Since January this year, SARS-CoV-2, the coronavirus out of China’s Hubei province has swiftly spread to 76 countries worldwide, infected over 12,000 people and killed over 214, and this is just outside China, where the virus has infected over 80,000 people and killed nearly 3,000. The WHO has also declared its spread a ‘public health emergency of international concern’.
These details indicate how quickly an infectious disease outbreak can cause widespread havoc and socioeconomic disruption beyond the geographical boundaries of the country of its origin. Today, COVID-19, the disease caused by the coronavirus, is present on every continent except Antarctica.
While the number of new cases in China has been declining due to the country’s rigorous containment and mitigation efforts, the incidence of infection has been steadily rising in Italy, Iran, South Korea and many Eastern Mediterranean and European countries.
Meanwhile, India reported its first COVID-19 case in Kerala in the last week of January 2020, followed by two more cases in quick succession, forcing Kerala to declare a state calamity. All three people have since recovered and been discharged from hospitals. The government’s timely containment and management of these three incidents, along with rigorous surveillance and quarantine of many others, prevented any local spread of the coronavirus. This is a remarkable achievement of Kerala’s health system. That said, Kerala is comparatively more robust among India’s states; the ability of other state health systems to contain the virus’s spread may not be the same.
A window of opportunity
On March 4, a sudden spurt in the number of confirmed cases in North India due to local transmission from people who had recently travelled abroad, including a group of Italian tourists, sent shockwaves through the country. A techie who had returned from Dubai to Bengaluru and then traveled to Hyderabad also tested positive, following which Telangana and Karnataka began taking measures to quarantine all people and closed spaces this person had come in contact with.
However, it is important to underline that all these cases of infection were either due to travel outside India or after having come in contact with people who had contracted the infection outside India. Thus far, the government is yet to document an incident of community spread: the spread of a disease for which the source of infection to patients is unknown. Then again to detect community infections, the case definition of ‘suspected cases’ has to be expanded to include tests of people with no history of travel abroad and/or contact with an already infected person.
As long as there is no community transmission, the window of opportunity to contain the spread of SARS-CoV-2 remains wide open. There is also no need to panic if the number of COVID-19 cases increases in the coming days among close contacts of those who have already tested positive provided they are under quarantine. Further, with the local transmission of the virus in the Middle East and Europe – both regions with which India has a higher traffic than it does with China – we cannot rule out an increase in the number of cross-border cases, and local transmission to people in their orbit, in the coming days and even after factoring travel-related controls and universal screening at all ports of entry.
Keeping this in mind, it’s important that nationwide health systems stay on high alert and undertake sustained surveillance with immediate isolation or quarantine of suspected cases of infection as well as their contacts. It is of paramount importance to equip more labs in the network of Virus Research and Diagnostic Laboratories, with additional resources to start testing. State governments should further strengthen the Integrated Disease Surveillance Programme, review the supply chain of masks and other personal protective equipment (PPE) to ensure their uninterrupted availability for medical workers. Third, the National Centre for Disease Control should revise the case definition of ‘suspected cases’ in India in line with the WHO’s own revision to include patients with severe acute respiratory infection requiring hospitalisation or clinical conditions that cannot be explained by any other causes.
In the coming days, as the incidence of infection is likely to increase, hospitals should have a sufficient number of isolation beds with mechanical ventilation facilities. While much of the focus is currently on COVID-19, remember that there are several other communicable and non-communicable diseases that our health systems already deal with on a daily basis. So we must ensure hospitals don’t become overwhelmed by SARS-CoV-2 patients, adversely affecting other patients.
Availability of protective equipment
Dr Tedros Adhanom Ghebreyesus, the director general of WHO, expressed concern on March 3 about countries’ ability to respond being compromised by the increasing disruption of the global PPE supply chain thanks to rising demand, hoarding and misuse. It is important for the general public in India to understand that, currently, there is no need for them to wear masks or hoard PPE. These products are aimed at frontline health workers who risk their lives while performing their duty to save the lives of infected patients.
A shortage of PPE will in turn risk the lives of these brave workers and could even affect our overall response, since successfully responding to an outbreak depends on the availability of uninfected frontline health workers. In fact, studies have shown that the availability of PPE and drugs for health workers increases their willingness to respond to infectious disease outbreaks.
Finally, India desperately needs a comprehensive national policy to set up a ‘strategic national stockpile’ to make sure we have an uninterrupted supply of medical countermeasures, such as drugs, consumables, vaccines, devices, etc. for use during public health emergencies. There are already concerns about a shortage of drugs considering India imports around 70% of its active pharmaceutical ingredients (APIs) – the raw materials required to make drugs – from China.
The directorate general of foreign trade has also restricted the export of certain drugs, masks and PPE, and there are news reports that the government is contemplating a ‘Drug Security Authority’ to stock up on drugs. However, such an authority would only be a piece of the ‘Health Security Authority’, which can take a fuller view of an impending epidemic instead of just the drugs.
Misinformation and fake news
Aside from the availability of drugs, hospital beds and PPE, another cause of concern during outbreaks is misinformation and fake news. Misinformation is often spread with the objective to create fear and panic among the masses. Thus, it is important during outbreaks that the general public receives authentic information directly from government sources, and always cross-checks social media forwards with government notifications.
In the near future, if the case load increases, the government could consider large-scale mandatory movement restrictions and social-distancing measures to prevent further spread of the virus, as the Chinese and Italian governments have done. In such scenarios, proper risk communication with affected communities, explaining the pros and cons of each measure, will be very important to minimise social disruption. Various NGOs as well as the private sector can play a significant role on this front.
Moreover, a recent AYUSH ministry notification on Ayurvedic and homeopathic prophylaxis for the coronavirus was met with widespread disapproval. SARS-CoV-2 is a new virus and we still don’t understand its pathophysiology well enough, forget about treatment or prophylaxis. However, the people taking these medicines might develop a false sense of protection from COVID-19, leading to complacency and then adverse consequences.
Similarly, some political leaders’ decision to avoid gatherings on Holi seems to be out of an abundance of caution, not scientific advice. While social distancing is advisable during an outbreak, it has to be proportional to the risk. Bearing in mind that India has only a few clusters of cases, excessively precautionary measures by public figures might not help alleviate fear among the public.
Last, the people themselves can play a significant part in combating the new coronavirus by following simple preventative habits such as, hand-washing, staying home when sick, covering their mouth when coughing and sneezing, etc., to keep themselves and others safe.
Let’s hope that with the concerted efforts of the government, the private sector and the public, we can all together contain the virus.
Mahesh Devnani is an associate professor of hospital administration and joint medical superintendent at PGIMER, Chandigarh. The views expressed here are personal.