COVID-19 and India’s response: Example of a Developing Country

A densely populated country like India is a hotbed for rapid spread of an infectious agent like SARS-COV-2.  India reported the first confirmed case of COVID-19 on 30 January 2020 in Kerala. Since then the numbers showed gradual increase, reaching to 9500 cases with active infections as on 13th April. Government of India has put collaborative intersectoral efforts to contain the spread of epidemic and reduce the number of confirmed cases.

Being one of the resource-constrained countries with inadequate  it is interesting to look how India planned and acted on mitigation of the COVID-19 pandemic and what factors enabled to keep the number of cases lower than estimated by the statistical models.

Testing

  • The Indian Council of Medical Research (ICMR) – the apex health research body of India- decided the testing criteria for SARS-COV-2 cases, using the real-time reverse transcription polymerase chain reaction (rRT-PCR) tests to detect the coronavirus from samples of throat or nasal swab of suspected individuals, within 7 days of illness and after 7 days of illness. If antibody test comes negative, it is confirmed by rRT-PCR test.
  • Testing criteria

The criteria of testing were developed based on the expected volume of cases, and the availability of resources for testing. Figure below shows how the criteria evolved over time.

  • Reporting of confirmed cases
    • ICMR has been closely monitoring the status of disease transmissions in the country. The daily reporting by states on the number of cases is reviewed and updated on the website of the Ministry of Health, Family and Welfare (MoHFW) of India, and used to plan the further steps in each state and identified hotspots.

Early measures

  • The Prime Minister’s Office and the MoHFW planned and reviewed the public health preparedness and response efforts; including surveillance, diagnostics, hospital preparedness, infection prevention and control, logistics and risk communication.
  • Surveillance-
    • Surveillance was strengthened and enhanced at points of entry, in health facilities and in the community including contact tracing and follow up around the confirmed case.
    • Sentinel surveillance was started to see if there was a community transmission of COVID-19. By March 15, the number of surveillance sites was increased to 51 sites.
    • MoHFW is working closely with WHO Country office for India Welfare to strengthen COVID-19 Special Surveillance System (S3) through the Integrated Health Information Platform (IHIP).
  • Contact tracing
    • As early identification is important in COVID-19, contact tracing is a crucial strategy for early recognition, immediate isolation and implementation of appropriate infection prevention and control measures; provision of symptomatic care for those with mild illness; and optimised supportive care for those with severe disease.
    • Contact tracing was deployed by state and districts authorities to identify people in close contact with individuals having COVID-19 or at risk of getting infected.
  • Screening and travel advisory
  1. In early weeks of January, MoHFW and Ministry of Civil Aviation initiated inflight announcements and entry screening for symptoms of fever and cough for incoming travellers, initially from China and later extending to all high-incidence countries at 21 airports of India.
  2. A travel advisory was issued advising Indians to avoid non-essential international as well as domestic travel.
  3. International traffic at land borders was allowed only through designated check posts with robust screening facilities.

  • State level preparedness-
    • MoHFW advised States to open their control rooms, appoint a nodal officer and popularize the control room number to enhance coordination between actors.
    • Government ramped up Dedicated COVID-19 hospitals at both Centre and State level to take care of COVID patients.
    • IEC materials were developed and adapted in local languages by the concerned States.

Containing the spread

  • After  declaring COVID-19 outbreak a “notified disaster”, GoI allowed the state-level disaster relief funds to be used to care for quarantined people.
  • Isolation wards are set up to house symptomatic suspected and confirmed COVID-19 persons. Others were referred to home quarantine.
  • The MoHFW also undertook social media campaigns and issued messages about measures like hand-washing and social-distancing in English and Hindi.
  • Travel restrictions
    • The GoI suspended all tourist and student visas as well as the visa-free entry of Persons of Indian Origin (PIO) card holders beginning from March 13, 2020; the entry of passengers from all member countries of the European Union, Turkey and the UK prohibited from March 18.
    • Apart from the visa suspension, the new advisory also announced a tough new mandatory quarantine regime for passengers entering the country after March 13, for a minimum period of 14 days.

Nationwide Lockdown

Considering the already saturated and overburdened healthcare system, a 21-day nationwide lockdown, with a complete ban on people from stepping out of their homes was announced, with further extension of 3 weeks after reviewing the status. All the businesses and services except the essential services were discontinued for this period.

  • The rationale behind this physical distancing is to break the virus’s chain of transmission and thus reduce its ability to spread. Although brutal in its economic effects, this would enable the preparedness of healthcare providers and readiness of facilities with supply of testing kits, protective gears and medical equipments.
  • This would also prevent the overwhelming of healthcare system that is facing challenges of understaffing, inadequate resources and protective equipment.
  • Although the testing is done only for cases with severe symptoms, the magnitude of asymptomatic or cases with mild symptoms might be even greater. Thus this lockdown also serves to prevent spread from these cases by isolating them at their houses.

