Covid-19: Risk of second wave is very real, say researchers
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2294 (Published 09 June 2020) Cite this as: BMJ 2020;369:m2294Read our latest coverage of the coronavirus pandemic
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That the ‘Non-Pharmaceutical Interventions (NPIs)’ are the ‘COVID-19 Pandemic Interventions that Work’ is no longer in doubt! What is lacking are the ‘Political Will’ and the ‘Courage of Scientific Conviction’ to do the needful: take the ‘Right Decisions’ to ‘Effect the Desired Actions’ to significantly alter the ‘Current Unacceptable Global Scourge Picture’!! The recent ‘Communication’ that indicates the inevitability of ‘Second Pandemic Waves’ is instructive [1]!! Previous ‘Communications’ disposed the unquestionable impact of ‘Pandemic-induced Lockdowns’ [2,3]!! It is reported that ‘Lockdowns’ have saved 3.1 million deaths across 11 European Countries [2]!! The ‘Reproduction Number (R Value)’ for the ‘SARS-CoV-2’ is reported, due to the ‘Pandemic Interventional Lockdowns’, to be largely below 1 in the European Countries [2]!! The resultant low rates of ‘COVID-19’ in the Populations, largely below 4% in the 11 Countries, imply that ‘Herd Immunity’ is very low!! The ‘Pandemic Intervention’ that can ‘Rapidly Increase Herd Immunity’ is ‘Mass Vaccination’ but the ‘SARS-CoV-2 Candidate Vaccines’ are in various ‘Phases of Clinical Trials’ and do not immediately provide answers to the worrisome low ‘Herd Immunity’. The ‘Issues’ of ‘Viral Genomic Diversity’-‘Viral Mutation Capacity’-‘Viral Recombination Capacity’ and ‘Neutralizing Antibodies Status’-‘Monoclonal Antibodies Production’ etc ALL contribute, together with ‘Unacceptable Politics’, to ‘Kicking the Vaccines Intervention Further Down the Road’ in ‘Accelerating Increased Herd Immunity’!! The impact of the ‘NPIs’ has also been reported for China, USA, South Korea, Italy and Iran with projected increases in ‘COVID-19 Cases’ from 38% to 68% in the absence of such ‘Pandemic Interventions’ [3]!!
Given the extant ‘Situational Realities’ with the ‘Pandemic Interventional Lockdowns’, and with the pervading ‘Low Herd Immunity’, the widespread ‘Policy and Practice’ of ‘Interventional Precocity’ in many parts of the World with the ‘Easing of Lockdowns’ only portend ominous ‘Signposts’ for most Countries and ‘Definite Cog in the Wheel of Progress’ in the ‘COVID-19 Pandemic Fight’ [4-6]! There is the suggestion that ‘Prolonged Lockdowns’ are not justified [7]! To achieve ‘Pandemic Interventional Lockdowns’ with ‘Differentially Distributed Lockdown Impact/ Burden’, the ‘Stratified Shielding Pandemic Intervention’ was proposed [8,9]!! In a previous ‘Communication’, there was a ‘Critical Discourse’ on the ‘Stratified Shielding Intervention’ countering its suggested value re: Panacea for ‘Beneficial Precocious Easing of Interventional Pandemic Lockdowns’ [10]!!
With the ‘Pandemic Interventional Lockdowns’, there is ‘Global Huge Economic Burden’ but ‘Global Lockdown’ is not definitely equivalent to ‘Global Lockout’6! With several evolving ‘ICT-compliant Cloud-based Technologies’, the World is conducting several ‘Transactions-Activities-Engagements’ in ‘Virtuality’! There MUST be guaranteed Effective and Efficient ‘Testing-Isolation-Treatment’/ ‘Containment’ and ‘Tracing-Tracking-Quarantining’/ ‘Mitigation’ verifiably evident as part of the ‘Pandemic Programmatic Intervention’ before implementing any ‘Easing of Lockdowns’! The ‘Easing of Lockdowns’ without the antecedent ‘Testing-Isolation-Treatment’ and ‘Tracing-Tracking-Quarantining’ Capacities amounts to ‘Interventional Precocity’ and, coupled with ‘Low Herd Immunity’, an ‘Invitation to Inevitable Second Pandemic Waves’ [1]: ‘SURGES’ for those still on the ‘Ascending Limb’ of the ‘COVID-19 Epidemic Curve’ and ‘RESURGENCES’ for those on the ‘Descending Limb’ but without fulfilling the ‘Prescribed Epidemiological Metrics’!! There MUST be SANITY in achieving the ‘Desired Balance’ between ‘Livelihood and Life’ and ‘Making a Living and Living’!! Kowtowing under undue and irrational ‘Political Pressure’ or ‘Perceived Economic Strain’ is NOT an ‘Option’!!!
