The title picture comes from: Figure Worm Ideas, this article comes from WeChat public account: eight Jian Wen Plus (ID: jianwennews) , author: Lori Yao
Lakshmi (Lakshmi) in Bangalore, a community in Bangalore, the third largest city in India. I felt it for the first time in 30 years. Threat of infectious diseases.
In March, the highest temperature hit a record 34 degrees. Lakshmi saw that the residents in the community were not afraid of the heat and put on a mask. Soon after, she heard from the younger brother who was a handyman in the hospital that infectious virus appeared, and the property company began to distribute masks and provide disinfectant.
She vaguely knows that an outbreak has also occurred in China. There are many Chinese-faced residents in the community. Lakshmi wants to know how widely the virus spreads in China, but the language is inaccessible and communication is impossible.
The epidemic situation is gradually escalating. Many people are starting to work from home. Many residents put more garbage on the door every day. Some people also actively find Lakshmi and let her use disinfectant when cleaning public areas. She works 9 hours a day and wears disposable masks throughout. Unlike most residents in the community, she does not have the option of “home work”.
On March 22, the property gave Lakshmi a vacation. On the same day, a public curfew was implemented throughout India. Railroad and urban transportation were suspended. All stores except pharmacies and essentials were closed. People were required to be separated from their homes between 7 am and 9 pm. The shutdown of the city allowed Bangalore, the fast-growing “Silicon Valley of India,” to spend the quietest Sunday in the past 30 years.
Sunday peace was suddenly broken at 5pm. Residents came to the balcony one after another, applauded, knocked dishes, and some even took outDrums knock. This was the idea of Indian Prime Minister Narendra Modi and proposed that residents pay tribute and cheer to medical staff and others involved in the epidemic prevention work together.
△ Residents applaud on the balcony
On the eve of the curfew, Shiva, who works at a cross-border e-commerce company in Bangalore, (Siva Kumar) returned to his hometown 360 kilometers away. In the third-tier city of Coimbatore, which houses about two million people, (Coimbatore) , he saw a very different picture.
Most people stay at home because the market and the station are closed, but they do n’t seem to understand the reason and significance of this-his neighbors put on new clothes like the holiday, and everyone is at 5 pm People lined up in the yard, applauded rhythmically, then took videos and posted them on social media.
No one has been diagnosed in Coimbatore. But Shiva is concerned that by the time the epidemic spreads to towns and villages, the situation is likely to get out of hand.
On the day of the curfew, 341 cases of new crown pneumonia were confirmed in India. As of press time, this number has increased by a factor of 1.5 (Total 887 confirmed diagnoses, 20 deaths) .
City Parking
As of the afternoon of March 22, a total of 20 confirmed cases were reported in Karnataka, including 14 from Bangalore, the capital. This city of more than 12 million people is on alert.
On the day before the public curfew, traffic on Bangalore Road was significantly reduced.At most only half of the weekdays. Some tutu cars are equipped with big speakers, and the epidemic reminders are broadcast in local languages.
△ Bangalore’s busiest Gandhi Road on weekdays, there are almost no vehicles now
The Kabon government has asked companies to open remote offices, and schools, shopping malls, and movie theaters were closed a week ago. According to the Indian Economic Times, unit orders for Uber and local ride-hailing platform Ola fell by at least 1/3. Gandhi Road, the busiest commercial district, although most of the shops are still open, the gate is deserted. The buses are no longer crowded, and about a third of the passengers wear masks. There are fewer people at the subway exits, and staff also wear masks.
A high-end community in Bangalore with an average price of Rs 200,000 per square meter layer-by-layer defense
The cautiousness of urban residents is largely due to the rapid alarms at the government level.
In the early morning of January 21, Li Yu, who was on a business trip to India for printing (pseudonym) flew from Hong Kong to Bangalore. It took her three hours to get out of the airport. As soon as the plane was off, airport staff required passengers from mainland China and the Hong Kong Special Administrative Region to fill out health information forms and take their temperature one by one. Li Yu was a little surprised. She didn’t feel the severity of the epidemic in Beijing. Two days after Bangalore, Wuhan suddenly closed the city.
