"Between lockdowns and relaxations": Time for an introspection

by Sayan Das*, Priya Tiwari# , Ujjayinee Aich*, Amitabha Sarkar*, Indranil Mukhopadhyay+

Image courtesy: Zee News

‘With the Lockdown Relaxing but COVID-19 Continuing to Rage, It’s Time We Re-examine COVID-19 Containment Strategies in India'

Now that India has claimed the unenviable position of being in the top 10 worst COVID affected countries, it’s perhaps time to re-examine some of our core strategies in this ongoing battle. The infectivity of SARS-CoV-2 virus, causing COVID-19 disease, and the lack of clinical cure have forced countries to primarily depend on Non-Pharmaceutical Interventions and containment strategies to control the spread of the pandemic. As we know, the containment strategies led by the government primarily rest on the twin prongs of testing and surveillance.

Testing more or more strategic testing?

From the beginning of the epidemic, we’ve been hearing that ‘testing, testing, testing’ should be the mantra in our fight against this disease without a cure so far. Compared to the initial days, no doubt we have massively scaled up testing across the country. On an average, cumulative tests per million (samples tested) by first half of April was less than 300 tests per day. Now by the end of May, more than 2708 tests have been performed each day on an average. That’s quite a jump. The metric of testing coverage or the number of tests done per thousand or millions of people, which helps in adjusting for population size, is being used extensively.

Figure 1 presents the number of Covid-19 tests per 1000 people across some of the Covid-19 affected countries along with data on tests performed per confirmed case. We can see that while countries like South Korea, Australia, New Zealand, later on even Italy and the United States pursued an aggressive testing strategy, many Asian countries like Vietnam, Thailand, even India have done much lesser tests per 1000 population.

However, testing coverage may not be a very reliable indicator in understanding the pandemic through its various stages. For instance, in the initial period, the number of infections will be low and so will be the testing coverage but as time passes, infection will spread, and a greater testing coverage will be required for a reliable assessment of the spread. The numbers therefore do not necessarily indicate whether adequate testing is being done, just that more tests are performed as more people get infected over time.

Number of tests per confirmed case, on the other hand, indicate how many people or samples were tested for each confirmed case, reflecting efforts to identify each positive case. A country/state that does more tests per thousand or million population but less for each confirmed case is actually testing the symptomatic more than the many others who are also infected but with mild or no symptoms. Identifying this group of people is vital to control community spread of infection. Those who test less per confirmed case are likely to miss these spreaders and misjudge the spread of infection in the community, adversely impacting their containment objectives. Effective screening and contact tracing thus become crucial in ensuring that mainly those with increased likelihood of exposure or infection get tested, not all and sundry. This targeted approach to testing if executed properly can serve well in resource poor settings.

In this regard, there is a wide variation between countries on tests performed per confirmed case (Figure 1). Countries like Vietnam, Thailand, Taiwan or New Zealand have done more tests per confirmed case than tests per 1000 people. The USA and the UK, on the other hand, have done fewer tests per confirmed case, despite their aggressive testing strategy. For India, however, both the metrics show a pretty low figure.

Data source: Our World in Data

(Note: There may be differences in reporting testing data across countries, making direct comparison compromised.)

If we shift our focus to the tests per million data (Figure 2) for the 10 Indian states which have the highest number of cases along with the two southern states of Karnataka and Kerala, Delhi ranks at the top with the highest number of tests (8805), followed by Andhra Pradesh (6024).

Data source: covid19india

The tests performed per confirmed case in Delhi, however, is rather low at 12.4. It is interesting to note that, except for Rajasthan, states with lower caseloads have done more wider testing in terms of tests per confirmed case. Both Karnataka and Kerala’s tests performed per million is lower than Delhi, but they consistently fare better on tests performed per confirmed case (Figure 3). Perhaps it’s no coincidence that the countries and the Indian states that from the early days had focused on more strategic testing, throwing the net wide, have been able to control the outbreak better.

