|Year : 2020 | Volume
| Issue : 5 | Page : 83-92
A multipronged strategy operationalized to combat the COVID-19 pandemic in India
Vikas Bhatia1, Neeraj Agarwal2, Bijit Biswas2
1 Department of Community Medicine, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Community and Family Medicine, All India Institute of Medical Sciences, Patna, Bihar, India
|Date of Submission||19-Jun-2020|
|Date of Acceptance||21-Jul-2020|
|Date of Web Publication||13-Aug-2020|
Dr. Bijit Biswas
Department of Community and Family Medicine, All India Institute of Medical Sciences, Phulwarisharif, Patna - 801 507, Bihar
Source of Support: None, Conflict of Interest: None
Background: COVID-19 is an ongoing largest public health emergency of the 21st century. India is effectively controlling the pandemic by taking bold and stringent steps right from the beginning of the pandemic. This article aimed to formulate a multipronged strategy to combat the COVID-19 pandemic in India. Method: We have gone through websites of World Health Organization, Centers for Disease Control and Prevention, Indian Council of Medical Research, and Ministry of Health and Family Welfare of Government of India to avail updated information on COVID-19. Result: We found that there may be three pillars of this COVID-19 pandemic management, namely public health measures, diagnostic and testing, and hospital and health care. These pillars should be aimed to achieve three primary goals, namely containment, capacity building, and recovery. For India, gradual relaxation in lockdown with social distancing and personal and environmental hygiene measures must be the more suitable exit plan.
Keywords: Capacity building, COVID-19, hand hygiene, health services, public health
|How to cite this article:|
Bhatia V, Agarwal N, Biswas B. A multipronged strategy operationalized to combat the COVID-19 pandemic in India. Biomed Biotechnol Res J 2020;4, Suppl S1:83-92
|How to cite this URL:|
Bhatia V, Agarwal N, Biswas B. A multipronged strategy operationalized to combat the COVID-19 pandemic in India. Biomed Biotechnol Res J [serial online] 2020 [cited 2023 Mar 24];4, Suppl S1:83-92. Available from: https://www.bmbtrj.org/text.asp?2020/4/5/83/292084
| Introduction|| |
COVID-19 is an ongoing pandemic affecting more than 13 million people, over 200 countries and territories around the world, and claimed over five lakh lives as of July 16, 2020, making it the largest medical emergency of the 21st century., The global spread of the virus led to overwhelming of health systems and caused widespread economic and social disruption. It is posing an unprecedented threat, especially to the countries affected by it. The primary routes of transmission of COVID-19 are respiratory droplets and social contact. The spread of the disease, exponential growth, and absence of effective treatment and vaccine led affected countries to implement distancing measures by shutting down the schools, colleges, offices, factories, public transport, and even to the extent of complete lockdown.,
In India, the first case of COVID-19 was reported in the southern state of Kerala on January 30, 2020, who was a medical student who returned from Wuhan. Right from the very beginning of the pandemic, India has taken stringent steps (i.e., thermal screening at airports, contact tracing of cases, and isolation/quarantine of contacts) to keep it under control., On March 24, 2020, at 20:00 h. India surprised the world with the announcement of 21-day lockdown all over the country, with merely around 500 reported cases in the country and 4-h notice to its people. Later on, the lockdown was further extended in five phases till July 31, 2020. As of July 16, 2020, at 14:00 h. Indian Standard Time (IST), the country has reported 972,144 cases with merely 24,936 (2.6%) deaths, while 613,881 (63.1%) have already recovered from the disease. In this article, we aimed to formulate a multipronged strategy to combat the COVID-19 pandemic situation in India.
| Methods|| |
We have gone through the websites of World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), Indian Council of Medical Research (ICMR), and Ministry of Health and Family Welfare (MOHFW) of Government of India (GOI) to avail updated information on COVID-19 to formulate a multipronged strategy to combat the pandemic situation in the country. Simultaneously, we have also gone through several published literature on different aspects of COVID-19 to give more insights to our formulated strategy.
| Results and Discussion|| |
Through our literature search, we have formulated that there may be three pillars of this COVID-19 pandemic management: (1) public health measures; (2) diagnostic and testing, and (3) hospital and health care. These pillars should be aimed to achieve three primary goals: (1) containment; (2) capacity building, and (3) recovery. To contain this epidemic, various activities which need to be performed include testing, contact tracing, and distancing measures. Similarly, capacity building in the form of teleconsultation; provision of primary physical care along with screening services; and development of quarantine homes/zones, isolation ward, and an optimum number of intensive care unit (ICU) beds with ventilators should be made. Finally, a recovery or exit plan should be designed to initiate and restore normalcy in the health care of the country [Figure 1].
