Dr Pankaj Kumar Panda, Senior Research Officer, Apollo Proton Cancer Centre and Dr Srinivas Chilukuri, Senior Consultant Radiation Oncologist, Apollo Proton Cancer Centre examine India’s approach towards combating Covid-19 outbreak in the country
Covid-19 pandemic is probably humanity’s single largest enemy right now. As per the Indian Council of Medical Research’s (ICMR) daily bulletin, it is now an open war against the pandemic which has been wreaking havoc all across the world. As the number of Covid-19 cases in India keep exceeding every day, we are in this unprecedented crisis. All the simulation models to predict viral replication among Indians, have predicted extremely tough days ahead with severe strain on our healthcare resources. We believe in many ways it is indeed a litmus test for our healthcare and public health infrastructure. It is also a test of grit, determination, resilience and survival instincts for people, governments, bureaucracy and even media.
The Covid-19 exigency
With no specific treatment available currently other than only symptomatic treatments, the diagnosis of Covid-19 is less likely to benefit the individual and yet will immensely benefit the community. Despite the World Health Organization’s (WHO) call for extensive testing and the success of widespread testing in South Korea and Taiwan, India has so far adopted the strategy of selective testing. The ICMR, by virtue of its random testing, had been constantly maintaining till recently that India has not yet progressed into the community transmission (phase-3) stage and hence there was no need for widespread testing. In India, testing is being currently recommended for only all asymptomatic individuals who have undertaken international travel in the last 14 days, all symptomatic contacts of laboratory confirmed patients, all symptomatic healthcare workers, all hospitalised patients with severe acute respiratory illness (SARI) and asymptomatic direct and high risk contacts of confirmed cases. Given the mammoth 1.3 billion Indian population, the current testing proportion is alarmingly low (<10 per million population). Selective testing will result in not being able to isolate the affected and trace the contacts effectively, especially in asymptomatic individuals. Because of this approach, we do not have reliable infection numbers, which has impaired our ability to accurately predict the course of the epidemic and in turn, our readiness with respect to our healthcare infrastructure. It also puts a question mark on all the models, which have been based on assumptions rather than real numbers with extrapolation from models derived from China, South Korea or Italy.
India’s preparedness for testing has lagged behind other countries with limited availability of home grown resources and over dependence of imported kits to perform RT-PCR — considered the gold standard in testing globally and currently the only test approved by ICMR. Though the test is robust, to be able to do large-scale testing, we need a steady supply of imported reagents and test kits. However, the national institute of virology (NIV) and ICMR have recently approved indigenously developed kits, which can potentially escalate our capacity to test nearly from 6000-10,000 to nearly a lakh people per week with rapid turnaround time. The chasm between WHO’s advisory for extensive testing and the ICMR’s selective testing approach seems to have heightened public sentiments and brought about a wide variety of perspectives amongst the Indian healthcare service providers. Could we have done better with widespread testing very early in to the epidemic, is something we will never know for sure. Also, serological tests to detect antibodies in the serum of an individual after four to five days of infection, is something which is being looked at by the ICMR. This test can detect not just those who have active infection, but also past the infection. Since this test potentially is prone to false positives and false negatives, it is not yet approved. However, widespread serological tests have a great potential to understand the penetration of infection in the population. Going forward, ICMR will certainly study its potential in Indian context.
Are we prepared to take on the demon?
As more and more individuals become infected, the burden on the already fragmented Indian healthcare sector is bound to multiply. With an abysmal doctor to patient, beds to million populations, intensive care unit (ICU) beds to million population ratios, inadequate medical infrastructure and essential equipment like ventilators, India sits dangerously on a ticking time-bomb ready to explode any moment. With an increasing number of infections, the demand for additional testing and care for patients with Covid-19 will increase by leaps and bounds. In such a scenario, the focus of the healthcare sector will shift and will impact the care of non-Covid-19 patients. Covid-19 patients presenting with SARI need dedicated isolation wards with regular intensive-care beds, round-the-clock monitoring, protective gear and many other resources. Healthcare professionals involved in the care of such patients also are at an equal risk and their infection will impair already inadequate manpower. As per rough estimates, there are approximately 40,000 mechanical ventilators in India. With around two to eight per cent of all Covid-19 patients requiring ventilators during the entire course of stay in the healthcare facility, it will be a humongous challenge to use them judiciously. Another challenge is the inequitable healthcare in urban vs rural setting with sketchy infrastructure and human resources in the rural setting, there is a higher probability of mortality in the rural areas. We need to urgently work on ramping up healthcare facilities in every geography on a war footing. But how do we ramp up medical and paramedical personnel is something which is going to remain a challenge for the government.
Has the lockdown come a little late for India?
The Covid-19, with its rapid transmission and replication figures, is almost similar to the Spanish Flu during 1918. Researchers have been drawing parallels between the Covid-19 pandemic and the Spanish Flu which had led to around 50 million deaths worldwide. Even though medical science has evolved tremendously in the past several decades, evolution in general has brought with it necessary evils such as increased population portability, which pose as challenges to effective containment of the virus. Many countries have delayed implementation of aggressive social distancing and lockdowns fearing a negative impact on their economies. This short-sightedness has cost them dearly which is evident from the latest Covid-19 statistics from the United States, Italy, Spain, United Kingdom and Australia to name a few. With a rapid increase in the number of Covid-19 infections being detected in India, we are well past keeping the pathogen out of the country. Lessons learnt from other countries should be used to implement strict suppression measures while it can still work. There is some evidence to show delaying the lockdown has led to devastating consequences as seen in Italy with more than 80,000 cases and around 82,00 fatalities.
Compulsory social distancing, which is already being implemented in India post the 21-days lockdown, will definitely have a beneficial effect in halting the transmission rate of the virus. But has it been undertaken at the right time? Have we missed the golden opportunity by delaying a bit? Nobody will be able to answer that question without reliable numbers and models.
With the Indian government enforcing a complete lockdown in the country for 21 days, there will be a major reduction in the contact rate amongst people. This, coupled with assurances to protect the interests of the citizens in the long run, is necessary to secure compliance to the lockdown. This strategy, no doubt, will be a major shot in the arm in our war against the Covid-19 pandemic. However, it needs to be supported by a host of other measures also to offset some of the adversaries such as a weakened economy and strained healthcare sector, amongst others. The Indian government recently in its $23 billion (Rs 1.7 lakh crores) stimulus package has provisioned to alleviate a majority of the ill effects of this pandemic such as unemployment, scarcity of essential goods, services and other resources and the subsequent effects of the lockdown. In a way, we need to understand the cost of this epidemic and its control to ensure that the cost of the control is not more than the disease itself. Explicit details regarding the path of action and its implications must be made available to all stakeholders, so as to provide them the required impetus to march on this war path together.
As India is counting days under the lockdown, there is very little evidence or data regarding the most appropriate duration of the lockdown, when can it be lifted and to what extent?
Hopefully, we will learn from those who are ahead of us in the pandemic cycle.