India breaks global record for highest number of daily COVID-19 infections

India’s outbreak is rapidly worsening as it struggles with oxygen shortages, overwhelmed hospitals and rolling out vaccines for its large population.

India logged more than 314,000 new coronavirus infections on Thursday (Apr. 22), the highest number of single-day cases reported globally since the start of the pandemic, according to The New York Times. The previous record was set by the U.S. on Jan. 8 with a single-day count of 300,669 new coronavirus cases. 

India has recorded a total of 15.9 million COVID-19 infections since the start of the pandemic, second only to the U.S., according to the Johns Hopkins University dashboard. The country has logged more than 184,600 deaths in total, up by 2,104 since yesterday.

Crowds are forming outside overwhelmed hospitals and people are dying while waiting for oxygen, according to The BBC. Oxygen supply in the country has massively dipped, with some hospitals in Delhi completely running out and others running low. In a meeting on Thursday (April 22) Prime Minister Narendra Modi asked officials to find ways to produce more oxygen and to really crack down on anyone hoarding supplies, according to the BBC.

Hospitals are understaffed, intensive care units are full, nearly all ventilators are in use and the dead are piling up at crematoriums, according to The Associated Press. “I get numerous calls every day from patients desperate for a bed. The demand is far too much than the supply,” Dr. Sanjay Gururaj, a doctor at Bengaluru-based Shanti Hospital and Research Center told The Associated Press. “I try to find beds for patients every day, and it’s been incredibly frustrating to not be able to help them. In the last week, three patients of mine have died at home because they were unable to get beds. As a doctor, it’s an awful feeling.”

India is not implementing a national lockdown but regions are setting their own restrictions, according to the BBC. Delhi, where one in three people are testing positive for COVID-19, announced a week-long lockdown starting next week, according to The BBC.

India’s COVID-19 cases had dropped for 30 consecutive weeks starting last September; but then they started to rise again in mid-February. Experts told the AP that the country did not use that opportunity to vaccinate quickly enough to outpace disease spread and improve healthcare infrastructure.

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India administers about 2.7 million vaccine doses a day, which isn’t that much different than the U.S. pace of around 3.02 million doses per day. But India’s massive population of 1.4 billion people — more than four times the population of the U.S. —makes the vaccine rollout difficult. less than 10% of India’s population has gotten their first of two shots, according to the AP.

This extreme surge in cases may have been driven by the spread of new variants including a “double mutant” variant that seems to both spread more easily and evade some antibodies, a massive Hindu festival known as Kumbh Mela that millions of people attended, big election rallies and relaxed safety protocols, according to the BBC.

Originally published on Live Science.

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Tracking the global movement of malaria parasites and their variants

malaria

An international collaboration of researchers have developed a computational method to identify malaria parasites as they move around the world with their human hosts—key to measuring impact of elimination campaigns.

Led by University of Melbourne Professor Karen Day, Laboratory Head at the Peter Doherty Institute for Infection and Immunity (Doherty Institute) and Bio21, the team collected parasites from 23 locations in 10 countries.

Malaria is the world’s most deadly parasitic disease, killing over half a million people every year. It is hampered by drug resistance and the first recently developed vaccine offers only partial protection.

The team sequenced parasite DNA from 1,248 malaria infected patients and established a global database of 32,682 variant surface antigen genes, to track down to country level where parasites originated. Findings from the 10-year project were published in PLOS Genetics.

“In malaria, we have to deal with tens of thousands of variants in one endemic area. This database is a significant step forward in tracking those variants, and understanding how malaria is moving around the world,” Professor Day said.

“The impact of this is we can follow contemporary patterns of parasite migration in a cost-effective manner without having to sequence the whole genome. The signature of the past is very much visible in what we found but now we can see if anything changes. It gives us another window into how we can adapt parasite genomics to inform malaria surveillance.”

Professor Day said these evolutionary findings have translational implications in providing a diagnostic framework for geographical surveillance of malaria.

“It can also inform efforts to understand the presence or absence of global, regional and local population immunity to specific variants,” she said.

“Our next step would be to grow our database in the Asia -Pacific, with more collaborators and opportunities for regional training.”

An example of what Professor Day and her research team are striving towards is similar to ‘FluNet’, a global web-based tool for influenza surveillance by the World Health Organization.

