3 𝗦𝘁𝗲𝗽𝘀 𝘁𝗼 𝗺𝗮𝗻𝗮𝗴𝗲 𝘁𝗵𝗲 𝗖𝗼𝘃𝗶𝗱 𝗿𝗲𝘀𝗽𝗼𝗻𝘀𝗲 𝗶𝗻 𝗠𝘂𝗺𝗯𝗮𝗶 - 𝗡𝗲𝗲𝗱 𝗳𝗼𝗿 𝗮 𝗳𝗿𝗲𝘀𝗵 𝗮𝗽𝗽𝗿𝗼𝗮𝗰𝗵
If one looks at the way the New York State’s Governor Andrew Cuomo has handled the Covid crisis. It has primarily revolved around Strategy, Plan & Execution. It is first class. Based as it is on data, evidence and science. And an unwavering focus day on day in full public view
We saw the classic " inverted U curve " all play out in three months (March- May). From a peak of around an alarming 800+ dead every day (early April) on the upslope, to just about single digits now well p͟a͟s͟t͟ the backslope.
What did this all show?
It indicated that ‘deaths’ coming down in the USA was clearly a function of timely access & availability of hospital beds, and overall health care improvement in public & private hospitals, nursing homes, veteran & care centers.
Be that as it may.
What is the situation in Mumbai?
As ~153 days on it shows a prospective doubling rate of ~66 as end July (and 47 days based on actual growth rate of last 7 days of July). And ~ 90 days now (as of 1st week of Aug).
My estimate is Mumbai will hit a projected doubling rate of ~120 by end August. Second only to Bhiwandi with a DR of 130.
[Even as the overall State is now ~20 days: 2 to 4 lacs!]
Even then Mumbai DR is four times better than India’s and Maharashtra!
So, in simple english does this mean that the peak Pandemic moment is over as rate of addition of new cases over a 7/14 day period to 0.84% sees a a dip?
The quick answer is clearly, NO.
[Of course there are surges which happen with a lag. As has been evidenced elsewhere e.g Melbourne, Israel & Vietnam recently where the second surge has been worse than the first]
One must also evidence a fall in daily fatalities too. But since this is a l͟a͟g͟g͟i͟n͟g͟ indicator. It will take some time to reflect (2/3 weeks).
Unfortunately the daily fatality rate is still stuck at between 45–65 (July avg 58 per day). And keeps wobbling up and down due to reconciliation issues. Even as daily growth rate of active cases falls below 1% in 19/24 wards.
So one could argue that whilst spread has declined, fatalities are still stubborn.
It’s surroundings MMR, NMMC and Panvel, Palghar region yet shows no sign of any improvement. And is between a rock and hard place. With DRs still in early 20s.
While India could well exceed USA at some point (currently 5 million active cases with DR of 60.2). India as a whole shows a stubborn doubling rate of 21 days (1 million -2 million case load). India is a long way of from where the USA is at this point.
Mumbai is like NYC it’s a city which never sleeps. It is the melting pot of India. Around the same population. Same underbelly economy. Dense living conditions. Rich and poor, cheek to jowl. Local trains as lifeline. Economic migrants, financial capital. Same moniker - as the “city which never sleeps”.
What should Mumbai do now?
Right now we are still doing rear view driving which is looking at things on a single axis of viz. testing nos, positive cases, etc.
Since active cases GR is coming down. And recovery rates are going up.
We should perforce keep a focus on:
(1) deaths per million (DPM) , and
(2) daily deaths
The Mumbai DPM (265) should be bought to the 9- city urban agglomeration average level of 79. (India DPM 34) Or, extant fatality rate 5.47% should be in line with State (3.38%) or the national fatality rate of 1.94%.(down from 4% in July).
Therefore Mumbai needs a clear objective to get there.
And that objective is "fatalities control". As the CFR has remained a stubborn level for over a few months now. Unlike NYC
The BMC dashboard perforce will have hospital footfalls/admissions, ICU & oxygen beds , Ventilator cases, ratio of ICU to active, admissions to active cases and finally total daily deaths amongst positive cases. Useful metrics to be able to track , monitor and control — whether these nos are steady, going down or up. As these are the key control variables, or toolkit, in the hands of authorities at level of Addtl Municipal Commissioner and Municipal Commissioner.
If all who need hospital (serious, symptomatic, underlying causes, potential co morbidity cases, 60+ age cohort, SPO2 levels <95) get medical help in a timely manner say within two- f͟o͟u͟r͟ hours of the triage decision to go to Jumbo Centre or hospital and/or admit. Not 24 hours. Or when the test report is awaited for confirmation prior to admission. Or when it’s absolutely too late and patient is serious. Or ping pong between hospitals on account of last minute referrals. Or no Covid facility available. Specially for poor. And then makes the next days papers for the wrong reason. This itself can reduce actual daily deaths from the current two digits (~ 50s). To a single digit. But still there is many a gap which needs to be plugged to reduce daily fatalities. And now it’s not due to stretched health capacity or lack of resources or information assyemtry. But due to cases coming in too late from home quarantine. And table tennis of such serious patients being sent from pillar to post looking for free beds at a hospital of their choice — not just any centre with a free ICU bed. And poor admission / bed allocation process/ work flow automaton still even after six months.
Therefore by plugging these simple gaps if Mumbai can first bring down the daily fatalities to low two digit that itself will be a credible achievement. That then becomes the metric to determine success on progress of war on covid. And creates a groundswell of positive public perception and trust in public authorities which will yield immediate benefits. One can’t stress this enough, given how NYC managed to do this and beat covid. And gave pride of place to NYC efforts globally. Somehow this same feat evades Mum.
Secondly, the main and critical issue of "transmission control" or " secondary transmission". Without getting into whether Mumbai is in transmission stage or not, and the polemics of that.
