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      Healthcare impact of COVID-19 epidemic in India: A stochastic mathematical model

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          Abstract

          Background

          In India, the SARS-CoV2 COVID-19 epidemic has grown to 1,251 cases and 32 deaths as on 30 Mar 2020. The healthcare impact of the epidemic in India was studied with a stochastic mathematical model.

          Methods

          A compartmental SEIR model was developed, in which the flow of individuals through compartments is modeled using a set of differential equations. Different scenarios were modeled with 1000 runs of Monte Carlo simulation each using MATLAB. Hospitalization, ICU requirements and deaths were modeled on SimVoi software. The impact of Non-Pharmacological Interventions (NPI) including social distancing and lockdown on checking the epidemic was estimated.

          Results

          Uninterrupted epidemic in India would have resulted in over 364 million cases and 1.56 million deaths with peak by mid-July. As per the model, at growth rate of 1.15, India is likely to reach approximately 3 million cases by 25 May, implying 125,455 (±18,034) hospitalizations, 26,130 (±3,298) ICU admissions and 13,447 (±1,819) deaths. This would overwhelm India’s healthcare system. The model shows that with immediate institution of NPIs, the epidemic might still be checked by mid-April 2020. It would then result in 241,974 (±33,735) total infections, 10,214 (±1,649) hospitalizations, 2,121 (±334) ICU admissions and 1,081(±169) deaths.

          Conclusion

          At current growth rate of epidemic, India’s healthcare resources will be overwhelmed by end-May. With the immediate institution of NPIs, total cases, hospitalizations, ICU requirements and deaths can be reduced by almost 90%.

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          Most cited references9

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          SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients

          To the Editor: The 2019 novel coronavirus (SARS-CoV-2) epidemic, which was first reported in December 2019 in Wuhan, China, and has been declared a public health emergency of international concern by the World Health Organization, may progress to a pandemic associated with substantial morbidity and mortality. SARS-CoV-2 is genetically related to SARS-CoV, which caused a global epidemic with 8096 confirmed cases in more than 25 countries in 2002–2003. 1 The epidemic of SARS-CoV was successfully contained through public health interventions, including case detection and isolation. Transmission of SARS-CoV occurred mainly after days of illness 2 and was associated with modest viral loads in the respiratory tract early in the illness, with viral loads peaking approximately 10 days after symptom onset. 3 We monitored SARS-CoV-2 viral loads in upper respiratory specimens obtained from 18 patients (9 men and 9 women; median age, 59 years; range, 26 to 76) in Zhuhai, Guangdong, China, including 4 patients with secondary infections (1 of whom never had symptoms) within two family clusters (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). The patient who never had symptoms was a close contact of a patient with a known case and was therefore monitored. A total of 72 nasal swabs (sampled from the mid-turbinate and nasopharynx) (Figure 1A) and 72 throat swabs (Figure 1B) were analyzed, with 1 to 9 sequential samples obtained from each patient. Polyester flock swabs were used for all the patients. From January 7 through January 26, 2020, a total of 14 patients who had recently returned from Wuhan and had fever (≥37.3°C) received a diagnosis of Covid-19 (the illness caused by SARS-CoV-2) by means of reverse-transcriptase–polymerase-chain-reaction assay with primers and probes targeting the N and Orf1b genes of SARS-CoV-2; the assay was developed by the Chinese Center for Disease Control and Prevention. Samples were tested at the Guangdong Provincial Center for Disease Control and Prevention. Thirteen of 14 patients with imported cases had evidence of pneumonia on computed tomography (CT). None of them had visited the Huanan Seafood Wholesale Market in Wuhan within 14 days before symptom onset. Patients E, I, and P required admission to intensive care units, whereas the others had mild-to-moderate illness. Secondary infections were detected in close contacts of Patients E, I, and P. Patient E worked in Wuhan and visited his wife (Patient L), mother (Patient D), and a friend (Patient Z) in Zhuhai on January 17. Symptoms developed in Patients L and D on January 20 and January 22, respectively, with viral RNA detected in their nasal and throat swabs soon after symptom onset. Patient Z reported no clinical symptoms, but his nasal swabs (cycle threshold [Ct] values, 22 to 28) and throat swabs (Ct values, 30 to 32) tested positive on days 7, 10, and 11 after contact. A CT scan of Patient Z that was obtained on February 6 was unremarkable. Patients I and P lived in Wuhan and visited their daughter (Patient H) in Zhuhai on January 11 when their symptoms first developed. Fever developed in Patient H on January 17, with viral RNA detected in nasal and throat swabs on day 1 after symptom onset. We analyzed the viral load in nasal and throat swabs obtained from the 17 symptomatic patients in relation to day of onset of any symptoms (Figure 1C). Higher viral loads (inversely related to Ct value) were detected soon after symptom onset, with higher viral loads detected in the nose than in the throat. Our analysis suggests that the viral nucleic acid shedding pattern of patients infected with SARS-CoV-2 resembles that of patients with influenza 4 and appears different from that seen in patients infected with SARS-CoV. 3 The viral load that was detected in the asymptomatic patient was similar to that in the symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients. These findings are in concordance with reports that transmission may occur early in the course of infection 5 and suggest that case detection and isolation may require strategies different from those required for the control of SARS-CoV. How SARS-CoV-2 viral load correlates with culturable virus needs to be determined. Identification of patients with few or no symptoms and with modest levels of detectable viral RNA in the oropharynx for at least 5 days suggests that we need better data to determine transmission dynamics and inform our screening practices.
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            Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China

            To identify the epidemiological characteristics and transmission patterns of pediatric patients with the 2019 novel coronavirus disease (COVID-19) in China.
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              Is Open Access

              Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020

              On 5 February 2020, in Yokohama, Japan, a cruise ship hosting 3,711 people underwent a 2-week quarantine after a former passenger was found with COVID-19 post-disembarking. As at 20 February, 634 persons on board tested positive for the causative virus. We conducted statistical modelling to derive the delay-adjusted asymptomatic proportion of infections, along with the infections’ timeline. The estimated asymptomatic proportion was 17.9% (95% credible interval (CrI): 15.5–20.2%). Most infections occurred before the quarantine start.
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                Author and article information

                Contributors
                Role: Professor & Head
                Role: Associate Professor
                Role: Professor & Head
                Journal
                Med J Armed Forces India
                Med J Armed Forces India
                Medical Journal, Armed Forces India
                Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd.
                0377-1237
                2213-4743
                2 April 2020
                2 April 2020
                :
                Affiliations
                [a ]Medical Informatics, INHS Asvini, Colaba, Mumbai, India
                [b ]Dept of Psychiatry, Armed Forces Medical College, Pune 411040, India
                [c ]Dept of Community Medicine, Armed Forces Medical College, Pune 411040, India
                [d ]Dept of Internal Medicine, Armed Forces Medical College, Pune 411040, India
                Author notes
                [] Corresponding author. shankarsid@ 123456gmail.com
                Article
                S0377-1237(20)30060-5
                10.1016/j.mjafi.2020.03.022
                7126697
                32292232
                0d3b788e-562f-4e72-a353-4951972b8814
                © 2020 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 23 March 2020
                : 31 March 2020
                : 31 March 2020
                Categories
                Article

                covid-19,models,theoretical,quarantine,coronavirus,sars-cov2,epidemiology

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