|Year : 2022 | Volume
| Issue : 3 | Page : 56-62
COVID-19 pandemic response by India and future directions
Department of Community Medicine, AFMC, Pune, Maharashtra, India
|Date of Submission||02-Oct-2021|
|Date of Acceptance||05-Feb-2022|
|Date of Web Publication||14-Sep-2022|
Dr. Suraj Kapoor
Department of Community Medicine, AFMC, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: It has been more than a year since COVID-19 was declared Pandemic by WHO on 11 March 20. India with the initial slow rise of cases had a peak of cases at around September 20 followed by a gradual fall in the number of new cases and faced the second wave with the rising number of cases from March 21 to July 21. There is limited literature examining the pandemic response in India considering policies adopted, economic factors, health-care capacity factors of selected states influencing the variation of the spread of infection in various states. Hence, this study is conducted to understand COVID response, policies adopted by India, and lessons learned. Materials and Methods: This is a descriptive study conducted across the country covering important states covering the period from January 2020 to September 2021. States were selected based on high caseload, high test positivity ratio. Data for the study are compiled from the health bulletins, official handles of health ministries, WHO, World bank, Worldometer, John Hopkins University Centre for Science and Engineering, NFHS 5, etc., Results: On comparing key epidemiological indicators of selected states, Maharashtra has the largest number of cases with the highest Case fatality rate (CFR). Kerala has the second-highest cases among selected states but with the least CFR. On comparing key sociodemographic factors, Kerala has a maximum literacy rate and elderly population, while Delhi has maximum Population density. Despite having maximum risk factors such as the prevalence of diabetes, obesity, and hypertension, Kerala managed to have the least CFR. The reason may be due to the robust surveillance system, high literacy rate, and good doctor–patient ratio comparing other states. Maharashtra the worst affected state managed to do better in the second wave in respect of oxygen supply and vaccination drive. Conclusion: Full lockdowns and early border closures appeared to lessen the peak of transmission and thus prevent health system overcapacity. However, these measures had an impact on the lives of people as well as the economy of the countries. Addressing vaccination drive issues such as supply chain and manufacturing capacity, focussing on the young and pediatric population as well as focussed cluster containment strategies seems to be the most effective strategy to combat the anticipated third wave.
Keywords: COVID-19, India, pandemic response
|How to cite this article:|
Kapoor S. COVID-19 pandemic response by India and future directions. J Public Health Prim Care 2022;3:56-62
| Introduction|| |
The current outbreak of the novel coronavirus had its epicenter in Hubei Province of the People's Republic of China with the first case reported on 12 December 19 and further clusters of cases on 30 December 19. It rapidly spread to many other countries. On January 30, 2020, the WHO Emergency Committee declared a global health emergency based on growing case notification rates at Chinese and international locations.
It has been more than a year since COVID-19 was declared Pandemic by the WHO on March 11, 20. There was a rising trend of global new cases starting from March 20 to January 21 with a subsequent fall in the number of new cases. India with the initial slow rise of cases had a peak of cases at around September 20 followed by a gradual fall in the number of new cases and faced the second wave with the rising number of cases from March 21 to June 21 with at a present limited number of cases [Figure 1].
There are several studies conducted that have examined the impact of public health measures on local transmission of COVID-19, but the evidence was primarily from modeling evaluations.,, Various studies have suggested restrictive measures such as social distancing, lockdown, case detection, isolation, contact tracing, testing, and quarantine of exposed are the most efficient actions to control the disease spreading.,, However, there are limited literature examining the pandemic response in India considering policies adopted, economic factors, health-care capacity factors of selected states influencing the variation of the spread of infection in various states. Hence, this study is conducted to understand COVID response, policies adopted by India, and lessons learned.
| Materials and Methods|| |
This is a descriptive study conducted across the country covering important states covering the period from January 2020 to September 2021. States were selected based on high caseload, high test positivity ratio [Table 1]. Data for the study are compiled from the health bulletins, official handles of health ministries, WHO, World bank, Worldometer, John Hopkins University Centre for Science and Engineering, NFHS 5, etc., Health-care capacity indicators and health-related characteristics influencing COVID outcomes such as diabetes, hypertension, obesity, and sociodemographic factors of various selected states having an impact on pandemic response were chosen to compare pandemic response and to understand variation in epidemic response [Table 2]. The natural history of the pandemic response of the country is highlighted [Table 3].
|Table 1: Coronavirus disease-2019 key epidemiological indicators as of October 02, 2021|
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|Table 3: Comparison of sociodemographic/health capacity/health-related risk factors for coronavirus disease-2019 (health and welfare statistics report 2019-2020), national family health survey 5|
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[Figure 1] highlights the epidemic response of India along with selected states. The country had an initial slow rise of cases had a peak of cases at around September 20 followed by a gradual fall in the number of new cases and faced the second wave with the rising number of cases from March 21 to July 21. The prevalence of key risk factors,, influencing COVID outcome in India is highlighted in [Table 3]. Maharashtra has the highest number of cases followed by Kerala and Karnataka among selected states.
