In search of a strategy

There is a lack of clarity on the epidemiological basis for the extension of the lockdown and an information gap at various levels on containment procedures.

Published : May 02, 2020 07:00 IST

Migrant workers and homeless people wait for food outside a government-run shelter in Delhi on April 9. (Photo by Yawar Nazir/Getty Images)

Migrant workers and homeless people wait for food outside a government-run shelter in Delhi on April 9. (Photo by Yawar Nazir/Getty Images)

O ne of the distinctive features of the Central government’s response to the outbreak of COVID-19 has been in the nature of dealing with it as a law and order problem in successfully implementing the nationwide lockdown and in comparing the mortality and morbidity rates in the country with that of developed countries where they have been high. Prime Minister Narendra Modi’s address on April 14 announcing the extension of the lockdown had little to offer by way of assurances on how the outbreak was being handled save for an exhortation to adhere to the lockdown at any cost.

Informed sources told Frontline that the National Task Force for COVID-19, which comprises medical experts, including from the Indian Council of Medical Research (ICMR), was not consulted before extending the lockdown. Hence, what the epidemiological basis was for continuing with the lockdown is not known. “While the lockdown is appropriately a political decision, taking many factors into account, the considerations we would reasonably expect to inform the decision-making are evidence and scientific assessments. To disregard these is problematic, particularly with the stakes involved,” said a public health expert.

The spread of the epidemic by and large has been in cities in States that report a higher per capita income than others. This is akin to the international pattern of least developed and developing countries reporting fewer cases than Western democracies. The Central government, in its daily briefings by representatives from the Health and the Home Ministries, says that everything is under control, yet there have been reports of shortfalls in protective gear for medical personnel, and overcharging, even denial of health care, by the private sector. There were reports of a doctor being terminated from service in a government hospital for raising the issue of shortage of personal protective equipment (PPE). He apparently secured it from a source and distributed it in the hospital he worked. On April 15, five lakh rapid antibody testing kits arrived from China, but Raman R. Gangakhedkar, head of the Epidemiology and Communicable Diseases Division at ICMR, told the media that it was not for diagnosing COVID-19 but for surveillance purposes.

The trend so far

There is little disagreement on the point that the lockdown has limited the spread of the epidemic, but inadequate testing remains an issue. The government still maintains that there has been no widespread community transmission. However, between March 25 and April 10, there was a sevenfold increase in the number of COVID cases in the country. Maharashtra, Madhya Pradesh, Rajasthan and Gujarat accounted for nearly 47 per cent of the total number of cases in the country and the number of active cases continued to indicate an upward trend in Maharashtra, Madhya Pradesh and Gujarat. In Madhya Pradesh, the number of cases saw an upward spiral from March 29, while in Gujarat it rose steeply between April 7 and 16 and showed little sign of slowing down even beyond that date.

On April 16, two days after the lockdown was extended, Kerala became the first State in which recovered cases outnumbered active cases. In fact, the Central government has fallen short of acknowledging Kerala’s success in containing the spread even before the lockdown was announced on March 25. On the other hand, the Bhilwara model, where an entire district in Rajasthan was sealed after a doctor in a private hospital passed on the infection to a patient who died later in Jaipur, was the focus of all the attention.

As many as 22 States have reported COVID-19 cases. As of April 18, the four contiguous States of Maharashtra, Gujarat, Rajasthan and Madhya Pradesh accounted for 48.5 per cent of all confirmed COVID-19 cases, 67 per cent of all deaths and 31.9 per cent of recoveries. In contrast, the hill States and those in eastern and north-eastern India, except West Bengal, accounted for 2.8 per cent of all the cases, 1.67 per cent of the deaths and 7.8 per cent of all recoveries.

States in the north-western region, like Punjab and Haryana, too have relatively lower number of cases. The situation in Delhi and Tamil Nadu, after seeing a spike, seemed to be plateauing in the past few days. The number of positive cases in these two States had gone above a thousand. As many as 1,080 of the 1,640 positive cases in Delhi were listed as “under special operations”, a term that was used to refer to cases relating to the Tablighi Jamaat congregation in Delhi.

