key: cord-0850027-82o75tet authors: Kaushik, G.; Kaushik, S.; Mantri, S.; Kalbande, D.; Chaudhari, B. N. title: Analysis of Effectiveness of Quarantine Measures in Controlling COVID-19 date: 2020-04-26 journal: nan DOI: 10.1101/2020.04.21.20074245 sha: dc7726fbace94aca0f29a112cafe36198734b13a doc_id: 850027 cord_uid: 82o75tet COVID-19 has created an interesting discourse among the people of the world particularly regarding preventive measures of infectious diseases. In this paper, the authors forecast the spread of the Corona virus outbreak and study how the reduction of transmission rates influences its decline. The paper makes use of the SIR (Susceptible Infected Recovered) Model which is a deterministic model used in the field of epidemiology-based on differential equations derived from sections of the population. The Basic Reproduction Number (Ro) represents the criticality of the epidemic in numeric terms. Forecasting an epidemic provides insights about the geographic spreading of the disease and the case incidences required to better inform intervention strategists about situations that may occur during the outbreak. Through this research paper, the authors wish to provide an insight into the impact of control measures on the pandemic. By drawing a comparison of three countries and their quarantine measures, observations on the decline of the outbreak are made. Authors intend to guide the intervention strategies of under-resourced countries like India and aid in the overall containment of the outbreak. Infectious disease outbreaks result in huge losses. The 1918 Spanish Flu caused around 20,000,000 deaths (1) . According to (2) , approximately 3.3 billion people throughout the world are at the danger of contracting malaria, and a patient dies due to malaria every 60 seconds. Tuberculosis has become the deadliest disease as its death rate crossed that of AIDS. In South Africa, about 80% of the people suffer from latent tuberculosis with 450,000 confirmed cases of tuberculosis in 2013 (3; 4) . At the time of this research, 234,073 people had been confirmed to be infected by COVID- 19 . Six new regions have reported cases of COVID-19 (5) . The total number of deaths touched 9840 (5) . In this paper, estimation of COVID-19 cases is done for Italy, Iran and India. Followed by analysis of intervention measures enforced at different stages in China, Italy and Iran. The insights drawn aim to identify the best possible approach to control the COVID-19. developed this symptom during hospitalization and 67.8% had a cough. Only 3.8% presented with Diarrhea. The paper also defined the mean incubation period at 4 days. Of the 1099 patients, 926 patients were classified non severe and 173 patients were classified severe, on admission. The severe category of patients belonged to an older age group and had a higher prevalence of underlying illnesses as compared to non-severe patients. According to research on inanimate surfaces, human corona viruses have the capability to be infectious for up to 9 days at room temperature, however, at temperatures greater than or equal to 30 C, they are infectious for a shorter period (7) . Research on the effect and feasibility of containment measures has been carried out for the H1N1 outbreak in (8) by Brian J Coburn et al. and in (9) by Joel Hellewell et al. In (9) the paper assumed that isolation could prevent transmission completely. Up to a 1000 simulations were run by considering varying values of Ro, total cases that existed initially etcetera. It considered two factors: infections resulting from a single individual and transmission that occurred before symptoms appeared. The research agreed that it is crucial to quickly follow the onset of symptoms by isolation. The isolation delay factor, as well as the number of cases to begin with, had a major influence in containing the outbreak. Subclinical infections might go unreported and cause a surge in transmissions. The SIR Model which was introduced for modeling influenza came forth in the early 1900s (10) . The paper (8) describes an extension of the SIR model with three new behavioral interventions-Q s , Q e , and Q i . Where Q s represents susceptible people that All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. can be quarantined, Q e is asymptomatic and not yet infectious individuals that are quarantined and Q i are infected individuals that can be quarantined once determined as such. Discussions on how behavioral interventions that involve social distancing measures such as the closure of schools, quarantine or travel-based restrictions reduced the number of cases of influenza in (11; 12; 13; 14; 15; 16) . Some papers evaluate a combination of behavioral and biomedical interventions and determine them extremely effective (12; 15; 16) . There is agreement among all papers and how implementing such strategies early on in the epidemic is the crucial part. The paper makes use of the SIR Model to forecast the progress of COVID-19. An SIR Model is a mathematical and an epidemiological model which generates the number of infections theoretically during a certain time period. The model derives its name from the coupled equations related to the susceptible population S(t) , the population infected I(t) , and the population that has recovered R(t). An individual who is susceptible can become infected. An infected individual may recover or die. But an infected individual cannot become susceptible again as inFigure 1. Population flow for SIR Model Three differential equations make the SIR Model. They are as follows (17): All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Where t is the time, S(t) represents the population susceptible to infection at t, I = I(t)represents the population infected at t, R(t) represents the population that has recovered at t . β denotes the contact rate, and 1/ γ denotes the average infectious period. N denotes total population size. From the above three equations, we get a total population size N governed by the equation: i.e. For SIR Model, R 0 (Basic Reproduction Number) is obtained from the following equation: The graph in the Figure 2 shows how the disease will progress in Italy according to the SIR model. This shows that after 55 days from 20 th February 2020, specifically on 10 th April 2020, the infection would reach its peak and infect around 31 million people in Italy, if no quarantine measures are implemented. The model predicted the value of confirmed cases on 20 th March 2020 with an accuracy of 86%. Considering the equations of the SIR model, Equations (1), (2) and (3) Therefore, Equation (2) becomes, All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 26, 2020. . https://doi.org/10.1101/2020.04.21.20074245 doi: medRxiv preprint Representation of the Susceptible, Infected and Recovered population in Italy from 20 th February 2020. Where η ≡ ( β N − γ) By integral calculus we have, Thus, Equation (6) shows us that the growth of the epidemic will initially be exponential as in For forecasting the number of confirmed cases in Iran for 19 th March 2020 and 20 th March 2020, Equation (??) is used. Inspection ofFigure 4 reveals the exponential growth of the number of cases in Iran. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 26, 2020. A discussion of the different factors that influence a quarantine and the necessary precautions that must be taken for it are presented. We then delve into the measures put in place in China, Italy and Iran to determine how effective these strategies have been. The ability to anticipate the possible spread of the outbreak is important to devise strategies for effective resource allocation as well as implementing various intervention policies in favor of public health. For this, identification of appropriate factors is necessary. Consideration of population density, geographic land area, and spatial demographic data is critical so as to curb the growth of the outbreak. Considering the mobility of humans is essential All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. in understanding the spread of the disease geographically but unfortunately, the data regarding the dynamics of mobility on spatial and temporal scales limit the accuracy of the forecast. Environmental and host susceptibility can help interpret the potential drivers of the infection and can improve the efficiency of forecasting and implementing policies of public interest (18) . A quarantine of 14 days must be taken by any person that comes in contact with a laboratoryconfirmed case of infection. People in quarantine should be placed in spacious rooms with adequate ventilation facilities. Ensuring that people who are quarantined practice proper hand hygiene should be done. Environmental disinfection processes should be carried out consistently. Quarantined people should be examined daily (19) . All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 26, 2020. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. To prompt citizens to go see a doctor in case of fever or cough, some provinces temporarily banned the sale of fever and cough medicines in retail pharmacies. Hubei didn't allow the sale All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Within the next 2-3 days, various provinces relaxed their public health emergency levels from level 1 to level 2 and 3. Wuhan relaxed its quarantine measures by allowing people to leave the city on certain conditions with continuous monitoring. People of Wuhan were still asked to take their temperature twice a day and report if it was higher than 99.1F. Those who had recovered from COVID-19 were put on a 14-day quarantine. By the end of February, various provinces began screening people coming from countries like Japan, South Korea etc. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 26, 2020. . In March, the number of new cases saw a huge drop and on 2 nd March 2020, Wuhan closed its first hospital that was constructed for the epidemic. Wuhan closed 10 more of its COVID-19 hospitals. The current scenario is such that there are less than 10 new cases everyday. Their effective quarantine measures in the month of February have brought down their percentage increase in new cases to less than 0.1%. The first cases of COVID-19 were confirmed in Italy on 31 st January, travelers from Wuhan. The major reason for this was that initially, only patients coming from red zones were tested. But once all patients with symptoms were tested the number of cases in Italy increased. The more crucial period, was when asymptomatic-people didn't take necessary precautions and transmitted the disease unknowingly. