|Year : 2020 | Volume
| Issue : 6 | Page : 588-594
Strategies of India against coronavirus disease-2019: A strengths, weaknesses, opportunities, and threats analysis
Sitikantha Banerjee, Arvind S Kushwaha, Sujiv Akkilagunta, Kajari Bandyopadhyay, Jaya P Tripathy, S Kalaiselvi, Mubashshera F Khan, Ranjan Solanki, Pradeep R Deshmukh
Department of Community Medicine, AIIMS, Nagpur, Maharashtra, India
|Date of Submission||11-Sep-2020|
|Date of Decision||21-Sep-2020|
|Date of Acceptance||21-Sep-2020|
|Date of Web Publication||6-Nov-2020|
Arvind S Kushwaha
Department of Community Medicine, AIIMS, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
The coronavirus disease-2019 is a rapidly progressing pandemic that has jeopardized health infrastructure in many countries. India was to some extent successful to slow the rate of spread of disease by implementing multipronged strategies. Unfortunately, despite all efforts, the disease is rapidly progressing in India. The aim of this review is to critically appraise the strategies adopted by the Government of India to tackle this pandemic and to suggest suitable strategies for the current scenario. Strengths, weaknesses, opportunities, and threats analysis was done to assess the current scenario. Delayed and selective implementation of regulation on international travel, self-reporting of symptoms and undue reliance of thermal scanning for screening at the point of entry screening, poorly monitored home quarantine strategy with noncompliance, narrow testing strategy at the beginning with inability to capture asymptomatic case were some of the loopholes identified in the existing strategy. Improvement of inter-sectoral coordination by the development of Multi-disciplinary Epidemic Management board, involvement of AYUSH, judicious use of health manpower, and capacity development for indigenous production of personal protective equipment and other logistics, up-gradation of rural health facility and preparedness for second wave are the key recommendations.
Keywords: Coronavirus disease 2019, entry screening, quarantine, strengths, weaknesses, opportunities, threats analysis
|How to cite this article:|
Banerjee S, Kushwaha AS, Akkilagunta S, Bandyopadhyay K, Tripathy JP, Kalaiselvi S, Khan MF, Solanki R, Deshmukh PR. Strategies of India against coronavirus disease-2019: A strengths, weaknesses, opportunities, and threats analysis. Med J DY Patil Vidyapeeth 2020;13:588-94
|How to cite this URL:|
Banerjee S, Kushwaha AS, Akkilagunta S, Bandyopadhyay K, Tripathy JP, Kalaiselvi S, Khan MF, Solanki R, Deshmukh PR. Strategies of India against coronavirus disease-2019: A strengths, weaknesses, opportunities, and threats analysis. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Nov 25];13:588-94. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/588/300150
| Introduction|| |
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS), began in Wuhan, China, on December 31, 2019, and has rapidly spread worldwide, jeopardizing the health system of a large number of countries, including those of first world nations. The World Health Organization (WHO) announced the event as a Public Health Emergency of International Concern (PHEIC) on January 30, 2020. It was declared as a pandemic on March 11, 2020. Considering the gravity of the situation, the Government of India (GOI) started preparedness and containment strategies before its entry of infection in India on January 30, 2020, and is fighting against this ever-increasing pandemic with different innovative approaches. Despite all the interventions, the disease is progressing steadily with a cumulative total of 4,204,613 cases, 882,542 active cases, 3,250,429 cured/discharged, and 71,642 deaths as reported by the Ministry of Health and Family Welfare (MOHFW) as on September 7, 2020. In today's context, it is very pertinent to critically appraise the already adopted strategies, so that if required course correction can be made and lessons learnt for future. On the other hand, opinions of subject experts and program implementers are of utmost importance for betterment of the existing strategy, which could explore newer insight into the topic. The objective of this study is to review the strategies adopted by GOI to tackle this COVID-19 pandemic and suggesting suitable future strategies based on a strengths, weaknesses, opportunities, threats (SWOT) analysis of current scenario.
