COVID-19 Insights The middle Road
The pandemic is pushing millions of people into poverty, increasing unemployment rate apart from the unmeasurable mental trauma of suffering and loss of loved ones. More than 3.3 million people have died of COVID-19 with unofficial figures much higher. This publication includes detailed analysis of data from various countries to compare how selected nations fared comparatively in fighting the COVID-19 crisis. During the ongoing pandemic, some countries stood out for deploying techniques and processes to handle the COVID-19 crisis much better than others. The purpose is to understand how effective practices implemented by selected countries to stem the proliferation of the novel coronavirus could be shared for a better social outcome globally. These steps range through testing and social distance norms, national or regional lockdowns, self-isolation of the population, travel restrictions, contact tracing, genome sequencing, and vaccination drives for adult populations across nations. The publication covers a few countries significantly the United Kingdom and China to understand the impact of vaccination and Wuhan Intervention especially lockdown in bringing down new daily cases and deaths, flattening the total COVID-19 cases curve, saving lives through vaccines etc.
The study includes a selected group of countries due to limitations of employees at Middle Road OPC Pvt Ltd. Nishant Malhotra is the sole founder of the organization and the sole contributor of all the content at The middle Road platform unless otherwise stated. Feel free to reach out to nishant@themiddleroad.org if you would either want to feature as a guest author (read guidelines ) on topics related to the mission of the organization or bring to notice insightful analysis on the pandemic with due credit.
How did countries like New Zealand, Vietnam, China, Australia, Singapore, Japan to name a few do an excellent job in containing the spread of the novel coronavirus without using vaccinations while many others faltered? Why do some countries have so few cases and deaths per million, example Vietnam has 0.36 deaths per million but for many countries this figure is in thousands ? How did some countries flatten the curve of daily cases and deaths due to COVID-19 ? Why did Sweden perform worse among the Nordic countries in handling the pandemic ? Why are daily COVID-19 cases in India rising at an alarming rate ? Why an effective, well planned and executed vaccination rollout is a gamechanger in stopping the pandemic ? You will find answers to many of these questions after reading this work which has more than 4000 words.
There is an add-on note on simple regression analysis to understand the causality between total number of cases per million and total number of deaths per million using data for selected countries. Tutorials on regression will start after the Stabilization series kickstarts under the Macroeconomics on The middle Road under the tutorial section.
COVID-19 has made the spread of diseases through viruses mainstream dinner tables conversations, the pandemic has brought down governments for mishandling of the novel coronavirus crisis, attracted more capital for its vaccination research through the public-private partnership than any other vaccination program in history. The investment in Research & Development led to the fastest release of effective vaccines in public arena. More than 1.2 billion vaccines have been administered globally with 8.28% of the population receiving at least one dose of the vaccine as of 8 May 2021. China leads in the total number of vaccinations administered to its population at 280 million (WHO) with some figures shooting upwards of 300 million. The US is close behind and gaining speed with ~220 million doses plus and India with 160 million-plus jabs are the top three countries in the world in administering total vaccines to their population, respectively. (Data as of 8 May, 2021). However, statistics for vaccination as a percent of its population or adult population showcases a different picture. Refer graph below.
Key policy enabler for economies: During times of extreme distress to the healthcare system have a decisive plan to upscale exponentially critical healthcare facilities and infrastructure within 48 hours. It could range from setting up makeshift hospitals in stadiums to doubling the existing staff of healthcare personals, ancillary medical requirements, or driving massive vaccination drives for the city or region’s population. A community model to drive smaller initiatives through champions can be used using a multilayered model. This model could have been useful for New York, the US, and New Delhi, India.
Vaccination as percent of adult population for the US is close to 50 percent (percent of its population) as both China (20 percent plus) and India (10 percent plus) are hindered by their population size. India can ill afford to be complacent towards the vaccination drive as it reels under the steep rise in COVID-19 cases in the second wave. China, on the other hand, has been exceptional in handling the COVID-19 crisis, flattening the curve of total COVID19 cases long time back.
A key insight with the quick and effective rollout of vaccinations since January points to the efficacy of the vaccination drive in saving lives by reducing new COVID-19 cases or curing COVID-19 infected patients who had at least one dose of the vaccine (citation needed for underlined sentence).
In United Kingdom, COVID-19 vaccines have prevented 10,400 deaths in older adults above age of 60 years.
The vaccination drive in the United Kingdom, the United States, and Israel are excellent examples of how vaccines can successfully help to either flatten the curve or enable the curve to flatten. (Curve of cumulative COVID-19 cases.)