On January 23, Wuhan announced that in the early hours of the closure of the city, 30 or 40 Indian students studying medicine at Wuhan University decided to return to India immediately. A girl arrived in Kunming by high-speed rail, flew to India the next morning, and turned back to her hometown in Kerala. Six days later, she went to the regional hospital for fever and other symptoms, and was diagnosed as the first patient with new coronary pneumonia in India-at this time ten days have passed since India pulled the first cordon.
The next two days, two of her classmates were also diagnosed one after another. All three came from Kerala.
The emergence of confirmed cases triggered a second line of defense. On January 31, the Indian government announced a ban on the export of masks, gloves and other medical protective equipment in order to avoid shortages in the country; on February 2, the Indian government announced that all Chinese passport holders and foreigners who have been to China within the past 14 days Its electronic visa was temporarily invalidated, and soon all paper visas for non-public passports were also suspended, and the India-China border was closed.
Now it looks like the move has paid off. On February 1, the epidemic had spread to 26 countries and regions around the world and gradually spread to Europe and the United States. India did not find any new cases in February, and all three previously diagnosed patients were cured and discharged.
But India’s risks are far from being lifted. Since March, the threat of the epidemic has approached from other directions. At this point, Italy, Iran, and South Korea had more than a thousand confirmed cases, while India has closer ties with Europe, the Middle East, and Japan and South Korea than China in terms of labor and commerce-the big test has just begun.
On March 2, India announced two new confirmed cases. One was a resident of Delhi who had visited Italy; the other returned from Dubai and was confirmed in Telangana. The next day, another Italian tourist was diagnosed in the tourist city of Agra, where the Taj Mahal is located. immediately,India has drawn a third line of defense and has suspended visas for Italian, Iranian, South Korean and Japanese passport holders.
In the following week, 12 states in India saw confirmed cases, with a total of 60 cases, all of which were imported from abroad. Of these, 17 cases were diagnosed in Kerala, which is the country most closely connected with the rest of the country. In the tour group where the Italian tourists were diagnosed earlier, another 14 were confirmed.
On March 11th, the Indian government set up its last foreign defense line—suspending all short-term visas for tourism, business and other foreign passports before April 15th, with the exception of those holding long-term work visas and staff of international organizations. This will also treat overseas Indian citizens equally, including local residents, and all people entering from abroad will be quarantined for 14 days.
Non-profit public health research organization CDDEP (Center for Disease Dynamics, Economy, and Policy) Qiao Xi, head of South Asia (Jyoti Joshi) believes that this rapid and proactive response stems from the judgment of the Indian government on the status of the country and the medical system, and also based on its previous experience in dealing with epidemics.
In 2018, the Nipah virus broke out in Kerala. Through rapid control, 17 people died.
“ In general, India’s health care system is relatively fragile. Most people live in a very crowded environment, especially in urban slums and rural areas where social isolation is not feasible. ” Dr. Qiao Xi He said that what the Indian government can do is suspend visas, quickly cut off overseas epidemic imports, control domestic personnel movements, and strictly track contacts of confirmed cases.
As the number of confirmed diagnoses rises, the Indian government has announced that all commercial international flights have been suspended for one week since March 22.
Chen Zhaofeng, the head of a Chinese-funded institution in India, caught the last train to India. He has been trapped in the country after the Spring Festival. In the early morning of March 22, Chen Zhaofeng successfully entered from Chennai, and the back of his hand was stamped with the seal of home isolation.
His luck is based on adequate preparation. On March 5, he flew from China to Cambodia, where the epidemic was not serious at that time. After 14 days of isolation, he had a nucleic acid test in Cambodia, obtained a health certificate, and prepared a health certificate issued by China. The work visa holder of the Chinese passport has been released. After a few twists and turns, the customs clearance was successful.
Fears of virus detection
At the same time as “locking the country”, India’s epidemic prevention focus has returned to the country, and the blockade policies of various governments have begun to increase.
In India, as a federal state, the operation of the medical system and the management of public facilities are mainly led by the state government. On top of the “prescribed actions” of the central government, each state government has a greater scope for “optional actions” and its epidemic prevention policies The implementation level and the provision of medical resources in the later period also depend on the states.