Public health measures
Public health measures consist of mass interventions that help the communities to protect their health. It is key to success in case of any communicable disease pandemic. Its importance in case of COVID-19 becomes more evident as till date there is no effective treatment for the disease. Thus, the importance of prevention is higher than the early diagnosis and treatment. Some effective public health measures to combat the COVID-19 pandemic are as follows [Figure 2]:
In the case of COVID-19, it helps in slowing down the transmission and lowering the risk of infection. However, it requires the co-operation of every member at risk and the affected communities for being effective. It may be imposed in various levels right from national till family level depending on the risk of transmission and infection. The WHO currently recommends at least 1-m physical distancing between two individuals to lower the risk of transmission. At the community level, it should be implemented by suspension of mass gatherings. India adopted the lockdown strategy from the very beginning stage of the pandemic, with merely around 500 reported cases of COVID-19.,,
In COVID-19, contact transmission occurs when a person touches the mucosa of nose, mouth, or eyes with contaminated hands, which facilitates indirect contact transmission of the virus. International health organizations such as the WHO and CDC recommends handwashing for at least 40 s. The instances when one must wash his/her hands during the ongoing pandemic are after return from a public place and touching surfaces frequently touched by others (i.e., door handles, tables, and lift switches) in addition to the preexisting norms of handwashing., Considering the use of gloves, in community settings, the WHO currently recommends it only for caregivers of a COVID patient at home. Similarly, the MOHFW, GOI, recommends gloves for the designated caregiver nursing a home-quarantined COVID suspect.
It prevents the spread of infectious droplets from an infected person to others and their potential environmental contamination. The WHO currently does not recommend the use of a medical mask in community settings except for vulnerable population, symptomatic patients, and their caregivers. Currently, the WHO and CDC recommends the use of a nonmedical mask while visiting public places and people living in cramped condition (i.e., slums and camps). The reason for being an asymptomatic person before being symptomatic may act as a source of infection to other community members.,,, Indian prime minister (PM), Sri Narendra Modi, has also advocated for face cover use for all while visiting public places in his address to the nation. Already, homemade or cloth masks, in a large scale, are being prepared by the community folks, particularly women who are in large numbers skilled in stitching and sewing, self-help groups, and many others. It will not only provide some financial support but also reduce the transmission of corona and other airborne diseases among financially vulnerable population of the country.,, For health workers, those who are directly nursing COVID-19 patients, N95 mask, filtering face piece (FFP) 2, or FFP3 respirators are recommended, especially during performing aerosol-generating procedures.,
This should focus upon raising awareness regarding the disease (i.e., symptoms, routes of transmission, and protective health behaviors) and promote protective health behaviors. Various mass media such as a mobile phone; television; social networking sites; radio; newspaper; and mike announcements in religious places should be used as the medium of disbursement.
As per existing evidence, antibodies against novel Coronavirus (2019-nCoV) are being isolated from recovered COVID-19 patients, but till now, evidence lacks on the protective role of antibodies for subsequent infection. Considering vaccine as of July 15, 2020, there are 23 candidate vaccines in the clinical evaluation phase and 140 vaccines in the preclinical evaluation phase. Considering the unprecedented scale and speed of researches on COVID-19 vaccine, it is predicted that a potent vaccine may be available by the early 2021. Thus, for now, we must rely upon the existing immunity-boosting agents to boost the immunity of the community against COVID-19. In this regard, the Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy of India currently published a guideline which recommends daily intake of any of the following: herbal tea, basil, cinnamon, black pepper, dry ginger, jaggery, turmeric milk etc., for boosting the immunity system. Although the protective role of these agents against COVID-19 is still unclear, they are known immunity-boosting agents in Ayurveda.