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Global demand for cancer surgery set to grow by almost 5 million procedures within 20 years

cancer

Demand for cancer surgery is expected to increase from 9.1 million to 13.8 million procedures over the next twenty years, requiring a huge increase in the workforce including nearly 200,000 additional surgeons and 87,000 anaesthetists globally. With access to post-operative care strongly linked to lower mortality, improving care systems worldwide must be a priority in order to reduce disproportionate number of deaths following complications.

The findings of the two studies, published in The Lancet and The Lancet Oncology, highlight an urgent need to improve cancer surgery provision in low- and middle income countries, while also scaling-up their workforces in order to cope with increasing demand. Until now, a lack of data examining outcomes of cancer surgery in different income settings, and an absence of evidence-based estimates of future demand, had limited efforts to improve cancer care globally.

Cancer is a leading cause of death and disability globally, and exerts substantial economic impacts, with recent evidence suggesting a disproportionate burden of disease in LMICs. With more than half of cancer patients predicted to require surgery at some stage, it is a pivotal component of multidisciplinary care globally and plays a key role in preventing deaths. A 2015 study estimated that US$6.2 trillion in global GDP could be lost by 2030 if surgical cancer systems are not improved.

While the new studies did not assess impacts of COVID-19, the authors acknowledge that the delivery of high-quality post-operative care is more challenging during the pandemic.

Increasing future demand

The Article in The Lancet Oncology journal is a modelling study of global demand for cancer surgery and estimated surgical and anaesthesia workforce requirements between 2018 and 2040.

Using best-practice guidelines, patient characteristics and cancer stage data, the authors calculated the proportion of newly diagnosed cancer cases requiring surgery in 183 countries. To predict future surgery demand, they applied these rates to GLOBACAN cancer incidence predictions from 2018 to 2040.

The team’s analysis estimates that the number of cancer cases requiring surgery globally each year will rise from 9.1 million to 13.8 million (52%, an increase of 4.7 million) from 2018 to 2040. The greatest relative increase will occur in 34 low-income countries, where the number of cases requiring surgery is expected to more than double by 2040 (314,355 cases to 650,164, 107%).

Current and future surgical and anaesthesia workforces needed for the optimal delivery of cancer surgery services were also predicted using staffing estimates based on optimal surgical use in high-income countries as a benchmark for global requirements. To evaluate staffing gaps, the optimal estimated workforce (median workforce of 44 high-income countries) was compared with numbers of surgeons and anaesthetists in each country.

The authors estimate there is currently a global shortage of 199,000 (56%) surgeons and 87,000 (51%) anaesthetists (current workforce of 766,000 surgeons and 372,000 anaesthetists, compared with 965,000 and 459,000 optimal workforce, respectively, estimated by the team’s model). The gap is estimated to be greatest in low-income countries, where the current surgeon availability is 22,000 fewer than the model estimated optimal number of 28,000 surgeons. The current number of anaesthetists in low-income countries falls 11,000 below the model estimated demand of 13,000 anaesthetists.

In recognition of the rising global demand for cancer surgery, estimates were calculated for the optimal surgical and anaesthesia workforces needed in 2040. Extrapolating 2018 data, taking account of predicted future cancer incidence burden in each country, revealed that the surgical workforce will need to increase from 965,000 in 2018 to 1,416,000 (47% increase) in 2040. The anaesthetist workforce would need to rise from 459,000 in 2018 to 674,000 (47% increase) in 2040.

The greatest relative increase in optimal workforce requirements from 2018 to 2040 will occur in low-income countries, where surgeon numbers are required to rise from 28,210 to 58,219 by 2040 (106%). Anaesthetist numbers will also need to increase from 13,000 to 28,000 by 2040 (115%).

However, to match the current benchmark of high-income countries, the actual number of surgeons in low-income countries would need to increase almost 400% (increase from 6,000 to 28,000), and anaesthetists by nearly 550% (increase from 2,000 to 13,000), of their baseline values. This is because the current workforce in these countries is already substantially smaller than in high-income countries.

Dr. Sathira Perera, from the University of New South Wales, Australia, said: “Our analysis has revealed that, in relative terms, low-income countries will bear the brunt of increased future demand for cancer surgery, bringing with it a need to substantially increase numbers of surgeons and anaesthetists. These findings highlight a need to act quickly to ensure that increasing workforce requirements in low-income countries are adequately planned for. There needs to be an increased focus on the application of cost-effective models of care, along with government endorsement of scientific evidence to mobilise resources for expanding services.”

