COVID-19: A chain of blunders by the Central government

Print edition : September 25, 2020

At a mobile testing centre in Vijayawada on September 1. Even though India’s testing rate continues to be among the lowest in the world, this metric, as health specialists have recently pointed out, is no longer relevant as the disease spread has gone beyond the stage where universal testing is a strategy for containment. Photo: V. Raju

Spectators showing their entry passes for the “Namaste Trump” event in Ahmedabad on February 24. Public health experts criticised the large public events, including the “Namaste Trump”, that were held in the country even when it was known that the spread of the disease was well under way in Europe. Photo: Vijay Soneji

The Centre’s top-down approach to COVID-19 and its exercise of control on the release of data to the public domain have led to flawed strategies and mismanagement in the battle against the pandemic.

The response to COVID-19 has been driven by political priorities rather than by public health and epidemiological expertise.” This is the retrospective assessment three well-known public health specialists have made of the manner in which the pandemic has been handled so far in the country. They are the epidemiologist Ramanan Lakshminarayanan of the Centre for Disease Dynamics, Economics and Policy, New Delhi, and Princeton University; the virologist Shahid Jameel, formerly of the Wellcome Trust/DBT India Alliance, New Delhi; and the epidemiologist Swarup Sarkar, formerly with the World Health Organisation’s South-East Asia Regional Office, New Delhi, and currently a Delhi-based independent public health consultant. In an editorial commentary published on August 14 in The American Journal of Tropical Medicine and Hygiene (AJTMH), they have analysed and critiqued the way the government has responded to the COVID-19 pandemic.

Criticising the large public events, including the “Namaste Trump” function in Ahmedabad to greet United States President Donald Trump in February 24-25, that were held even when it was known that the spread of the disease was well under way in Europe, the scientist trio faults the government for having resorted to a nationwide lockdown on March 24 when State-level or more localised lockdowns would have been preferable given that there were only around 500 cases and 10 deaths then. Not knowing the precise location of hotspots because of low levels of testing, “the lockdown represented a law-and-order solution to a problem for which India was poorly equipped from a public health standpoint”, says The AJTMH article. “The sudden lockdown [with just four hours’ notice],” the authors say, “imposed a significant burden on the urban poor and migrants who found themselves both out of work and with no means to return to their villages.”

“India,” the authors point out, “was slow to provide testing despite significant capacity for reverse transcription-polymerase chain reaction (RT-PCR) testing in both public and private laboratories. Testing in the early days of the epidemic was limited to a few public laboratories. Private laboratories, which typically provide the bulk of pathology services, were not allowed to test at all. The restriction was not only ostensibly to maintain quality but presumably also to control information [emphasis added].”

Even though India’s testing rate continues to be among the lowest in the world (at about 33,000 per million population as of September 2), this metric, as health specialists have recently pointed out, is no longer relevant as the disease spread has gone beyond the stage where universal testing is a strategy for containment. However, the low level of testing implies that a large number of infections (and consequent deaths) have been missed, and as has been pointed out in earlier Frontline reports and as recent sero-surveys too have indicated, the official caseload figure is only a small fraction of the actual number of total infections.

An important observation the authors make, which is indicative of the lack of transparency and the Centre’s exercise of control on what data relating to COVID-19 are available in the public domain, is that there has been limited published epidemiological or clinical research emerging from India unlike the case with other significantly affected countries. The article, however, has referred to a notable study authored by Indian and American researchers (and posted on the preprint repository medRxiv on July17) that for some reason has gone unnoticed in the media.

On the basis of preliminary and limited data from a comprehensive surveillance exercise carried out in Tamil Nadu and Andhra Pradesh of a cohort of 4,206 primary cases and 64,031 contacts, the study found that the risk of transmission from a primary case to a close contact ranged from 2.6 per cent in the community to 9.0 per cent in the household, and significantly, these results did not vary with the age of the primary case. Since a third of infected individuals are under the age of 30, “[t]his finding”, the article points out, “indicated an important role for children and young adults in transmission”. According to the study, a prospective follow-up testing of exposures showed that while 83 per cent of the infected individuals did not infect any of their contacts, 5 per cent accounted for 80 per cent of new infections. On the basis of this finding, the authors infer that “[s]uperspreading seems to have been the rule, rather than the exception”.

The quoted study also found that unlike in high-income countries where deaths are mostly in the older than 65 age group, here COVID-19-related deaths were highest in the 50-64 age group. Also, unlike in the U.S., where there is a secular increase in incidence with age, the incidence of reported cases here did not increase with age (>64 years) but, in fact, declined. “Strikingly,” notes The AJTMH article, “these differences cannot be fully accounted for by differences in population age distributions.”

That this is so despite the observation that the risk of transmission from a primary case is higher within a household could be due to greater compliance with the precaution of ensuring that the elderly are protected from getting infected, and perhaps other sociological factors. The other interesting and significant finding of the study was that “contrary to the long hospital stays reported in high-income settings, the median time to death was 5 days following admission”. One reason for this could be that patients were probably reaching hospitals only when symptoms were severe and/or conditions became serious. Unfortunately, such clinical studies have either not been done in other parts of the country, or if done, the results have neither been published nor made public.

