COVID-19: Containing the Pandemic through Syndrome Approach
By Sandhya Mishra
Dr Giridhara R Babu, Professor and Head Lifecourse Epidemiology, PHFI in an interview with Sandhya Mishra, shares how strong containment along with lockdown can help to control the pandemic.
Is India Under-testing or Doing it Right?
India has tested 10,40,000 samples (as on May, 2) and 3.6% tested have been found to be positive for COVID-19. The number of tests conducted has grown almost 22 times since April 1 to as on date an average of 70,000 daily which shows India is constantly upgrading its testing capacities. But again, looking only at the national averages could be misleading. It is like saying that average per capita is above USD 2000, while half of our people live below poverty line. Currently, four states account for more than 60% of the tests in India. In addition, all the southern states are doing well in testing rates (higher than national average). Three states with high populations (UP, Bihar, West Bengal) are way below national average. Hence, it is time to disaggregate the data at state or at the district level to see whether we are testing enough.
Best Strategy to Test
It is testing only when one suspects the cases. And for that, need of strong surveillance systems is highly desired. It is important to improve severe acute respiratory infections (SARI) / influenza-like illness (ILI) surveillance first, and then go beyond the symptomatic individuals to test those who do not exhibit the symptoms.
We have strong presence of ASHAs, ANMs in rural areas. They can do the surveillance using house-to-house visits. Such programs are done many times a year (NIDs aka pulse polio days). In urban areas, taking help from volunteers, NGOs and associations such as Rotary International can prove useful.
We should also shift our focus to states that may be missing the transmission in some areas but are doing low tests. We have to step up the review mechanisms at state and district level for initiating appropriate containment measures.
Do Patients get Re-infected?
There is emerging evidence from China and South Korea that people may get re-infected. It is not certain if it is the same serotype that is resulting in reinfections. Therefore, one infection may not give immunity for life time. Here, ICMR is also planning seroprevalence surveys to know, how long people are immune and what are the kind of measures the country should be taking. These survey will tell us regarding the immune response.
How different States are Faring?
To curb a growth in infections, the central government has been working with the all the states and territories.
The following States are of high concerns namely;
States with high case fatality: It was reported that West Bengal was showing lower mortality for longer time earlier but now it is said that there is a sudden massive increase in mortality. This does not happen suddenly; death rates do not increase overnight. It only means that surveillance measures weren’t effective in the state in earlier phase.
Three states with higher deaths and poor testing and poor SARI/ILI surveillance indicates that surveillance needs to improve.
Focus should be on states with higher proportion of silent districts and states with poor surveillance for ILI and SARI
Kerala has done well in most containment and mitigation measures. It is perfect example on how to manage a pandemic such as COVID-19.
The high COVID-19 mortality in Maharashtra could be attributed to the fact that a higher proportion of COVID-19 patients fall in the elderly group, who have higher co-morbidities or delayed detection and delayed treatment of disease. The fact that many cases are missed being caught at the onset of infection and not treating the cases well enough could also be the reason. Another reason being the crowded population in the slums along with the fear and stigma around the disease that is making people not seek the care early enough. This disease progresses rapidly and people usually seek treatment when it is a bad one to begin treating with.
Also, case fatality by all means depends a lot on how deaths and cases are reported. The numerator or reported COVID-19 deaths may increase due to number of reasons like severity of symptoms, delayed admission due to neglect of patients, speed which with breathlessness develops or poor facilities in hospitals and clinical care. Whereas, the denominator could decrease by poor surveillance or inefficient testing.
Yet, if the state is not picking up enough cases, for me that is a hotspot.
Is Lockdown the Best Strategy to combat Novel Coronavirus?
Containment works! We are in good shape in terms of both containing the numbers in most states and also how we are continuing ahead in that trajectory. Having said that, lockdown alone is not enough to contain the virus. During the lockdown, we have a golden opportunity to find every possible case in every area and isolate, thereby containing the transmission. If we do not do it now, then all the efforts can go vain. Through syndrome approach, if we manage to pick up a number of cases for every district which is at least somewhere near to the national average, we may lift the lockdown with lot more confidence.
Dr Giridhara R Babu, Professor and Head Lifecourse Epidemiology, PHFI
We need to consider every individual with fever and respiratory symptoms as a COVID-19 case and treat him/her for the same without waiting for the test kits and follow the syndromic case management. At the same time, we must make sure that every suspect is isolated and all their contacts are quarantined. We should do this in every states and every district. In summary, the lockdown along with strong containment, is the strategy.
In the future, we should follow an evidence-based approach in deciding to reimpose, extend or release the lockdown. Once the lockdown is lifted, the virus transmission will ensue in most parts due to huge pool of susceptibles in the country. We should continue some of these measures for sometime. For example, the IT HR folks say that nearly 90% of the workforce can be permitted to work from home, with minor logistical measures. Strict enforcement of cough etiquette, use of masks, and physical distancing should be the new normal. Avoiding large congregations, malls or events should help at least for the next few months till a vaccine or a drug is available. The government should focus on importing test kits and equipment, but also on developing and manufacturing homegrown test kits.
Are we in Community Transmission?
It is a matter of nomenclature. So far, there is no declaration that India has entered the stage of community transmission. However, absence of evidence is not same as evidence of absence. In a study conducted by ICMR, it was found that 40 of 104 COVID-19 patients neither had a travel history to any foreign land nor came in contact with a person who has contracted the infection. These people account for 39.2% of the total cases.
The Government is yet to announce the districts with higher proportions of SARI cases having COVID-19 positivity. It might be possible that silent districts (districts that have not reported single cases) have SARI cases showing COVID-19 positivity and by not notifying these districts, the transmission can affect several people and result in higher deaths.
Ideally, once a country goes through different phases of epidemic, it should revise its overall strategy. The guiding principle remains the same: find every possible case and area having transmission. The only thing that changes is the strategic and rational allocation of different types of tests and resources that we have with the case burden at any given point of time.
Could Herd Immunity Strategy work in India?
There are two different ways populations may develop herd immunity. The most beneficial way, is the one where people are given the vaccine and this vaccine having the antigenic property causes an individual to release enough antibodies, thus immunizing the person. At least 60-80% of the people can get immunized using vaccine. Therefore, when the real threat of the real pathogen, virus or bacteria comes, the population is already protected. However, expecting the population to be infected with the real virus, not with the vaccine, and then expecting them to have immunity is the other extreme. I don’t believe in this model where we want many people to get infected and then see what the numbers are. If we look back, this was the same logic followed by few nations and we know what tragedy they ended up into, not to mention their leaders infected and hospitalized.
If we just follow the epidemiology of this virus all over the world, out of the total infected, nearly 15% require hospitalisation while 5-6% require critical care. In a country like India, this means 5-6% of 1.3 billion population requiring critical care! Do we have any sense of what kind of casualty figures we should brace ourselves for?
Therefore the key challenge is— if you want herd immunity through the virus itself, then you need to have an appropriate health system response. You should have enough doctors, ventilators, health system response; in case there is any surge in cases, you’re ready to prepare the system to such a level that you minimize all the casualties. Now if that’s not possible, if you don’t have it, then the alternative is lockdown, which every country is following in order to mount an appropriate health system response. If containment is not done well and we don’t prepare the health system well, then the lockdowns are wasted opportunities at a great costs to society.