|Ahead of print publication
Public health action for controlling COVID-19 pandemic in India: Way forward
Arvind Singh Kushwaha, Sitikantha Banerjee
Department of Community Medicine, AIIMS, Nagpur, Maharashtra, India
|Date of Submission||16-Oct-2020|
|Date of Decision||19-Nov-2020|
|Date of Acceptance||19-Nov-2020|
Arvind Singh Kushwaha,
Department of Community Medicine, AIIMS, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
The ongoing Covid-19 pandemic has not only crippled the already overburdened public health system of India, but also adversely affected its economy. Due to gross difference in pandemic stage, geographical variation and socio-demographic diversity in different parts of India, a 'fit-for-all' strategy will not be suitable for managing ongoing pandemic. It necessitates the rationale to develop a decentralized district or city specific action plan. This article brings forth how strategies could be modified based on disease load in different parts of the country.
Keywords: India, pandemic, public health, way forward
| Introduction|| |
The COVID19 pandemic, caused by severe acute respiratory syndrome coronavirus 2, initiated in Wuhan, China, and rapidly spread worldwide. India is one of the worst affected countries in this pandemic till date, not only because of the mortality and morbidity but it also resulted in profuse economic and social impact. The Pandemic has been for around 6 months and gradually much of the characteristics of the virus and disease have become known with still some grey areas. The basic strategy of “Test, Track, and Treat” remains true even today. From the beginning of pandemic Government of India implemented a “fit-for-all” strategy all over India with marginal state-wise difference. It is evident from state and district stratified data that different areas in different stages of pandemic. Hence, it was strongly felt that decentralized planning is of utmost importance in this crucial time point. What is important is to weave this principal strategy into our unlockdown strategy seamlessly in regions with different stages of pandemic.
| Situation Analysis|| |
Till October 1, 2020, the total number of active cases and deaths in India were reported as 940,705 and 98,678, respectively. It was observed that in this country majority of infected people are either asymptomatic or having mild symptom, with good recovery rates. Mortality in India is also rather low compared to western countries. By and large, mortality is concentrated among certain vulnerable groups (i.e., those aged >65 years, or with chronic diseases, particularly type 2 diabetes, ischemic heart disease, hypertension, chronic obstructive pulmonary disease, and Malignancies) with pediatric age group being largely unaffected. Transmission mainly occurs by droplets in close contacts and in enclosed spaces, where as it is not significant in outdoor settings and through fomites. Population density is a key factor in the transmission of infection, which is reflected by its urban predominance.
The management of pandemic initially centrally controlled is now state-controlled. Lockdown was effective in retarding the speed of pandemic, and to build up the capacity of health-care sector. Unfortunately, lot of scare, stigma, and fear prevail in community due to administrative fallout with minimal community involvement. Majority of the population still remains susceptible and eventually, most will get infected. There has been a significant change in people's behavior by the majority of population. The public has generally understood the concept and practicing nonpharmacological interventions like “Mask,” “Social distancing” and “hand sanitization.” On the other hand, pathology and treatment of disease are much better understood now, and the primary goal is now to “Prevent deaths” rather than controlling infection in most of the high burden settings.
| Principles for Strategies to Control COVID-19|| |
Public is in favor of resuming economic activity, so all measures have to be in concordance with the aim of “unlocking” and “economic revival.” Continued lockdown will only result in diminishing dividends, which is unacceptable in this stage. Measures need to be taken to avoid “explosion” of cases overwhelming the capacity by keeping incidence in check to a “manageable” level. All measures need to be adopted to prevent “mortality” due to corona. Care of “Non-COVID” cases (Dengue, Malaria, Influenza) as also for preventive programs (as Immunization) should not get neglected. Health care establishments (HCEs) need to be kept functional and open. Further strategy need to be developed based upon epidemic staging, different strategies for different places in different stages of pandemic. Stringent measures need to be de-escalated to reduce fear and stigma. Community centered approach and ownership (using recovered cases) are key to disease control. Policy decisions need to be taken after consulting medical/health experts. The system must look at the weaknesses and threats to take care of them and catch opportunities coming by.
| Recommendations|| |
After thorough discussion with public health specialists and epidemiologists, it was suggested that the districts could be divided into four zones based on the risk of transmission. Details of strategies that need to be adopted in those zones are described in [Table 1]. Some common recommendations are discussed here.
|Table 1: Suggested strategies in different categories of districts based on risk of transmission|
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All districts must undertake district-level facility-based surveillance for COVID-19 by point of care (POC)-antigen test in low and high-risk populations as mandated.
