Coronavirus Outbreak: Aggressive testing, containment in small pockets — what India really needs to combat COVID-19
India’s handling of the crisis until now, barring testing, has been hard to fault. By aggressively acting, the hope is for the spread of coronavirus to be curtailed.
This is part 3 of an explainer on the coronavirus pandemic. In part 2, how effectively will policies of travel restrictions and social distancing control the spread?
Fear is the emotion that makes us blind.
Usually I go to Shakespeare for inspiration, but this time, it was Stephen King, who perfectly captures what we are feeling.
Meanwhile, “CDC estimates that so far this season there have been at least 38 million flu illnesses, 3,90,000 hospitalisations and 23,000 deaths from flu.”
23,000 deaths in one country, in one season, despite the isolation and the flu vaccine.
This may be an unpopular question to ask now, but are we responding appropriately to the SARS-CoV-2, aka the coronavirus ?
As of 18:04 pm on 23/03/20, as per the website of the Ministry of Health, eight people have died in India from COVID-19 out of almost 400 confirmed cases. With our low testing levels, there very well could be more. Projecting what percentage of the population will be infected, and then extrapolating that to the number of deaths is always a tricky exercise. There have been statements that COVID-19 can infect up to 60 percent of the Indian population, in a worst-case scenario. This is somewhat like projecting revenue growth numbers in start-ups. And about just as useful.
And then there is Italy.
Yes, the situation in Italy is tragic and horrifying.
But India is not Italy.
What are the differences?
The age profile is probably the critical difference between India and Italy. One in every five Italians is over 65. Only about one in twenty Indians is over 65. This is meaningful, while America’s experience shows that people in their 30s and 40s are in the ICU because of COVID-19 , the population group most at risk for hospitalisations, ICU admissions and death, remains above 65 years of age.
The average temperature in Italy is in the early teens now. Last I checked, Lombardy was at 11°C. The temperature in Indian metros is double that, and in Tamil Nadu, three times that. Ambient temperature always plays a role in infections. It appears to do so in Dengue transmission, and may play a role here. That is why the seasonal flu gives way to the poxes and diarrhoea as summer rolls along. It is part of the seasonal cadence of infection. This could be one explanation of why colder countries are affected more, and warmer countries less. But we cannot be complacent – cases are rising, and other RNA virus pandemics have raged through summer months.
India does not have Italy’s (especially Northern Italy’s) medical infrastructure. Ours would fall to a lighter blow.
There are similarities too. We also love our Nani’s and our Paati’s, and we tend to be packed quite closely together.
To repeat, we cannot be complacent.
India’s handling of the crisis until now, barring testing, has been hard to fault. The hammer has been falling quite hard (recommended reading: The Hammer and the Dance). The travel restrictions, bringing back stranded overseas Indians back, even the Janata Curfew. Shutting down schools, cinema theatres, postponing exams. The article refers to the hammer as aggressive complete lockdown measures for weeks followed by a dance, with testing and tracking, until a vaccine is developed. By aggressively acting, the hope is for the spread to be curtailed (see figure)
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The hammer fell harder as the number of cases ramped up. 75 districts, where a case of COVID-19 has been reported, have been shut down – meaning only essential services are allowed to function. Passenger trains, including metros and suburban trains, have been suspended. Moreover, interstate travel has been suspended, with the goal that travellers from metros don’t take the virus to rural India where the medical infrastructure cannot take the shock. As I write, Tamil Nadu, with nine confirmed cases in a 1,30,000+ square area, has announced Section 144.
The goal is the same: reduce contagion by lowering social contact, allowing hospital capacity to cope. Take Chennai, for example. As of 23/03, there were four confirmed cases in the city. Assume, worst-case, the ‘true’ number is ten times that, or 40 confirmed cases in the city. Now, let us use the reproduction number of 2.79 (this is the number the CDC came up with). This means each infected Chennaite would, in turn, infect 2.79 others. Extending this chain up to 31 March gives us,
Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="294" />
The blue line means introducing social isolation measures, bringing the reproduction number to 1.5. Without it, Chennai may have had 14,000+ cases, with it, only 103 cases by 31 March. Chennai has 20,000 Hospital Beds, 1,200 ICU Beds, 250 of those with Ventilators (Source: Sam Mehta, Vice Chairman, Dr Mehta’s Hospitals).
Now, consider the situation, where the true number of cases is far higher, 10x, as one expert claimed. That means the true number of COVID-19 cases in Chennai on the 23 is 40. The disease spread would look like this —
Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="291" />
Now, thanks to the CDC again, we have hospitalisation, ICU-admission and fatality rates by age group. We also have the age breakup of Chennai’s population. Putting these two together, with the data above, we get
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Without lockdown, if the true number of cases was 10x what was reported, then, without lockdown, the ICU capacity would be overwhelmed, and we would have had above 1,300+ deaths more than with a lockdown in place.
Take, Mumbai, one of the epicentres of the COVID-19 epidemic in India. Mumbai had a cumulative total of 53 confirmed COVID-19 cases as of 23/03 (Source: Gayatri Nair Lobo, ATE Chandra Foundation). Projecting this forward to 31 March, we get this —
Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="293" />
If we assume the true number of cases is 10x of 53 confirmed cases, that takes us to 530 cases as of 23/03/2020. Now, if we assume each infected person was to in turn infect 2.79 other persons, then we land up nearly two million infected persons in Mumbai by 31/03. A mind-boggling number. Most of those would still not require hospitalisation, and many will not even show symptoms. If we again assume that hospitalisation, ICU-admission and fatality rates by age group were similar to the US, then we get this —
Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="302" />
It’s a no-brainer to take Mumbai into a lockdown.
