New Delhi: The exact impact of the Covid-19 lockdown in India will only begin to come to light this week, a health expert who serves on the ICMR coronavirus task force has said.
“We will only know the impact of the lockdown after the restrictions are eased but knowing the incubation period (the time it takes for the virus to manifest as a disease, 14 days for coronavirus), the impact of the lockdown will be seen in this week and next,” said Srinath Reddy, president of the Public Health Foundation of India (PHFI), a New Delhi-based non-profit public-private initiative.
Reddy’s comments offer a perspective on the lockdown hours before PM Narendra Modi is scheduled to address the nation, at 10 am Tuesday, to possibly announce an extension, even if a partial one, of the 21-day countrywide shutdown declared 25 March.
The three-week lockdown, which has seen nearly all workplaces either shut down, adopt work-from-home practices, or operate at skeletal strength, was scheduled to expire Tuesday. However, with the number of cases still rising, several chief ministers have urged the prime minister to continue the restrictions, which only exempt essential services like healthcare and food supplies.
Some states, including Punjab, Odisha and Tamil Nadu, have already decided to extend the lockdown until 30 April.
In the absence of a vaccination, widespread lockdowns that minimise social contact are believed to be the only way to check the spread of coronavirus, which has claimed over 1 lakh lives around the world since it was first detected in December last year in China’s Wuhan.
The figures, so far, suggest it has helped slow down the disease in India.
As of 12 April, according to health ministry data, India had recorded 8,447 cases and 273 deaths. Without a lockdown, experts at Chennai’s Institute of Mathematical Sciences had estimated that the number of cases could have been around 35,000 by 20 April, while the health ministry had offered the rather iffy projection of 8.2 lakh cases by 15 April (which it didn’t back with methodology or explanation).
Even though an extended national lockdown may help check the spread of the virus and reduce its rate of growth, it won’t kill it, which means transmission may again gain pace once the restrictions ease.
But the government claims it has strategies in place to keep people safe.
“India is doing all it can to ensure that when the lockdown is lifted we have the strategies to prevent its spread,” said Principal Scientific Adviser K. VijayRaghavan, the government’s top science official who is also a member of the ICMR task force.
VijayRaghavan also claimed India had measures in place to prevent the spread of the virus, with increased testing as well as tracking of contacts. He said the Aarogya Setu app, which alerts you if a Covid-19 patient is in the vicinity, “is especially useful since people show no signs of the virus during the incubation period and continue to spread it”.
Despite the assurances, experts remain split about the efficacy of a nationwide lockdown in beating Covid-19. While some credit it with slowing the progression of Covid-19 and claim it bought India some crucial time, others say India missed the bus on tackling coronavirus with its lackadaisical approach to testing.
‘Can we go blind into a battle?’
It took India 59 days to reach 1,000 cases, but the next 5,000 were recorded in a span of 12 days — that is a rise from nearly 17 cases a day on average to around 417.
Reddy said the increasing number of cases shouldn’t be alarming as it points towards improved screening.
Over the past two weeks, India has ramped up its testing capacity by engaging private laboratories too — the number of centres stands at 200, with a capacity to conduct upto 18,000 tests a day.
India has tested 1.4 lakh samples in 1.3 lakh suspects but its current rate of testing — 145 tests per 10 lakh people as of 10 April — is still much lower than that of countries like the US (8,220), UK (5,280), Italy (16,725), and South Korea (9,973).
Until 24 March, India had only been testing those with symptoms and a travel history to certain countries, besides those who had come in contact with confirmed cases.
After the diagnosis of the first two patients who had neither travelled abroad or been in touch with infected people, India widened its testing strategy to include severe acute respiratory illness (SARI) patients, health workers treating SARI patients, and asymptomatic high-risk contacts.
It was only on 8 April, a week before the official nationwide lockdown was to end, that the guidelines were expanded to cover patients with potential Covid-19 symptoms such as fever, cough and sore throat (symptoms also associated with the common flu), but even this was in areas recognised as coronavirus clusters.