Since March 14, the Kabon government has requested that all schools, shopping malls, cinemas and other public places be closed. Since then, the state’s blockade policy has been increased by almost a day: states require companies to work remotely, Maharashtra suspends intercity trains, Delhi requires restaurants to close, Rajasthan bans public gatherings, Kabang public transport Limiting the number of people … These restrictive measures were quickly pushed to the whole country by the central government.
Behind the layering of prevention and control measures, there is an epidemic situation in which states cannot be directly reflected by numbers, but are escalating rapidly.
Maharashtra, where Mumbai is located, is the state with the most confirmed new crowns in India. Initially, the vast majority of its cases came from a tour group returning from Dubai, and since March 14, more than 10 new cases have started.
Signs of local community transmission have long begun to appear. As of March 20, according to media statistics, of the 63 confirmed cases reported in Maharashtra, 12 to 14 had no history of foreign travel, and no local confirmed cases were tracked. A woman from Pune (Second largest city in Mapang) has no history of traveling abroad, but went to Mumbai to participate before being diagnosed A wedding.
Similar cases have been reported in other states. A 20-year-old man also had no history of traveling abroad. He arrived in Chennai by train from Delhi on March 12 and was diagnosed 6 days later. This is the first case announced by a state government without a history of foreign travel.
Although India ’s Federal Minister of Health Vardan (Harsh Vardhan) insisted at the March 20 press conference that there was no community transmission in India In the case of (based on the 826 samples randomly collected in all places were negative) . butIn the early morning of the next day, the Indian Medical Research Council (ICMR) , affiliated to the Ministry of Health, issued a notice to amend the new coronary pneumonia test standards, all of which appeared severe Patients with respiratory illnesses, dyspnea, and fever and cough symptoms will be tested. In addition to 52 public laboratories, 60 private laboratories are also authorized for testing.
Previously, the Indian government authorized only public laboratories to test people with a history of foreign travel or contact with confirmed cases. As of March 20, only 13,500 people had been tested. Before the standard was revised, there were 270 confirmed cases in India.
Dr. Josh is worried that because of the low detection rate and fewer confirmed cases in India, some people may still not be treated with caution, increasing the risk of community transmission. In Indian media reports, although some cases were voluntarily quarantined after returning from overseas, many patients concealed their whereabouts after returning home, and even participated in weddings, parties, and public transportation.
The change in detection standards is considered to be the acquiescence of the Indian government’s community.
Ganga Ram Hospital, India Private Hospital (New Delhi) Kurmar, Chairman, Thoracic Surgery Center (Arvind Kumar) In an interview with the Economic Times on March 22, it was said that now is the golden window for the government and the public to control the epidemic.
Kumar emphasizes that detection is the most important part at this time. “We should assume that a lot of people are already infected, there will definitely be a large-scale outbreak one day, and then go to test in large quantities now.”
However, India ’s overall virus detection capacity remains a bottleneck. Take Mapang, with a population of nearly 120 million and the largest number of confirmed cases, as an example. Counting the three approved private laboratories, the testing capacity has increased from only 100 to 600 per day, plus all private laboratories being approved. , The daily detection capacity can only reach 2200.
States with fewer reported cases have even more concerns about their detection capabilities. Seven laboratories in Northeast India, with a population of 45 million, have three laboratories, and no confirmed cases have been reported as of March 22. Bihar, with a population of nearly 100 million, has only one laboratory. (The state reported the first confirmed case and the first death on March 22) .
On March 23, the first Indian test kit developed by Mylab Discovery Solutions, a molecular diagnostics company in Pune, was approved, and India’s detection capacity is expected to gradually increase.
Prevention and stratification crisis
Dr. Josh said that the first wave of the epidemic has hit metropolises that are closely connected with foreign countries and spread to first-tier cities. So far, government-designated hospitals and laboratories are concentrated here. As the community spreads, the epidemic will soon reach slums and villages in small cities, and the situation will be very pessimistic.