The ICMR currently recommends hydroxychloroquine (HCQ) prophylaxis for health workers nursing suspected or confirmed COVID case and asymptomatic household contacts of a confirmed case. However, this should not lead to a sense of false security among its recipients as there is limited evidence on the efficacy of HCQ chemoprophylaxis on the prevention of COVID-19. India has also supplied HCQ to a large number of countries including the USA. The other drugs suggested for chemoprophylaxis for COVID-19 are chloroquine, ivermectin, etc.,,
COVID-19 is a highly contagious disease. Thus, maintenance of good personal, environmental, and food hygiene reduces the chances of infection. In personal hygiene, one should avoid touching face, nose, or mouth; should maintain respiratory etiquette, should frequently wash hands, etc. Regarding environmental hygiene, one should regularly clean high touch surfaces (i.e., door handles, taps, table, chairs, light switches, handrails, mobile phones, keyboards, remote control, toilets etc.) and clothes daily with either soap water or an alcohol-based cleaner (≥70% alcohol content) depending on applicability and feasibility. This is because COVID-19 virus may survive ranging from few hours till days in high touch surfaces and clothes. Regarding handling and preparation of food, there is no current evidence that COVID-19 spreads by food or food packaging. Still, one should maintain adequate hand hygiene before and after food or food package handling as an added precautionary measure., The COVID-19 respiratory droplets may remain suspended in the air for hours. Thus, maintenance of adequate ventilation lowers the chances of infection. For an air-conditioned room, temperature range (24°C–30°C) with relative humidity level in between 40 and 70 can be considered to be relatively safe., Benefits of regular physical activity are known to all. During COVID-19, even a short spell of physical activity (for 3–5 min) improves blood circulation, relieves mental stress, and eases muscle strain. The WHO recommends physical activity of 60 min/day for children aged 5–17 years and 150 min/week for adults in and around the home, keeping physical distancing and performing frequent hand hygiene. In this context, yoga and meditation at home are also beneficial.
A pandemic of COVID-19 magnitude can easily exert a negative impact on the spiritual health of an affected individual, community, and nation. Those who are involved with essential services during lockdown (i.e., health workers, and policemen) are at higher risk of this than any others. To overcome this, PM, Sri Narendra Modi in his address to the nation told to clap or ring bell or ring similar such item on March 22 and light diya or candle or mobile torch on April 5 for approximately 10 min at the vicinity of their homes or workplaces to boost the morale of countrymen. To upkeep the morale of health-care workers in the country, the Indian army also showered flower petals pan India at COVID hospitals in honor of corona warriors on May 3, 2020. Meanwhile, other countries around the world had also made similar gestures., At the individual level, engagement with various spiritual actions, meditation, creation of positive energy, and thoughts may help.
The day-to-day stressors for health-care workers during the pandemic may be fear of infection, shortage of personal protective equipment (PPEs), high workload, stigma in society, etc., Similarly, for suspected or confirmed COVID-19 cases, day-to-day stressors may be spread of infection to family members, severe disease consequences, financial insecurity, societal discrimination, loneliness, etc., while for the general population it may be fear of infection, losing loved ones, loneliness, financial insecurity, availability of daily goods, etc., These stressors may increase the chances of insomnia, anxiety, obsessive-compulsive symptoms, depression, posttraumatic stress disorder, etc., in an affected individual. Those who already have preexisting mental illnesses are at higher risk. The WHO recommends minimization of access to the news which may act as a stressor. Considering the lack of mental health specialists and other feasibility issues in the country, the day-to-day stressors in COVID-19 patients/suspects may be dealt with by the health workers taking care of them while their peers may fulfill their own counseling needs. For the general population, peripheral health workers (PHWs) (i.e., accredited social health activist, auxiliary nurse midwife, and Anganwadi worker) may play the same role. Specialist consultations may be provided telephonically for those who cannot be managed by health workers themselves.,,,,,
Minor ailments such as mild fever, diarrhea, and headache may be treated using home remedies or if required teleconsultation may opt. Home delivery of medicines may be done to reduce exposure, especially for persons with comorbidities (i.e., hypertension, diabetes, and cancer) as they are at higher risk for COVID-19. Those with COVID-compatible symptoms (fever, cough, and breathlessness), travel history, exposure history, severe acute respiratory illness, influenza-like illness (ILI) (fever, cough, sore throat, and runny nose) must immediately visit a nearby health facility to be screened for COVID-19. Those with minor symptoms (i.e., mild fever, cough, and headache) must home isolate themselves. Those with moderate-to-severe symptoms must be isolated in a health-care facility. Those who are asymptomatic but had exposure history must be quarantined either at a facility or home depending on the feasibility.,,, Considering death registration, India has a weak death registration system., Telephonic verbal autopsy may be done in case of community deaths to avoid missing out of health-facility COVID-19 deaths.