“Can we go blind into a battle?” said Jayaprakash Muliyil, former principal of Christian Medical College, Vellore, and one of India’s leading epidemiologists. “Testing only the symptomatic patients who came to the country, we missed on the asymptomatic patients, who we now know continue to shed the virus,” he said.
A recent study by the Indian Council of Medical Research (ICMR) showed 1.8 per cent of 6,000 hospitalised pneumonia patients were diagnosed with coronavirus between 25 February and 2 April across 52 districts.
But Dr Tarun Bhatnagar, a scientist at the National Institute of Epidemiology and member of the national task force, said it was just the “tip of the iceberg”. The study, he added, caught only the very serious patients. “Eighty per cent of the mild cases, if they weren’t tested and isolated, would be spreading the infection in the community,” he said.
Oommen Kurian, a senior research fellow at the New Delhi-based think-tank Observer Research Foundation, said an “early lockdown is a very expensive weapon that was used with a lot of thought”, but added that there was a price to be paid for it.
“It has surely bought us time, but these two weeks we lost could’ve been used much better by mapping the spread of the virus using wider testing,” he said.
Even now, India’s bid to widen testing continues to meet hurdles. While India has approved the use of rapid diagnostic antibody tests — that can give results in 15-30 minutes and do not need laboratory settings — for patients with flu-like symptoms, their procurement reportedly remains stuck over quality concerns, slow decision-making by states and delays in supplies.
‘A more local approach required’
Many experts say India should experiment with a more localised approach to lockdowns, citing Bhilwara as an example.
Last month, Bhilwara in Rajasthan emerged as one of the hotspots of the Covid-19 outbreak, registering 27 positive cases and two deaths. But the containment strategy adopted by the Rajasthan government and the district administration has ensured that the textile town has not registered any new Covid-19 cases in over a week, while 13 patients who had tested positive have recovered so far.
“A Bhilwara model of containment that is purely based on fixed areas around positive cases seems more like an administrative response to the outbreak,” said Rakhal Gaitonde, a public health expert who is a member of the Kerala government’s expert committee on Covid-19. “India needs a public health response that is more nuanced and granular.”
This means grading the response based on the spread of the disease in a particular area.
A lockdown is not feasible in the long run, it extracts a heavy economic cost on the poorest and even the state’s ability to cater to them, he added.
Kerala is among the states that seems to be making promising strides in tackling coronavirus. A state that had the highest number of cases in India until 31 March is now registering the slowest increase in confirmed cases — 10 new cases Sunday, only two Saturday. It also has the highest number of recovered cases and is now planning to ease the lockdown in a phased manner by resuming essential services with some restrictions.
The state is also looking at proposals to conduct community-level random sampling to assess the proportion of the population that is exposed and thus has the antibodies (immunity) to beat the virus, said Gaitonde.
Other planned initiatives include testing of healthcare workers and creating a database of vulnerable people with chronic illnesses like diabetes, heart disease so that the state can estimate the number of critical patients it may need to treat, he added.
Gaitonde’s suggestion in favour of a localised approach was echoed by Tanmay Mohapatra, team lead, concurrent measurement and learning unit, at Care India, a non-profit that is consulting with the Bihar government on its Covid-19 response.
“Rather than a national lockdown, it should be a more localised approach with states deciding their response based on their own local disease data along with the Centre’s directive,” he added.
Explaining a possible road map for the days ahead, Mulyil said the government could restrict the lockdown to vulnerable populations, for example the aged and those with comorbidities, who are likely to suffer more critical consequences of the disease.
A virus, he added, survives as long as it has a susceptible population around it. Once a large proportion of the population gains immunity, the transmission of the virus stops, he said.
“This can be achieved by controlled easing of the lockdown,” said Muliyil. “That is, by letting young people who volunteer to go out while maintaining physical distance and hygiene, and keeping the older vulnerable population inside their homes.”
This is the only way to safeguard lives without destroying the economy, he said.