It must be undertaken at the district level, which can guide in the development of the strategy. It can be done periodically based on the stage of the epidemic in a city. Essential services workers need to be targeted. Further, carrying out serosurveillance in containment areas can depict the spread of infection, which can assist in changing strategy. Recent news on seroprevalence points to 15%–40% in the Urban settings., Target should be to slowly open up the young population in colleges and universities based on herd immunity developed in that community.
| Testing|| |
With the epidemic well established as local transmission in clusters or community transmission in urban areas and sufficient testing facilities available, it is important that testing (by POC, reverse transcription-polymerase chain reaction [RT-PCR] or antibody test) must be opened up to every citizen, at least in private laboratories. This will not only lead to increased uptake of testing (in line with the test, track, treat policy) but also instill confidence in the public, which feels getting a test is not easy. This will also help non-COVID patients to seek access to healthcare, which is often denied in the absence of a test. This POC-antigen test must be made available at the Primary Health Center/Community Health Centre/Rural Hospitals. Those who are tested by POC tests and RT-PCR tests and are negative may be offered antibody testing. No asymptomatic should be tested except high-risk contact (>55 years, multiple comorbidities, immune-compromised) of a known positive case. Routinely, RT-PCR must be reserved for symptomatic contacts, asymptomatic high-risk contacts as defined above, and severe acute respiratory infections cases only.
The antibody tests, which has been recommended as a tool for serosurveillance by the Indian Council of Medical Research can also be gainfully utilized for various other purposes with all its limitations. First, all health-care workers/high-risk essential services workers can be tested and those with positive antibody test can work more confidently in high-risk areas, thus decreasing the chance of spread and conserving susceptible workforce. Those found positive for antibodies can become pool for plasma donation. The government and private establishments can get their workers tested and accordingly distribute high-risk and low-risk work to optimize function and decrease the spread of disease. This will help in achieving the objectives of economic revival by unlockdown. Some indications of seroprevalence ranging from 10% to 40% in different cities have come in the media.
Contact tracing, home isolation, and home quarantine
At present, the strategy adopted after the occurrence of a case is putting a positive person in isolation and tracing of contacts and putting them in institutional quarantine and then declaring the area as a containment zone. This is the main source of anxiety, fear, and stigma amongst the public, which eventually causes public to hide their illness till a crescendo is reached and spills over in the form of a clinical case needing hospitalization. There is a need to address this. If a person tests positive and if he is asymptomatic/mildly symptomatic as ascertained by a medical officer, he should be allowed to stay at home isolation and his family members not to be taken to institutional quarantine. The family is told to take care and report anyone coming down with symptoms. They will be visited by a health worker daily to see the progress of the family members and look for anyone developing symptoms so that tests can be done and hospitalization done if warranted. The society or area should not be sealed, but residents must be told that strict adherence to the use of masks, social distancing, and other measures must be observed to prevent further cases. This will instill confidence in the citizens and they shall start coming forth, which they are presently hiding for fear of severe administrative actions. The entire management of the epidemic has to become community-centered and owned rather than system-centric and administration centric. The residents' welfare organizations can be targeted for video conferencing with administration every week or fortnight. The “sealing,” “lockdown” and “declaring containment zone” at this stage of pandemic does not serve much purpose, especially in urban areas with a large number of cases (Moderate to high transmission Risk) and cases reported from across the city. We must do an assessment of vulnerable population like the elderly who should be monitored regularly for any signs or symptoms and early diagnosis and treatment. The period of contact tracing must not be >7 days because first, it is often not available and unreliable but increases the administrative workload without much benefit. Contacts must not be tested unless they are symptomatic. Our goal should be to take care of those falling ill and prevent deaths.
There is a need to address the other seasonal diseases which might start appearing like Dengue, malaria, GI diseases like enteric fever, Scrub typhus in patients presenting to outdoor dept. We need to take a thorough history, evaluate clinically, and order tests as required for a case with fever. Drugs which are still under investigation or very difficult to obtain should not be included in the protocols; otherwise, there is a tendency among medical professionals to use these drugs even in the large majority of mild/moderate cases. The clinical protocols need to be suitably addressed and modified. The admission and discharge criteria also need to be made more flexible depending on the clinical and risk profile.