Data source: covid19india

Tracking contacts, tracing life

Strategic testing as discussed above will only work if it is complemented with competent surveillance through effective screening and contact tracing.

India began universal screening on March 06th, while it reported its first positive COVID case on 30th January 2020. Before that, it had been thermally screening passengers traveling from China and Hong Kong at three Indian airports only. According to an RTI reply India had screened only 19% of arriving passengers between 15/01/2020 – 23/03/2020. No such data is available for domestic passenger screening during the same time period.

Statistically it is not possible to give numbers of COVID-19 positive cases who evaded thermal screening. Nonetheless, the continuously increasing caseload indicate that screening checks did not give full protection either. Despite repeated denials of community transmission by the government, many states like Goa, Andhra Pradesh and Assam took matter in their own hands and began door to door surveys to actively find cases with travel history or suspicious symptoms. Bihar built on the polio micro plan of house to house surveillance to a similar end.

With an already existing country wide network of ASHAs and other community health workers this strategy can be easily scaled up across other states. But to ensure proper implementation, training of health workers to successfully discern suspected COVID cases from other similar symptomatic, provisioning of personal protective equipment (PPE) to them, smooth linkage between screening and sample collection would be crucial.

Different approaches were adopted in different countries for tracing contacts (Table 1). In India, mostly two categories of persons have so far been traced for COVID 19 - travellers who have tested positive and primary contacts of all positive cases. States like Kerala, Odisha and Rajasthan have successfully used traditional methods to trace contacts from an early period of the outbreak to control the spread. The Bhilwara model is a successful example for screening and tracing contacts.

To speed up tracing, Government of India launched ‘Arogya-Setu’ app, which has now been mandatory for travellers to download while boarding a train or a flight. However, as per epidemiologists, at least 60% of the population needs use the app along with all complementary intervention for it to be effective. Privacy is also a major issue while using such apps.

Table 1. Contact tracing strategies adopted in different countries

Data source: Compiled from several online platforms.

Contact tracing, despite its extensive use in public health programmes, is perhaps the more difficult of the two strategies. It is not just tracing people but actually coaxing them to reveal parts of their lives. The role the health workers are expected to play is that of the social worker who can evoke trust and confidence in people. This is crucial because reports suggest many fever cases are going unreported due to the fear and stigma attached with the disease. Moreover, while interrogating people on their exposure or movement history, the health workers can additionally disseminate useful information and offer help or advise for issues other than COVID. Thus, the human angle becomes critical in not just tracing COVID-suspects but also ensuring that people remain otherwise healthy in this period of crisis.

Community against COVID-19

Finally, the strategy that seems to be amiss in most of our discussions is the role of the community. This becomes even more significant as nationwide lockdown becomes relaxed while specific containment zones remain.

In epidemic planning and preparation, involvement of community is a primary condition. Prevailing uncertainty, fear, hunger call for a more inclusive, supportive and empathetic approach. Guidance and information along with solidarity and reassurance can be reinforced through the existing social mechanisms/support systems. Volunteers and civil society have taken initiatives to reach out to the ones in need, but this has been largely unorganised and non-uniform. After intense scrutiny, stricter regulation and revoking of at least 14500 licence of NGOs with FCRA license in India in the last 5 years, NITI AYOG and MHA has reached out to 92000 NGOs and other global institutions for joint COVID help. Centre’s continuous suspicious attitude towards non-profit sectors has generated a sense of fear and distrust in them. Government needs to promptly allay such anxieties to pave the way for more coordinated efforts, especially when lockdown measures become more localised in nature.

In addition to collaborating with civil societies and encouraging community-based initiatives and organising them to render a more uniform and penetrative plan, the government needs to embolden these local efforts by decentralising power, relaxing the stringent eligibility criteria for receiving foreign funding and making local level leadership stronger for long term benefit and stronger association.

*PhD Scholars at the Centre of Social Medicine and Community Health, JNU, #Independent researcher, + Associate Professor, School of Government and Public Policy, OP Jindal Global University. The opinions expressed in the article are personal views of authors.

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