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GUEST EDITORIAL
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 119-122  

COVID-19: The quagmire of policies and responses


Department of Community Medicine, AFMC, Pune, Maharashtra, India

Date of Submission09-Dec-2020
Date of Decision23-Dec-2020
Date of Acceptance23-Dec-2020
Date of Web Publication3-Mar-2021

Correspondence Address:
Arun Kumar Yadav
Department of Community Medicine, AFMC, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_701_20

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How to cite this article:
Faujdar D S, Yadav AK. COVID-19: The quagmire of policies and responses. Med J DY Patil Vidyapeeth 2021;14:119-22

How to cite this URL:
Faujdar D S, Yadav AK. COVID-19: The quagmire of policies and responses. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Apr 13];14:119-22. Available from: https://www.mjdrdypv.org/text.asp?2021/14/2/119/310715




  International Response Top


The first news of an atypical viral pneumonia was picked up by the World Health Organization (WHO's) Country Office in the People's Republic of China through a media statement by the Wuhan Municipal Health Commission from their website as early as December 31, 2019. Later, in the 1st week of January 2020, Chinese officials provided information to the WHO on the cluster of cases of “viral pneumonia of unknown cause” identified in Wuhan. A detailed information about a cluster of cases of pneumonia of unknown cause was shared by the WHO through the IHR (2005) Event Information System, which is accessible to all Member States.[1]

By the 2nd week of January, the WHO reported that Chinese authorities have determined that the outbreak is caused by a novel coronavirus following which the WHO published a comprehensive package of guidance documents for countries, covering topics related to the management of an outbreak of a new disease. The first travel advise to reduce the general risk of acute respiratory infections while traveling in or from affected areas (Wuhan City) was released. However, the WHO did not recommend any specific health measures for travelers. By the end of the 2nd week of January 2020, the first imported case of the novel coronavirus was reported outside of the People's Republic of China by the Ministry of Public Health in Thailand. During this time, the possibility of limited “human-to-human transmission” was raised but could not be confirmed. The first epidemiological alert on the novel coronavirus was sounded on January 16 by the Pan American Health Organization/WHO Regional Office for the Americas.[1] Initially, as there were not much clarity on human-to-human transmission, the usefulness of medical mask by the general public and transmissibility from asymptomatic individuals remained questionable. Among all the confusions about the disease, it took 1 month for the WHO from the initial report to take a decision on declaring it as a public health emergency of international concern on January 30, 2020. It took another 1½ month for the WHO to declare the COVID-19 outbreak as a pandemic on March 11, 2020. Since then, the WHO has taken out many technical guidance from transmission, disinfection, quarantine, contact tracing, sero survey, diagnostics, etc., to guide the Member States. There were some good innovation and initiatives taken up by the WHO such as compiling all publications on COVID-19, starting training modules specific to COVID-19, and providing daily updates on the spread of COVID-19.


  Indian Response Top


Prelockdown phase

The first part of response was restricted to prevention of imported cases and the subsequent spread in India. India issued its first advisory as early as on January 17 to restrain people from traveling to affected areas in China. Although the first case of coronavirus was detected in India on January 30, 2020, as a preemptive measure, thermal screening was started for passengers traveling from China and Hong Kong from January 18, 2020. Further advisories restricting travel to the affected countries were issued as more cases were reported from the countries across the world. It was only on March 4, 2020, that universal screening of all international flights and quarantine or isolation at home or in hospital based on screening and risk profile was started. On March 11, a quarantine of 14 days was made compulsory for travelers returning from the affected countries. International flights in India were suspended on March 22, 2020.[2]

Lockdown phase

The PM of India announced a Janata Curfew on March 23 which was followed by a lockdown of 21 days and the same was extended for a total of 68 days in four phases till May 31 [Figure 1]. During the lockdown, areas were divided into green zones if no case was reported in the last 21 days, red zones with high caseloads accounting for 80% of cases in the state, and rest as orange zones, with restrictions varying as per their status. Although the pace of rise in cases remained slow despite the lockdown, the cumulative cases reached 0.19 million by May 31, 2020. The lockdown was considered hastily prepared, which led to severe economic losses and job loss for people, with large migration of workers from urban areas to their hometowns ensued.[3] The government allowed gradual unlocking with limited movement, allowing trains to ply migrant people through Shramik trains.[4] The Indian economy shrunk by 23% during its first quarter.
Figure 1: Daily new cases during the lockdown and unlock phase

