What India needs to do to win against Covid-19

India must get three things right to stop new cases of the coronavirus disease (Covid-19) from overwhelming its health system — rapid testing, enforcing home-quarantine, and protecting health workers.

The only thing it has got right so far is protecting health workers. No medical worker has developed the disease, including the ones working in isolation wards and those who have had unprotected exposure to patients in private and public hospitals before diagnosis. With deaths being disproportionately high among healthcare workers, India must take all possible steps to keep them safe.

Where India has failed woefully is in providing rapid diagnostic tests across platforms. This is critical to mount a public health response strong enough to stop a surge in Covid-19 cases, which typically tend to spike three weeks after the first few infections are identified. Pleading that these tests don’t have 100% accuracy is simply not a good enough argument in a pandemic scenario, when rapid tests can become the first line of screening for people who can afford them.

People need access to rapid diagnostic testing that give results in 15-20 minutes because the sooner clinicians, patients and public health officials know whether someone is infected, the sooner they can be isolated to stop them from infecting others. China has used such testing effectively to keep the quantum of new cases down. India must do this before cluster infections turn into an epidemic. India must learn from the mistakes of the United States, which is scrambling to scale up diagnostics against a rising wave of infection by fast-tracking testing. It is funding companies developing rapid tests that give a result within an hour and setting up a hotline to help laboratories get supplies.

What has worked for India so far are its protocols for dealing with the perennial threat of outbreaks from new and deadly diseases like bird flu, Sars, Mers, Nipah and Zika. The bird flu (H5N1) outbreak in Maharashtra in 2006 forced it to get its clinical diagnostic systems in place in 2008, before which all samples were being sent to the US Centers for Disease Control and Prevention for testing. Since 2008, across the country, influenza surveillance network laboratories routinely test patients admitted in hospitals for ‘influenza-like’ illnesses and severe acute respiratory infections, including pneumonia. A second round of random testing of patients with fever and pneumonia will begin tomorrow to detect unrecorded cases of Covid-19 in the community, if any.

This diagnostic advantage, however, will collapse when the epidemic surges and government labs get flooded with samples that run into hundreds and thousands each day. India has to plan for this contingency given that close to 70% of India’s population of 1.35 billion is dependent on the private sector for treatment. Private sector participation in diagnostics and treatment must start now, or we risk going the way of the US and Italy, where the explosion in cases has led to panic and the collapse of the public health system.

At the risk of being called a nanny state, India must enforce home-quarantine to stop super-spreading in the community. India began screening travellers for Covid-19 symptoms at airports and major seaports on January 17, when most European countries and the United States were dismissing it as another Asian outbreak, much to their own peril. This jumpstart in screening helped postpone the first wave of infection in India to February, when Europe has started reeling from an onslaught of cases.

But India’s failure to ensure compliance of home-quarantine of travellers from affected countries has led to local transmission. India’s second Covid-19 death on Friday could have been avoided if the traveller, who had visited Japan, Switzerland and Italy before arriving in India on February 23, had stayed home for two weeks as recommended. He has the potential to be India’s first super-spreader because he not only infected his mother, who died, but also used public transport to go work across town for two weeks. This has put 813 of his close contacts, including 707 colleagues, at risk.

With many travellers returning from affected countries like Italy developing symptoms several days after landing or having no symptoms at all, a self-imposed home lockdown for two weeks is absolutely essential. It is also crucial to test for Covid-19 for those who develop fever, dry cough, fatigue, phlegm cough, or shortness of breath. This is what helped the three students from Wuhan in Kerala recover without infecting anyone.

Super-spreading can be contained only by enforcing home-quarantine for people who have recently come back from affected countries. India must consider acting like Singapore, which has fined people who lied about their travel history, and revoked the residency status and work permits of people who breached quarantine.

Forced home-quarantine would have spared several states from virtual lockdown to ensure social distancing. If India fails to contain new infection over the next few months, we will have to run businesses, organise public events, and interact socially differently. Closed schools, flexible shift plans, employees working from home, and bans on large gatherings, events, concerts and festivals are the new reality, however temporary, for the world.

The urgency of partnering with private players for diagnostics, infection control and bed capacity cannot be emphasised enough given India’s population and overstretched health infrastructure. If infections surge, it will not be able to hospitalise and isolate every case. India must prepare to partner with the private sector to treat 80% of the patients with mild symptoms in isolation at home. This will help speed up response time and focus healthcare resources on the seriously ill.

Covid-19 is here to stay and frequent handwashing and social isolation will replace handshakes across cultures. Countries that act fast can reduce the number of deaths by a factor of ten. With less than 100 cases and two deaths, India still has the window of opportunity to screen, diagnose and isolate to flatten the curve of infection.

Given the scale of the global outbreak, the government cannot go it alone. To ride out this storm, we need all hands on deck, across sectors, skills and communities. India eliminated smallpox and polio. It has the experience in scale. Ending Covid-19 is possible if we act now.

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