“The virus has gone.” That was in January 2021. “No, it hasn’t. It is back with more family members to attack us with greater force.” This is in April 2021. These scene changes are akin to what happens in village feuds or urban brawls that feature in news reports across India. While leaders are debating whether India is experiencing a second wave or Delhi is experiencing a fourth wave, the virus is spreading rapidly across the country, helped by the more infectious variants that arrived from abroad or emerged at home as a ‘double mutant’.
Changes, a year on
There are several differences from the pandemic which we experienced in 2020, both in its spread and in our response. The virus affected relatively small numbers by March 2020, by the time the lockdown was announced. The long nationwide lockdown gave governments across the land time to strengthen the health system capacity, streamline administrative coordination, power up procurement and production processes for essential equipment and supplies, educate people on the dangers posed by the virus and advise personal protection measures that needed to be adopted. Release from the lockdown was phased, limiting transmission even as society gradually opened up. Large cities and neighbouring districts were more affected, with urban crowding and mobility driving the transmission. Rural areas and less developed States were mostly protected. This time, the pandemic has resurfaced in a fully open society. There was unrestricted movement, markets were crowded, domestic and international travel was brisk, election campaigns were boisterously run for local bodies and assemblies, religious gatherings received state support and cricket matches were celebrated as a joyful advertisement of return to normalcy as rest of the world was still struggling with the pandemic. Masks were mandated notionally and the public decided to follow the leaders and celebrities who disdained to wear them in public. The virus had an open road for its travel, with only the welcome arches missing.
We now need to proceed beyond reflections and remonstration on what went wrong, to design and deliver a resolute response that can help us to rapidly regain control and limit the damage. This has to incorporate several strategic components, cohesively connected and collectively implemented, to have a sustained impact. They are:
First step is decentralisation
Decentralise the response to district level. Knowledge of existing and evolving local conditions matters, for the design and the delivery of an effective response. Local data gathering and analysis provide real time intelligence for rapid response. Local community networks are important channels for information dissemination and for partnering the administration in implementation. We need consultative policymaking at the national level, inter-departmental planning at the State level. and data-driven decentralised decision making for situation adaptive implementation at the district level. The district collector must coordinate health-care services across all facilities in the district and be empowered to commandeer hospitals, hotels and transport facilities as needed.
Prevent super spreader events and mandate masks. Testing numbers are again being projected as the best measure of an efficient and effective response. This is incorrect. While tests are indeed an important component of the strategy, we cannot test asymptomatically infected persons and mildly symptomatic persons who do not report themselves. These constitute a very large number at any time, as we know from antibody surveys. We cannot randomly and repeatedly test large proportions of the population to detect virus presence in such potentially infective persons. Masks, if worn well and regularly in public and even in indoor gatherings, will greatly reduce risk of transmission from any infected person, known or unknown. Even the more infectious variants will be blocked by effective masks, even where physical distancing is not possible.
Stop the events
What is absolutely essential is preventing super spreader events. Crowding, whether indoor or outdoor, offers the virus an opportunity to seed itself among many exposed persons who then carry it elsewhere to perpetuate the chain of transmission. There should be a ban on large gatherings, for at least the next eight weeks. Travel restrictions too must be imposed during this period. The notion that all of India has acquired or will soon acquire herd immunity must be dispelled with clear messaging for some months to come.
Use smart testing and tracing, but case detection needs more. The past year has taught us that viral tests are useful but have limitations. A single RT-PCR test can miss between 30%-40% cases, due to limitations posed by swab collection, transport efficiency and laboratory competency apart from testing too early or too late during the infection when a replicating virus is not detectable.
We need to detect possible cases through household surveillance of symptomatic individuals by primary health-care teams supported by citizen volunteers. All suspect cases and household contacts must be tested. Positive cases must be isolated and provided home or hospital care depending on severity. Symptomatic but negative persons and household contacts should be re-tested three to five days later but wear masks and observe distance even at home till the re-test result too is negative and the infected person has recovered. Genomic analyses must be performed in at least 5% of test positive samples. Contact tracing, for persons from whom the case may have acquired the infection and to whom the case may have passed it on, needs to be conducted with speed and efficiency. Local networks help in early case detection and contact tracing. The use of just apps will not do.
Step up vaccine rollout
Speed up vaccine rollout, recognising value and limitations. The benefit of currently available vaccines is to provide protection against severe disease, not infection per se . This information must be clearly conveyed to the public, politicians and the media so that wrong expectations of complete protection against infection do not lead to laxity in behaviour or an outcry of vaccine failure.
Given this objective, available vaccines must be prioritised for vulnerable persons. Initially, the aim must be to immunise all persons above 35 years of age and all younger persons with at-risk health disorders. We must get more vaccines quickly into the supply chain by incentivising greater production volumes of already approved vaccines and waiving the requirement of a bridging trial for domestic manufacture of vaccines approved by credible international regulators, subject to submissions of full trial data to our regulators. We must train more vaccinators for delivery closer to home, stepping up daily administration rates at more centres.
Social support is key
Involve people, not just instruct. Citizen engagement is critical for a successful pandemic response. Formal and informal networks that exist at the local level must be activated and supported to educate people and motivate them for adopting COVID-19-appropriate behaviours, symptom reporting, providing contact information and registering for vaccination, while providing social support to affected families. Masks can be produced at the State or district level, for free distribution to households by community-based organisations. People partnered public health must become the credo and lasting legacy of the COVID-19 campaign.
Provide empathetic social support. District authorities must identify vulnerable persons and families who may suffer hardships due to loss of income, shelter or incur high health-care costs. Proactive support must be provided from public financing, as state policy, even as philanthropy is mobilised to supplement. Children must be supported for education at home or in the neighbourhood, through voluntary agencies, to overcome the digital divide of online teaching. Social solidarity must become the soul of our pandemic response.
Prof. K. Srinath Reddy, a cardiologist and epidemiologist, is President, Public Health Foundation of India (PHFI). The views expressed are personal