We are now facing the global spread of COVID-19, the new coronavirus disease , with confirmed cases being identified in new countries on an almost daily basis. As of March 2, 2020, according to the World Health Organisation, there are around 89,000 confirmed cases from 65 countries; 27 countries have reported local transmission. In addition to China, there are now epidemics in South Korea, Iran, Italy and Japan. India has reported six confirmed cases to date in Kerala, Rajasthan, Delhi and Telangana . High income countries with resources such as the United States, Italy and Germany have reported local transmission clusters. Dr. Nancy Messonnier, U.S. CDC, says: “It’s not so much a question of if this will happen anymore, but rather more a question of exactly when this will happen and how many people in this country will have severe illness.”
Getting the system ready
In India, we should anticipate the possibility of a rapid viral spread due to its uniqueness of being a respiratory pathogen with capability of community transmission. India needs to be ready to mount a coordinated, coherent and sustained response.
Even if the disease does not reach epidemic status in India, it behoves us to continue to develop and maintain infrastructure to respond to new novel infectious agents capable of rapid spread. Over the past decade we have already seen outbreaks in India of swine flu and Nipah. As such, outbreak preparedness is an investment which will pay dividends immediately at worst or in the medium to long term at best. Preparedness allows a health system to take proactive steps to mitigate or lessen the adverse impacts of an outbreak and to be in control without being overwhelmed. COVID-19 has given us an opportunity to test our systems and build resilience for the future.
The objective of the response should be to adapt to the stage of the outbreak. In the initial days when travel-related cases are few and manageable, such as the current status in India (known cases), it makes sense to do extensive screening, testing of all suspected cases and do contact tracing to prevent its spread into the wider community. But once an outbreak takes hold with sustained community-wide local transmission, then testing lessens in significance and may in fact rapidly overwhelm the laboratory capacity. At that point, the response should change from containment to mitigation so that the health system does not crumble. Akin to a team chasing in cricket: with 10 wickets in hand and power play, it can go for big shots to win the game quickly. But if it loses wickets, then taking ones and twos to ensure that the required run rate does not go out of hand makes sense (epidemic peak and surge capacity in outbreak response terms).
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Components of a response
India has a fragile health system which is fragmented. It is critical to mount a coordinated and coherent response. This not only means involvement of both public and private sectors but also allopathic and non-allopathic medical systems, different departments such as police, fire, transportation, tourism, food supplies and other sectors. The response should be proportional and based on scientific principles while ensuring transparency and respecting human rights. The National Crisis Management Committee (NCMC), currently designed to be set up in situations of large natural calamities, should be leveraged; it should coordinate across ministries and departments. It should set up a dedicated web portal which includes a dashboard with key indicators, current case definitions, guidelines, risk communication materials and micro plans. Transparency and fact-based information are hugely important as in moments of crisis, rumours and unsubstantiated claims can rapidly spread. Utilising social media, media outlets effectively is also crucial. An epidemic of fear and misinformation can be damaging, stigmatising and corrosive to public interest.
The Ebola example
Trust in government, its institutions and fraternity among fellow citizens forms the bulwark of an effective response. An outbreak which is unaddressed will have short- and long-term impacts on health. The 2014-15 West Africa Ebola outbreak overwhelmed local fragile health systems; many front-line health workers and prominent doctors fell victim. The subsequent outbreak response absorbed all available health resources and impacted other programmes such as routine immunisation leading to measles outbreaks in the aftermath. So, a response plan should be able to maintain ongoing regular health programmes while at the same time devoting adequate resources to the response. This in itself would be a delicate balancing act on the part of the NCMC. They, in conjunction with duly constituted State and district-level crisis committees, also have the even more difficult task of determining whether cluster containment measures such as those practised in China are feasible in the Indian context given its diversity and resources, and if so, how effective it would be and when to call it off. The response should be informed by the requirement to balance public health measures and the rights of those impacted.
With neither a definitive cure nor a vaccine on the immediate horizon (multiple teams are working on this internationally), the response plan undoubtedly relies on basic measures such as risk communication, health education, social distancing, and home isolation to reduce the speed at which the outbreak will spread. Large-scale behaviour change will be the cornerstone of a successful response. It is worthwhile to remember that Ebola was brought under control by people who within a short time changed their long-held traditional burial practices and routines such as hand shaking, and not just by people in hazmat suits treating patients in temporary hospitals. Though media shows people in hazmats more than people washing hands properly, it is the latter which plays an equal if not bigger role.
In Iran, the Deputy Health Minister is among those infected. So a response plan should ensure that critical personnel (deemed irreplaceable) across sectors such as health, energy, defence, and food supply are identified and protected. Priority also needs to be given to protecting front-line health workers, intensive care unit nursing staff, doctors including specialists such as intensivists, pulmonologists, etc. In India, infection prevention and control practices in health-care facilities are often lenient. The reasons range from non-availability of personal protective equipment to a relaxed attitude towards safety norms, analogous to how seat belt or helmet use is practised in India. Risk communication should address this and make people feel comfortable entering hospitals where all the staff, right from parking attendants, security guards, receptionists, nurses, paramedical workers and doctors, are wearing appropriate personal protective equipment.
The government should draft and publish clinical guidelines for triage, admission, discharge, ventilator support and other components, as applicable for various levels of the health system. These should be updated on a regular basis, as we learn more about the virus and how to tackle it. There should be strict enforcement to ensure equity and considerations built in so that those vulnerable are protected and get equal access to care.
Across the board
A simple back of the envelope calculation will show that current health-care resources in themselves will be inadequate for the response — for example, the number of ambulances needed or the number of contact tracers in the Department of Health, etc. As such, resources from other departments and general public, financial, in kind and personnel, need to be pooled and mobilised. They need to be trained on a fast track without making compromises on quality. Preparedness is neither the sole domain nor the prerogative of government; all institutions, entities, firms both private and public and even individuals and households should make contingency and advance preparedness plans.
Companies need to decide on a nimble basis putting in measures such as work from home, suspension of non-essential travel, and reinforcing workplace hygiene and health information protocols, expansive leave policies for the sick or those under quarantine. Local authorities can make plans for school closure, home isolation and social distancing.
The unprecedented containment measures taken by China have bought the world some lead time. India has been fortunate to only see limited cases so far, but we must not squander this time window and be ready for a worsening situation. Preparing for the worst case scenario will hold us in good stead.
Dr. Manjunath Shankar is a Public Health Specialist. He participated in the U.S. CDC Emergency response (Modelling Task Force) to the West African Ebola outbreak in 2014-15. Dr. Anant Bhan is a researcher in global health, bioethics and health policy