Estimates in the study relied on several assumptions. Predictions of future cancer rates were based on 2018 estimates, however, country-level changes—such as economic developments or altered capacity to screen for early diagnosis—could alter cancer incidence and therefore surgical demand and workforce requirements. Observed gaps in the workforce could also be narrower than the actual gaps in practice, as predictions were conservative because they only considered initial surgical encounters and did not account for any follow-up interactions.

Cancer surgery outcomes

The Article in The Lancet is an observational study exploring global variation in post-operative complications and deaths following surgery for three common cancers.

Deaths among gastric cancer patients were nearly four times higher in low/lower middle-income countries (33 deaths among 326 patients, 3.72 odds of death) than high-income countries (27 deaths among 702 patients).

Patients with colorectal cancer in low/lower middle-income countries were also more than four times more likely to die (63 deaths among 905 patients, 4.59 odds of death), compared with those in high-income countries (94 deaths among 4,142 patients). Those in upper middle-income countries were two times as likely to die (47 deaths among 1,102 patients, 2.06 odds of death) as patients in high-income countries.

No difference in 30-day mortality was seen following breast cancer surgery.

Similar rates of complications were observed in patients across all income groups, however those in low/lower middle-income countries were six times more likely to die within 30 days of a major complication (96 deaths among 133 patients, 6.15 odds of death), compared with patients in high-income countries (121 deaths among 693 patients). Patients in upper middle-countries were almost four times as likely to die (58 deaths among 151 patients, 3.89 odds of death) as those in high-income countries.

Patients in upper middle-income and low/lower middle-income countries tended to present with more advanced disease compared with those in high-income countries, however researchers found that cancer stage alone explained little of the variation in mortality or post-operative complications.

Between April 2018 and January 2019, researchers enrolled 15,958 patients from 428 hospitals in 82 countries undergoing surgery for breast, colorectal or gastric cancer. 57% of patients were from high-income countries (9,106 patients), with 17% from upper middle-income countries (2,721 patients), and 26% from low/lower middle-income countries (4,131 patients). 53% (8,406) of patients underwent surgery for breast cancer, 39% (6,215) for colorectal cancer, and 8% (1,337) for gastric cancer.

Assessing hospital facilities and practices across the different income groups revealed that hospitals in upper middle-income and low/lower middle-income countries were less likely to have post-operative care infrastructure (such as designated post-operative recovery areas and consistently available critical care facilities) and cancer care pathways (such as oncology services). Further analysis revealed that the absence of post-operative care infrastructure was associated with more deaths in low/lower middle-income countries (7 to 10 more deaths per 100 major complications) and upper middle-income countries (5 to 8 more deaths per 100 major complications).

Professor Ewen Harrison, of the University of Edinburgh, UK, said: “Our study is the first to provide in-depth data globally on complications and deaths in patients within 30 days of cancer surgery. The association between having post-operative care and lower mortality rates following major complications indicates a need to improve care systems to detect and intervene when complications occur. Increasing this capacity to rescue patients from complications could help reduce deaths following cancer surgery in low- and middle-income countries.

“High quality all-round surgical care requires appropriate recovery and ward space, a sufficient number of well-trained staff, the use of early warning systems, and ready access to imaging, operating theatre space, and critical care facilities. While in this study it wasn’t possible to assess cancer patients’ full healthcare journey, we did identify several parts of the surgical health system, as well as patient-level risk factors, which could warrant further study and intervention.”

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Global vaccine campaign gains pace as Brazil approves jabs

vaccine

The global COVID-19 vaccination drive gained pace Sunday as Brazil gave its first injections and India pushed on with its massive campaign, while European authorities sought to allay concerns about delays in supplies.

Brazil’s health regulator gave the green light for the Oxford-AstraZeneca vaccine and China’s CoronaVac to be used as the Latin American giant suffers a devastating second wave of the coronavirus.

Monica Calazans, a 54-year-old intensive care nurse in Sao Paulo became the first person in Brazil to receive the Chinese CoronaVac jab after the Anvisa watchdog’s highly anticipated ruling.