As of April 17, of 18,784 persons who were tested in Delhi, 1,640 were found positive, 14,692 negative and the results for 2,251 were pending. Some 2,571 persons were in institutional quarantine, and 30,983 “contacts” of positive cases were in home quarantine. Some 1,825 samples were collected from cluster containment zones after house-to-house surveillance. The number of people in intensive care units and on ventilators in the State numbered 34 and six respectively.

Tamil Nadu, which reported a large number of cases from among people who had attended the Delhi event, used the term “single source”. On April 15-16, it dropped using this term. Apparently, a section of the media and several others had brought it to the government’s attention that religious profiling of infected persons was against international norms, including that of the World Health Organisation (WHO). The obsession in some quarters to link the spurt in cases in the country with the congregation, however, could not explain the spike in cases in Maharashtra, Madhya Pradesh and Gujarat.

Hotspots and clusters

Meanwhile, the Central government has listed “hotspots” to describe areas that have reported a large number of cases or a cluster of cases.

After initially refusing to reveal the hotspots , on April 15 the government issued a list classifying districts. Of the 170 districts classified as hotspots, 123 had large outbreaks and 47 had several clusters. A district is declared a hotspot-free zone, or a green zone, if it has been free of any case for 28 days. There are 207 such districts.

Tamil Nadu had the largest number of hotspots (22), followed by Maharashtra, Andhra Pradesh and Rajasthan with 11 each; Uttar Pradesh and Delhi with nine each; Jammu and Kashmir, and Kerala six each; and Gujarat and Madhya Pradesh five each. The largest number of green zones was in Uttar Pradesh, followed by Telangana, Madhya Pradesh, Maharashtra, Gujarat, Haryana and Karnataka. In eastern India, West Bengal had four hotspot districts.

In eastern parts of India and the north-eastern region there has been no large outbreak. Narendra Gupta, a public health expert from Rajasthan with years of experience in working among tribal people, told Frontline it was quite possible that there were not too many COVID cases in these States. “There is a lot of respiratory illness in rural India due to tobacco chewing and the smoke emitted during cooking, and generally in winter people sleep next to lit fires inhaling all that smoke. There is a lot of mortality from chronic obstructive pulmonary disorder. Until such time it is not diagnosed as COVID-19, one will never know. And the majority of the poor do not even reach a public health facility,” he said.

All States have been told to set up dedicated COVID hospitals apart from containing cases with severe acute respiratory illness and influenza-linked illnesses. The Central government has declined to give details of the location of the dedicated COVID treatment hospitals. This would create panic, said Joint Secretary (Health) Lav Agarwal. However, this has resulted in COVID hospitals and beds going literally empty and being inaccessible to persons with critical illnesses other than COVID. With no new government hospitals being set up for COVID cases, it is the existing ones that have been converted into COVID treatment facilities. The downside of this is that primary health centres (PHC) are getting overcrowded as people seek secondary and tertiary care at these PHCs.

Logistics is another problem. The advisory issued by the Director, Public Health and Family Welfare, in Telangana, for instance, asks people who develop “flu like symptoms irrespective of travel history/contact history” to report to the nearest government facility. This is easier said than done since all forms of public transport have been curtailed. The only State perhaps where health services were taken to the public was Kerala.

Lack of testing

Experts from Jan Swasthya Abhiyaan (JSA), a broad coalition of public health experts, expressed concerns about the rise in the number of cases in Madhya Pradesh, especially in Indore, Bhopal and Ujjain divisions. Indore alone accounted for 70 per cent of the deaths in the State. While the national ratio of deaths in cases with an outcome (death or recovery) owing to COVID-19 was 22.5 per cent, in Madhya Pradesh it was close to 50 per cent, JSA experts said. In Rajasthan this ratio was 8.33 per cent. “If there was proper screening, quarantine and testing strategies, this could be stopped,” they said, requesting special focus on early identification in Indore.

