Dr Rajeev Kumar Gupta
India which started its lockdown on 25th march 2020 due to Covid-19 pandemic has entered into lockdown 3.0 till 17th May 2020. As per WHO, pandemic of COVID-19 has accelerated quickly but it decelerates much more slowly. It must be acknowledged that since COVID-19 is a new threat and therefore public health strategies are still relying on measures like lockdown, quarantine and isolation, role of herd immunity and trials on drug therapy. Therefore it makes it incumbent on Governments across the world to emulate the best practices. Our country, India, in this context, too will have to chart its own strategy.
The current situation of COVID-19 in our country reveals that we may be ahead of the curve when it comes to enforcing a lockdown even though we may be behind the curve when it comes to widespread testing. For the epidemic to start ending, basic reproduction rate(R 0 – pronounced as R naught) has to drop below one. Before lockdown was imposed in China, in the first fortnight of January 2020, R0 of the virus had risen to 2.38 and after a complete lockdown, RO plummeted to below one; suggesting containment of the epidemic. It is in fact the essence of lockdown. A Yale university study has suggested that a hard lockdown may benefit developed countries more than developing and low income countries indicating that policy makers need to keep in mind the human and economic context of sweeping restrictions in place to stem the spread of COVID-19. The study also reported that epidemiological and economic benefits of social distancing are much smaller in poorer countries and they also levy a heavy toll on the poorer and the most vulnerable sections of the society – by limiting their ability to earn a living, so it can lead to increase in hunger, deprivation and related morbidity and mortality in these poor countries. It has been duly considered by GoI while announcing lockdown 3.0.
Some experts have introduced the concept of ‘Rolling Shut-down’- on off and on strategy including geographical sectioning to keep the pandemic in check till such time full control can be established through proven medical therapy or vaccine. Many nations face the prospect of rolling shutdown lasting months with accounts of the corona virus resurfacing whenever countries and communities relax mitigation measures and restrictions. There could be wave of flare ups, controls, flare ups and controls until therapy or vaccine arrives on the horizon. Even Anthony Fauci, USA expert on infectious diseases in White House, has expressed a similar outlook suggesting a gradual and partial re-opening of the economic activities and reeling things back if the virus resurfaces.
India too has to find a balance between the economic costs of enforcing a strict lockdown and retain curbs that can slow the virus’s spread. Key to restoring economic activity lies in conduction rapid blood tests. These antibody tests will identify those who have been exposed to virus and are therefore immune to it and these people can safely return to work. Only after lifting of lockdown, it would be known whether keeping the R0 value well below 1 for a reasonable period of time will really help us.
Instead of multiple lockdowns, another option is to achieve Herd Immunity (HI)- a concept which predicts that all of India would be protected as long as about 65% of population has experienced the infection; even if without symptoms or in its mildest forms .Sweden has taken a controversial approach to this pandemic imposing fewer restrictions than neighbours. Sweden proclaims that its capital Stockholm could reach HI by early May.
About two-third of India’s population is below 35 years of age and bulk of infection in younger individuals are mild and asymptomatic. Exposure to this at a pace that is controlled would allow for smaller epidemic peaks. But pursuing HI by allowing the virus to spread, rather than through a vaccine, is fraught with danger of many more deaths. Epidemiologists have debunked the idea of promoting a pre vaccine ‘Herd Immunity Strategy’. It is still unclear how much protection antibodies confer on people who have recovered from COVID-19. Early research has shown that not all recovered patients develop corona virus neutralizing antibodies to the same degree. It is too early to distinguish a person who is functionally immune from an another who has an immune response that is not protective. Also it is difficult to say at this stage that how long the immunity would last. If some people are at greater or lesser risk of infection with COVID-19 because of previous history of exposure to corona virus is an open question. It will be equally important to study immune responses of people with asymptomatic cases of COVID-19 to determine if symptoms and their severity predict whether a person becomes immune. A recent analysis from USA suggests that pandemic may stretch to 18-24 months as immunity slowly builds up in the population.
What India needs to do now
* Expand RT-PCR and antibody testing to keep containment and lockdown options for communities and hot spots where infections are spreading too quickly. Need to build in house rapid test kits after the debacle with Chinese kits.
* Voluntary social distancing and use of face masks by people in public places.
* Ban on gatherings- may be religious, rallies, weddings. Tele working and work from home whenever possible. Prioritize PCR testing to at-risk population that is 65 years and above with co- morbidities for early identification.
* Need to ramp up the health care system and out of box solutions like use of railway coaches as critical care units is a step in the right direction.
Models suggest that lockdown pushes the peak by about a month if there is no substantial change in behaviour. But with the policies detailed above, India can push the peak by about 3 months and help in flattening the curve substantially. Another important milestone by India is development of a diagnostic kit as a substitute to RT-PCR to diagnose COVID- 19 patients. It is less expensive and more accurate than RT-PCR and has been duly validated by NIV Pune. Experts are also working on use of Artificial Intelligence to analyse voice like sound of cough, breathing or the way an individual speaks to find if he is infected with COVID-19.Antiviral remdesivir seems promising in the initial results.
Potentially favourable factors for India are the younger age profile and a higher rural population as compared to China, Europe and USA where population are usually older, urban and highly mobile. For up to 6 weeks after the lockdown ends, restricting urban to rural movement to essential goods and essential needs is likely to help us. Containment zones is likely emerging model whenever the lockdown is eventually lifted.
The reality of COVID-19 is such that there can’t be return to normalcy overnight but Governments need to plan for a sequential restoration of activity. Regarding Herd Immunity, Dr Greta Bauer, an epidemiologist wrote-
We want to get there slowly and ideally through vaccines.
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