Growing concerns over different strains of the virus have meanwhile prompted governments to tighten curbs in a bid to stem a global death toll that has already surpassed two million.

Good start in India

India’s vaccination drive got off to a successful start on Saturday with more than 224,000 people receiving their first jabs and just three people hospitalized after side effects, the health ministry said Sunday.

The government plans to immunise some 300 million people out of its population of 1.3 billion by July—equivalent to almost the entire US population.

In Europe, both France and Russia were gearing up for a key week in the vaccine effort.

Russia starts mass immunisations on Monday using its homegrown Sputnik V vaccine, while the French government is hoping to overcome fierce criticism of a sluggish rollout as it begins inoculating the over-75s.

Across the European Union there have been concerns that delays in the delivery of the Pfizer-BioNTech vaccine could further slow a campaign which critics have condemned as less agile than in the United States or Britain, a recently-departed EU member.

US drugmaker Pfizer said it was working to “significantly” scale up production at its plant in Belgium in the second quarter.

After a short delay, deliveries should be back to the original schedule to the EU from January 25.

“There’s a dip,” France’s Europe minister Clement Beaune told Franceinfo radio.

“But it’s better that it happens now when we have stockpiles than when the wider vaccination campaign starts.”

Biden eyes 100 million doses

Joe Biden’s goal of seeing 100 million vaccine doses injected within his first 100 days in office is meanwhile “absolutely” achievable, top US scientist Anthony Fauci said, days before he is to become the new president’s chief advisor on COVID-19.

“The feasibility of his goal is absolutely clear, there’s no doubt about it,” Fauci told NBC’s “Meet the Press”.

Biden has unveiled a $1.9 trillion stimulus plan to revive the economy of the country worst-hit by the virus, which has killed more than 397,000 people in the US.

In Israel, the prison service said it would begin vaccinating all inmates, following an outcry over an announcement from Public Security Minister Amir Ohana that Palestinian prisoners would be the last to get inoculated.

Israel has given at least one vaccine dose to more than two million of its citizens, a pace widely described as the world’s fastest per capita.

Spain has begun administering second doses to people who had already received the first at the end of December, mostly nursing home residents and care staff.

And in Norway, where 13 frail elderly people died after a first vaccine injection, the Medicines Agency said there was no cause for alarm after suggestions last week that the deaths could be linked to side effects.

“It is quite clear that these vaccines present very little risk, with the minimal exception of the most fragile patients,” agency official Steinar Madsen told public broadcaster NRK.

100 arrested in Amsterdam

Until vaccination is widespread, countries across the globe are still having to rely on lockdowns, curfews and social distancing to control the spread of the virus—particularly as new variants proliferate.

On Sunday a Belgian elderly care home said that a British strain of the coronavirus, which several studies suggest is up to 70 percent more contagious, had been detected in 111 residents and staff. Three residents have died.

Fears over the strain were cited as the justification for Austria’s decision to extend its third national lockdown by another two weeks until February 8.

After months of restrictions resentment is growing in some quarters, with around 100 people arrested Sunday at an anti-lockdown protest in Amsterdam.

Police used water cannon to clear the demonstrators, some of whom threw stones at the officers, Amsterdam city hall said in a statement.

Switzerland and Italy are tightening their restrictions from Monday and Britain will require all arrivals to quarantine and show negative tests. Oman meanwhile said it will close its land borders for up to two weeks.

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Who should get the first COVID-19 vaccines? Global study provides insights

Should people who already had COVID-19 step aside and give their place in the vaccine line to someone else? In some cases, yes, suggests new University of Colorado Boulder research.

“Our research suggests that prioritizing people who have not yet had COVID could allow hard-hit communities to stretch those first doses farther and get to some of the herd immunity effects sooner,” said Dan Larremore, a computational biologist at the BioFrontiers Institute whose team used mathematical modeling to determine how different distribution strategies could play out in cities around the globe.

He and lead author Kate Bubar, a graduate student in the Department of Applied Mathematics, teamed up with colleagues at the Harvard T.H. Chan School of Public Health and the University of Chicago, to do the study. They found that if, in general, saving lives is the objective, enabling people 60 and older to go to the front of the line works best. If reducing future infections is the goal, however, the 20- to 49-year-old crowd should get the first doses. In very few cases did vaccinating children first make sense.

