Wednesday, April 1, 2020

COVID-19 Community Spread: Failure Modes, Potential Effects, Occurrence, Detection and Control

As all of you know we are at the doorstep of a life-threatening challenge. Yes, I am talking about the community spread of CORONA virus or COVID-19 in India, the challenge becomes more critical because we know the cause but still don't know how to eliminate that cause. As of now, no vaccine is ready to kill the coronavirus, research is going on across the world by the medical scientists and doctors.
Many countries across the world are already entered into this stage and trying to control the mortality rate, the average mortality rate across the world is 4.5%.  Hope is there, but it'll take at least one-year and before that, we have to break the transmission of COVID-19 as early as possible so that it couldn't outbreak in India.
I don't know.. what would be the number... if it outbreaks..because till the date 979 confirmed cases of COVID-19 and 25 deaths have been confirmed and what could be the actual number of infected people in 1.4 billion population in that situation...don't know... but definitely it would be an alarming figure.
The only matter of some relief is that 87 cases recovered successfully from this dangerous disease because of extraordinary efforts by the medical and paramedical staff in this tough time, I salute them from my bottom of heart. So we are at the threshold of an outbreak of COVID-19, but before we move on and study the risk of community spread using FMEA we have to understand, how we have arrived at this stage!

The Beginning

At the first stage, there was not a single case in India the only threat was infected cases in affected countries like China, Italy, Iran, etc. etc. At the second stage, there were isolated imported cases in India, these cases couldn't come into detection in thermal scanning and symptomatic testing because the symptoms of COVID-19 appear in 2 to 14 days after exposure. Therefore, imported cases were advised by the authorities for self-isolation in their homes for 14 days but the infection has passed on to isolated people, isolated places, and isolated items from the imported infected cases. And after that we entered into the third stage, the isolated infected cases are being reported from all parts of India with a few death cases. here we are at the doorstep of community spread and therefore I thought to use FMEA to study the risk of community spread and its subsequent effects as a real-life case study.
Now if you want to know what is an FMEA and how to use an FMEA for risk analysis then please click here

Failure Modes and Potential Effects (Severity) of Community Spread of COVID-19

In this case, the failure is community spread and the modes of community spread are imported cases, local infected cases, infected items and isolated infected places in different parts of India and if we talk about the potential effects of the community spread then the effects will be deadly, the infected cases will increase at an exponential rate and so the mortality rate, like in Italy even after that availability of best medical facilities the current mortality rate is about 10% with 8165 death cases out of 80,539 infected cases but here in India the medical facilities are limited against 1.4 billion population and because of that the mortality rate could go higher than 10% and will become out of control and as a subsequent effect. The GDP growth rate dipped to less than 2% with the shattering world economy, so I ranked the severity of the community spread as 10.

Causes/Mechanism (Chances of Occurrence) of Community Spread of COVID-19

Now let's talk about the occurrence of infection in case of community spread of COVID-19. As we know that coronavirus transmits from an infected person to healthy person through water droplets while sneezing coughing and kissing, it also transmits through handshaking and hugging with the infected person and also through an infected item or surface when used or touched by the healthy person, because it stays alive on the surfaces for a few hours to 9 days depending on the surface. Therefore there are very high chances of occurrence of infection in case of community spread which means on every 3 test cases one will be an infected case this implies about 33% population will be infected from COVID-19 which is an alarming figure. Therefore here I rank the occurrence of infection in case of community spread as 9.

Detection Controls (Ability of Detection of Infected Cases) of Community Spread of COVID-19

Now we discuss the detection, right now the current controls for detection of the actual number of infected cases are;
  • Thermal scanning and symptomatic testing of the suspected cases.
  • Isolation and quarantine of imported cases, 
  • Isolation, and quarantine of confirmed cases of COVID-19,
  • Tracking the 14 days history of the confirmed cases
But the biggest problem is, the symptoms appear in 2-14 days in an infected case after the exposure with COVID-19….And therefore till the symptoms will appear, an infected case would have transmitted the infection to 3 other healthy persons unknowingly. And this creates the gap between the number of confirmed cases of COVID-19 and the actual number of infected cases of COVID-19. Hence the chances of detection of the actual number of infected cases are very low with current detection controls. And Therefore I ranked the detection of infected cases with current controls as 7, Now the resultant value of RPN, means risk priority number for community spread will be 630.
It implies the risk of community spread is very high in the context of India. Now before the current situation outbreaks and turned into community spread, it's an urgent requirement to break the transmission chain of COVID-19. And for that, there must be a proper action plan including containment actions, corrective actions, and preventive actions.