The stylised transmission trends from my study of 52 USA States shows two broad trends (1) Rt, a key measure of how fast the virus is growing, shows material improvement between June and July during the series of lockdowns, but currently worse off than 2 weeks back!(post reopening in many states), and (2) there is a cycle of surge and fall within 11 week period post re opening! New York is case in point —Rt of 0.74 to 1.05 in four weeks, and 1.05 to 0.94 in 7 weeks!
In Mumbai it is good to note that the daily growth rate of cases (GR) is finally coming down 0.78% from 1.03% in July after recognition of this key objective by the new Municipal Commissioner in late June as part of its “Mission Save Lives” initiative. So that’s sone good news.
the "super spreaders" (people who spread to 5–50 others) wherever they are ‘index cases' or ‘first contacts’, has been key to this end.
First place to start that was from already declared "super spreaders zones" (wards) viz. the present containment zones and hot spots. What is now emerging are new “micro” hot spots viz. hospitals, bus depots, work-place canteens, fruit & vegetables markets, train stations and hi rise buildings just about anywhere. From northern suburbs Ghatkopar Ward N to posh areas e.g Mumbai Ward-D. Which now constitutes most cases amongst hi rise buildings. For Kerala the super spreader cohort is “returnees” from Gulf & other Indian States. For some States it medley of Wedding & Birthday parties and gatherings!
(a)House to house surveillance, and aggressive CT is key to contain the spread limited to these areas. As in the likelihood of inability to do widespread specific testing, tracking down contacts tracing is equally as effective in slowing its spread. Bhilwara, Rajasthan and Karnataka are good examples of this. As also Rajnandgaon, Chattisgarh and Punjab where micro containment is employed and testing is at high levels in and around the containment building.
(b) mass specific and rapid testing (with new kits & quick results viz. voice based test based on AI) wherever possible (and also quick second order RT PCR testing to mitigate false negatives for symptomatics) and reporting in such areas as well as amongst front line essential workers in hospitals, transport, security staff, canteen workers, fruit & vegetable sellers is important to catch out not only the symptomatics. But also the invisible asymptomatics who may be shedding. Front line HCW (incl ancillary staff) seem to be at forefront in being hit. With 25 % testing sero positive.
Clearly as Mumbai goes back to phased unLock. The incidences rising or a s͟e͟c͟o͟n͟d͟/t͟h͟i͟r͟d͟ s͟u͟r͟g͟e͟ i͟s͟ not an impossibility like is happening in Israel, New Zealand, Melbourne, Japan, HK, Germany, Spain, Korea, NYC, Wuhan (in May) and closer home Kerala, Guwahati, Hyderabad, Pune & Bangalore. As social distancing and mask wearing is given a go by due to crowding in the heat of the moment. And a happy go lucky mindset kicks in.
(c) quick and instant Isolation and quarantine as case for such people will be key to control and manage the spread. Like in North MUMBAI. With door to door screening of high risk and active cases being immediately quarantined.
The best use case which depicts this is the largest slum in the World — Dharavi, which “flattened the curve”, with its chasing the virus approach in a period of just 70 d͟a͟y͟s͟! With innovative fever clinics, local GPs, community workers, public involvement and House to house screening. Rigorous CT. Hopefully the same stratagem will work in sister Municipality of Kalyan-Dombivili.
Therefore the strategy for Mumbai has to be one based on:
𝘾𝙤𝙣𝙩𝙖𝙞𝙣. 𝘾𝙤𝙣𝙩𝙧𝙤𝙡. 𝙈𝙖𝙣𝙖𝙜𝙚. 𝙀𝙡𝙞𝙢𝙞𝙣𝙖𝙩𝙚
Now, in Orange and Green zones/ wards, stick to "random stochastic sampling" of the general population (even for serological tests) which is also another form of surveillance and use general community based strategies to inform, track, contact visitors, returnees, direct contacts, sick, etc using testing to confirm or nullify that things are within the threshold norms, and within limits specified for those areas to remain Green or Orange. This is what Sangli and Pathanamthitta Districts has done effectively in Maharashtra and Kerala.
Thirdly, comes the Plan to get back to “near normal”.
This is key.
F͟i͟r͟s͟t͟, is to identify what are the key metric(s) viz. deaths per million , daily deaths, daily positive cases, doubling rate days, 7 day smoothed average of deaths/ admissions/hospital visits, etc. Which determine that you are ready to start a graded Exit from lockdown.
S͟e͟c͟o͟n͟d͟ establish clear thresholds for those metrics viz admission to total positive cases, ICU to positive cases, etc.
All measurable. And visible to all. (More details in the below link.)
https://medium.com/@probir.roy/unlock-2-0-lessons-for-india-6238c586973c
L͟a͟s͟t͟, when a commercial aircraft is in distress the pilots have a maxim: aviate, navigate and communicate. In that order.
In any crisis, specially a pandemic. It is quite the opposite. One must over communicate - meet the press regularly. With latest status on various metrics in dashboard, updates, various steps, measures, resources and operational issues taken up for attention viz N95 pricing, hospital pricing & billing, admission delays, ambulances availability, admin actions planned, new modus operandi for testing. A checkpoint on the sense as to where we are w.r.t the stated strategy. As also use the occasion to stress precautions on how to stay safe. The same has been done in Bastar Kankar District, Chattisgarh by the local collector to great effect. As also proved to be beneficial in a randomised control trial (RCT) in rural Bengal conducted by Nobel Prize winner Abhijeet Bannerjee using SMS to bring about awareness on following basic hygienic precautions about COVID. And also cricketer Munaf Patel’s public services campaign to reduce community transmission in his village in Bharuch dist Gujerat.