For the study the researchers used demographic data—including age distribution and published contact rates amid and between different age groups—from countries around the world.

They also drew on information on the percentage of people who are already “seropositive” or previously infected with the virus in different locations.

Then they modeled what would happen in five different scenarios in which a different group got to be first in line: Children and teenagers, adults between the ages of 20 and 49, adults aged 20 or older or adults aged 60 or older. In the fifth scenario, there was no distribution strategy and anyone who wanted a vaccine got one while supplies lasted.

Results from the United States, Belgium, Brazil, China, India, Poland, South Africa and Spain are included in the paper.

Local circumstances matter

Different strategies worked better or worse, depending on each area’s population but a few findings jumped out.

“In the broadest array of scenarios, across countries, prioritizing adults 60-plus first was the best way to minimize mortality,” said Larremore. “If we want to go back to pre-pandemic behavior, giving the first wave of vaccines after healthcare workers to older adults is the way to go.”

That finding has already been used by global health experts to inform vaccine distribution strategies, with the World Health Organization and the Centers for Disease Control referencing the study in recommendations to prioritize older adults.

But after that, as individual states determine who’s next, the story gets more complicated.

“If transmission is rampant, and hospitals are being overwhelmed, then directly protecting those who are at the highest risk for severe outcomes is the best way to save lives and decrease the stress on our healthcare system,” said Bubar. “But, if instead, transmission is relatively low in a given area then prioritizing those who have the most contacts would be better— provided that the vaccine blocks transmission.”

In communities where COVID had already infected large swaths of the population, prioritizing those who are “seronegative” or did not already test positive for the virus, could allow health agencies to stretch the vaccine farther and save more lives.

For instance, in New York City where 27% of people have already been infected, vaccinating one in five people over age 60 could bring mortality down by 73%.

“But the city could get that same level of population protection by vaccinating just one in six older adults —if those without antibodies were brought to the front of the line,” said Larremore.

A COVID test before your shot?

Just how might a city go about identifying people who’d already been infected?

In cases where vaccine availability was scarce, the authors said, it might be worth having individuals take an antibody test before getting the vaccine. Alternatively, people who’d already had COVID-19 could just be asked to consider sparing their dose for someone who does not already have partial protection from the virus.

In a city like Boulder, however, where only a small percentage of people have already been exposed, testing people prior to vaccination might not yield enough benefit to be worth the effort.

“We hope that state governments will consider the local status of the epidemic in their decisions about who to prioritize,” said Bubar.

This work is under peer review, and the authors hope to publish in early 2021. Meantime, as vaccines become available and policymakers begin to make tough decisions influenced by emotions, ethics and the economy, the authors hope their work can provide some statistical footing.

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US rescinds global ‘do not travel’ coronavirus warning

The Trump administration on Thursday rescinded its warnings to Americans against all international travel because of the coronavirus pandemic, saying conditions no longer warrant a blanket worldwide alert.

The State Department lifted its level-four health advisory for the entire world in order to return to country-specific warnings. That move came shortly after the Centers for Disease Control and Prevention revised its COVID-19 travel advisory information. The CDC lifted “do not travel” warnings for about 20 locations but advised staying away from the vast majority of the world.

“With health and safety conditions improving in some countries and potentially deteriorating in others, the department is returning to our previous system of country-specific levels of travel advice in order to give travelers detailed and actionable information to make informed travel decisions,” the State Department said in a statement.

“This will also provide U.S. citizens more detailed information about the current status in each country,” it said. “We continue to recommend U.S. citizens exercise caution when traveling abroad due to the unpredictable nature of the pandemic.”

The State Department invoked the blanket warning against all international travel on March 19 as the pandemic spread. The revised country-specific travel advice is available at travel.state.gov. However, Americans still face travel restrictions across the world because of the uncontrolled spread of the coronavirus in the country.

Earlier Thursday, the CDC revised its travel guidance, saying the changes were driven by how the virus was spreading in different places and how well the public health and health care systems were functioning in dealing with new cases.

Seven places, including Thailand, Fiji and New Zealand, are in a low-risk group, according to the CDC, although officials there advised that certain people, such as older adults and those with certain underlying medical conditions, talk to their doctors before making the trip. For more than a dozen other locations, it had no precautions. Taiwan, Greenland, and Laos are on that list.

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