Viability of smart lock-down strategies

Daily: Daily Times [Blog]
Date: 25.04.20

[Alternatively:
The Pulse]
(Under a pseudonym: Dr Amjad Mehmood)

COVID-19 is a strain of Severe Acute Respiratory Syndrome-Corona Virus (SARS-COV)
called SARS-COV-2 that came to human knowledge in 2019, hence the title COVID-19. The
virus is both contagious and virulent, and hence is the focus of attention for preventing its
spread by an active intervention.

As a preventive measure, Pakistan introduced a complete lockdown in mid-March and now,
on April 24, Pakistan is planning to convert the complete lockdown into a smart lockdown on
the patterns practiced by western countries. The smart lockdown means closing selectively
the areas experiencing an outbreak.

For a smart lockdown, there are two justifications: first, the number of deaths are short of
the projected ones; and second, a complete lockdown cannot stop the virus from
spreading, as it is impossible to predict for how long the virus would persist, and this is why
people will have to learn to live with the virus. The purpose of a smart lock down is to
provide relief to the labour class and the lower strata of society to survive economically
along with fending off the virus.

This article will address the viability of smart lockdown strategies, a single-stage or a multi-
stage, as preventive measures.

COVID-19 with an oddity                                          

The direct spread of virus is through an airborne route by cough and sneeze whereas the
indirect spread is through touch. The virus is virulent because it harms the respiratory
system of a patient. Related to virus, there is now sufficient information available.

Chinese scientists have performed its genetic sequencing and found an S-Protein on its
surface offering the virus the dreadful virulence. The S-Protein lets the virus enters the
respiratory cells uninhibited even before the immune system notices the virus. It takes two
or three days to appear the symptoms, frequent sneezing or persistent coughing.
Nevertheless, COVID-19 shares about 85 percent of its genetic material with the SARS
virus that gave an outbreak of epidemic proportion in China in 2002-2003, after being
transferred from animals to humans, and China dealt with it by using the mode of lockdown.
COVID-19 has also Chinese origin and it mutates slowly, but it has attained a pandemic
proportion affecting most countries of the world. Dry weather with low humidity and bright
sunshine quickly kill both kinds of viruses and significantly reduce their contagious
character, but not their virulence. The general behavior of COVID-19, in terms of
epidemiology and pathology, is similar to that of SARS virus and this is why China used the
mode of lockdown once again in 2019-2020 to contain the spread of COVID-19.

Unnerving the West

Western countries had not experienced the SARS virus and this is why they are in trouble.
COVID-19 found Europe unprepared. Against the background of under-preparedness of
Europeans, two factors hastened the spread of virus. First, the canal water irrigation
system passing through cities adding more humidity to already damp weather of European
cities. Second, the recycled air of centrally air-conditioned buildings, offices, shopping malls
and recreation points such as theatres, cinemas, pubs, etc., accelerated the transfer of
virus from one person to another, whether they were sitting near or far. Both the virus-
injecting factories dispatched COVID-19 infected patients to hospitals en masse. Almost
same was the case with the United States. A sudden numerical surge in patients unnerved
health authorities and unleashed panic in western societies.

In Europe, the main spread of virus was from Western Europe towards Central and Eastern
Europe and this was the reason the Germans were more prepared than the Spanish,
French and Italians were. The same was the benefit for the United Kingdom to get ready
before the blight took over its citizens. Similarly, learning from the Chinese experience,
South East Asian countries were better prepared to conserve themselves. Europe opted for
prevention. Consequently, the lockdown in European countries sequestered people from
both types of COVID-19 injecting factories. Promising results are surfacing now.

Beast is understood

In March 2020, when the first COVID-19 infected patient reported officially in Pakistan, the
country was luckily shorn of both the aforementioned virus-injecting factories. This is why
Pakistan’s situation is mild from what is happening in Europe or in the United States, and
this is why the computer models predicting the spread and virulence of COVID-19 in
European countries are unsuccessful in foretelling the epidemiological trends in Pakistani
society. That is, the beast is understood, but Pakistan has been erroneously banking upon
the computer models functional in Europe and the United States for the projection of the
disease. Certainly, blind following is misleading for both the public and the government.

Single-stage game vs multi-stage game

A lockdown is effective in a single-stage game. That is true also for COVID-19, which is
dismissive of a multi-stage game, especially when the case is Pakistan. In the context of
Pakistan, in April, weather has opened satisfactorily with bright sunshine and low humidity
influencing the regions at least from South to northern Punjab, though occasional showers
are breaching the Sun’s heat.

A healthy human body develops a full immune response against a virus from fifth to
seventh day. An under-nutrition human body may develop a full immune response by
fourteenth day. Convalescence may take from one to two weeks. The duration of the
immune response simply means that a single-stage uninterrupted lockdown of three weeks
is enough to do two things. First, to isolate COVID-19 infected patients from the healthy
population and permitting the patients to either recover from the disease on their own or
get reported to a hospital for advanced care and management. Second, to let any latent
COVID-19 patient surface from apparently healthy population to grab medical attention. To
encourage latent (carrier) cases to get reported, the lockdown can be extended for another
week. This type of lockdown will help classify population into three types: healthy, semi-
healthy (or carriers), and diseased.