# Elimination Life cycle of a Virus
In the lifecycle of a virus from the time of detection to its elimination through vaccination, there are multiple processes and techniques to contain the spread of the virus within and outside its geographies, until the discovery of an approved vaccination.
The above diagram preferably uses logarithmic base. Time in years
The fight against a virus according to The middle Road is divided into two phases one pre-vaccination, and the final phase of vaccination rollout. As the process will differ for various viruses, the reasoning here is limited for Severe acute respiratory syndrome coronavirus 2 SARS-Cov-2, the virus causing COVID-19. Until the discovery of the virus, testing, contact tracing, social distancing norms including banning big social gatherings, self-isolation, lockdowns, and genome sequencing are major steps in containing the spread of the virus. The first would be a strict lockdown either in the region or in the country restricting travel both within and outside the country. This will impede the spread of a contagious virus, especially like novel coronavirus to restrict its presence within a region. Once out in the open, novel coronavirus can have a staggering impact multiplying exponentially as cases increase. Lockdowns give a brief pause to a panic situation; Wuhan Intervention is an excellent case study to understand the framework of methodology deployed apart from quarantining a region. This phase needs to be backed by restricted travel, testing majority of the population for the virus, upscaling the healthcare system i.e. developing makeshift hospitals to increase beds for patients, increasing number of doctors and caregivers at the earliest with required medical supplies. New Zealand excelled since it diligently deployed lockdown strategy, restricted travel among other initiatives listed.
The middle Road awarded Jacinda Ardern, Prime Minister of New Zealand the coveted Person of the Year award 2020 for her brilliant work in containing the pandemic. She follows up Nancy Pelosi who won the award in 2019. The awards commenced in 2019. Jacinda is a role model for millions around the world and The middle Road salutes her spirit, wisdom, decisiveness and leadership qualities.
During the initial phase, aggressive contract tracing is prudent due to the asymmetric behaviour of the SARS-Cov-2. Patients who tested positive for SARS-Cov-2 have shown symptoms but many are asymptomatic i.e. did not show any symptoms and unknowingly were seeders of the infection. Vietnam’s strategy to proactively test its population also used by Japan among other countries helped in identifying COVID-19 cases (those that would not have been diagnosed as many of those who tested positive did not show any symptoms) and isolating them worked well in limiting the spread of COVID-19. The initial phase of the outbreak of any disease is the most uncertain time with little data to work and estimate the underlying mechanism of spread of the infection among humans. Genome sequencing helps in unraveling the mystery of the virus and a continuous one for a virus that has shown a probability to mutate and a high priority even after the discovery of the vaccination. Applied technology for contact tracing is a key enabler identified by The middle Road.
One clear perspective that has emerged from the last year is the strict adherence to social distancing especially banning of mass celebrations of any kind including religious and political rallies. Read more about the second wave and analysis by The middle Road here.
Fig. above data from Our World in Data for 9 May, 2021. Vietnam, New Zealand, China and Japan recorded some of the lowest total confirmed deaths due to COVID-19 per million people
In a report published by Lancet, Sweden softness towards enforcing social norms dealt Sweden a serious blow during the second wave late last year. The savior for any pandemic is an effectively and easily available vaccine and in this case some countries did an excellent job especially the United Kingdom, Israel and United States under President Biden’s leadership.
United Kingdom vaccination drive is going full steam. Apart from Social Impact in saving thousands of life, the first successful public rollout of the vaccinations against COVID-19 in the western hemisphere, UK vaccination drive led to a valuable data on efficacy of the vaccines against the SARS-Cov-2 bifurcating data on parameters including age group. Based on the data provided by the UK Gov, 66.6 percent of the adult population has had one dose of the vaccination with 31.8 percent with the second dose of the vaccination. The number of people admitted daily in hospitals has come down remarkably down to 121 on 3 May from the high of 4000 plus in January. The data is the COVID-19 database provided by the UK Government COVID-19 portal.
# Understanding United Kingdom Case in Detail
The above graph compares the 14 days moving average of people who have had first and second doses. An uptick in the second dose of vaccination confirms the propensity of a significant portion of the population to vaccinate themselves on a priority, signifying an effective and efficient rollout of the vaccination drive nationally. Second doses of most COVID-19 vaccines have a lag of about a month, it explains the upward trend of 14 day moving average of new people vaccinated by second dose.
As the vaccinations have moved to the younger generation, it remains to be seen that the rate of vaccination would plateau or go down as we move forward and/or the world will see sticky behavior by a small portion of the population towards getting vaccinated. This remains a grey area and leads to a valuable behavioral analysis of adverse attitudes towards vaccination.