After seven months of the pandemic in the country, the total number of confirmed cases as of September 2 stood at 3,848,968. On this count, India currently ranks third, but in terms of the daily increase in caseload, which is at present over 80,000 (82,860 on September 2), India is at the top. With this rate of increase, India is estimated to overtake the number 2 country, Brazil, by September 10 and will also soon overtake the number 1 country, the U.S. According to the Union Ministry of Health and Family Welfare, however, only 7 per cent of the districts (49/739) in eight States—Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu, Uttar Pradesh, West Bengal, Odisha and Telangana—accounted for 73 per cent of the cases, and seven States—Maharashtra, Delhi, Tamil Nadu, Andhra Pradesh, Karnataka, Uttar Pradesh and West Bengal—accounted for 81 per cent of the deaths due to COVID-19.

No ‘community transmission’

On the basis of these data, the Ministry continues to claim that there is no “community transmission”. But how this follows is not clear and is never explained. For instance, the recent sero-survey in Chennai, which accounts for 69 per cent of all the cases in Tamil Nadu (and is obviously, therefore, one of the 49 districts), found that 173 people out of the 12,405 surveyed had no history of contact with any COVID-19 patient, a clear indication of community transmission. “The epidemic,” the scientist trio observe in The AJTMH article, “is in different stages in different parts of the country, but the response has been driven by a national, overarching centralised strategy instead of being locally owned.”

Given the present situation, the article says that an important aspect of COVID-19 management now should be averting deaths, a point a group of public health experts and epidemiologists made in a recent statement (dated August 25 but issued on August 30). “The current national guidelines,” notes The AJTMH article, “do not prioritise high-risk individuals for early testing, and this is a missed opportunity for averting deaths in vulnerable populations of the elderly and those with comorbidities.” The article also highlights what is generally known: because many individuals in India die without a COVID-19 test, reporting of deaths due to COVID-19 in the country is incomplete. The number of reported deaths is, therefore, likely an underestimate.

Pointing out that the correct identification of COVID-19 deaths was an opportunity to learn about the disease and, thereby, prevent future cases and deaths, the article recommends the creation of a formal system of mortality surveillance, specifically to measure the additional mortality attributable to COVID-19. “The epidemic response should be data driven and locally owned,” the article adds. “More granular data and greater openness to data sharing and coordination would enable surveillance data to be used for management decisions, including planning regarding personal protective equipment, medicines, supplies, and, most importantly, ICU capacity and health care personnel. This would provide a clear picture of the impact of COVID-19 to the public.”

Indiscriminate testing

In their third joint statement on the COVID-19 pandemic in India—referred to above as the recent statement by public health experts—the Indian Public Health Association, the Indian Association for Preventive and Social Medicine and the Indian Association of Epidemiologists strongly criticised the Centre’s continuing approach of indiscriminate and universal testing with the apparent solitary aim of meeting the benchmark for adequacy of testing: 140 tests per million population a day and test positivity rate of less than 5 per cent.

Widespread “testing, tracing, isolating and treating” was the appropriate strategy in the early stages of the pandemic (when the caseload was low). It would have then served the purpose of early identification of the cases to limit disease transmission to others so that the infection did not get a foothold in the community. But the government failed miserably in achieving this at the time when it was necessary. Now, since the virus has already spread widely in the community in many geographical areas, testing by itself is no longer a control strategy, the statement points out. Sero-survey reports from different parts of the country and the Indian Council of Medical Research’s (ICMR) own nationwide sero-survey have indicated that the (much belated) current testing strategy is picking up less than 5 per cent of the true number of SARS-CoV-2 infections in the country. Currently, India is testing at the rate of over a million a day (11,72,179 tests as of September 2). This rate of testing of a mostly ill-defined population, as the public health specialists point out, is imposing a heavy economic cost without the commensurate benefit of disease control.

“Universal scaling up of testing,” says their statement, “at current community transmission stage of the pandemic may not be an optimal control strategy and will divert attention and resources from control measures….The testing strategy needs to be pragmatic from a public health perspective, promoting differential/targeted testing of high-risk individuals and discontinuing universal testing at this stage.” This echoes the observations made in The AJTMH article. “However,” adds the statement, “[in] areas in [the] very early phase of pandemic (where zero or very few cases have been reported) testing may be used as a surveillance tool.” Pointing out that reducing deaths due to COVID-19 should now be the primary goal, the statement adds that the strategy should now shift to syndromic management (before testing and diagnosis), especially in high-seroprevalence States and districts for efficient management of resources.

Similarly, the primary purpose of lockdown in the early stage of the pandemic was to slow down the disease spread and gain time to prepare to fight it, particularly by shoring up the health care infrastructure. “There is no evidence any more that any useful purpose would be served by weekend or intermittent or night time lockdowns, banning of domestic flights and establishing large sized containment zones,” says the statement.

