Seven months into the coronavirus pandemic in the country, the Joint Task Force of eminent public health experts on Monday wrote to Prime Minister Narendra Modi and said it must be assumed that an effective vaccine against the novel coronavirus “would not be available in the near future”. They also said that any false sense of hope that this panacea is just around the corner must be avoided.
In a joint statement, experts of the Indian Public Health Association (IPHA), Indian Association of Preventive and Social Medicine (IAPSM), and Indian Association of Epidemiologists (IAE) said, “Vaccines do not have any role in current ongoing coronavirus pandemic control in India. It must be assumed that an effective vaccine would not be available in near future. We must avoid false sense of hope that this panacea is just around the corner.”
The group’s third joint statement on hope for a coronavirus vaccine against Covid-19 states, “Vaccines with proven efficacy and safety, as and when available, should be administered according to the WHO’s ‘strategic allocation’ approach or a multi-tiered risk-based approach.”
From graded re-opening of schools to discontinuing the lockdown strategy for pandemic control are some of the measures suggested by the public health experts.
The statement also states that now, a “lockdown as a strategy for control should be discontinued.”
While the health ministry or the ICMR has never admitted to any community transmission of the novel coronavirus in the country, the statement outlines that “cluster restrictions should be considered only in areas with no community transmission.”
The statement goes on to list the action plans that the government must take up at this point when the infection has seeped into not just in urban cities but also in rural areas of the country. India has been witnessing a rapid surge in the new cases, clocking a tally of more than 80,000 new cases on Monday, highest in the world when it comes to single-day cases in the USA and Brazil.
No lockdown, only short defined “cluster” restrictions duration to be imposed
Lockdown as a strategy for control should be discontinued. Geographically limited restrictions for short periods may be imposed in epidemiologically defined clusters. Cluster restrictions should be considered only in areas with no community transmission. Even cluster restrictions should be imposed after weighing the impact of the same on the livelihood of the target population.
With adequate health system preparedness, including facility care for severe cases, cluster restrictions can be totally done away with and should be the ideal way to address this pandemic.
In large cities (Y class), where there already has been substantial spread (can be assessed by the expert committee), there is no advantage of creating containment zones and aggressive testing.
The focus should be to prevent deaths from coronavirus and not on containing the infection. IEC should advise people to watch for the symptoms and early reporting for testing on demand and contacting the doctor for proper advice.
In Y class cities with moderate spread: Containment zones should be revamped with clear roadmap and timelines for periodic review by an expert committee, with the aim to test all suspects, isolate all infected individuals for proper treatment. All such zones should be de-contained in 14 days maximum.
Small cities and rural townships with mild/limited spread: Existing testing and cluster containment strategy may be continued. Although testing strategy with mandatory isolation needs to be reviewed in view of social stigma. In small cities, this is a major factor preventing persons from coming forward for testing.
Rural areas: syndromic surveillance by ASHA and village Nigrani Samiti and periodic review at PHC level could be done.
Role of vaccines in controlling ongoing outbreak: Vaccine has no role in current ongoing pandemic control. However, whenever available, the vaccine may play a role in providing personal protection to high-risk individuals like HCWs and the elderly with co-morbidities.
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 a false sense of hope that this panacea is just around the corner.
Opening of schools and educational institutions: It’s time now to move towards normalcy. The opening of schools and other educational institutions could be started in a graded manner. There should be a pragmatic approach, especially in areas where a sufficient population is already infected with SARS CoV-2 (ss assessed by expert committee).
Even in low infection areas, schools may be opened with due safety measures (social distancing, alternate work days, etc.), and with adequate surveillance for any outbreaks acceleration due to schools.
Quarantine and Isolation Policy: It should be community-friendly. The present policies, where houses of all persons who test positive, are stamped, isolated by barricades, is creating fear in society. This practice should be abandoned immediately.
When majority of states/districts are affected, there is no rationale for quarantine of inter-state travellers who are required to be in mandatory facility (hotel or health facility) quarantine (for 14 days). This should be stopped immediately. Citizen friendly measures like following home quarantine/isolation, which has been an effective strategy in many cities/states should be followed.
Pragmatic testing as a control strategy: Universal scaling up of testing at the current community transmission stage of the pandemic may not be an optimal control strategy and will divert attention and resources from control measures.