Diagnostic and testing
This is of immense importance during a pandemic as it helps us to diagnose, manage, and isolate COVID cases to prevent the further spread of the disease and useful for epidemiological surveillance to assess the community burden of infection [Figure 3].
|Figure 3: Outlay of diagnostic and testing measures for the COVID-19 pandemic|
Click here to view
In India, as of July 16, 2020, there are 880 government and 364 private labs conducting COVID testing. Considering COVID testing lab in terms of population, India currently has one testing lab for approximately per million people, which is far less than the USA (18 labs/million people as per the last data available), but the USA has approximately 3.5 times higher number of reported cases compared to India as of July 16, 2020, 21:30 h. IST.,,,, Gradually, the COVID testing lab network in India may be extended as per need.
There should be designated and dedicated microbiologist and pathologist in each COVID-19 diagnostic lab to conduct the tests along with other supporting staffs. For swab collection, a trained person (preferably an otolaryngologist) should be deployed. Considering its population size, India is a resource-constraint country. For maximal utilization and minimize wastage of available test kits, attention must be given that specimen collection, transportation, testing, and biomedical waste management are done abiding standard operating procedures.,,, The number of specialists (i.e., microbiologist, pathologist, and otolaryngologist) and support staff (i.e., lab technician, field worker, cold chain handler, sweeper, and driver) must be deployed based on the test load. All staffs involved in diagnostic and testing must be supplied with appropriate PPE.
India is currently following ICMR recommendations for the testing strategy of which the last update was released on June 23, 2020. The current testing strategy of ICMR focuses upon testing patients with ILI and asymptomatic direct and high-risk contacts of a confirmed case using the test-track-treat approach., Gradually, as the pandemic progresses and the availability of resources (i.e., testing kits) declines, the testing strategy may be revised as per need to offer testing to more people at risk.
The current gold standard for diagnosing COVID-19 suspected cases is real-time reverse transcription-polymerase chain reaction. It is a nucleic acid amplification test (NAAT) that detects unique sequences of COVID-19 virus in respiratory tract specimens. Upon determination of a suspected case based on laid testing criteria, samples should be rapidly collected for testing. As per current recommendations for initial diagnostic testing, any upper respiratory specimen may be collected. In addition, the ICMR approved TrueNat and cartridge-based NAAT using throat or nasal swab specimen of the suspected case as additional confirmatory molecular tests for COVID-19., This may help immensely in increasing the testing capacity of the country.
Testing for surveillance
For surveillance purpose, serological tests may be used with limited or no diagnostic value. Both antigen and antibody-based serological tests for COVID-19 are available. Venous or capillary blood samples as per feasibility are recommended for these tests. The major drawback with serological tests is late detection (after 7–10 days of illness) and cross-reactivity with other coronaviruses. Currently, neither WHO nor CDC recommends serological tests for patient care. In future, these tests may be used as a tool of public health monitoring and surveillance, which is subject to further evaluation and validation.,
Hospital and health care
Overwhelming of hospital and health-care system during a pandemic is usual and expected. COVID-19 is imposing an unprecedented demand on our health-care system like never before. During this pandemic, our health system must be actively involved in activities for its containment without compromising on essential health-care services [Figure 4].