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Postlockdown phase

The unlocking went on in a phased manner with a new guideline issued on the 1st of every month starting from June. During unlock, the interstate and intrastate restrictions were removed, but power to regulate the movement remained with the state and union territories. Private offices were allowed to operate in all areas except the containment zones. Wearing face cover was made compulsory in public places; in workplaces; and during transport. Social distancing of 6 feet was advised in public places, and gatherings during public events were restricted to fifty persons and during funeral to twenty persons. Public places such as malls, restaurants, and religious places were allowed to function with caution.[5] However, even during unlocking, the restrictions continued in the containment zones which were identified by the states/districts from a time-to-time basis based on the active cases reported from the areas. The active cases peaked in the mid-September with about 1 million cases and later the active cases declined to 0.45 million by the end October with a flattening of curve.[6] During the ensuing winters and festive seasons observed in the country, a second wave has been contemplated and caution is advised as most of the economic activities have opened up and the COVID fatigue seems to be set up among people.


  Quarantine, Testing, Admission, and Discharge Policy Top


Initially, very little was known about the novel coronavirus, and the epidemiology of the disease was unclear. As imported cases got reported from various countries in the late January 2020, the policy in India focused on home quarantining people for 28 days who had a travel history to COVID-affected countries or were close contacts of a confirmed case and at that time, only symptomatic cases were tested using real-time polymerase chain reaction (RT-PCR) as transmissibility from asymptomatic individuals was not known.[7] As more evidence on the incubation period came pouring in March 2020, home quarantine policy was revised to 14 days of quarantine for those living in the same household or had physical contact or within 1 m of the COVID case.[8] At the same time, the testing policy was revised to include all symptomatic cases with international travel, contact with a case, health-care workers (HCWs), severe acute respiratory illness patients, and asymptomatic high-risk individuals.[9] The discharge policy was based on a clear chest radiograph and two negative samples taken 24 h apart after a minimum 14 days of isolation.[10] The government introduced rapid antibody test as a screening tool as a point-of-care test, but these tests were highly unreliable and many states refused to use them.[11] Moreover, there were discrepancies in kits approved by the DCGI and ICMR. In the early May, the evidence emerged that the virus loses infectiousness after the 8th day of illness and virus could not be cultured from samples taken from mildly symptomatic individuals after the 8th day of disease although the RT-PCR test may remain positive for varying periods.[12] The Indian government revised its policy that an infected person can be discharged after 10 days without testing if he/she has no fever for 3 days, but as a precautionary measure, the patient can be advised to remain in home isolation for a further 7 days. Only severe cases should be discharged after a negative RT-PCR.[13] Thus, the discharge policy was changed from a test based to symptomatic based.

With increased local transmission reported from various parts of the country, the testing strategy was further revised to include all symptomatic cases from containment zones, hospitalized patients, and returnee/migrants with Influenza like illness.[14] As the resources fell short and there was growing evidence that very little care is required for asymptomatic or mild cases, home isolation was allowed for asymptomatic very mild and presymptomatic cases.[15] A severe shortfall was reported in HCW availability as many of them got exposed during work and were required to be quarantined. Therefore, the quarantine period for HCWs was revised to 7 days after which individual was to be tested and the decision to continue quarantine for a further 7 days for HCWs who were found negative was left with the HOD/hospital subcommittee based on their risk assessment.[16] The WHO called for increased testing and contact tracing to control the spread and asked the member countries to follow the policy of test, trace, and treat. In order to increase the testing capability, molecular diagnostic methods such as TrueNat and CB-NAAT were permitted as confirmatory tests and rapid antigen test (RAT) was allowed as a point-of-care test. The RAT has high specificity but low sensitivity, so it was advised that RAT should be used where pretest probability is high and in the case of negative test the sample should be retested with RT-PCR.[17] The travel policy for international travel was revised later on May 24; initially, only special flights were allowed to operate and it was only in the later part of July that routine international flights were resumed. Under the policy, the persons coming in international flights were institutional quarantined for 7 days followed by testing, and if negative a further 7 days of quarantine was allowed to be undertaken at home.[18] Later, it was revised to any person having a RT-PCR-negative report up to 72 h prior to travel will be exempted from institutional quarantine.[19] The quarantine policy for domestic travel was left to the state.[20]


