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Covid-19 risks and response in South Asia

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1190 (Published 25 March 2020) Cite this as: BMJ 2020;368:m1190

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Covid-19 : Catch the tiger by its tail.

Dear Editor,

This editorial is just what was needed. Our thanks and compliments to all the authors [1]. For the South Asian region, poverty as well as the economic health of the governments are the important issues, which must be considered when we discuss, suggest, draft, or finalize any course of action.

Starting how and from where in the world COVID 19 had first started, point number one is that no one would like to eat a rotten rat, snake, left over carcasses, or a spoiled fish, if poverty wouldn't have prevented their access to fresh bread. If only people had adequate fresh food and water, COVID 19 wouldn't have started.

Our second point is that we are ignoring and discounting the expertise and experience of the doctors and healthcare personnel of this whole region, the South Asia. Experience gained from other countries will be of tremendous help. Many deaths can be prevented, and many unfortunate adverse outcomes due to overtreatment, ignorance or inexperience. Now we know that just a Paracetamol or Acetaminophen occasionally, along with rest and self isolation until 3 days after being asymptomatic, would just be fine for most patients infected with COVID 19. Use of cough suppressants is to be avoided, as that will only aggravate the congestion of lungs, which is obviously the main problem with COVID-19. Ventilators may not be useful in already packed up lungs.

At the cost of reiteration [2], third point is that unlike Ebola, where both the infectivity and fatality rates are very high, while COVID 19 has shown a markedly high degree of infectivity, the fatality rate is luckily quite low. It ranges from about 2 to 9 percent. Essentially, not all those infected will die, and with caution, prudence, and good care, this total may be just about 1 to 2 %, coming from the Group A (as described below).

Fourthly, we already know from a recent data that has been published in JAMA [3] and another one from the BMJ [4] as to the type of patients succumbing to this pandemic of COVID 19. Mostly some of the elderly patients have other co-morbidities as well, and thus they are more likely to take the hit. By far we also know that all those with preexisting serious illnesses, malignancy, low immunity, HIV/ AIDS, organ recipients, on immunosuppressant and steroidal therapy, morbid obesity, severe malnutrition, preexisting heart and lung diseases, compensated lung, heart, liver, kidneys, or uncontrolled diabetes, perhaps pregnancy, hospitalized patients, etc, will be vulnerable. In these cases perhaps mortality rate may be high. Let's call them as Group A for better understanding of what I have to say further. We must also include all healthcare workers and care givers into this list of those vulnerable.

Our fifth point is that, God forbid, if just for example let's assume for an instance the worst case scenario for our region is at 10% mortality. Now wouldn't it stand to reason and be more meaningful to give maximum healthcare and preventive coverage to this set of people (Group A), so that the mortality can be kept as low as possible, without frittering away our limited financial and healthcare resources as the remaining 90 % who will just be fine with mild to moderate sickness that will clear off by itself usually within 7 to 10 days. These are by and large healthy individuals, and for convenience of understanding my point, let's talk of them as Group B. From the available literature, they will likely have few symptoms that are mild, and would require rest, self isolation until three days of being asymptomatic and afebrile. However, they can always fall back on the available healthcare facilities should their condition deteriorate, which is possible, but very unlikely. It would therefore seem appropriate to allow them to continue to work as well without isolating them when they are not sick.

Now that we have nearly identified all those who will be more prone for bad prognosis, this brings us to our sixth point. Won't it be logical to identify this group first (Group A), and get them fully isolated, and make them as safe as possible, rather than imposing a full lockdown on all or on most towns, cities, states, etc.

Our seventh point is that rather than spreading thin all the resources, let them be concentrated on about 30 to 35 % of the population that comprise our Group A, who might have a bad prognosis if not given special care right from the start. This way the governments will not go overboard on their precarious budgets. Unnecessary panic will be lessened as complete population will not be mandatorily isolated.

Our eighth point is that policy makers must realize there is no vaccine or any cure in sight as yet. Vaccines, whenever they come, will be coming at a cost. It will be required for Group A, but do we actually see a need for a vaccine for those in Group B, where 90 % patients who will be already OK by the time we count the seventh day of this sickness. Here the sickness is anticipated to be mild, as has been the experience elsewhere in otherwise healthy individuals.

The ninth point, and also the final point as of now, is that gradually we will be going to have a huge population forming up Group B, who would eventually gain active immunity, and would be the harbingers of the much needed "herd immunity" against COVID-19. This in turn will be protective for the frail and the weak of the Group A. This herd immunity, attained actively, would possibly work well for the posterity as well.

The general population somehow feels that anyone catching this infection is bound to die. This is also the reason for the chaos and panic. We need to put it straight to the masses that more than 90 to 95% of those found positive for this COVID 19 and all their contacts will get well and recover fully within a week or so. Total mortality will be just about 1 to 2 %, or maybe a little less. It will be prudent to advise the policy makers to let the people of Group B continue working, rather than confining them by a lockdown. Should they catch COVID 19 infection, they will need to accept treatment under a healthcare professional's care and guidance, plus self isolation until afebrile and asymptomatic for a continuous period of three days. On the other hand, limited and therefore manageable Group A can be given special protection and care, right from the start.

Best regards.

Dr (Lieutenant Colonel) Rajesh Chauhan
MBBS (AFMC), Master in Medicine (CMC Vellore), PGDGM (Geriatric Medicine), PGDDM (Disaster Management), AFIH (Industrial Health), DFM (Family Medicine), FISCD, ADHA (Hospital Administration) & LLB

Dr. Ajay Kumar Singh, MD (Medicine)
Asst Professor, Department of Medicine,
Index Medical College, Indore. India.

Dr. Shruti Chauhan, MDS
Reader, Index Dental College, Indore. India.

References:

1. Bhutta Zulfiqar A, Basnyat Buddha, Saha Samir, Laxminarayan Ramanan. Covid-19 risks and response in South Asia BMJ 2020; 368 :m1190

2. Chauhan Rajesh. COVID 19 : Fresh approach, initiative, and opportunity. BMJ 24 March 2020. Available at : https://www.bmj.com/content/368/bmj.m1141/rr-4 Accessed on 26 March 2020

3. Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. Published online March 23, 2020. doi:10.1001/jama.2020.4683

4. Chen Tao, Wu Di, Chen Huilong, Yan Weiming, Yang Danlei, Chen Guang et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study BMJ 2020; 368 :m1091

Competing interests: No competing interests

28 March 2020
Dr (Lieutenant Colonel) Rajesh Chauhan
Consultant Family Medicine, Geriatrics,Industrial Health, Disaster Management
Dr. Ajay Kumar Singh, MD (Med); Dr Shruti Chauhan, MDS
Family Healthcare Centre, 154 Sector 6-B (HIG), Avas Vikas Colony, Sikandra, AGRA -282007. INDIA.