The various ramifications of the ‘COVID-19 Infodemic’ have also contributed to the avoidable ‘Interventional Precocity’ in ‘Easing the Pandemic Interventional Lockdowns’ with the equally avoidable POTENTIALITY for the ‘Second Pandemic Waves’ [4-6]! More disturbing is the ‘Unacceptable Polluting Politics’ which seems to be drowning and possibly overshadowing the ‘Science, Facts and Best Available Research Evidence (BARE)’ concerning the ‘COVID-19 Pandemic’ [11]!! Beyond assuring the ‘Adequacy and Availability’ of Effective and Efficient ‘Containment’ and ‘Mitigation’ Interventions, there should be proper attention to, and focus on, the ‘Universal and Specific Precautionary Measures’ including Appropriate Hand-washing Techniques/ Hand Hygiene, Hand Sanitizer Use, Face Masks Use, Social Distancing, Mass Gatherings Restrictions etc!! It is quite bothersome watching the ‘Unbelievable Denialism’ seen across several parts of the World which completely defy ‘Advisories/ Guidelines/ Guidance’ from several ‘Reputable Authoritative Renowned Bodies’ with reported ACTUALITY of ‘SURGES’ and ‘RESURGENCES’. First time ‘Single-day High Numbers’ are reported for ‘New COVID-19 Cases’ and ‘New COVID-19 Deaths’ across the Globe in these ‘Inexplicably Defiant Polities’!! Attention has also been drawn to ‘Critically Determinant Eight Pandemic Dimensions’ [12], beyond ‘Test and Trace’, that MUST be addressed in effecting ‘Easing from Lockdowns’ to avoid ‘Second Pandemic Waves’ as ‘Unnecessary Programmatic Interventional Unforced Errors’!! These ‘Avoidable Second Pandemic Waves’ are REAL and clearly undeserved ASSAULT on Humanity with the horrifying loss of Human Lives!! For those playing ‘Politics with Human Lives’, remember always: ‘One Avoidable Death is One Death Too Many’ (Former UN Secretary-General Ban Kii Moon; 2010)!!!
The WHO has recommended that ‘Politics’ should be ‘Quarantined’ in ‘COVID-19 Pandemic’! We have on our hands a ‘Global Public Health Burden’ which is a ‘Raging and Ravaging Novel Coronavirus Disease 2019 (COVID-19)’ caused by the ‘Novel Coronavirus (SARS-CoV-2)’. While it is a ‘Novel Problem’ and the World is grappling with the ‘Increasing Challenges of Unearthing the Difficult Pandemic Realities’, the ‘Rational Programmatic Interventional Approach’ MUST remain ‘Encapsulated with SCIENCE’! The ‘Way to Go’ in the ‘Global Fight’ against the ‘COVID-19 Pandemic’ with the ‘UNSEEN ENEMY’ is ‘Global Pandemic Interventions’ enamoured with ‘SCIENCE, FACTS and EVIDENCE’!! Undue recourse to ‘POLITICS’ pollutes ‘Interventional Armoury’ mounted against the ‘COVID-19 Pandemic’. The ‘COVID-19 Infodemic’ MUST be aggressively avoided and countered as feasible!! Nature abhors Vacuum!! There is the ‘COVID-19 Pandemic Information Production Pressure’ which has possibly resulted in the ‘Avalanche of COVID-19 Research Data/ Output’!! Unfortunately, the pressure and imperative to have an ‘Outpouring of COVID-19 Research Information’, and with concerns about compromised ‘Research and Data Governance’, a ‘New Problem’ has crept into the enlarging ‘Pandemic Difficulties’: the ‘COVID-19 Research Waste’ [13-15]!!!
