 will infect 40 to 70 percent of adults in the world.

Based on the rate of mutation in the virus genome, the current rate of infection doubling is about seven days. This means that 100 infections will become 200 in a week and 400 in the next. Backlog and underreporting can change this estimate, but it will likely keep doubling unless strong non-pharmaceutical measures are enforced.

Another concern is reinfection. Antibody-dependent enhancement, or ADE, increases the severity of disease if the patient is reinfected with a different strain of virus after recovering from the first infection. It is prominently seen with the dengue virus. Some experts are concerned that SARS-CoV-2 too can show similar behaviour. Animal studies are required to ascertain this, though.

As we move further into this pandemic, it’s a good time to introspect on the urgent need for global cooperation, collaboration, and investment in infectious disease surveillance and containment.

What should India anticipate?

Thermal screenings and testing are being carried out across all airports in India. Patients testing positive are kept under isolation and observation. To track all the potential transmission, contact tracing is being carried out by the Integrated Disease Surveillance Programme under the National Centre for Disease Control. In case any asymptomatic person comes in contact with a patient, home quarantine for at least 28 days is recommended.

Currently, there are 15 centres in India that are testing for SARS-CoV-2. These include 13 virus research and diagnostic laboratories (VRDLs), the National Centre for Disease Control, Delhi, and the National Institute of Virology, Pune. NIV is the apex body that reconfirms all the positive RT-PCR diagnosis. RT-PCR is the first line of diagnosis to confirm a COVID-19 infection.

Containment is more about buying time to prepare for an outbreak and get a headstart. Thermometers and a single page self-declaration form at airports certainly cannot stop a contagious pathogen.

Now that we move towards mitigation, the lessons from China seem to be very clear. As WHO epidemiologist Dr Bruce Aylward puts it, “It’s all about speed.”

One of the reasons why the CFR for COVID-19 is low is because of the supportive care that allows severe cases to recover. In the worst-case scenario, 15-20 percent of patients requiring ICU-level care and ventilation may overwhelm our health system. The rich may escape in private hospitals, but the poor will likely pay the cost as they always do. Countries with excellent health infrastructure like South Korea are falling short of hospital beds and ventilators. India can only learn from them and brace for impact.

No matter how intuitive, quarantines are not really very effective. Social distancing and avoiding packed spaces like malls, metro stations and places of worship is important. PM Modi’s decision to suspend Holi celebrations this year is a good step in that direction. Hand hygiene, contact tracing, and social distancing are paramount for preventing new clusters from springing.

“Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate,” said Michael Leavitt, the former US secretary of health and human services. Policies and strategies to control COVID-19 should not swing between apocalyptic alarmism and willful denial.

Another important arsenal in battling a pandemic is information. Most of what we know in this article is because China openly shared the genetic and epidemiological data of their outbreak. India doesn't seem to learn. The first positive case in India was reported on 30th January. Despite sequencing it, ICMR-NIV has still not uploaded the genome sequence on GISAID or any other sequence sharing database. They didn’t share the sequences with anyone during the 2015 H1N1 outbreak in India. This sort of uncommunicative nature not only hinders international progress but also is a disservice to Indian scientists who can provide their valuable insights when data is publicly shared.

The New Indian Express recently published a piece advising readers on how to survive coronavirus using their insights from astrology. Pandemics are often a cesspool of disinformation and conspiracies like this. In the face of uncertainty, many develop mistrust in the system and take refuge in misinformation.

As WHO puts it, combating this infodemic is equally important.

Along with dispelling rumours, journalists should be careful about the language they use to cover the outbreak. As it did during the Nipah outbreak in 2018, homeopathy and other members of AYUSH have started dispensing ineffective medicines with false claims for COVID-19. The media should proactively nip these buds of misinformation and hold the government responsible for peddling some of them.

A reader's guide to surviving the pandemic

Despite what BJP leaders claim, neither yoga nor spraying cow dung or urine will control the spread of COVID-19. Nor will gargling bleach or some garlic concoction. Stick to WHO and CDC recommendations. Here is a rundown of things you can do to prevent being infected:

Hand hygiene: Twenty seconds of handwashing with regular soap and water works like a charm. The outer membrane of SARS-CoV-19 is made of lipids and fats. The virus is gutted open because the soap emulsifies the fats and breaks it open. It is very similar to washing off grease or butter chicken stains from clothes using soap.

Alcohol-based hand rubs and sanitisers work well too, but are expensive and understocked, and should be reserved for clinical and health care workers. DIY folks, meanwhile, can make their own sanitisers using this WHO guide.

Regularly washing our hands does not come intuitively to us. It’s a good idea to add a recurring alarm in your phone to remind you to wash your hands every few hours or so.

Masks: You don’t need masks unless you are sick. Lay people not trained in mask usage and disposal will end up inadvertently infecting themselves. Also, front line healthcare workers are running out of masks and the current stock should not be hoarded at their cost.

Don’t panic: COVID-19 symptoms are very non-specific. If you feel sick, remember it can simply be your neighbourhood rhinovirus causing your runny nose or the seasonal strep infection. In the case of symptoms, call in sick for work, isolate yourself, and get in touch with the helpline number.

If you can, then work from home and avoid travelling or going to crowded places unless it’s important. It will be a good idea to buy medicines and other essentials in advance to add slack in the system in case the outbreak worsens.

Cover your mouth while sneezing with a tissue or your elbow. Avoid handshakes and avoid touching your face. Your nose, mouth and eyes are the primary points of entry. Don't touch them.

In shared spaces, disinfect tables and doorknobs with phenyl or bleach wash.

UV in the sunlight is an incredible disinfectant. One to three minutes of direct sunlight can inactivate the virus. As there is no airborne transmission, opening windows and modes of ventilation can also help by diluting the viral load in the air.

The news cycle can be a bit anxiety-inducing. Stick with a trusted news source and daily WHO media briefings.

Take care of yourself and others. Avoiding infection is not just a personal necessity but also an altruistic endeavour. The more healthy folks avoid getting infected, the less will be the transmission in vulnerable populations because of collective herd immunity.

The next few weeks can be challenging, but with proper care and vigilance, we can manage to control this outbreak and minimise its impact.

If you or anyone you know has symptoms of COVID-19, exercise self-quarantine and call the coronavirus helpline at +91-11-23978046, managed by the Ministry of Health and Family Affairs.