India’s public health system is divided into three levels. From bottom to top, they are CHC (Rural Community Clinic) , PHC ( Primary Medical Center) and regional hospitals, public health care is free of charge and mainly provides basic health care for low-income people in rural and urban areas, while the private health care system accounts for the bulk of the total.
Dr. Josh also pointed out that with the urbanization and immigration wave, the medical system and accessibility in the suburbs of the city have become more chaotic.
The first death in Kabang is a wake-up call for epidemic loopholes in rural India.
The patient is a 76-year-old male who went to Saudi Arabia at the end of January and returned to India on February 29. On March 6, he developed cough and fever, and a family doctor went to treat him. After his condition worsened on March 9, he was taken to a local private hospital and was diagnosed with suspected neo-coronary pneumonia. The hospital collected medical samples for him for examination.
According to the official disclosure, the patient did not wait for the test results, but went to another private hospital 230 kilometers away by himself. Late at night on March 10, the patient died on the way home. Two days later, the government announced that his test results were positive.
Five days later, the family doctor who treated him was also diagnosed.
The deceased patient did not choose to be treated in public hospitals, but torn between private hospitals. One important reason is that free public hospitals often mean low quality services. According to media reports, Suspected cases were observed in public hospitals in isolation, and there was no lack of simple conditions.Ugly and unauthorized.
Private hospitals also have problems. According to Indian media Scroll.in, in the central state of Chhattisgarh, patients were suspected of being “forced to be evicted” by doctors in private hospitals, while the hospital claimed that patients were “forced to leave the hospital without following their doctor’s orders.” On March 21, the Federal Ministry of Health requested that all hospitals must not reject suspected patients. However, in the case of temporary absence of treatment training, protective supplies and insurance payment mechanisms, the implementation will be questioned.
Dr. Qiao Xi introduced that symptomatic suspected cases of new crown may appear in any designated hospital, and those who need inpatient treatment will enter PHC and regional hospitals. ICU equipment is needed to diagnose critically ill patients, which are usually treated by regional hospitals. “But ICU beds and ventilators in regional hospitals are also very limited, and they will be filled quickly without expansion, because they also have other patients.” She said that the general number of beds in regional hospitals is between 100 and 200. between.
Josh further pointed out that the biggest risk in rural areas and suburban slums is that due to the limitations of testing standards and laboratory distribution, regional hospitals in these areas do not have testing equipment and need to be sent to laboratories in other large cities for testing. Private laboratories are approved to further supplement testing capabilities; and these regional hospitals have limited patient transport and medical staff protective equipment. With the emergence of new crown cases in rural areas, these hospitals may not be able to diagnose suspected patients and further As a result, the epidemic has spread.
And in rural areas, large-scale blockades are an impossible task. Taking Kabon’s patient number 15 as an example, after returning from Dubai, he was tested positive for neocoronavirus in the (Kodagu) area in Kudugu. Before the diagnosis, he took a bus back to his hometown, which eventually led to the entire village being blocked. The local government used 15 police officers to guard the blockade, which contained 325 families. If the epidemic spreads further, such a blockade will be difficult to replicate.
△ Indian media reported that police used baton to drive away citizens without masks.
Taking into account these risks and worrying about the safety of parents and family members, Shiva mentioned in the article first ventured to return to his hometown from Bangalore with better medical conditions. He brought a pile of masks, disinfectant and hand sanitizer, but more importantly he wanted to persuade his family to strengthen their protection.
While educating his family, he also gathered children from the neighborhood to try to use them to indirectly persuade people not to go out. Most people’s indifferent attitude made him very worried, and he foresaw that if someone was admitted to the hospital, people would probably run out of curiosity to visit the patient.
“Probably a small number of people who are educated are more cautious, but there are still a lot of people who don’t care at all and feel that they are resistant and will be fine.” Shiva said. Although the government requires non-necessary stores not to open doors, many shop owners have resumed operations after the police left. He saw in the market that there was no relative reduction in the flow of people, and only a few people wore cotton masks.