| Appraisal of Key Strategies Implemented till Date|| |
Regulation on international travel
First travel advisory was issued by MOHFW, GOI on January 17, 2020 stating, the travellers visiting China (in particular Wuhan city) to follow hygienic practices, monitor their health closely, and if sick, consult health authority. The next guideline came on January 25, 2020, where Government asked to avoid non-essential travel to China. Other advisories included, self-monitoring of health status and reporting if not feeling well, for the travellers to China. Self-isolation at home was advised for the travellers who fell sick within one month after return from China. By that time (January 25, 2020), the disease had spread in ten countries in across four WHO regions, including two countries of South-east Asia region-Thailand and Nepal, of which Nepal is India's neighboring country. Though, at this point of time, there were cases reported in 10 countries, and human-to-human transmission was documented outside China (Vietnam), no travel restrictions were imposed. First travel restriction was issued in India on February 5, 2020, where Indian travellers were advised to refrain from travelling to China. Existing visas for foreign nationals travelling from China were cancelled. It was also decided that people returning from China will be quarantined. Travel advisory was issued, but only toward China. By that time, 24 countries excluding China were affected by this epidemic, and India had flight connectivity with many of them. No flight restriction was imposed on any other country except China. Only travel advisories came into action, which hardly act as deterrent for most of the population. In next travel restriction order of February 26, 2020, travel restriction and home quarantine for returning passengers were issued for four more countries (Singapore, Republic of Korea, Islamic Republic of Iran, and Italy). The total number of countries affected was 35 by that time, including neighboring countries such as Nepal and Sri Lanka.
Cancellation of flight for China was initiated in the phased manner from January 31, 2020, after first positive case was isolated in India. All types of international commercial passenger aircraft were stopped in India from March 22, 2020 by which time already 2, 92,142 confirmed cases and 12,783 deaths had been reported in 172 countries and about a dozen territories (Travel advisory Issued on March 19, 2020). Different travel advisories issued and magnitude of disease at that time points are depicted in [Figure 1]. It is possible that the transmission of infection from other countries to India could have been largely prevented by more rigorous travel restriction at an early stage of pandemic, say when it was declared a PHEIC by which time about 9826 cases were reported globally with major contribution (9720) from China, and by which time, 20 countries had been affected and five regions of the WHO had become involved leaving little doubt about its pandemic potential. By this time, India had reported its first case and most neighboring countries reporting cases.
Screening at ports of entry
The strategy adopted at the arrival of international passengers at ports of entry was a self-declaration form and screening by a thermal scanner for fever. Thermal scanning was introduced in many countries, including India, for checking temperature of incoming travellers, to detect the signs of coronavirus-related fever. On January 17, 2020, MOHFW announced that international travellers arriving only from China will be screened with thermal scanners at only three airports, in Delhi, Mumbai, and Kolkata. On January 21, 2020, India expanded thermal screening to seven airports. However, by that date, the infection was reported from three more countries (Japan, Korea, and Thailand). Travellers from those countries were exempted from thermal scanning. Moreover, evidence shows that thermal scanning cannot accurately detect fever as it measures surface temperature of the skin. Its accuracy can be affected by human, environmental, and equipment variables. It is also limited by the fact that it measures skin temperature, not core body temperature. It was also reported that multiple thermal scanners reporting different temperatures for the same human body, and variation of temperature reported by same machine in a very short interval. Thermal scanners are ineffective in detecting infected individuals in the incubation period and those with subclinical illness. During the SARS epidemic, while Canada saw 251 cases of SARS, the country's intensive border screening failed to flag up a single one. A study conducted by London School of Hygiene and Tropical Medicine to quantify the effectiveness of thermal screening to detect COVID-19 showed that out of every 100 infected travellers taking a 12-hour flight, 42 would pass through both entry and exit screening undetected. The chance is more during the incubation period of the virus, which can be as long as 14 days. The WHO also does not recommend thermal screening, stating on a 10-Jan-2020 release: “It is generally considered that entry screening offers little benefit while requiring considerable resources.” In India, passengers in whom high-body temperature was shown by thermal scanning were considered to be having the symptoms of COVID-19 and quarantined. In this context, over-reliance on thermal scanning in detecting COVID-19 could lead to the non-detection of considerable number of positive travellers, and generation of a false sense of security among them as they got a negative result in scanning. Moreover, traveller who may be having fever may resort to using antipyretic drugs to escape detection and subsequent quarantine. Preferably, irrespective of fever or not all the passengers from countries arriving from or traveling through countries reporting pandemic disease should have been put under quarantine for minimum of 14 days and tested before their release. Both self-declaration and thermal scanner proved ineffective in checking the entry of incubatory carriers of infection.