This ‘Communication’ is a ‘Contribution’ to the extant ‘Inevitable Second Pandemic Waves Conversation’ which amplify the avoidable deleterious ‘Consequences of Interventional Precocity’ in ‘Easing Lockdowns’ in the ‘Global Fight’ against the ‘COVID-19 Pandemic’. The ‘Name of the Game is SCIENCE’ and we MUST ‘Play the Game by the SCIENTIFIC RULES’! For the ‘COVID-19 Pandemic’, ‘Lockdown is not Lockout’ and ‘Interventional Precocity’ MUST be avoided; it is ‘SCIENCE IN’ and ‘POLITICS OUT’!!
REFERENCES
1. Wise J. Covid-19: Risk of second wave is very real, say researchers. BMJ 2020; 369:m2294
2. Flaxman S, Mishra S, Gandy A et al, Imperial College COVID-19 Response Team. Estimating effects of non-pharmaceutical interventions on COVID-19 in Europe. Nature 2020 (Jun). doi:10.1038/s41586-020-2405-7.pmid:32512579
3. Hsiang S, Allan D, Annan-Phan S et al. The effect of anti-contagion policies on the COVID-19 pandemic. Nature 2020 (Jun). doi:10.1038/s41586-020-2404-8.pmid:32512578
4. Melnick ER. Should governments continue lockdown to slow the spread of covid-19? BMJ 2020; 369:m1924
5. Godlee F. Covid-19: It’s too soon to lift lockdown. BMJ 2020; 369:m2202
6. Eregie CO. COVID-19 Pandemic Interventions: Lockdown is not lockout; avoid interventional precocity with easing lockdowns. https://www.bmj.com/content/369/bmj.m2202/rr-4 of 14th June 2020
7. Ioannidis JPA. Coronavirus disease 2019: The harms of exaggerated information and non-evidence-based measures. Eur J Clin Invest 2020; 50:e13222
8. McKeigue PM, Colhoun HM. Evaluation of ‘stratify and shield’ as a policy option for ending the COVID-19 lockdown in the UK. medRxiv 2020.0425.20079913 (Preprint) doi:10.1101/2020.04.25.20079913
9. Smith GD, Spiegelhalter D. Shielding from covid-19 should be stratified by risk. BMJ 2020; 369:m2063
10. Eregie CO. COVID-19 pandemic and stratified shielding: some more matters for the works. https://www.bmj.com/content/369/bmj.m2063/rr-2 of 18th June 2020
11. Eregie C.O. COVID-19 Pandemic, ‘COVID Phenomenon’ and the politics of the science, facts, research evidence and ‘evidence-based medicine (EBM): the imperative for rekindling the ‘multiparameter-based medicine (MBM)’ in the 21st Century. https://www.bmj.com/content/369/bmj.m1336/rr-20 of 17th April 2020
12. Eregie CO. COVID-19 pandemic tragic octad: The evolving conceptual qualitative interventional equation to fight the pandemic. https://www.bmj.com/content/369/bmj.m2303/rr-9 of 24th June 2020
13. Clinical Trials.gov. History of changes for study. NCT04280705, 1 May 2020. https://clinicaltrials.gov/ct2/history/NCT04280705?A=10&B=15&C=Side-by-S....
14. Yan W. Coronavirus tests science’s need for speed limits. New York Times 2020 Apr 14. Waste
15. Eregie CO. COVID-19 Pandemic: The multifaceted picture of compromised COVID-19 research and the ‘COVID Phenomenon’. https://www.bmj.com/content/369/bmj.m1847/rr-12 of 10th June 2020
Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria.
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria.
UNICEF-Trained BFHI Master Trainer,
ICDC-Trained in Code Implementation,
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria.
*No Competing Interests.
Competing interests: No competing interests
The debate on how to use mathematical simulations to predict the impact of Covid-19 on the population health and healthcare needs is vivid. While researchers have predicted a huge number of deaths and overwhelmed healthcare systems [1], others have predicted that the burden could be much smaller [2]. Now, predictions aim at estimating the probability and the scale of a second wave [3]. Many prediction models share the problem of being built on fragile epidemiological data, especially early in the course of an epidemic, and are opened to wide uncertainties [4]. Being highly mediatized, people are stressed by these predictions and policy makers are skeptical about using this information for decision making.