△ In Chiva’s hometown, the second day of the curfew is normal again
“ Many people are daily paid workers such as drivers and domestic helpers. They do n’t earn a day if they do n’t work. ” In India, the proportion of informal employment in rural and rural areas is high Daily wage workers cannot be isolated at home for long periods of time.
On March 24th, the local government announced a one-time distribution of April’s sugar, rice and other rations, and a relief of 1,000 rupees per person. On this day, many of Shiva’s neighbors flocked to the government store again to receive rations and cash.
How to fill the medical gap?
Ramanan, founder and director of CDDEP and lecturer at Princeton University (Ramanan Laxminarayan) said that in the worst case, 60% of the population in India will be infected with the new crown virus. He believes that the figures released by the Indian government are inconsistent with the current situation, and an estimated at least 1,500 cases have not been detected.
The forecast given by the CDDEP is that without human intervention, the peak of the Indian epidemic will come between April and May 20, and 100 million people will be infected. By July, 300 to 400 million people will be infected.
The mathematical model adopted by the center is IndiaSIM (Simulated for Indian Population) , based on the dynamic real population of India, It includes factors such as population distribution, age, gender, socio-economic characteristics, and access to health care. The model also uses data available in Italy and China. Key indicators are infectivity, age- and sex-specific infection rates, severe infection rates, and mortality.
According to CDDEP’s calculations, about 10 million patients will be more severe during the peak period, and 2 to 4 million of them will need hospitalization. According to this model, the current capacity of ICU and ventilator beds in India is only marginal.
CDDEP estimates that there are currently 30,000 to 50,000 ventilators in India, and ICU beds are about 70,000 to 100,000. At the peak of the epidemic, India will need 700,000 or even 1 million ventilators. The CDDEP said in its report that the government has not released accurate figures, but it is likely that the size of beds will need to be increased immediately. Second, tracheostomy and low-cost ventilators can be used as alternatives.
According to the Indian media The Print estimates, India currently has only 0.5 beds per 1,000 people, and hospital beds will be full by the end of April.
In Dr. Josh ’s opinion, given the varying health systems in each state, India needs the central government to coordinate with the state governments to fight the epidemic. For example, in several northern India’s most populous states, the overall economy is backward and medical conditions are worse. If there is a shortage of medical resources in the state, the central government needs to do more than just deploy medical staff from other states. It is more important to quickly set up designated hospitals. And provide the required medical equipment.
Although some state governments have proposed that each hospital must establish an isolation zone, CDDEP believes that the level of infection control in conventional hospitals, including urban areas, is relatively low, and cross-infection among patients The risk is high. Therefore, in the next three months,The construction of large-scale temporary hospitals should be taken into account, and home treatment should also be considered, otherwise the spread in the hospital will accelerate the spread of the epidemic.
CDDEP also emphasizes that medical staff must be equipped with adequate protective equipment such as masks, protective clothing, etc. Otherwise, infection by medical staff will increase the overall mortality rate.
“In India, the best situation is to take time for the expansion of medical resources through social isolation, urban blockades and other measures to cope with the large number of inpatient cases that are likely to occur thereafter.” Dr. Josh said.
But the crisis is here. Although the Indian government quickly banned the export of related equipment after the outbreak in China, and began to seek import channels for equipment such as ventilators after the outbreak in the country, media reports have increasingly worried about the shortage of medical equipment for Indian medical personnel.
When Modi applauded medical staff, medical staff continued to speak on social media, saying that they needed protective equipment, not just applause. According to the Times of India, since mid-February, relevant Indian manufacturers have asked the Ministry of Health for specifications on medical protection products, but have not received a response, so production cannot be carried out.
As the epidemic has spread, already inadequate medical staff have begun to become infected.
According to data from the Indian Ministry of Health in July 2019, there are 1.157 million registered doctors in India, with a doctor-patient ratio of 1 to 1457, which is lower than the World Health Organization’s 1 to 1,000 standard. According to incomplete statistics reported by the media, more than 10 doctors in India have been tested positive for new coronavirus, of which 6 were confirmed in a hospital in Rajasthan.
This article is from WeChat public account: 八点 健 闻 Plus (ID: jianwennews) , author: Lori Yao, editor: Liu Ran