Dr Sandeep Dogra
Deciding on exiting a nationwide lockdown is as critical as initiating it in first place. There cannot be a one-size-fits-all approach and every country has to adopt a strategy that suits them according to their socio-political and demographic factors. The new knowledge of transmission and virulence of the coronavirus as stated by WHO which has described it ten times more deadly than H1N1 Swine Flu virus is another reason to take exit decisions after recognizing that there remain deep uncertainties about its real nature.
There is sufficient evidence that states which implemented hard lockdowns with the cluster management and containment strategies have fared better than others. As desired, the trend of positive cases has been more or less linear, and not exponential with the steadily increasing doubling rates. In a hope for an end to the present crisis, we should be prepared to face the fact that COVID-19 is not going away for a long time to come and some states may see transmission increase in coming weeks. Therefore, the critical decision to exit the lockdown has to be driven primarily by scientific data which is generated by testing and surveillance surveys. Further, this data has to be useful, reliable and accurate. One very important data pertains to the number of asymptomatic cases in a community because they constitute around 80% of the COVID-19 cases and are difficult to detect. Here comes the rationale of recently started door-to-door surveillance in J&K wherein teams are going to all the households. Those at moderate to high risk are being prioritized for testing, home quarantine and follow-up care. There is a valid apprehension of genuine ‘voluntary disclosure’ by the respondents in these surveys. That’s because of the fact that in addition to the fear of COVID-19 positivity, certain past events in the public domain have attached a stigma to COVID-19 suspects and cases. Here lies the need for administration and enforcement agencies to be sympathetic and accommodative while being firm and focused. Once the cases are identified, they need to be immediately tested with a reliable and fast testing technology, the results of which will empower the health authorities to either send them back or isolate them at home or a hospital.
Are we still doing ‘enough’ testing? The question is not that we are doing enough testing but how much COVID-19 testing does India require? Mathematics and demographics of our population does not make it feasible and scientific to chase testing numbers of other countries with different COVID-19 dynamics. Further, the quickly initiated lockdown along with tougher containment measures has largely helped us to flatten the curve and contain the coronavirus infection. It is pertinent here to understand that testing and containment are connected and have serious implications. Doing aggressive testing without first enforcing strict containment and social distancing measures would have led to high positive cases which in turn would have burdened our fragile healthcare resources and infrastructure. Acknowledging this, our country approach was opposite wherein administration initiated early lockdown to first enforce containment and social distancing and also to buy critical time to build up our healthcare infrastructure and ramp up our COVID-19 testing capacity both of which have been significantly achieved.
Another point in favor of going slow initially with respect to rapid testing is the fact that ICMR, well versed with documented performance of rapid screening tests was reluctant to use them in COVID-19 settings. Experts have always known that rapid tests are not perfect and that is why GoI has already banned rapid tests for tuberculosis and dengue in India. But under pressure from certain quarters, rapid testing was allowed and then quickly withdrawn after results were found to be invalid and unreliable. On the other hand, RT-PCR tests being gold-standard offer a confident result, and therefore states should continue scaling up their capacities to perform both conventional and point-of-care RT-PCR tests to provide accurate, reliable and precise data on the rise or fall in the number of infections in the anticipatory secondary wave. As we hope to move forward with the availability of indigenously-manufactured kits and adopting innovative game-changing pooled testing methodology, we are looking towards accurately mapping the prevalence of COVID-19 in India and guiding our decision makers towards moderating containment measures leading to exiting lockdown.
Secondary infections/positivity: Last month, South Korea reported more than 263 COVID-19 positive cases among patients who had earlier fully recovered. India also reported few such cases that came out to be positive after being discharged from quarantine. So far, scientists have attributed secondary infections in COVID-19 patients to false positive testing. These false positives are due to technical limitations of the RT-PCR testing. The RT-PCR looks for genetic material of the coronavirus in order to report positives. In certain cases, it picks up genetic material of dead virus which may take months to clear from recovered patients.
What next? A lockdown is not a permanent solution for any pandemic. The fight against COVID-19 is going to continue till we get an effective preventive vaccine or a therapeutic drug for all those who require it. Until then, the threat of the virus returning when conditions are conducive to its spread cannot be ruled out. States which are having high caseloads need to further tighten lockdown measures and containment strategies. They also need to complete the ongoing upgradation of their healthcare infrastructure which includes adequate availability of isolation beds, ICU beds and ventilators at the earliest.
Present pandemic has exposed the gaping inadequacies in our healthcare system. It is fairly acceptable that in all small and big hospitals around the globe, there are fault lines and the gaps in them are usually filled with adhoc and inadequate solutions. This pandemic made us watch Government hospitals facing the first frontal assault of COVID-19 leading to an overwhelmingly equal head-on response by COVID-19 healthcare warriors. It’s high time that the healthcare sector is given its long due share in the annual GDP allocation. Also, it’s time that the importance of preventive and social medicine is realized. Strengthening of the public health surveillance system through the Integrated Disease Surveillance Program (IDSP) network should be a post-pandemic priority for the policy makers.
The Lockdown Exit: To put it straight, the right time to completely exit would depend on achieving a R0 (R naught) lesser than one. RO is a mathematical term that tells you the average number of people who will catch a contagious virus from one infected person. With the current local trends, a fair assumption for coronavirus R0 to meet the required target is ending May. Till then, it’s time to put our hopes and beliefs into scientific perspective and carry on staying at home and follow advisories to stay safe if moving out of homes.
(The author is an Associate Professor, Department of Microbiology, Govt. Medical College, Jammu)
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