Decentralise Covid fight, don’t bury head in sand like ostrich. Be like a peacock

People waiting to be be vaccinated at a clinic in Delhi | Representative Image | PTI

Our national bird is the peacock, not an ostrich. We cannot live with our heads buried in the deep sand of denial, ignoring the fretful fact that the recent surge of Covid-19 is devastating and has caught India unprepared. The supreme confidence with which pronouncements were made in January by experts and politicians alike, that India had acquired herd immunity, has evaporated like aerosols of the virus. The super models of intricate and intriguing mathematical projections, which said India would not experience a second wave, are muted by the variants that are spreading with a speed and scale that is overwhelming our health system.

The time now is for a coherent and concerted response. ‘What went wrong’ and ‘why’ is an investigation that can be taken up later, even though some reasons seem obvious. We need to plan our response along several tracks, recognising the strengths and limitations of each.

Prevent super-spreader events

First and foremost, we need to prevent super-spreader events, both indoor and outdoor. Even though the former locations have greater transmissibility than the latter, the larger numbers involved in outdoor gatherings will yield higher counts of infected persons. This measure requires political will, administrative skill, public education and civil society collaboration.

Personal protection measures must be adopted by every person. Proper masks must be worn by all above the age of four years when moving out of the house and even at home when a member of the family is under home care for diagnosed mild Covid-19 or is awaiting test results after exposure to an infected person. Whether it is the original wild virus or any variant thereof, the portals of entry into our body are the same — nose, mouth and eyes. They must be zealously guarded. Masks of adequate quality can be mass produced and supplied to all families free of cost by state governments. Even where physical distancing is not possible, good masks can markedly curtail transmission if worn by everyone.

Ventilation is key to protection against formation of aerosols and airborne spread. Homes, offices, schools and shops must adopt measures to provide good ventilation and airflow as much as possible. Persons working in closed spaces must physically distance and double-mask. I use a multi-folded face tissue inside my surgical mask, to add an extra barrier that also absorbs the moisture from my breath and reduces the fogging of my spectacles. America’s top infectious diseases expert Dr. Anthony Fauci says he often double masks.

Don’t over-rely on tests

Diagnosis of Covid-19 infection is helped by tests but should not be dependent on those results alone. This is known from international experience of the first wave but is still not well recognised. That is why there is much debate now about RT-PCR tests showing negative results even in highly suspect cases. A single RT-PCR test has a sensitivity of only 60-70 per cent to pick up the virus. It can be negative too early or too late in the infection, when the virus is not actively replicating in high quantity. With many more labs now testing, even on demand, errors made by inadequately trained technicians in sample collection, transport and lab storage can result in negative tests. Clinical features increase or decrease the probability of diagnosis in suspected cases and must always be taken into consideration. In seriously ill persons who test negative, chest X-Ray and CT-Scan will help but they are not needed in a stable mildly ill person who is managed at home.

While we must test as efficiently as we can, we should not obsess about testing rates per million as the sole tracker of an efficient pandemic response. Countries like Vietnam achieved excellent control, despite modest testing rates while the US, which topped in test numbers, is the leader in global deaths. Early testing of symptomatic and clinically suspect persons or highly exposed contacts is helped by efficient household surveillance visits by primary health care teams and citizen volunteers. While contact tracing is difficult and unhelpful when community spread is rampant, it can still help to track and interrupt the spread of recently imported or domestically emergent mutants, if testing is backed up by adequate and efficient genomic analysis. Personal protection measures and avoidance of super spreader-events will outperform testing alone in pandemic control, but an efficient strategy combines all of them.

Scale up vaccination

Vaccination must be scaled up swiftly. The gears must shift to speed up production, procurement, distribution and administration. People must clearly recognise that currently available injectable vaccines provide protection against severe disease but offer no guarantee against infection and mild disease. While correcting false expectations, vaccine confidence must be built up through community networks besides mass media. Priority must be retained at present for essential workers and vulnerable persons, while each of those categories can be expanded. As vaccine stocks increase, we must aim to cover everyone over 15 years of age. Can we achieve this in the 75th year of our Independence?

We do need to ramp up our hospital care capacity, while enhancing support for efficient home care. Clinical management must be based on best available evidence. Panic buying of remdesivir is unjustified, when the largest trial on its use (WHO‘s multi-country Solidarity Trial) did not show any mortality benefit. A smaller US trial too did not demonstrate mortality benefit but claimed shortened hospital stay, a finding that has been challenged by reputed scientists due to differences in prognostic indicators between the treatment and control groups. Physicians in India may use it if they wish but the public panic around a drug of doubtful value is unjustified. Treatments that are now being prescribed for home care must also be rigorously evaluated, along with inhaled budesonide — a new entrant for home care reported this week in The Lancet. Will the Indian Council of Medical Research conduct such trials in India, when home care is being advised for many patients?

Curtailing transmission from person to person and place to place is our highest priority now. Short of a lockdown, we must impose severe restrictions on travel and limit gatherings of persons to minimal numbers, as per event. Frequency of trains and flights may be temporarily reduced to curb non-essential travel or seating capacity should be substantially reduced in each to facilitate physical distancing. We must protect our large rural areas from incursions of the virus from urban areas. Administrative actions have to be differentiated and decentralised to the district level. The district collector and the district health officer must be the dynamic duo driving the response from now on, with administrators in Delhi and the state capital as the support cast. If that happens, the second wave may usher in a surge of administrative reform too.

Prof.  K. Srinath Reddy, a cardiologist and epidemiologist, is President, Public Health Foundation of India (PHFI). Views are personal.