Avove graph: Total confirmed deaths of COVID-19 per million people from 15 countries. The data source Our World in Data as of 9 May, 2021 except for UK (5 May, 2021), New Zealand (7 May, 2021), Switzerland (6 May, 2021) and Ghana 2 may, 2021.
This segment of the population would be the most difficult to vaccinate and be the most vulnerable to be infected. However, even if this is a small fraction of the sample to be vaccinated, policymakers are unlikely to ignore them looking at devastation caused by the second wave and possibility that the virus could mutate further. The uncertainty surrounding how the novel coronavirus mutates, is causing governments to stock pile vaccines leading to vaccination inequality. This behaviour would be detrimental to less privileged nations globally. A long-term strategic thinking is important in making sure logistics and supplies are in abundance for vaccinating the population.
# A key policy enabler in driving and enabling faster vaccination drive would be for the United Kingdom government to sell vaccinations from government approved pharmacies to the adult population. But the caveat here would be to restrict it to adult population only and those requiring doses.
Left Graph shares a poignant story. Left; new deaths 28 days by death date and new people vaccinated. The death data is within the 28-day span of first getting tested positive for SARS-CoV-2, data from 15 Jan 2021 is available on the UK Government site. Keeping other factors constant, the roll out of the national vaccination program had a substantial impact on reduction of daily new deaths by novel SARS.
The data is the COVID-19 database provided by the UK Government |https://coronavirus.data.gov.uk/details/deaths Number of deaths of people who had had a positive test result for COVID-19 and died within 28 days of the first positive test. Data from the four nations are not directly comparable as methodologies and inclusion criteria vary. Data for the period ending 5 days before the date when the website was last updated with data for the selected area, The data is as of 8 May, 2021, site updated on 7 May, 2021.
United Kingdom had moderate success in flattening the curve of daily COVID-19 cases before it was hit hard by the second wave. The magic pill for the UK turned out be the fast rollout of vaccinations that reversed the trend of daily cases and deaths due to SARS-Cov-2. Vaccinations are proving to be very effective in fight against the COVID-19 as seen from the United State case. The election of President Biden proved to be the turning point for the United States as it led to a scientific and effective roll out of vaccinations. (Refer to the Graph below comparing US with India and Brazil). Although paucity of evidence limits the scope of understanding the effect of vaccination against more vicious mutants that could come ahead, it remains the safest bet as a long-lasting solution until the virus is completely eradicated from the world.
To understand the causality between COVID19 cases and COVID19 deaths, The middle Road operated a simple regression analysis with only one regressor. The data includes total confirmed cases of COVID-19 per million people and total confirmed deaths of COVID-19 per million people from 15 countries. The data source Our World in Data as of 9 May, 2021 except for UK (5 May, 2021), New Zealand (7 May, 2021), Switzerland (6 May, 2021) and Ghana 2 may, 2021. Total confirmed cases of COVID-19 per million is the regressor or independent variable and Total confirmed deaths of COVID-19 per million the dependent or response variable . The countries included in the analysis are Canada, Sweden, United States, Denmark, Sweden. Ghana, China, Vietnam, New Zealand, Bahrain, Brazil, France, Switzerland, Finland and India.
Regression analysis is used across industries. The straight line shows a positive relationship between the two variables.
The simple linear equation Y= 0.0146X + 85.235 implies
0.0146 and 85.235 are regression coefficients with 0.0146 slope of the linear equation. 85.235 is the intercept i.e. the value when x=0. No. of observations 15. This is just to explain basic regression concepts.
On an average, for every addition of one confirmed total case per million people, the total confirmed deaths per million people increases by 0.146 keeping other factors constant.
Test for slope is significant at 95% confidence interval, with p-value less than 5% (the level of significance). Test statistic test can also be used but as discussed in tutorials on The middle Road, p-value is the best and easiest way to test. R2 =0.5674 means the regressor is explaining only 56.74% of the variation. The model has omitted variable bias as we are estimating total COVID-19 deaths like variables related to the healthcare sector etc. F-test are better for multivariate analysis, the above regression is a bivariate regression.
For the above equation, if total confirmed cases increase by 100 per million population, the total confirmed deaths per million population increase by 1.46 units keeping other factors constant. Refer to the tutorials on Statistics under the tutorial section on The middle Road to know about hypothesis testing confidence intervals etc. A brief on simple regression equation below.
The slope of the equation (beta 1) is the change in the mean of Y for a unit change in X. We discussed above the regression equation for a mean of Y. Since the error term is a Stochastic random number , the mean Y will also be random and have a random probability distribution. The randomness implies that one error terms are independent of each other.