  Review Top


The policies both at the international and national level remained dynamic, as not much was known about the novel coronavirus. The policies were framed to keep a balance between the available scientific evidence, quality of life, and economic impact. Initially, the Indian government focused on gaining time to build up the resources and keep the disease curve flattened so that the health system does not get overwhelmed. The predictive models forecasted a high number of cases and mortality, leading governments to implement drastic measures such as whole-country lockdown. With time, as understating of the disease improved and as falling economies were required to be bolstered, unlocking of activities was done in a graded manner. The countries around the world followed different models for containment of the disease with varying successes and even in places where initial success was reported, the disease rebound had occurred as economies tried to open up. At present, no model can be deemed as perfect and with unfolding of new knowledge about the disease now, a more balanced evidence-based decision can be undertaken.

As the country eagerly awaits the licensing of vaccines against COVID-19, many of which have shown efficacy of up to 90%,[21] the wearing of face mask, social distancing, and hand hygiene have to be continued, which is now considered a new normal. However, many experts have warned that vaccines are no panacea. Mass vaccination drive without proven long-term safety may have its own problem. The WHO has made a value-based framework to prioritize persons for vaccination. However, distribution and making the vaccine to reach prioritized persons remains a massive task, especially in all developing countries.

Since there was uncertainty because of the novel disease among the medical fraternity, the response to COVID-19 became an administrative matter. With the government relying on special acts and powers to fight the pandemics, the lack of preparation and investment on public health became acutely visible in these times. In this topsy-turvy journey, may be future would only tell what part was right or wrong, but at every phase of the pandemic, the decision was taken hopefully keeping in mind the larger public good.



 
  References Top

1.
World Health Organization. Timeline of WHO's Response to COVID-19. Available from: https://www.who.int/news/item/29-06-2020-covidtimeline. [Last accessed on 2020 Nov 01].  Back to cited text no. 1
    
2.
Ministry of Information & Broadcasting, GOI. India's Response to COVID Outbreak; 28 March, 2020. Available from: https://pib.gov.in/PressReleasePage.aspx?PRID=1608727. [Last accessed on 2020 Nov 01].  Back to cited text no. 2
    
3.
The Lancet. India under COVID-19 lockdown. Lancet 2020;395:1315.  Back to cited text no. 3
    
4.
Ghosh A, Nundy S, Mallick TK. How India is dealing with COVID-19 pandemic. Sens Int 2020;1:100021.  Back to cited text no. 4
    
5.
Ministry of Home Affairs, GOI. Guideline for Reopening; 30 September 2020. Available from: https://www.mha.gov.in/sites/default/files/MHAOrderDt_30092020.pdf. [Last accessed on 2020 Nov 01].  Back to cited text no. 5
    
6.
Ministry of Home Affairs, GOI. Guidelines for Surveillance, Containment and Caution; 25 November 2020. Available from: https://www.mha.gov.in/sites/default/files/MHAOrder25112020.pdf. [Last accessed on 2020 Nov 01].  Back to cited text no. 6
    
7.
Ministry of Health and Family Welfare. Guidance document for POEs, States, and UTs for Surveillance of 2019-nCoV; 25 January 2020. Available from: https://www.mohfw.gov.in/pdf/Guidance%20 document%20- %202019-nCoV.pdf. [Last accessed on 2020 Nov 01].  Back to cited text no. 7
    