Containment Actions, Corrective Actions, and Preventive Actions

Right now the govt. announced nationwide lockdown for 21 days and asking people to remain in their homes and follow the social distancing.
  • All international and domestic flights, rail and road transportation will remain canceled during the lockdown period. 
  • All imported cases are in isolation and quarantined in their homes, close surveillance imposed on them. 
  • All confirmed cases are also in isolation and quarantined for medical treatment. Thermal scanning and symptomatic testing are used if a person reports symptoms like fever, dry cough, and breathing problems.
All these actions are considered as the containment actions that possibly hold the number of infected cases for the given period of time. But according to the director-general of WHO,  Dr. Tedros Adhanom Ghebreyesus, “Social distancing and asking people to stay at home are the defensive measures, that will not help us to win…to win we need to attack the virus with aggressive and targeted tactics, tested every suspected case…isolating and caring for every confirmed case, and tracing and quarantining every close contact.”
Now some of the infected cases recovered successfully because of isolation and proper medical care, therefore these cases are considered as a correction. So to increase the number of recovered cases, the first and foremost requirement is to build a large number of hospitals with a good capacity of beds, ventilators, doctors, medical and paramedical staff. The biggest problem is the detection failure of the infected cases and the root cause of this problem is, the symptoms appear in 2-14 days after the exposure.

The Need of the Hour

Therefore the need for the hour is the formation of the task forces at the district level for asymptomatic testing at a large level and provide the medical care to the infected cases to kill the virus aggressively so that infected cases could turn into recovered cases. Like Germany tested 300,000  to 500,000 cases per week and recovered most of the infected cases caring for them in isolation, and control the mortality rate effectively at 0.6%.
The govt. of India along with all state govt. is doing well to control things as much as possible.
  • Providing personal protective equipment (PPE) like masks, medical suits, gloves, testing kits to the doctors, medical and paramedical staff. 
  • Using the train coaches for medical care for COVID-19 infected cases is the ultimate example of resource utilization. 
  • Apart from this sanitizing the cities, villages, malls, cinema halls, railway stations, bus stand, airports, seaports, religious places, apartments, community halls, hotels, marriage halls, markets, and other public gathering places.

Stop Community Spread of COVID-19

The center and all state govt. are continuously providing the advisory to aware the people how to stop the community spread, through print, electronic and social media such as;
  • Stay at home during the lockdown and practice social distancing
  • wash hands with soap for 20 seconds frequently or use an alcohol-based sanitizer
  • Avoid touching your mouth, nose, and eyes,
  • Use your elbow to cover the mouth while sneezing and coughing
Apart from this all state govt. are tracing and isolating the imported cases as early as possible before they transmit COVID-19 to others. Providing medical help to the suspected cases in case of fever, dry cough, and breathing problem, and test for COVID-19.

Conclusion

I have a firm belief that following these actions with public support the mortality rate will remain in control and further reduced to 0. And this will turn the ranking of severity from 10 to 1. And also it will reduce the infected cases out of test cases possibly to 5% and it will turn the occurrence ranking from 9 to 7 and then 1. It also improves the detection ability which is the main problem, with asymptomatic testing to a large number of people per week as early as possible. And so the chances of detection of infected cases improve from low to very high and turn the detection ranking from 7 to 2 and then 1.
Hence by early detection of the infected cases and controlling them less than 5% and recovered them with proper medical care and hence control the mortality rate as low as possible and possibly make it zero, we will definitely win the situation of community spread.


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