Keep in mind for every Mumbai and Chennai, there is a Madurai with no reported cases (as of now). The logic of shutting down balancing saved lives vs shattered lives starts coming apart.
Because every action carries price tags – yes, that is plural. Each tag is paid by a different section of the population. Some people are relatively unaffected – they are well off, and can enjoy the lack of pollution and sound and traffic. Others are affected but manageably so – these are the information warriors who can work from home, using laptops.
Others have their income protected. Many corporates have come forward saying wages and jobs will be protected.
These jobs form but a few strands of India’s employment tapestry. Informal employment in India is vast – most of the workers managing your waste for you in Dharavi are informal. Many of them are migrants. Payments from the state are unlikely to reach them. Another vulnerable set is the millions of sex workers in India. “HIV can be stopped with condom use. But this [the coronavirus ] means no physical proximity – that message has gone out far and wide. Likely, very few clients will be going to them [the sex workers] now,” says Ashok Alexander, who earlier headed the Indian operations of Bill and Melinda Gates Foundation, where he helped set up the world’s largest-ever privately sponsored HIV prevention program. “Sex work in India is largely invisible. It is a consumer product that has not been recognised as a profession. Which means there is little prospect of any support reaching these women. Many of these women have children dependent on them. Life, is often is about day-to-day survival.”
That survival is in question now.
Work-from-home is a cruel joke for those who work with their hands and bodies and for daily wages. The silence so many of us applaud as the streets turn empty is the sound of hunger in other people’s homes. And for many of those, neither the forbearance of their corporates nor dole-outs from governments, will reach and help. By shutting down indiscriminately, for the thousands we are hoping to save, are we choosing death-by-a-hundred cuts for thousands of others? State after state has begun implementing Section 144, whether it makes sense in the price-tag logic. Politically, it’s a no-brainer – your next-door neighbour has declared it. You don’t lose anything if you do – not now, when the whole population is held in fear-thrall. But, if you keep society and economy open, and people die, you become rich fodder for news channels and your political opponents. Competitive federal populism.
The more important consideration is if the lockdown is effective. A Janata curfew is rendered meaningless if people come together at five to celebrate together. No, the virus does not die in 12 hours. Italy declared a lockdown on 8/9 March. But, as per accounts, the lockdown came late, and was not strict enough: one account has over 50,000 people in Italy charged for breaking quarantine rules. With this kind of flouting, lockdowns are futile, worse, counter-productive – you pay the economic price, without reaping the safety gain. The hammer was more like a Shiatsu massage, and it did not work as planned. Sure enough, Italy called in the military to enforce the lockdown less than two weeks later. What matters is effective containment – size, as in many things, was not important.
This was the belief behind Singapore and South Korea approach.
They got an early start. Tested aggressively, and adopted different types of ‘hammers’ for different levels of exposure: positive cases, even cases without a single symptom, were held in hospitals, while those with exposure were asked to maintain strict home quarantine. The home quarantine included SMSs several times a day, which would verify location, and by spot checks. Singapore also ensured that business could stay open while following certain precautions: Each person entering a shop would have their temperature tested, and would note down their ID number, which helped in contact tracing. Any ‘cheating’ would be punished. For this approach to work, we need to start early (so all cases are caught), be disciplined (if only half the shops complied with the order, this wouldn’t work) and test aggressively.
In other words, Singapore and South Korea are following the needle approach — pin-pointed, intense action — rather than a broader hammer. And it appears to be working. Japan, where the outbreak appears to have been controlled, seems even more sanguine. A Japanese Health Ministry official was quoted as saying, “We don’t see a need to use all of our testing capacity, just because we have it. Neither do we think it’s necessary to test people just because they’re worried.”
What does this mean for India?
India (except perhaps Kerala) may have missed the early boat. On discipline, we have people actively flouting controls, with not enough punishment. And we have been held to not fare so well on testing. Most importantly, we do not have the capacity to ensure the curbs are held long enough.
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Testing can be expensive. Two-part testing – with a cheaper screening test and a more expensive confirmatory test. The ICMR has recommended that the two tests should not cost more than Rs 4,500, with an appeal that they be free. Apart from availability, where the private labs will add capacity, there is accuracy. PCR’s need specialised technicians to run (yours truly has run PCR tests two decades ago, and know, from painful personal experience that they can be prone to error), there can be contamination in sample collection leading to further error.
Then there are bottlenecks.
Dr Prabu Thiruppathy, Kois, a global healthcare investment firm (that has invested in molecular diagnostics across the world), says “The testing kits (PCR) need to be certified to be of acceptable accuracy by National institute of virology. Then these can be shipped and deployed at labs. However, protocol changes over the weekend mean that tests now need to be US FDA or European CE approved. A big problem is that the reagents seem to be still imported, although Indian companies make the final product in the country. Moreover, Gloves and masks are already in massive shortage across Indian hospitals.” Meaning there is a risk of contamination to the technicians collecting and testing the sample, is elevated.
One additional option is the just-approved testing in Cepheid machines, which require minimal human intervention and boast of a quick turnaround in a hospital setting.
What appears to balance out the need to overwhelm our health services, while not strangling the informal sector, is aggressive testing and containment in small pockets, with the help of private testing and, this is key, the army. We may not be able to do this effectively across 80 districts, but we can try to do this effectively in smaller pockets, where the number of cases is very high, relatively speaking. Maximise the safety bang for the economic buck. What India really needs, to use a term from another context, is a surgical strike – pointed, intense, effective. The hammer may cause more harm than the virus itself.
The writer is the founder of the Sundaram Climate Institute, cleantech angel investor and author of The Climate Solution — India's Climate Crisis and What We Can Do About It published by Hachette. Follow her work on her website; on Twitter; or write to her at firstname.lastname@example.org.
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