The health experts have, in fact, advocated discontinuation of lockdowns as a strategy for control and favoured only the imposition of geographically limited restrictions for short periods in epidemiologically defined clusters where there is no community transmission. Cluster restrictions, the statement says, should be imposed after weighing their impact on the livelihoods of the target populations. With adequate health system preparedness, even cluster restrictions can be done away with, it adds. But with the Centre continuing to be in denial of community transmission, this advice is, as the Tamil saying goes, like blowing a conch shell into the ear of the deaf.

Nevertheless, health experts have advocated habitat-specific and epidemiologically appropriate strategies as follows. In large cities where there is already substantial spread of the disease, there is no advantage in creating containment zones accompanied by aggressive testing. Delhi, for example, has as many as 922 active containment zones (as of September 2) of which 207 have scaled down restrictions but have not been de-contained. “The focus [now] should be to prevent deaths and not on containing the infection,” the experts have said.

In large cities with moderate spread, they have advised revamping of containment zones with a clear road map and timelines for periodic review by expert committees and that all containment zones should be de-contained within 14 days. For small cities and rural townships with mild or limited spread, the group of experts has said that existing testing and cluster containment can continue, but the testing strategy with mandatory isolation of positive cases needs to be reviewed in view of the prevailing social stigma in these settings.

In fact, the practice of pasting a notice on the doors of homes of COVID-positive patients is being followed even in cities and big towns, leading to stigma and discrimination. Noting that in response, many patients left home for unknown destinations, defeating the very purpose of isolation, the statement has called for doing away with this practice immediately. “Of particular concern has been the issue of the dignity of death and cremations and burials of COVID-19 victims,” observes the statement. Regarding the prevailing restrictions on inter-State travellers, it has called for abandoning forthwith the policy of quarantining them for 14 days in designated hotels and health facilities. “When [the] majority of States/districts are affected, there is no rationale for quarantine of inter-State travellers…,” says the statement.

The public health specialists have also made observations on the issue of opening of schools and educational institutions. “Opening of school and other educational institutions could be started in a graded manner,” they have said. “There should be a pragmatic approach, especially in areas where sufficient population is already infected with SARS CoV-2. Even in low infection areas, schools may be opened with due safety measures and with adequate surveillance….”

“Closure of educational institutions, especially schools for children (5-18 years),” they have pointed out, “has had a significant impact on the teaching-learning system as well as mental health of the children. The impact has been disproportionately higher on the children of lower socio-economic strata who do not have social capital for alternatives like digital platforms. Sufficient evidence is available that infected, young children are at an extremely low risk of developing morbidity. The risk of young children transmitting corona infection to older family members would be the same as adult family members [as indeed the Tamil Nadu-Andhra Pradesh survey found] who are permitted to carry out activities outside of home environment.” Union Health Minister Harsh Vardhan said last month that the country would have its own vaccine by the end of the year. In his Independence Day speech, Prime Minister Narendra Modi, too, held out that hope, saying that the country was ready to mass-produce three vaccines once scientists gave the green signal. But the public health specialists have warned the people and the government that a vaccine, if and when available, will not be the panacea that the country has been waiting for in the hope that COVID-19 would then be banished. The three vaccines are in different stages of clinical trials in India.

“Vaccines,” they say in their statement, “do not have any role in current ongoing COVID-19 pandemic control in India. However, whenever available, the vaccine may play a role in providing personal protection to high-risk individuals like health-care workers and [the] elderly with comorbidities (according to the WHO’s ‘strategic allocation’ approach or a multi-tiered risk-based approach). While being optimistic, the prevention and control strategy should also prepare for the worst. It must assume that an effective vaccine would not be available in [the] near future. We must avoid false sense of hope that this panacea is just around the corner.”

Creation of public health cadres

The experts have also called for a significant increase in public expenditure on health care and the creation of national and State-level public health cadres similar to the Indian Administrative Service. “Public health care should be significantly strengthened and enhanced with overall public expenditure to be increased to at least 5 per cent of the GDP [gross domestic product],” says the statement. “The focus of increased health expenditure,” it adds, “should be on primary health care and human resource and infrastructure strengthening, rather than [on] opening/strengthening tertiary care centres.”

Pointing out that States such as Tamil Nadu and Gujarat that already had public health cadres were relatively better placed to handle such public health crises on their own, the specialists highlighted the “need to expedite the establishment of a dedicated, efficient and adequately resourced public health cadre as Indian Health Service (IHS) at the Centre and across States as [has been] recommended by various national committees and expert groups since 1946…”.

In a similar vein, The AJTMH article says: “The COVID-19 pandemic is an opportunity to invest in the public health infrastructure of India, an area of systemic neglect over the past few decades…. In the long term, a blueprint should be developed to empower and strengthen India’s national and State level mechanisms for public health research, surveillance, and policy activities.”

It remains to be seen whether the Health Ministry and the higher executive in the government pay any heed to the observations made by the authors of the commentary or to the statement of public health specialists.

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