Cluster containment strategy

  • As part of the COVID-19 management, GoI implemented cluster containment strategy. In districts such as Agra, existing Smart City Integrated with Command and Control Centre (ICCC) were utilized as war rooms for coordinated efforts by the State, District administration and frontline workers.
    • The District administration identified epicentres, mapped the impact of positive confirmed cases and deployed special task force as per the micro plan. An active survey and containment plan was prepared for management of the hotspots.
    • In the 5 Km buffer zone area from epicentre identified as the containment zone, teams of health workers including ANMs/ASHA/AWW from primary health centers were deployed for household screening. Isolation, testing and treatment facilities were set up through an active Public-Private Partnership.
  • Food and supplies were provided to the people in need and an essential supply chain was maintained. Doorstep distribution for citizens and e-pass facility helped in the movement of essential goods & services during the lockdown.
  • The District administration simultaneously emphasized on citizen awareness and engagement.

Other measures

  • Media campaigns were initiated for hygiene and sanitation as well as prevention measures, such as celebrities enforcing the importance of handwashing. The videos for handwashing were spread through various communications modes.
  • The GoI invoked the Disaster Management Act to regulate the price of sanitisers, gloves and surgical and non-surgical masks.
  • With a surge in novel coronavirus cases, the MoHFW activated helpline number 011-239 78046 and a toll-free 24×7 national helpline number- 1075, to address queries related to the infection. The ministry has also issued a helpline email ID ncov2019@gmail.com.
  • GoI launched a mobile app Arogya Setu through a public-private partnership to enable people to assess their risk of SARS-COV-2 infection.
  • MoHFW issued an order for insurance cover for all health workers for a period of 90 days through ‘Pradhan Mantri Garib Kalyan Package: Insurance Scheme for Health Workers Fighting COVID-I9’.
  • The Insurance Regulatory and Development Authority of India also instructed all insurers to cover all claims pertaining to hospitalisation due to coronavirus and medical expenses incurred due to treatment of coronavirus.

Approaches by states

All the state governments took appropriate containment and management measures, with directions from central ministry. To prevent crowding and large gatherings of people, many states imposed Section 144 of the Criminal Procedure Code, which restricts gathering of more than 4 people in public places. States where large numbers of migrant workers were stuck after the nation-wide lockdown also provided food and essential supplies to these workers, along with their screening and isolation if required.

The southern state of Kerala has been particularly successful in restricting the spread and limiting the number of cases, along with effective lockdown strategies.

Kerala:

Kerala’s response to COVID-19 (image source: theweek.in)
  • First COVID-19 case in India was reported in the Kerala state, followed by two more cases in quick succession. The state government took timely actions for containment and management of these three incidents. The rigorous surveillance and quarantine of other suspects prevented local spread of the virus.
  • The state formed a 24-member Rapid Response Team chaired by the health minister and begun preparatory measures through its emergency response model. On-ground information and updates are provided from 18 state-level committees that coordinate various aspects in liaison with district-level committees.
  • The government also used technology to drive the IEC campaign and has made the circulation of misinformation on COVID-19 a criminal offence.
  • Responding to the fundamental needs, the state govt ensured access to midday meals by underprivileged children by delivering rice, wheat, beans, oil and snacks to their houses through the Integrated Child Development Services programme. It is also providing additional support for children younger than 3, lactating mothers and pregnant women.
  • The state launched “Break the Chain”- a mass hand-washing campaign to initiate behaviour change.
  • A Psychological Support Team was formed to manage the aspects of mental health, and has devised many strategies to manage stress and other mental health concerns resulting from the outbreak.
  • The multi-disciplinary team under District Mental Health Program  provides counselling and psychosocial support for people in isolation and quarantine. 
  • DMHP coordinates with the local panchayat authorities for community level interventions, primarily regarding the stigma.

Odisha:

  • In response to the efforts of GoI, Odisha incentivised Indians returning from travel abroad to declare their itinerary and illnesses if any with a cash award of Rs 15,000.

Steps ahead

Although India has managed to contain the wide spread of COVID-19, the number of reported cases are still on rise, with variation in different states and areas. There is a need to undertake robust strategies to prevent further spread and loss once the lockdown ends-

  • National and state capacity should be scaled up rapidly, by means of gaps and risk assessment, additional investigation plans and execution to curb infections.
  • A comprehensive national policy must be developed for an continued supply of  resources such as drugs, consumables, vaccines, devices, and PPE for use during public health emergencies.
  • Testing: Random population sampling should be conducted in different parts of the country to detect both asymptomatic and symptomatic persons who have been infected.
  • Health system strengthening:
    • This pandemic can be utilized to build institutional memory and strengthen the public health system of India. Primary health-care facilities, district hospitals, public and private tertiary care institutions should be equipped with adequate essential resources and human resources.
    • Considering the higher risk to older health-care providers, the first line of care should be formed by younger staff members while the older staff members can provide supervisory support. This will prevent exhaustion or illnesses of the health workforce.
  • Community level
    • Volunteers and community-based organisations should be involved in case detection, isolation, counselling, severity-based care, mental and social support.
    • Further localised lockdown is needed in identified hotspots, based on numbers of self-referred symptomatic cases, persons identified on home visits and population survey results.

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