On February 05, 2020, a quarantine policy was issued by MOHFW, stating that all passengers returning from China will be quarantined on return. Later on February 26, 2020, people travelling to Republic of Korea, Iran, and Italy were also included in the list, and number of countries kept on increasing in a phased manner. As per a report of March 19, 2020, a total of 1.4 million people have been screened and among them around 40,000 (2.85%) were quarantined. In India, travellers were advised home quarantine, which is seldom monitored. A good number of evidence from the newspapers and media reports depict that home quarantine was ignored by many people, who were found to be travelling not just within their locality but also to other places in India. Some of the travellers were able to escape surveillance due to the lack of sufficient information. The government struggled to enforce home quarantine rules in many places, thereby creating a threat for the community. It is recommended that a supervised institutional quarantine involving local police and administration could be a better alternative in this respect. Appropriate GPS and Geo-fencing-based technology could be used to ensure it. Strict disciplinary actions could be taken against people not following the rules by stringent application of Epidemic Disease Act. At the beginning of this pandemic in India, no traveller, returning from the affected countries, should have been allowed to go home without at least one test done preferably between 5 and 14 days. Rather they should be quarantined under direct supervision at prespecified places near airport. The government should have planned to develop quarantine centre a priori, when the country was disease free. Institutional quarantine requires more resources, yet in this context, it could have been the most cost-effective strategy to contain such small clusters, rather than allowing the infection to spread in the community. Moreover, suspected people should have been quarantined for a period of twice the maximum incubation period since knowledge on duration of incubation period was still scanty (i.e., 28 days).
Indian Council of Medical Research (ICMR) issued testing strategy on March 9, 2020, where testing for COVID-19 was restricted to only symptomatic close contacts of laboratory confirmed COVID-19 case and symptomatic persons with a travel history to affected countries within 14 days. Later on March 17, 2020, symptomatic health-care workers were also included for testing. Only 15 days after the introduction of this strategy, around 50 doctors and medical staff were found to be positive for COVID-19 in India. It can be concluded that there was unnecessary delay to include symptomatic health workforce for COVID-19 testing. At the beginning, there was no scope for testing asymptomatic contacts of positive cases, which were included for testing on March 20, 2020. This delay could have made its contribution in the spread of infection in the community. Later, during contact tracing, for each positive case, two asymptomatic cases were identified. This also reveals the importance of asymptomatic cases in spreading disease. Being a novel viral outbreak, the identification of asymptomatic cases could have been of utmost importance for research purpose, as that cohort could be followed up to understand disease progression and natural history of disease, which could shape the control strategy. At the start of outbreak, a highly sensitive and aggressive screening strategy should be used which is able to capture as many cases as possible, so that the chain of transmission could be broken by isolating early cases. Unfortunately, a very narrow testing strategy was used at the beginning, with high possibility of spread of disease through asymptomatic contacts or travellers or health-care providers. The countries initiating sensitive testing strategy (e.g., Vietnam, New Zealand) also showed better disease control till date, which also justifies the point. Further, intensive testing should be carried out in hot spots and containment zones so that disease spread can be prevented.
The first cohort of (say 50–100 or more) cases diagnosed as COVID-19 positive could have been extensively followed up for research purpose, as county specific data can be generated from them, and the findings used to control the outbreak later. They could be made compulsorily available for the research purpose, and same could have been mandated under epidemic disease act. Similarly, all recovering cases may also be listed for possible role in developing treatment using their serum.
A country-wide lockdown was initiated on March 24, 2020 in India (for 20 days), 53 days after the identification of first positive case, and 19 days after establishment of local transmission in the country. By that time, 360 confirmed cases and 7 deaths from 23 States/UTs were reported. Later, the lockdown was extended to May 31, 2020 in a phased manner, followed by gradual unlocking. It was a commendable step by GOI to flatten the epidemic curve, as evidence from countries who did not impose country-wide lockdown (i.e., Iran) faced adverse consequences. However, if this was initiated before local transmission was established, it would have prevented local transmission. While lockdown is an interim measure, we must look at sustainable strategies that also keep economic activity in mind. Besides, an exit strategy must be also simultaneously worked upon.
| Did the Lockdown Flatten the Coronavirus Disease 2019 Curve for Us?|| |
India was quick to react to the global COVID-19 scenario and implemented a nation-wide lockdown from March 25, 2020. Subsequently, lockdown was extended to May 03, 2020, otherwise named as lockdown 2.0. However, the big question is, did the lockdown 2.0 flatten the curve for us? We used www.covid19india.org for extracting data from February 2, 2020 when India had its 2nd case. When first lockdown was announced, our response was slowly building. Very few samples were being tested and few disruptions also occurred. Hence, we did not consider first lockdown for evaluation. For evaluation of the lockdown measure, we used two datasets of cumulative cases; first dataset was from February 2, 2020 to April 14, 2020 and second dataset was from February 2, to April 28, 2020. We fitted curves to both the data sets. February 2, 2020 was counted as 1st day.
For the first dataset, exponential curve was the best fit (R2 = 0.928) with the equation:
Number of cases = 0.4088 × EXP (0.1364 × Nth Day).