The major challenge a multi-stage lockdown throws is that the carriers (or latent,
asymptomatic patients) would stay hidden and would keep on spreading viruses in their
given social clusters to exhaust the nerves of the administration engaged in lockdowns. The
assumption guiding the multi-stage lockdown is that COVID-19 offers multiple peaks and
troughs. It is as if the virus took some rest after getting active for some time. This is not the
case. Assuming that virus offers frequent peaks and troughs is an incorrect assessment or
interpretation. COVID-19 like other respiratory viruses spreads in a conducive environment.
Where the environment is suitable, the graph representing infected patients scales up with
an unlimited peak, as the virus is not self-effacing after reaching a certain point. Similarly,
where the environment is unsuitable, the graph scales down to hit zero. This is how China
got Wuhan eliminated of COVID-19, though an occasional reporting of latent patients still
exists.

A strict lockdown will show a downward trend in the infection rate. That is true, but to
convert it into a multi-stage lockdown just because people will relax, infection will rise and
the cycle will begin again is not a cogent refuge. If people are fed up with the lockdown to
let the infection rate rise, it means that the lockdown is not strict: it is slack, defeating the
rationale for a lockdown. In Lahore, for instance, during the given lockdown, on 4 April
2020, the reported cases were around 120; after one week, on April 11, the reported cases
reduced to around 40; and after another week, on April 18, the reported cases further
reduced to around 17. On 19 April 2020, in Lahore, only two new COVID-19 infected
patients were reported. Owing to relaxing the lockdown, on 22 April 2020, in Lahore, the
figure jumped to 40 new patients and on April 24, the number of new cases has arisen to
54. It means that a single-stage lockdown had yielded desired fruits, and relaxing the
lockdown has been taking its toll.

In principle, the single-stage lockdown should continue to see the zero number of reported
cases attained. The ground-zero must be sustained for two weeks, assuming that not all
patients of COVID-19 are having strong immune systems to get rid of the virus within one
week. On the ground, the forthcoming major challenge is the socializing trend or obligation
the month of Ramadan brings along with it.

Even incidence of disease

A nationwide lockdown assumes that the nature and level of disease is uniform across the
country. That is a correct assumption. As mentioned earlier, the assumption guiding the
multi-stage lockdown is that COVID-19 offers multiple peaks and troughs. This assumption
depends upon another assumption: the incidence of disease is uneven. That is, COVID-19
offers an uneven incidence of disease, which attains multiple peaks and troughs owing to
the cluster spillover and this is why the multi-stage lockdown is a better preventive model. In
fact, this is not the case. The incidence of disease is higher in the areas (or cities) where
Pakistani visitors reached from Iran. The same is true for the scattered devotees from
Raiwand’s Tableeghi gathering. In Pakistan, there has appeared no cluster spillover which
took place in Europe owing to factors, as mentioned above, different from those that exist in
Pakistan. Currently, taken together, around 50 percent COVID-19 patients are those who
visited Iran or Raiwand, and the rest of 50 percent patients are those who contracted the
virus locally from them. The final ratio is one patient has infected one person.

Behaviour modification

Behaviour modification is significant, but it is possible through mass awareness campaigns
and by supplying common people with physical barriers to the entry of viruses such as
masks. In the context of Pakistan, it was not the time lag between behavior modification and
resultant changes in perceived severity to produce a peak. Instead, it was the failure of the
political and administrative machinery to learn from the Chinese experience and the failure
to foresee consequences for Pakistani society, when the Pak-Iran Taftan border was
mismanaged and when the Raiwand gathering was permitted. Politico-administrative
behavior need urgent modification. As the accountability level is both low and trivial, the
culprits go scot-free.

High costs of deviation                     

In the game-theoretic terms, it is virus versus man as competitive players for survival and
not man versus man. Along with it, a multi-stage lockdown introduces the idea of keeping
on areas locked one after the other over a length of time, say for ten months. This would be
another error. Pakistan has two and a half months (the rest of April and full months of May
and June) to touch ground zero of declaring no new patient. These months offer Pakistan a
fighting chance. Otherwise, the month of July will bring high humidity through Monsoon
rains. High humidity (even in the presence of high temperature) would spur the virus into
causing a widespread loss of human lives in Pakistan.

Understanding our limitation

It is true that managing COVID-19 without vaccine or medicine calls for social distancing
and a lockdown. It is, however, not the case that either or both of them are useful in the
short run. Lahore is a good example to seeing a significant decline in the number of new
patients by 19 April 2020. Both incidence and pattern of the disease encourage a single-
stage lockdown, which is easier for the administration to thrust upon the public than a multi-
stage event-based to-and-fro lockdown which would exhaust the nerves and resources of
the administrative machinery. Certain international bodies and some foreign countries are
pledging Pakistan with financial aid and relief. Pakistan needs to utilize them to take food to
the doors of the deserving without lifting the single-stage lockdown. Testing facilities have
been deployed, but these should be applied preferably to the areas where a high number
of COVID-19 patients have been reported. Resources for testing should not be squandered
by performing random testing, as has been happening in several developed countries.

Conclusion

The national lockdown must continue to touch ground zero. After having no new patient, the
lockdown should continue for two weeks. A single-stage lockdown is an option better than
that of a multi-stage lockdown. Incidence of COVID-19 infected patients is more in the areas
that received Pakistani visitors from Iran or Raiwand. Instead of performing random testing
to discover carriers, to conserve resources, non-random or selective testing be done in the
areas of any city yielding high number of patients such as the surrounding localities of such
visitors. While lifting the lockdown, the government should issue a caution for people to
keep centrally air-conditioned system off for at least one month. Pakistan has two and a
half months as a grace period to overcome the menace, as from July onward the higher
humidity level would let the situation go from bad to worse.

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