To predict the values of Y, the regressor is controlled and the difference between the observed value and the predicted or fitted value is called the residual value. The ordinary least square or least square is a linear best fit line between dependent and independent variable/s. It is calculated by minimizing the square of the difference between the observed (Y) and predicted/fitted value (Y cap) of Y or the dependent variable i.e. sum of all the residuals. Look at the regression analysis in the original read.
# Lockdowns, Testing and Applied Technology
For the above graph, the first new daily case for US recorded 22 Jan 2020, India 30 Jan 2020 and Brazil Feb 26, 2020. Moving 14 day average is calculated for all the database for the three countries. Calculations: The middle Road Data: Our World in Data Above Its Brazil 14 day average
Implementation and strength of national lockdown along with various surveillance testing techniques like contact tracing, genome sequencing, testing, and applied technology are highly effective in flattening and bending the curve of new COVID-19 cases. Many countries did not need vaccinations to remove threats posed by the novel coronavirus. New Zealand and Vietnam have less than 5 percent of their adult population fully vaccinated as of 8 May, 2021, yet superlative in containing and removing new COVID-19 cases. Both these countries implemented well planned and strict lockdowns early during the pandemic, restricted international travel to their countries, proactively tested their population, used contact tracing etc., to remove SARS-CoV-2. New Zealand was completely free of the novel coronavirus until recently when it recorded a few cases while Vietnam records cases in double digits. Vietnam does not have a world-class health care system like New Zealand and shares a long border with China. Despite the limitations, Vietnam succeeded as it closed its border with China early during the pandemic, implemented travel restrictions, and aggressively tested its population for novel SARS. The Nordic countries and selected European countries excelled without strict lockdowns. Another country that stood out for its extraordinary management of the pandemic is China.
# Wuhan Lockdown Evidence
After a muddled initial response, Chinese government got its act together in a structured and measured manner. First country during the pandemic to implement the lockdown of a city, Wuhan and other cities in Hubei province laid pathways for the world in understanding the impact of this strategy in mitigating the spread of the virus and its impact on the inhabitants of other cities in mainland China. The Chinese government implemented one of the strictest and first city wide lockdown in the COVID-19 pandemic starting at 10 am 23 January, a week before World Health Organization WHO declared the COVID-19 epidemic a public health emergency of international concern. The large-scale quarantine caught international attention but looking past in history this technique proved to be immensely helpful. The series of intervention especially the Wuhan lockdown proved to be a gamechanger to understand practices that help in controlling an epidemic or a pandemic. Although 99 percent of travel was restricted in and out of the Wuhan city, people still managed to travel across the city.
A study conducted by Zheming Yuan, Yi Xiao, Zhijun Dai, Jianjun Huang, Zhenhai Zhang & Yuan Chen modelled the online data of population movements and confirmed cases of the SARS-CoV-2 in a regression model to understand the impact of the lockdown measures. The report analyzed 44 regions in China that received travelers from Wuhan including 29 other provinces in mainland China. The model used data from the Baidu Migration Index to understand flow of people in and out of Wuhan to quantify the effect of lockdown on the spread of then ongoing spread of COVID-19 in Mainland China.
Graph: China daily and 7 day moving average of daily new COVID-19 cases. Wuhan intervention implemented on 23 January 2020 lasted for 86 days. DataSource: our world in data; calculation The middle Road | The middle Road
Before we look at the importance of heath care sector, The middle Road classifies countries that used three mix of strategies to contain the damage due to the pandemic. A mix of lockdowns, travel restriction, aggressive testing and genome sequencing, contact tracing, implementing social distancing norms including self-isolation and other innovation as prime strategy. Second, use an all-out vaccination strategy of administrating free COVID-19 vaccination doses to adult population at the earliest. Third a blend of the above two strategies.
Importance of implementing stringent lockdowns and adhering to social norms like wearing a face mask in public gathering can be showcased comparing Nordic countries like Denmark, Finland and Sweden. All these countries are models of excellence and have one of the most equitable healthcare systems in the world. Sweden has performed poorly to other Nordic countries due to its complacent attitude towards social distancing norms, testing, source identification, etc. as stipulated by WHO. According to a publication by Lancet COVID-19 and the Swedish enigma, Swedes did not have sufficient recognition in their national strategy of the importance of presymptomatic and asymptomatic transmission, aerosol transmission, and use of face mask as of 22 December 2020.