For the second dataset, cubic curve was best fitted with R2 value of 0.994. Equation for the cubic curve was:
Number of cases = −1824.067 + 370.274 × (Nth Day) − 15.881 × (Nth Day)2 + 0.183 × (Nth Day) 3
These equations were used to extrapolate the number of cases expected up to May 15, 2020.
Had there been no 2nd lockdown, we would have reached 50,000 cases on April 27, 2020. However, with lockdown in force, we reached this figure by May 7, 2020. Thus, we have delayed the development of 50,000 cases by 10 days. This implies that India had flattened the curve to an extent and the strategy with lockdown has been successful [Figure 2].
|Figure 2: Effect of 2nd lockdown on number of coronavirus disease 2019 cases|
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Apart from those mentioned above, GOI adapted different strategies to prevent local spread, community transmission, development of health infrastructure, and health system readiness. Development of fever clinic, referral strategy, defining containment zone, and sealing that area and contact tracing were some of them. Rigorous implementation of lockdown along with these strategies could have worked for this country to decrease the rate of spread of disease and thereby flattening the epidemic curve. Initiatives to send migrant labors to their residence were taken by the GOI from the 1st week of May 2020. There was evidence of unplanned and abrupt initiatives in their transportation with poor inter-state coordination leading to chance of transmission during travel amongst them and then taking infection to rural areas which were free of infection.
| Strengths, Weaknesses, Opportunities, Threats Analysis and Suggested Strategies|| |
The researchers had the opportunity to witness the health-care response to COVID-19 pandemic, while working as members of Rapid Response Team at Maharashtra state, with special focus on Mumbai, and Pune, which were the worst affected areas of India, during mid-March, 2020. The authors had a first-hand experience of interacting with stakeholders and witnessing field activities. Visits to testing laboratories, hospitals and quarantine facilities were made. A SWOT analysis of the public health response in combating COVID-19 was carried out by discussion with subject experts and program implementers through group discussion, in-depth interviews, and participant observation. The result is depicted in [Table 1]. The following strategies can be suggested for betterment of ongoing initiatives-based response gathered through SWOT analysis.
|Table 1: SWOT analysis of public health response in combating coronavirus disease 2019|
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Multiple guidelines issued from different government organizations (MOHFW, ICMR, and National Center for Disease Control etc.), which were rapidly changing, resulted in confusion among the front-line health workforce, especially at the beginning of this outbreak. It can be strongly felt that a Multi-disciplinary Pandemic Management board needs to be developed, the function of which should be to take timely decision (after discussion with all specialist bodies) and issue administrative orders from the single window. Involvement of AYUSH in cluster containment and other field activities, as well as screening corner of COVID-19 cases at the outpatient department could be useful strategy to increase health manpower. Existing doctors, nurses, paramedical staffs, etc., should be judiciously used with some workforce kept reserved. Supply of personal protective equipment (PPEs) should be adequate. India should develop the capacity for indigenous production of materials and logistics (especially PPE) which may be required for future outbreak.
Government is earmarking hotspots/clusters and buffer zones where active positive cases are found. Contact tracing and house-to-house survey, disinfection using fogging can be used. People from this area and those with a history of travel in these areas should undergo testing of COVID-19, and testing strategy should be modified accordingly. There is a high possibility of a secondary wave in later half of the year. Administration should start planning from now and make necessary arrangements to tackle the possible upcoming problem. Up-gradation of rural health infrastructure to handle the urban to rural spread and home quarantine of anyone coming from outside needs to be ensured at the village level. Emphasis should be given on community engagement. Prevention of disease-related stigma, discrimination, social marginalization, spread of rumour, myths, and misconception should be given utmost importance and for that active involvement of Panchayati Raj Institution members are vital. Community involvement and ownership in COVID control should be emphasized. Community volunteers could be used for active surveillance with special focus on high-risk group. It will be helpful in decreasing stigma and discrimination from the society. Apart from that appropriate information technology need to be used for establishing effective ambulance and bed management system. Other issues that need to be focussed are Clinico-administrative death audit, improving hospital infrastructure, utilizing cured/recovered cases for COVID or allied services and managing social media.
| Conclusion|| |
The most cost-effective strategy for combating a pandemic like COVID-19 should be prevention of entry of the virus in the country by early and strict travel restriction, well organized and monitored quarantine strategy and early rigorous testing of susceptible cases using a highly sensitive testing strategy. Existing strategies can be strengthened by improving inter-sectoral coordination through the development of a pandemic management board, judicious use of health workforce, up-gradation of rural health facility to tackle rural spill over of infection, and preparedness for second wave.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]