I would like to raise one issue and make one proposal.
The issue is that there is a cultural gap between the world of simulation and public health surveillance. Surveillance consists in transforming health related data into useful information for decision makers [5]. Indeed, data does not speak by itself. To make data useful for decision, it has to be translated for policy makers. Scientists doing predictions, unless active in applied public health, may not be trained to do that. And policy makers struggle to understand strengths and limitations of prediction models.
The proposal is to prefer simulation at a local scale, e.g., at the level of a hospital or of healthcare facilities in a given jurisdiction. Key is to put in the same room data-scientists, health care providers, and policy makers. One advantage is that models are built accounting for the true needs of the health care system, based on actual and directly available data. Further, the predictions can be directly discussed with policy makers, and adapted as needed, increasing the probability of having an impact on decisions.
Reference
1) Patrick GT et al. The Global Impact of COVID-19 and Strategies for Mitigation and Suppression. Imperial College London (26-03-2020), doi: https://doi.org/10.25561/77735
2) Lourenco J et al. Fundamental principles of epidemic spread highlight the immediate need for large-scale serological surveys to assess the stage of the SARS-CoV-2 epidemic medRxiv 2020.03.24.20042291; doi: https://doi.org/10.1101/2020.03.24.20042291
3) Wise J. Covid-19: Risk of second wave is very real, say researchers. BMJ 2020;369:m2294
4) Adam D. Special report: The simulations driving the world's response to COVID-19. Nature 2020; 580(7803):316-8
5) Chiolero A, Buckeridge D. Glossary for public health surveillance in the age of data science. JECH 2020; 74(7):612-16.
Competing interests: No competing interests
Dear Editor
COVID-19 in India with lower Death Rate .
As of now today on 12.6.2020 in India, COVID-19 cases surpasses 3 lakh (307049)
At present about 0.02% (307039)of population is affected by COVID-19 infection in India.
The lockdown and the containment measures helped to keep the virus in check at India
India's Covid-19 recovery rate showed an improvement amid the novel coronavirus cases rising in the country.
In India if you look at cases per million, it is at just 151 cases per
million as compared to over 5,000 cases per million for the US and Spain.
If we look at death per million population, India has recorded four deaths per million only.
The number of patients recovered presently exceeds the number of active patients in India.
As of 11.6.2020 in the global list of a single day COVID-19 case report , Brazil has recorded the maximum 30465 cases . Next to it is USA, which has reported 23300 cases and India is in the 3rd place with 11123 cases . This is the highest number of cases so far recorded in a single day for the first time in India during this Pandemic.
Now India is in 4th place with reported 298283 COVID-19 cases next to USA (First), Brazil (second), and Russia (Third) in the global list as of on 11.6.2020
It is projected that India to hit a peak of 1.92 lakh active COVID-19 cases on June 18.
Another, more dire, projection, based on the SEIR model, puts the peak at 2.78 lakh active cases on the same date in India .
Yet another projection says that the projected total deaths in India may be about 136148 around October 1st.
Competing interests: No competing interests
A Simple Measure to Help Reduce Transmission Risk
Dear Editor,
In view of the COVID-19 crisis with the imminent risk of a second wave, we believe that there is an urgent need to explore innovative ways to reduce risk of transmission and our article puts forth a novel, simple and yet effective way to help lower risk of transmission.
Sir Charles Bell (who described Bell’s Palsy) once said “we ought to define the hand as belonging exclusively to man - corresponding in sensibility and motion … which converts the being who is weakest in natural defence to the ruler over animate and inaminate nature." 1 The uniqueness of human hands has two fundamental prehensile actions – the precision grip and the power grip.2 The precision grip enables accurate and precise motion, involving mainly the use of the thumb, index and middle fingers and is a throwing grip. The power grip enables application of tremendous force, involving all digits including the ring and fifth finger and is a clubbing grip.3 The ability to throw or wield a club offered significant reproductive advantages in evolution and resulted in the anatomical changes we see today.
