The Covid-19 pandemic has led to a range of social containment measures in different countries. These were introduced for two main reasons—first, to slow the spread of infection and second, to reduce the preventable loss of lives, mainly by increasing intensive care capacity for those who can be saved. However, the most important question that must be answered is—how deadly is the virus?
There are two terms to understand here—Case Fatality Rate (CFR) and Infection Fatality Rate (IFR). CFR measures the number of fatalities as a proportion of the diagnosed cases confirmed by a test. CFR varies tremendously across countries based on the amount of testing performed, as most cases are asymptomatic or mildly symptomatic. IFR estimates the total death rate based on all people with Covid-19 infection (whether symptomatic or asymptomatic, whether confirmed by a test or not). IFR is always an estimate as we cannot test all people.
At the outset of the Covid-19 outbreak, CFR was thought to be extremely high due to a selection bias, as only the sickest cases were identified and a higher proportion of them died. Current CFR estimates vary widely because of variance in testing from nation to nation. The current best assumption of Centre for Evidence Based Medicine (University of Oxford) is that CFR is about 0.72 percent.
However, it is IFR that is more vital. Several public health authorities in the West projected that for each death from Covid-19, there were likely to be 1,000 infected persons in the community, possibly based on the 0.1 percent death rate of annual influenza. Emerging data may back this assertion as in circumstances where there has been aggressive contact testing, a high number of healthy asymptomatic or minimally symptomatic individuals have been detected, who in normal circumstances would not be considered ill.
We also have a lesson to learn from the 2009 H1N1 influenza pandemic, which may have affected up to 20 percent of the world population. IFR ended up as a maximum of 0.02 percent, five-fold less than the lowest initial estimate of 0.1 percent, after the first ten weeks of the outbreak.
Studies have shown that a much wider section of the population has already been infected, especially in metropolitan areas such as New York. The US, that is currently performing the largest number of tests, has detected the largest number of cases and confirmed deaths. However, due to selection bias, the vast majority of tested individuals continue to be older adults. Also, it is possible that a significant proportion of deaths due to Covid-19 in the elderly and those with pre-existing diseases would anyway have taken place next year. Typically, one in 10 individuals above 80 years will die each year. Covid-19 may have hastened death in such cases. Such considerations suggest that IFR estimates will continue to drop, as more evidence emerges of the much wider incidence and prevalence of Covid-19 in the community.
India Extrapolation
So far, India has had relatively few Covid-19 deaths despite its large population. It has a young demographic with over half the population under 35, an average life expectancy of 68 years, with only 5.46 percent aged above 65. In contrast, in Britain (over 32,000 deaths to date, nearly 90 percent deaths occurring above 65), 16.4 percent of the population is aged above 65.
In the chart (see below), the key figure is IFR. As the Indian age pyramid is different from many western nations worse affected by Covid-19, we have in the best possible scenario, reduced IFR to 0.04 percent, in the middle case scenario to 0.06 percent and in the higher case scenario to 0.1 percent. Applying the 0.04 percent IFR, we estimate deaths of 3.25 lakh (60 percent of population infected). In the middle case scenario (60 percent of population infected), we estimate about five lakh deaths and in the higher possible scenario with an IFR of 0.1 percent, we estimate approximately 8.1 lakh deaths. Even with an IFR double that of influenza (0.2 percent), approximately 16 lakh Indians will die. A potential mitigating factor in the country could be faster development of herd immunity. Understandably, other local factors such as malnutrition and access to quality healthcare may increase IFR.
To put this in context, over 90 lakh people die each year in India, with 22,500 deaths each day. This includes more than 1.5 lakh dying in road traffic accidents annually. Tuberculosis, a deadlier infection, kills approximately 4.4 lakh Indians each year.
Medical Opinion
According to the Indian Council of Medical Research (ICMR), more than 60 percent of Covid-19 positive individuals in India to date are asymptomatic. In a random sampling of populations in Iceland and Italy, between 40-50 percent of Covid-19 positive individuals were asymptomatic. Such healthy infected individuals would not normally be identified, but would spread infection.
In India, social mixing is unavoidable, especially in the lower socio-economic strata. Therefore, once the Covid-19 virus has entered a community, nearly all members will at some point of time become exposed or infected.
It is improbable that a curative medicine will emerge soon. Influenza, despite being around for a long time, still does not have a curative medicine. A vaccine is likely to be 12 to 24 months away and will be more useful for future seasonal returns of Covid-19 (like winter flu jabs each year).
So, what can a person do to face Covid-19? Perhaps, the body’s natural immune response is the best defence. The public must, therefore, be encouraged to adopt healthier lifestyles. The added long-term benefit of this would be to reduce other lifestyle-related diseases such as heart disease and dementia. Under these circumstances, some pertinent questions can be asked.