With the availability of sufficient understanding of the natural history of the disease and at-risk population, testing should be used with due diligence. Targeted testing of high-risk individuals, healthcare workers, elderly with co-morbidities, screening prior to surgical procedure, etc. is recommended.
However, 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.
For cities and towns with high caseload:
(i) Consider all symptomatic coronavirus cases and treat them at home or hospital depending on the clinical condition, as Covid-19 even without testing (syndromic approach);
(ii) Monitor symptomatic patients (even without testing), through phone, family members, and paramedics, and also through SpO2 values (either by supplying pulse oximeter individually or making these available through local paramedics) for early shifting to hospitals to reduce mortality;
(iii) a reliable and accountable dashboard and central helpline for those requiring hospitalisation (in coordination with ambulance services).
Towns/districts with low caseload: Continue the practice of containment zones, identify the case
and contain that area, conduct a house-to-house survey, identify cases through testing, isolate all those cases preferably at some facility to avoid further spread or home quarantine if possible with strict instruction so that spread can be stopped.
Towns/districts with no caseload: Continue surveillance activity and precautions; actively promote physical/social distancing, mask use, and hand hygiene.
Immediate resumption of comprehensive health care services:
Primary, secondary, and tertiary health care services, including outpatient and inpatient services including routine/emergency surgeries, should resume as early as feasible, in at least those areas that are progressing towards higher levels of immunity and in towns/districts with no coronavirus cases.
Adequate safety measures should be put in place for the safety of the health care staff engaged with optimal PPE and testing of patients for coronavirus as may be appropriate.
Protecting high-risk populations including elderly and those with co-morbidities: Elderly persons (>65 years) and those with co-morbidities (hypertension, DM, Cancer, obesity, etc.) shall continue to restrict their outdoor activities as far as possible. Younger persons with co-morbidities should also exercise appropriate caution.
Continue preventive control measures of physical distancing, face mask use, hand washing: All should continue to practice distancing (avoiding mass gatherings), face mask usage, and hand washing to prevent and limit transmission.
ILI and SARI surveillance: Early detection of ILI and prompt management of SARI cases using a combination of syndromic surveillance and the ‘test and track’ strategy should be strengthened.
Periodic sero-surveillance survey for monitoring the pandemic: State and national-level sero-surveillance surveys need to be undertaken to monitor the pandemic and modify the control strategies accordingly.
In the future, the use of an already existing sero-surveillance platform could be a cost-effective way to do sero surveillance. All the sero-surveillance must be supervised by a trained public health specialist (MD Community Medicine) from local medical colleges, and public health institutions.
Increase healthcare expenditure to 5 per cent of GDP: 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.
The focus of increased health expenditure should be on primary healthcare and human resource and infrastructure strengthening rather than opening/strengthening tertiary care centers.
Public health cadre at national and state levels: States like Tamil Nadu and Gujarat with existing public health cadre are relatively better placed in handling such public health crisis on their own. There is a need to expedite the establishment of a dedicated, efficient, and adequately resourced public health cadre as Indian Health Service (IHS) in the center and across states.
The ongoing pandemic is a public health problem that is fast-worsening existing health inequities. It is not a law and order problem and should be dealt with empathy and meaningful community engagement. The way forward needs to take into account contextual constraints and community interests and design optimal interventions that require technical competence blended with good judgment, clarity, and trust.
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.
A joint task force — Indian Public Health Association (IPHA), Indian Association of Preventive and Social Medicine (IAPSM) along with Indian Association of Epidemiologists (IAE) — was created in April 2020 to advise the government for containment of the coronavirus pandemic in the country.
The experts include Dr AC Dhariwal, Former Director, NVBDCP & NCDC, and Advisor NVBDCP, MoHFW, GoI, New Delhi, Dr DCS Reddy, Former Professor & Head, Community Medicine, IMS, BHU, Varanasi, Dr Puneet Misra, Past President, IAPSM & Professor, CCM, AIIMS, New Delhi, Dr Sanjay K Rai, National President, IPHA and Professor, CCM, AIIMS, New Delhi, Dr Shashi Kant, Past President IAPSM, and Professor & Head, CCM, AIIMS, New Delhi and Dr Sujeet Kumar Singh, Director, National Centre for Disease Control, New Delhi amongst many others.