How does this then translate to the use of our hands in contemporary society? The radial three digits (thumb, index and middle fingers) are still used for activities that require dexterity and precision - buttoning of shirts; applying makeup; putting on accessories like earrings; picking of food for eating; communication including writing, texting and typing. Likewise, the ulnar two digits (ring and little finger) are also involved in activities requiring strength and power: using tools like hammers and drills; carrying heavy bags; grasping steering wheels. From these activities, it is also notable that the radial side fingers are more likely to come into contact with our face during everyday life.
In light of the Coronavirus Disease 2019 (COVID-19), there is a strong impetus to further evolve and modify how we use our hands to reduce transmission risk. COVID-19 is caused by human-to-human transmission occurring via respiratory droplets.4 The virus is released in the respiratory secretions whenever an infected person coughs, sneezes or talks and another person becomes infected when he or she makes direct contact with the droplets via their mucous membranes. A person can also become infected if he or she touches an infected surface e.g. a patient’s hands, tables or phones and proceeds to touch his or her eyes, nose or mouth which is more likely with the radial side of his or her hand.
An observational study found that students touched their faces 23 times an hour on average.5 This makes us highly prone to infection, and is notoriously a difficult habit to break, especially since most individuals are often unaware of the fact that they are touching their faces. Current recommendations to reduce transmission risks have hence shifted towards advocating frequent hand washing. However, there remain problems with relying predominantly on hand washing to reduce transmission risks. Firstly, people in developing countries do not have easy access to soap and clean water. Secondly, even if there is easy access to facilities for hand washing, individuals may not be able to wash our hands as frequently as they should. A study done on random public individuals showed that they touched their mouth or nose mucosa at a rate of 3.3 and 3.6 times per hour. In other words, “recontamination in public settings occurs at a much higher rate than any viable hand washing frequency.”6 Other measures being bandied around are less efficacious – using tissue to scratch nose or eye drops for dry eyes only works if the individual is conscious of the act of face-touching; wearing gloves offer feeble protection as the gloves can pick up the virus too; wearing a mask to prevent one from touching one’s mucosa would work better if masks were more readily available during this pandemic.
Consequently, we suggest using specific digits for “self” tasks and other digits for “external” tasks and to consciously change the way we use our hands as we go about our daily activities (see Fig. 1). Since we can’t seem to avoid touching our faces, we recommend continuing to use the radial side of our hands (thumb, index and middle finger) for dexterous activities such as self care (eye rubbing, nose scratching) as we do now. However, we also recommend actively making an effort to use ulnar two digits (ring finger and little finger) or the ulnar aspect of hand when it comes to touching public surfaces that may be contaminated such as pressing lift buttons, pushing public doors or flushing public toilets. As we rarely use our ring or little fingers to touch our faces, the hope is to reduce the risk of transmission by touching possible contaminated surfaces with only our ulnar digits.
Although this recommendation may seem counter-intuitive to implement at first, we have found that we were able to alter our habits effectively within a few days of practice. Our hope is that our simple recommendation can reach out to a large audience and even if it may just be one single individual who manages to avoid being infected after reading our recommendation, that individual may have been someone's mother, husband or daughter. As COVID-19 continues to rage on in various parts of the world, we hope that our simple yet effective recommendation will not only be life changing, but also life-saving.
References
1. Bell C. Definition of The Hand. In The Hand: Its Mechanism and Vital Endowments as Evincing Design. Cambridge: Cambridge University Press. 2009
2. Napier JR. Evolution of the human hand. Proc. Royal Inst. Great Britain 1965;40: 544–557.
3. Young RW. Evolution of the human hand: the role of throwing and clubbing. J Anat. 2003;202(1):165-74.
4. Zhai P, Ding Y, Wu X, Long J, Zhong Y, Li Y. The epidemiology, diagnosis and treatment of COVID-19. Int J Antimicrob Agents. 2020 Mar 28:105955.
5. Kwok YL, Gralton J, McLaws ML. Face touching: a frequent habit that has implications for hand hygiene. Am J Infect Control. 2015;43(2):112-4.
6. Alonso WJ, Nascimento FC, Shapiro J, Schuck-Paim C. Facing ubiquitous viruses: when hand washing is not enough. Clin Infect Dis. 2013;56(4):617.
Competing interests: No competing interests