8.
Ministry of Health and Family Welfare. Guideline for Home Quarantine; 11 March 2020. Available from: https://www.mohfw.gov.in/pdf/Guidelinesforhomequarantine.pdf. [Last accessed on 2020 Nov 01].  Back to cited text no. 8
    
9.
Ministry of Health and Family Welfare. Testing Strategy for COVID-19 in India; 9 March 2020. Available from: https://www.mohfw.gov.in/pdf/ICMRstrategyforCOVID19testinginIndia.pdf. [Last accessed on 2020 Nov 01].  Back to cited text no. 9
    
10.
Ministry of Health and Family Welfare. Discharge Policy of nCoV Case; 17 March 2020. Available from: https://www.mohfw.gov.in/pdf/Corona%20Discharge-Policy.pdf. [Last accessed on 2020 Nov 01].  Back to cited text no. 10
    
11.
Ministry of Health and Family Welfare. GOI. Advisory to Start Rapid Antibody Based Blood Test for COVID-19. April 20. Available from: https://www.mohfw.gov.in/pdf/Advisory&StrategyforUseofRapidAntibodyBasedBloodTest.pdf. [Last accessed on 2020 Nov 01].  Back to cited text no. 11
    
12.
Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020;581:465-9.  Back to cited text no. 12
    
13.
Ministry of Health and Family Welfare. GOI. Revised Discharge Policy for COVID-19; 8 May 2020. Available from: https://www.mohfw.gov.in/pdf/ReviseddischargePolicyforCOVID19.pdf. [Last accessed on 2020 Nov 05].  Back to cited text no. 13
    
14.
Ministry of and Family Welfare. GOI. Strategy for COVID-19 Testing in India (Version 5); 18 May 20. Available from: https://www.mohfw.gov.in/pdf/Revisedtesting guidelines.pdf. [Last accessed on 2020 Nov 05].  Back to cited text no. 14
    
15.
Ministry of and Family Welfare. GOI. Revised Guidelines for Home Isolation of very mild/pre-symptomatic/asymptomatic COVID-19 cases; 2 July 20. Available from: https://www.mohfw.gov.in/pdf/RevisedHomeIsolationGuidelines.pdf. [Last accessed on 2020 Nov 05].  Back to cited text no. 15
    
16.
Ministry of and Family Welfare. GOI. Advisory for Managing Health Care Workers Working in COVID and Non-COVID Areas of Health the Hospital; 18 June 20. Available from: https://www.mohfw.gov.in/pdf/updatedAdvisoryformanagingHealthcareworkersworkingin COVIDandNonCOVIDareasofthehospital.pdf. [Last accessed on 2020 Nov 05].  Back to cited text no. 16
    
17.
Ministry of Health and Family Welfare, GOI. Advisory on Strategy for COVID-19 Testing in India (Version VI); 4 September 2020. Available from: https://www.mohfw.gov.in/pdf/AdvisoryonstrategyforCOVID19TestinginIndia.pdf. [Last accessed on 2020 Nov 05].  Back to cited text no. 17
    
18.
Ministry of Health and Family Welfare, GOI. Guidelines for International arrivals; 24 May 2020. Available from: https://www.mohfw.gov.in/pdf/Guidelinesforinternationalarrivals.pdf. [Last accessed on 2020 Nov 10].  Back to cited text no. 18
    
19.
Ministry of Health and Family Welfare, GOI. Guideline for International Travelers; 5 November 2020. Available from: https://www.mohfw.gov.in/pdf/05112020Guidelinesforinternational arrivals.pdf. [Last accessed on 2020 Nov 10].  Back to cited text no. 19
    
20.
Ministry of Health and Family Welfare, GOI. Guidelines for Domestic Arrivals; 24 May 2020. Available from: https://www.mohfw.gov.in/pdf/Guidelinesforinternationalarrivals.pdf. [Last accessed on 2020 Nov 10].  Back to cited text no. 20
    
21.
Mahase E. COVID-19: Vaccine candidate may be more than 90% effective, interim results indicate. BMJ 2020;371:m4347.  Back to cited text no. 21
    


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