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Covid-19: four fifths of cases are asymptomatic, China figures indicate

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1375 (Published 02 April 2020) Cite this as: BMJ 2020;369:m1375

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COVID 19 : Alcatraz type maximum security for only those who really need it

Dear Editor,

Unlike a very powerful tornado or a cyclone that destroys everything in its path, here is this COVID 19 that has unfortunately been found to destroy and shatter the lives of about 2 % of all those infected by it. Remaining 98% or more scrape through and are almost fine in about a week or two. What more, it is only symptomatic in one out of five patients who are infected by this virus [1]. It is a given that this new corona virus is quite contagious, much more than whatever we might have come across so far, but it is not so virulent as Ebola is. Ever since COVID 19 made its first appearance in December 2019, in a short duration of time we already have millions who are already infected by this virus. However, this doesn't mean that all those who are infected are going to die.

It is almost a common knowledge that up until now we have witnessed increased mortality only amongst the weak, frail, and in those individuals who are suffering from multi-morbidities, malignancy, are bed ridden for prolonged period, have undergone transplantations, are recovering from major surgery, and also those who have precariously low immunity levels, for whatever reason. So far, this is the trend. This virus has luckily, for all of us, not undergone any mutation. We are sorry to be blunt, but COVID 19 is selectively seeking out its prey, and we already know who they might be. It is certainly not that every elderly person would die, or that only the elderly would die. The chances are that those elderly who are weak and frail, and have other serious diseases and conditions alongside, will have to be more careful now on. People at risk of bad prognosis must take additional precautions, including wearing masks, avoiding fomites, keeping social distance, isolating themselves from the normal crowd, etc, so that they can escape getting this contagion. They should try and weather it out as best as they can. Governments should be fully supportive for that. Weathering it out from within the confines of comfort zone needs to be explored rather than packing everyone off to an Alcatraz type establishment for safety.

Instead of trying to protect and isolate the individuals at risk of facing a bad prognosis, trying to isolate everyone by total lockdown of towns and cities may be overreaching and not be attainable. Instead, what can be achieved using the present resources must be given a try first, and the net may be cast wider once we succeed in our initial steps. As of now this virus seems to be too clever for mankind, and has been getting under the skin of even some of the high and mighty. Across the world, for all we know, many individuals, far more than the current statistics and figures, might have already been infected by COVID 19. It may also be possible that many amongst them would have barely realized it, as the sickness is usually quite mild in all those hale and hearty. The news is already out that in China, more than four fifths of cases of COVID 19 were asymptomatic [1].

We must not forget the importance of "herd immunity". So far there was no herd immunity for COVID 19, and this allowed COVID 19 to spread so swiftly all across the globe. Now we have millions who are infected by this virus, and many who had been tested positive have recovered fully. Howsoever best we may try to deal with this pandemic, we may not be able to test everyone. As the numbers of all those infected by this virus is expected to increase exponentially, it will be getting more difficult to trace and test all their primary, secondary and tertiary contacts. Even if this exercise is taken up with top most sincerity, it will turn out to be such a colossal exercise and possibly even those countries with the best of resources and limited population, may find it difficult to complete this whole exercise of getting their figures right.

But is it the figures of all those who are infected that we are interested in? So far these figures have created a panic of sorts and therefore those who are actually sick should be released to the media. Likewise, exposure of the general public to the data obtained from mathematical models and statistical work ups, should be delivered with caution, so as to avoid undue panic. There is as yet no real protection in the form of a vaccine or a specific cure, hence we may as well consider this wild card denoting "herd immunity", which will ultimately help rescue us from this pandemic. So, in a way, since this disease is usually mild in healthy individuals, the sooner this herd immunity gets to reach a certain threshold level because of them, the better it will be. While at it, it will be best and perhaps cost effective as well, if we dig into the immunoglobulin levels, wherein the knowledge of IgM levels as well as the IgG levels would be helpful in management.

From the present trend, in the coming days we may expect a steep rise in the number of new infections all across the globe, barring the People's Republic of China, Italian Republic, Kingdom of Spain, etc, where COVID 19 has already had a free run. However in the South Asian countries, where the elderly population is not as high as in developed countries, mortality rates will be much lower as compared to regions and countries where the percentage of elderly patients with multiple co-morbidities is high. Moreover we already know for sure that only one out of five persons who get infected by this new corona virus become symptomatic [1], and the overall mortality is below 2%. This percentage could be lower still on account of the sunny days ahead. Furthermore, existing bond in the families and the society will help ease the management of COVID 19 pandemic in this region. Much has already been said earlier [2-5].

If not soon anytime now, certainly the posterity will be reflecting upon the measures that were taken against COVID 19, and at what personal costs and financial outgo. They would surely be exploring whether we could have done any better than what we did, without the lockdowns, or isolation in Alcatraz type fashion for the whole population, pushing the economy so far back, and in bringing the whole world to a near halt for COVID 19. Given the information [1], where was that need for overreaction and overshoot, they might consider. Perhaps they will also be considering measures to stop undue panic, stress and anxiety that had nearly reached the Moon, back then.

Best regards.

1. 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

2. Dr. V.T.K. Titus.
MBBS (AFMC), MS (Ortho), Diploma National Board (Ortho), Diploma Orthopedics
Professor & Head, Department of Orthopedics,
CMC Vellore, Tamil Nadu. INDIA.

References:

1. Day Michael. Covid-19: four fifths of cases are asymptomatic, China figures indicate BMJ 2020; 369 :m1375

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 03 April 2020

3. Chauhan R, Singh AK, Chauhan S.. Covid-19 : Catch the tiger by its tail.
BMJ 28 March 2020. Available at : https://www.bmj.com/content/368/bmj.m1190/rr-1 Accessed on 03 April 2020

4. Chauhan R, Singh AK, Chauhan S.. COVID 19: The last straw that broke a weak camel's back. BMJ 01 April 2020. https://www.bmj.com/content/368/bmj.m1199/rr-11 Accessed on 03 April 2020

5. Bhutta Zulfiqar A, Basnyat Buddha, Saha Samir, Laxminarayan Ramanan. Covid-19 risks and response in South Asia BMJ 2020; 368 :m119

Competing interests: No competing interests

03 April 2020
Dr (Lieutenant Colonel) Rajesh Chauhan
Consultant Family Medicine, Geriatrics,Industrial Health, Disaster Management
Dr. V.T.K. Titus, Professor & Head, Department of Orthopedics, CMC Vellore, Tamil Nadu. INDIA.
Family Healthcare Centre, 154 Sector 6-B (HIG), Avas Vikas Colony, Sikandra, AGRA -282007. INDIA.