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. In Italy, the number of infected people and deaths were increasing at an alarming rate Figure 7 . This can be attributed to the fact that Italy is marked with the second largest percentage of old people globally with as many as 28% of Italians falling in the age group of 60 and above. COVID-19 is known to be more lethal for older people due to their weaker and compromised immune systems. But the rate of increase of reported cases in Italy is worrisome. It highlights the measures that should have been taken by the Italian government such as conducting enough All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 26, 2020. . https://doi.org/10.1101/2020.04.21.20074245 doi: medRxiv preprint tests during the early stages to contain COVID-19. Earlier detection of cases could have led to earlier isolation. Additionally, the red zones in Italy were not well-managed, further spreading the disease. The Italian government couldn't prepare their medical resources. Many medical facilities were operating at full capacity and therefore were unable to treat each and every patient. If Italy had been more proactive with testing people in the early days of February, then the situation could have been a lot better. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 26, 2020. . https://doi.org/10.1101/2020.04.21.20074245 doi: medRxiv preprint that this shrine along with a few others was closed. Protests followed outside the shrine and servants had to drive out the protesters. By 22 nd February, all concerts and cultural/ sports events were canceled. The Universities and Educational institutions were also closed in various provinces. On 26 th February, the president announced their plans to Quarantine only the infected individuals and not entire provinces. Friday prayers were canceled in Tehran and other gravely infected regions. The number of reported cases had grown to 978Figure 8 of which 23 were members of the Parliament. By the next day, (2 nd March) this number became 1501. On 3 rd March, Iran temporarily released more than 54,000 prisoners due to the spread of the coronavirus in crowded jails and announced plans to mobilize 300,000 soldiers/ volunteers. Several countries including, Singapore, India, New Zealand placed restrictions on travel to Iran. On 5 th March, 591 new cases were observed. This was followed by the parliament being suspended and international travel being banned for government officials. There was an announcement of plans for checkpoints between different cities to limit travel. Schools and universities were closed 28th March. According to a report on 7 th March, 1669 had recovered and 16000 had been hospitalized as suspected positives for testing purposes. That Iran was making tremendous progress at its hospitals, with facilities made available for treatment in every province was reported by a WHO representative placed in Iran. On 9 th March, up to 70000 prisoners had been released temporarily. By 14 th March, cases had risen to 12,729 and deaths to 611. A statement was made by the supreme leader on 19 th March to forbid unessential travel. 85000 prisoners were released. The celebration of the traditional fire festival of Persians was forbidden. The economic sanctions make Iran's health care system weaker and unable to deal with the outbreak. The public resentment towards containment measures and distrust of officials resulted in unsuccessful containment efforts. The clerics objected to a lock down and parts of the public were involved in acts of defiance. The forecasted values of confirmed cases for India and Iran are shown in Table 1 and Table 2 respectively. The accuracy of forecasting the confirmed cases in India and Iran obtained is 96.11% and 95.23% respectively. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Although China Implemented quarantine measures a little late, it made sure to correct the fallout by imposing strict regulations and taking the necessary steps. The release of medical resources as required reduced the infected population of China to a huge extent. The epicenter of the outbreak has now shifted to Italy with Iran becoming the third most affected country as declared by WHO. From the management of medical resources in Italy, one can infer that this outbreak must be taken seriously with more emphasis on precaution than cure. Considering how infectious COVID-19 is, it is important to not underestimate the epidemic and take the quarantine measures at the right time. India currently has more than 150 cases (as of 20 th March 2020). The first case was reported in Kerala on 30 th January, a student from Wuhan. Iran became a contributor in spreading the disease to other countries as it did not have any strict regulations on international travel. India has rightly placed travel restrictions on all international flights. To conclude, the right approach to decline of the COVID-19 outbreak lies heavily on quarantine measures imposed. Once screened, the tracing of contacts of the infected is crucial. This may be resource-intensive in a heavily populated country such as India. The next step is to ensure isolation of the infected and testing of their contacts. With the right resource planning and public collaboration, India can surely contain this outbreak. The data set made use of in this paper is from WHO. It is also used by JHU in the interactive Map on their website. It is available to the public. This data set encompasses the cases All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 26, 2020. Updating the accounts: global mortality of the 1918-1920 Spanish influenza pandemic Plasmodium ovale: a case of notso-benign tertian malaria The Global Burden of Respiratory Disease. 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Proceedings of the National Academy of Sciences Estimation of the final size of the Real-time Epidemic Forecasting: Challenges and Opportunities COVID-19). WHO, Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19 The authors declare that there is no conflict of interest regarding the publication of this paper.