In the graph above a comparison of total confirmed COVID-19 deaths per million for selected Nordic countries | The middle Road
The surge in Sweden in the total confirmed deaths per million people in the month of October 2020 is due to the second wave of novel coronavirus. The average of total confirmed COVID-19 deaths per million for Sweden, Finland and Denmark from Oct to December (202) is 657, 72, 142 respectively rounded off to zero decimal places. India recent surge in COVID-19 due to the second wave highlights how lack of foresight and total disregard for norms can exponentially change the rise in daily COVID-19 cases. India recorded ~2.6 million cases in the preceding week of 9 May, 2021 about ~45% of the total weekly cases recorded during the period.
Bend it like President Biden — Give me Blue
If President Biden could bend soccer ball the way his well thought policies reversed the curve of daily COVID-19 cases in the US, Mr. Biden would be competing with Messi and Ronaldo for football honors. Sadly it not American football but the plain old soccer that people play using their foot. Mass vaccination in the US only began on 4 Jan, 2021. The US daily COVID-19 doses smoothed per million increased to a staggering ~270.3% on 13 April, 2021 before dipping down from the number on 21 Jan, 2021, first day of President Biden in office.
President Biden has been very impressive during his first 100 days of administration. The daily cases had peaked before he took office looking at the data yet the situation in the US was horrendous. US led the world in cumulative cases by a wide margin stretching the healthcare system to its maximum limit. Biden administration signaled plans to purchase an additional 200 million COVID-19 vaccines, and increased vaccine distribution to states by ~16.3 percent within one week in office according to AJMC. President Joe Biden’s message of administering 100 million jabs of the vaccine in the first 100 days of his presidency sent out a clear message to Americans and the world that the most critical part of Biden’s administration is fighting COVID-19 and saving lives of thousands of Americans. This calmed the nerves of millions of Americans who had seen tragedy unfold every day for some time. In the first 100 days of President Biden’s Presidency, Americans crossed 220 million jabs of COVID-19 vaccines with at least 150 million Americans receiving one jab of the COVID-19 vaccine. Second, President Biden set up allocation benchmarks for receiving vaccines example setting up vaccine centers within a 5 mile radius for any American. In UK, its is 10 miles. This brought in accessibility and ease of distribution for the population and The middle Road finds this initiative highly rewarding and thoughtful.
# Healthcare a Critical Enabler
Above graph: Data source Hospital beds per thousand Compiled from World Bank database with WHO as original source Data for Japan, New Zealand and Singapore 2018; Germany and Brazil 2017 (Hospital beds include inpatient beds available in public, private, general, and specialized hospitals and rehabilitation centers. In most cases beds for both acute and chronic care are included.) Total confirmed deaths due to COVID-19 per million date from Our World in Data. Data for Brazil as of 7 May, 2021
Finally, the pandemic due to its ability to exponentially spread across geographies showcases the fragility of many country’s healthcare systems. The critical parameters to understand the healthcare system within a country would be the healthcare expenditure as a percent of the GDP, the number of physicians per thousand, number of hospital beds per thousand and supply of medical oxygen per population (India’s recent shortage of medical oxygen). The pandemic will force millions into poverty and take away years from the GDP growth of companies. The pandemic has thrown a few positive surprises and one among them is that Africa did much better than expected in managing the COVID-19 wave, surprising even Bill Gates, a well-known philanthropist. As nations battle globally to reduce daily cases until there is no incremental case leading to flattening of the total cases, vaccinating the population remains the way forward.
The data from Germany and India now points to children also getting infected, the journey ahead is long but the destination visible. A glance at hospital beds per 1,000 populations shares a mixed opinion. Germany with above-average hospital beds per 1,000 population and best in class healthcare system struggled equally if not more compared to countries with comparable equitable healthcare facilities but fewer hospital beds per 1000 population during the pandemic. France is another example of a country with excellent healthcare facilities with 5.91 beds per 1000 population (higher than many advanced countries) is struggling with the pandemic, highlights the havoc openly communicable viruses can cause. One reason for Japan’s high bed might be due to the rapidly aging population Many developed countries must look at the long-term benefits of increasing hospital beds per thousand including the US.
India remains a ticking time bomb as a center for the health crisis. India has 0.53 beds per 1000 population, compared to China’s 4.31, Sri Lanka’s 4.15, and Bangladesh’s (0.79). All figures are for 2017 except Bangladesh that is from 2016. India categorized as a low-middle-income country by World Bank, is below the figure of lower-middle-income countries ~0.627 (2016) and low & middle-level countries ~2.285 (2017). Data source World Bank, WHO. India needs to radically change its investment and strategic thinking in the healthcare services industry to be competitive in today’s super-connected world. Building infrastructure with a focus on ancillary industries and boosting manpower remains the most critical challenge.
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Originally published at https://themiddleroad.org on May 11, 2021.