- How do lockdowns help? Initially, Covid-19 was thought to be far deadlier than what we know now. The response was to lock down. We now have a better understanding and can recognise that lockdowns are effective only during that period. Once the virus comes in contact with susceptible individuals, it will start to spread again. Unless we can eliminate the virus across all asymptomatic and healthy reservoirs of humans (unlikely) in the local population and prevent any new infected humans from entering India (again unlikely), Covid-19 waves will continue. So, the only reason for a lockdown is to improve health facilities for the minority of people affected who may need additional medical support.
- What are the negative impacts of lockdowns on health? There are huge consequences from the non-Covid costs of lockdowns. These costs include disability and death due to non-Covid diseases such as cancer and heart disease, whose detection and treatment may be delayed during lockdowns. In addition, the mental and physical health of the population may suffer due to loss of livelihoods. The long-term impact on the next generation of children in terms of nutrition, education, skill-acquisition and job opportunities could be substantial. Economic depression could lead to impaired social and health indices, which could take many years to recover.
- What roles do society, media, industry and the government play? First, public education about Covid-19 is vital. Stigmatisation of Covid-19 patients must be stopped with a public awareness campaign and it should be considered as just another infection. Individuals with symptoms must be encouraged to step forward and families and contacts encouraged to adopt self-isolation measures after exposure to a positive case. Harsher measures of forced quarantine in distant facilities must be avoided as this encourages ill individuals to not self-report their illness.
Second, specific sections of society who are more vulnerable to the illness, such as the elderly, those with cancer, serious heart and lung diseases, must be educated about social distancing. This could involve personal measures to reduce unnecessary social interactions and wearing masks until a better treatment strategy emerges.
Third, there must be a coordinated effort between private and public healthcare systems to pool resources, especially intensive care facilities. Private hospitals could provide clean sterile non-Covid-19 facilities for specialist medical care such as heart surgery. Going forward, the partnership forged between government and private healthcare during the pandemic could continue, supported by increased public spending on healthcare.
Improvement in critical care infrastructure during the pandemic could help reduce deaths in future from common diseases such as pneumonia, sepsis and epilepsy. Technological innovations that have existed but not been widely adopted until now such as telemedicine and tele-critical care could be developed via national and regional networks.
Another positive outcome via increased public awareness of personal hygiene may be a decline in other respiratory infections like tuberculosis. Better hand hygiene may reduce diarrheal illnesses, a major cause of distress and death especially in young children.
Fourth, industry and the government need to consider strategies that keep the nation running, whilst at the same time protecting the physically and economically vulnerable. Many European nations have kept vital sections of their economies open during their lockdowns. Besides healthcare, sectors such as food, agriculture, public services and infrastructure projects have continued during this time. This has had the advantage of keeping nations functioning, salaries being paid, as well as companies and workers planning for their post-Covid-19 futures.
From a public health perspective, this has also allowed the younger, less vulnerable workforce to mix slowly at the workplace, perhaps allowing Covid-19 infection to spread over a period. In India, a large section of the workforce is healthy, young individuals in urban areas, living by themselves away from their elders. Resumption of work, with cautions at the workplace, is feasible. This may help develop herd immunity within younger sections of society and subsequently decrease the rate of spread from this younger “herd” to the elderly and other vulnerable groups later.
Therefore, the possible short-term benefits of a lockdown in a developing nation must be balanced against more definite, obvious long-term adverse effects of an economic slowdown, with natural implications on both the physical as well as the financial health of its people.
Legal Outlook
There are many acts such as the Epidemic Diseases Act, 1897, which were used by the government to take special measures for the pandemic. On April 23, the act was further amended, with the incorporation of punishments for individuals obstructing frontline health workers. It has also been clarified that no suit or other legal proceedings shall lie against any person, including healthcare workers, for acting in good faith.
The Disaster Management Act, 2005, also provides for the effective management of disasters and for matters connected therewith or incidental thereto. Additional regulations have also been introduced by various state governments such as the Delhi Epidemic Diseases Covid-19 Regulations, 2020, the Maharashtra Covid-19 Regulations, 2020 and the Kerala Epidemic Ordinance, 2020.
The pandemic has led to changes in the functioning of the judiciary. Advocates now put forth cases via video-conferencing, a first in India. This is likely to continue in the short term. However, this could be a future opportunity as advocates are able to participate in legal proceedings remotely. This addresses some of the imbalances in legal expertise available in some areas of India.
At a time when many countries facing the pandemic are working to get enactments through legally, the UK was the first to pass the Corona Virus Act 2020 that grants emergency powers to handle the pandemic.
The virus has to be fought on all fronts and by all stakeholders before this war can be won.
—Saif Razvi is a neurologist in the UK; Sai Praveen Haranath is a pulmonologist and critical care physician in India and the US; Vikram Ramakrishnan is a surgeon, management consultant and entrepreneur. Inputs were given by KG Krishnaraj and S Shanthakumari, advocates in the Supreme Court. The views and opinions expressed here are personal and don’t reflect the official positions of the organisations the writers work for
Lead picture: UNI