Travel associated quarantine
Quarantine is an effective strategy if applied when an individual suspected of carrying an infection moves from endemic zone to a zone where no cases are reported. The travelers between two cities with moderate/high incidence should not be quarantined. Only if, a traveler moves from a moderate/high transmission area to an unaffected or low incidence city/town/village he should be quarantined.
Despite our best efforts, some lives are bound to be lost due to COVID19 in high-risk individuals. There is a chance of “Over-labeling” where a person may suffer from a preexisting disease or a new ailment, and since he is residing in a containment area or an endemic zone, he is found to be positive on testing antemortem or postmortem by RT-PCR or POC antigen test and labeled as death due to COVID19. In some states if a COVID19-positive person dies whose death is not because of accident, suicide or not snake bite, then he/she is classified as “Death due to Corona.” This is definitely going to “Overestimate deaths.” More deaths mean more scare in public. A medical death audit for ascertaining cause and an “Administrative audit” to ascertain “delays” and “Other factors” must be carried out.
Involvement of health authorities in decision making in containment areas
Containment zones created are a crucible for more cases. Containment is a concept to be applied very early in the epidemic when only a few cases have been reported and no inward or outward movement is possible on account of lockdown. In this stage of the epidemic where we are “Unlocking down,” this containment serves little or no purpose. We should now move to “mitigation” which implies the prevention of deaths and taking care of the sick. It is seen that most beds till date in most hospitals are still being occupied who are “asymptomatic” or “mild” who otherwise can easily be isolated at home thus creating “artificial saturation” of capacity.” Containment should now be carried out by taking “public social behavior” as our main strategy. It has been observed that public is quite aware and adopting the “mask,” “social distancing,” and other measures. If at all containment zone is to be formed, it should be “smallest possible” for “shortest possible time of 7 days” and after taking the society on board. This “radical method” has not served the desired purpose and instead earned the public ire.
We should adopt the principles of unlocking most of the activities with all due precautions and let people start their economic activities as this adversely affects most the person at the bottom of society. It is not only helpful for people to resume their economic activities but also instills confidence and a sense of hope and positivity which people are trying to find in the “Vaccine” or “Cure” which may not be worth waiting for. For this workplace, rules may be suitably designed that are liberal and “Industry friendly.” Most of the instructions on the opening of different commercial activities have already been issued, but the implementation is not very healthy.
Opening of schools/colleges
To start with all Universities and professional colleges can be started with immediate effect. Regarding schools, classes from 6th upward can also be opened and those below class 5th, can be deferred for the moment. This young population will be a huge contributor to herd immunity without much morbidity and mortality.
Health care establishment
All HCEs must be allowed to function with all standard preventive measures. No HCEs must be closed down beyond 24 h even on occurrence of a case after sanitization. All HCWs if adopting adequate PPEs are unlikely to catch infection and even if are exposed accidentally can be allowed to function with personal protective equipment (PPEs) unless symptomatic. No closure of HCEs must be done. HCWs must be quarantined only if PPE breach occurs with self-monitoring. Contact tracing is not routinely recommended in health-care settings. The head of the HCEs must be empowered to decide course of action required in the best interest of patient care.
Different stages of an epidemic need different strategies. Thus, it is suggested that we adopt strategies suitable to the risk of transmission in a setting. We can divide cities and rural areas into different class of transmission dynamics and accordingly suggest measures. While deciding the staging of the cities, large institutional outbreaks like sudden large number of cases coming from a single institution like Jail where almost 100 cases can come in a day or a workplace where such cases occur must be discounted.
The districts/cities with the early phase of pandemic must prepare for the next 4–6 months with adequate beds for isolation, oxygen supported beds, and intensive care unit beds. This preparedness audit can be carried out routinely every month. The focus must be shifted to Dedicated COVID Hospitals rather than COVID Care Center and Dedicated COVID Health Center.
| Conclusion|| |
It is of utmost importance to develop area-specific strategy in a country like India, as it has been already proved considering the current situation that a “fit for all” strategy is not going to work. In this respect, categorization of districts based on transmission and developing strategies accordingly was conceptualized [Table 1] as a scientifically correct and feasible intervention, which will be highly effective to handle this pandemic in future.
It is to place on record the valuable guidance and inputs from Dr. Rajvir Bhalwar, Principal & Dean, Rural Medical College, Pravara Institute of Medical Sciences (Deemed University) Loni and also my colleagues at Department of Community Medicine AIIMS Nagpur besides MOHFW, which gave me an opportunity to work as part of Rapid Response Team in Maharashtra.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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