|Figure 4: Outlay of hospital and health-care measures for the COVID-19 pandemic|
Click here to view
During the pandemic, the main mode of primary health-care delivery should be through the application of telemedicine and its principles. Ambulatory patients should be encouraged to use tele platforms to seek health care as far as possible. In case of difficulty in seeking health care, our PHWs during their home visits may assess and mediate teleconsultation with the concerned medical officer. During their home visits, PHWs must create awareness for COVID-19 among the general population along with their regular services. PHWs must refer any person in the community with COVID-19 symptoms to the fever or screening clinic for further assessment. Community-based services (i.e., immunization, Village Health Sanitation and Nutrition Day, and screening camps) should be organized but only at the local level (at village or ward) on following fixed-day staggered approach keeping in mind physical distancing measures. All of the attendees of those fixed-day services must use face cover and thoroughly wash their hands on returning home.,,
Fever clinics/screening clinics
Every health-care facility must establish screening clinics near the entry point to triage COVID and non-COVID suspects to minimize contact between them. In the screening clinic, it should be evaluated that whether patient fits in any COVID-19 testing criteria or not along with at least temperature monitoring. Based on the findings of screening, one must be referred to either COVID or non-COVID area of the concerned facility for further management.,
There may be three types of COVID health-care facility, namely COVID care center (CCC), dedicated COVID health center (DCHC), and dedicated COVID hospitals (DCH). CCC, DCHC, and DCH are designated for mild, moderate, and severe COVID-19 suspects or cases, respectively. CCCs are makeshift facilities. It can be established in schools, hotels, stadiums, etc., At the same time, DCHC can be set in a full hospital or in a separate block of a hospital with preferably separate entry, exit, and zoning. DCH is the referral center for CCC and DCHC. It must have ventilator facilities. These hospitals must have different areas for confirmed and suspected COVID-19 cases. All the health-care staff providing care to the COVID or non-COVID patient must undergo training for infection prevention and control (IPC), including PPEs.,
This includes outpatient and inpatient services for both COVID and non-COVID patients in either separate health facilities or different zones of the same health facility with preferably separate entry and exit. As per the COVID status of the patient (suspected or confirmed or non-COVID), appropriate PPE use is recommended. Nevertheless, it is advisable to health workers to follow standard precautionary measures stringently even while dealing with non-COVID patients. Some standard measures to minimize risk may be asking the patient to cover his mouth and nose with a face cover all the time, using gloves while examining the patient, or handling his/her documents, etc.,
This includes emergency (medical, surgical, and trauma) and critical care services (i.e., intensive pediatric care, basic and comprehensive emergency obstetric care, burn wards, transfusion services, etc.). These services should be staffed with adequate human resource and equipment as per protocol. After screening the patient at the entry point of the hospital, the protocol similar to routine care must be followed.,, Considering critical readiness of India, it is being estimated that currently, it has 94,961 ICU beds (35,699 in public and 59,262 in private) and 47,481 ventilators (17,850 in public and 29,631 in private) across the facilities in the country. It is being reported that approximately 5% of COVID-19 patients require intensive care., Considering all these, India currently can deal with approximately five times higher number of cases on a given day compared to active COVID caseload as of today.,
The dead body of a suspected and confirmed COVID case must be handled carefully following all IPC measures. All these bodies must be stored at 4°C in an isolated COVID-designated area of a mortuary. All surfaces of the isolation area must be wiped with 1% freshly prepared sodium hypochlorite solution with at least 30-min contact time.,
Research and innovations
It should be encouraged and extremely relevant for self-reliance, strengthening capacity building, engaging academic and research organizations, enhancing funding in research and development, and ensuring innovative ways in the maintenance of supply chain of various vital items during the pandemic and similar such situation in future.
- Low-cost equipment such as ventilators, hospital beds, and stretcher; personal protective materials such as masks, gloves, face shield, and PPE suits; sanitizers; disinfectants; digital tools; bioinformatics services; biotechnological advancement; and many more
- Newer diagnostics, drugs, and vaccines.
As of now, distancing measures is the most proven public health strategy to control the pandemic. An extended period of lockdown will increase social and financial damage, whereas relaxation in lockdown may lead to an increase in the number of cases. Thus, a balanced approach is required for exit. Even though the government decides to lift the lockdown, social distancing, usage of masks, and personal and environmental hygiene need to be followed for coming months or maybe beyond ahead. There is an alternative strategy of repeated mass testing to identify the suspected case for home isolation, while others continue to do their daily activities., This may not be feasible in countries like India, considering its large population size and limited resources. Thus, gradual relaxation in lockdown with social distancing and personal and environmental hygiene measures must be the more suitable exit plan for the country. Progressively, initiation of elective surgeries, balancing of economy and livelihood with that of COVID, and shift from straight to strategic (containment zones with a high level of restriction and other zones with graded relaxation) level of lockdown may be done.
| Conclusion|| |
Three pillars of this COVID-19 pandemic management, namely public health measures, diagnostic and testing, and hospital and health care, are vital strategies in the war against COVID-19 to achieve three primary goals, namely containment, capacity building, and recovery. For India, gradual relaxation in lockdown with social distancing and personal and environmental hygiene measures must be the more suitable exit plan considering its large population size.
VB conceptualized and reviewed the manuscript. NA did literature search and reviewed the manuscript. BB did literature search and wrote the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]