A report compiled by JSA activists Amulya Nidhi, S.R. Azad and Shamarukh Dhara says that Madhya Pradesh was not doing as many tests as it should have. It had eight testing facilities (four in Bhopal, one in Jabalpur, two in Gwalior and one in Indore division) and had done 10,481 tests (as of April 13) as against 31,804 in Rajasthan and 39,735 in Maharashtra. The testing rate in Madhya Pradesh was only 143 per million, when the national average was 170 tests per million. The rates of testing were 347 per million in Maharashtra and 461 per million in Rajasthan.

As of April 16, a total of 2,90,401 persons were tested in the country, an addition of 30,043 over the previous day and the majority were from the ICMR network of laboratories. Only 28 laboratories in the private sector were involved in testing for COVID-19. The overall testing rate was 220 per million, the death rate 0.09 a million and the case rate was 10 cases per million people. This is being touted as a success story.

How other countries fare

Compared with India, Germany, Spain and Italy have done close to 20,000 tests per million, while in the United States, which has reported the highest number of cases and deaths, it was slightly over 10,000 per million people. Countries in the developing world that have conducted more tests than India include Pakistan (383 per million), Sri Lanka (223), Egypt (244), Nepal (542), Rwanda (482), Jamaica (481), Venezuela (9,442), Trinidad and Tobago (916), and Guatemala (402). Countries that fared worse than India in terms of testing were Bangladesh (103), Myanmar (59), Indonesia (132), Libya (102), Niger (183), Bolivia (187), Honduras (203), Uganda (168), Namibia (142) and Kenya (179). Economic reasons account for the low testing in these countries. Those that have been really low in testing according to the Worldometers website are Malawi (18), Nigeria (24), Ethiopia (47), Haiti (32), Zambia (92), Mozambique (27) and Algeria (77).

While the government continues to maintain its defined criteria of testing, tracing and isolation, some questions still remain. One such is the absence of the National Centre for Disease Control (NCDC), the premier agency dealing with outbreaks, from the scene. Linked to this is the Integrated Disease Surveillance Programme (IDSP), which is a part of the NCDC and whose primary job, like the Centres for Disease Control and Prevention (CDC) in the U.S. or the Chinese Centre for Disease Control and Prevention, is to collect and track communicable disease data. The tests conducted by the IDSP have not been shared.

There has also been some concern over objectivity in the process of designating clusters within districts. There were serious issues in terms of stereotyping certain communities as being carriers of the virus. The government has done little to assuage those apprehensions.

Updated containment plan

On April 17, the government released an updated containment plan for large outbreaks. It defines a large outbreak as one where there is a localised increase of 15 or more cases or where there is a progression of cases in a cluster. The plan recommends a geographic quarantine, or cordon sanitaire, where a single large outbreak or multiple foci of transmission have been noticed. The plan includes drawing a defined perimeter and containment strategies such as tracing, isolation, treatment and physical distancing within the perimeter.

The document says that the evidence for implementing geographic quarantine was drawn from the 2009 H1N1 influenza pandemic which showed that well-connected big cities with substantive population movement reported a large number of cases whereas rural areas and smaller towns with low population densities and relatively poor road/rail/airway connectivity reported fewer cases. The current geographic distribution of COVID-19 “mimics” the H1N1 pandemic influenza, says the containment plan. This suggested that while the spread could be high, it would not be uniformly affecting all parts of the country.

But the success of the containment strategy, the document cautions, depends on various factors, including the density of population and access to basic infrastructure and essential services.

The plan refers to an analysis released by the Chinese Centre for Disease Control and Prevention, which reported the largest cohort, wherein 81 per cent of the cases were found to be mild, 14 per cent required hospitalisation and 5 per cent required critical care and management. Deaths occurred among the elderly who had co-morbidities. This pattern has been noticed in India as well.

There is little clarity at present about the trajectory of the infection in India and whether at the end of the lockdown period, things will get back to normal. What is known, however, is the immeasurable damage the lockdown has done to lives and livelihoods, with the government having done little about this. Advisories to industry to not sack employees have fallen on deaf ears. The “health costs” for the economically marginalised and the jobless go way beyond the risks and consequences of being infected by COVID-19.

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