Ethical approval for this study (Ethical Committee IEC S.No. IEC/2022/397) was provided by the Ethical Committee Armed Forces Medical College, Pune on 26 November 2021.
| Results|| |
On comparing key epidemiological indicators of selected states, Maharashtra has the largest number of cases with the highest CFR. Kerala has the second-highest cases among selected states but with the least CFR. On comparing key sociodemographic factors, Kerala has a maximum literacy rate and elderly population, while Delhi has maximum population density. Delhi, Kerala, and Tamil Nadu have the best Doctor-patient ratio among selected states. Kerala spends maximum on health-care expenditure (4.5% of Gross domestic product [GDP]). Prevalence of risk factors for diabetes, obesity, hypertension being maximum for Kerala, whereas smoking is maximum for West Bengal [Table 2]. On comparing health-care infrastructure Tamil Nadu has maximum hospitals in the urban area, Karnataka has maximum hospitals in rural areas [Figure 2]. Tamil Nadu has maximum Hospital beds in the rural area, whereas West Bengal has maximum hospital beds in the urban area [Figure 3]. Comparing vaccination drive Maharashtra leading the list with vaccination of 8.3 crore population.
| Discussion|| |
India started screening at airports on January 20 itself with the first case being reported on 30 January 20 in Kerala. The Army launched an operation to rescue Indians arriving from foreign states with the creation and management of a quarantine facility. MoHFW issued quarantine, IPC, treatment, testing, and tracing-related guidelines and modified it as per the existing situation. ICMR set a benchmark of 140 tests/million population per day with sample positivity of <5%, however, there was a low testing rate initially with a test positivity rate of 8.5%. Till May 10, 2020, India had tested 1,609,037 samples for the Severe acute respiratory syndrome-coronavirus (SARS-CoV-2) virus, giving a rate of around 1200 tests/million people. It was swiftly scaled up in the later part of the pandemic with the present status of almost 35 crore population tested. For effective case identification and surveillance, Rapid response teams were made and line listing of all cases in the state list was started. For containing cluster of cases sealing of borders, containment, and buffer zones were created.
Response of selected states
On comparing the epidemic response of different selected states, Kerala has maximum health-care expenditure among selected states, with the leading state in the NITI Aayog index ranking. Despite the however large prevalence of lifestyle diseases in the state, Kerala still facing a large number of cases. Previous studies have suggested coronavirus patients with heart ailments have an almost 10% mortality rate and those with diabetes have a mortality rate of 7%. Still, the rate of hospitalization and overall CFR is one of the least for the state. The reason may be better surveillance, better testing, and better health-care infrastructure. Indirect factors like high literacy may be an indirect favorable factor.
On assessing factors influencing the pandemic response of key states, experience and investment made in emergency preparedness and outbreak response during the Nipah outbreak in 2019 helped Kerala with better surveillance, faster detection resulting in lower CFR (0.5%) as compared to country CFR, despite having more elderly population with higher population density comparing the whole nation. Test per million is almost double that of a whole nation. Still, a high-test positivity rate (13%), with comparative slow vaccination drive and the latest serosurvey showing 44% seropositivity is a matter of concern.
Why the daily number of new cases is still high in Kerala
The reasons may be robust contact tracing and surveillance, low seropositivity as compared to the rest of the country, a large proportion of the elderly population, with a high prevalence of obesity, diabetes, and hypertension.
Does Northeast states need special attention
Northeast states need special mention as these states despite having favorable factors like low population density, still showing a rising trend of cases from July 21, the reason may be significant naive population, less vaccination coverage with the rise of several delta variants.
The Government Divided the entire nation into three zones – Green Zone, Red Zone, Oand range Zone; Red zone (Hotspots) – districts with a high doubling rate and a high number of active cases; and Orange zone (Nonhotspots) – districts with fewer cases, Green zone – districts without confirmed cases or any new cases in the last 21 days.
Surveillance and contact tracing
More than 50 lakh people have been kept under surveillance as a part of the contact-tracing efforts in the country. Govt initiated timely and scientific contact tracing and surveillance guidelines from time to time as the Pandemic evolved in the country. The government launched contact tracing and surveillance app named Aarogya setu. The core function of the app is risk assessment with the option of reporting oneself to the government. It is translated into 11 languages for use across all states of India. However, there are many challenges in the effective functioning of the app like the population in rural and remote areas facing the problem of Internet connectivity, availability of smartphones, and digital illiteracy. Ethical issues such as privacy and confidentiality are other concerns.
Experience and investment made in emergency preparedness and outbreak response in the past during Kerala floods in 2018 and especially, the NIPAH outbreak in 2019 helped better surveillance, faster detection, and less CFR. Kerala implemented the strategy of triple-lock containment with emphasis on the utilization of technology, for example, GIS, drones, etc., for monitoring purposes along with motorcycle patrolling. Other key interventions include Active surveillance, setting up of district control rooms for monitoring, capacity-building of frontline health workers, risk communication, and strong community engagement, addressing the psychosocial needs of the vulnerable population.
Various legislative measures were enacted like Section 144, Section 2 of the Epidemic Diseases Act, 1897, and declaring the pandemic as a “notified disaster” under the Disaster Management Act, 2005. The government imposed lockdown in four phases for 68 days from March 24 to May 31, 2020.
IEC and risk communication
The IEC material for effective risk communication prepared and disseminated by MoHFW which was prompt, scientific, and consistent to combat COVID stigma and infodemic is worth appreciation. The government launched contact tracing and surveillance app named Arogya setu. The core function of the app is risk assessment with the option of reporting oneself to the government. However, there are many challenges in the effective functioning of the app like the population in rural and remote areas facing the problem of internet connectivity, availability of smartphones, and digital illiteracy. Ethical issues like privacy and confidentiality are other concerns.
Recognizing efforts of CORONA warrior, front-line health-care workers
While the deadly virus has brought attention to the inadequacies in the health-care systems globally, doctors, and health-care workers have been risking their lives to save all of us. They are also risking the lives of their family members, which indeed is a huge sacrifice. On top of that, the shortage of face masks, shields, and protective gear is not helping. This makes the efforts of the medical workers even more extraordinary. Efforts of CORONA warriors should be suitably recognized and any sort of discrimination against them must not be allowed.
The Government of India began a mega evacuation of distressed Indian citizens from across the globe called the “Vande Bharat Mission” in early May. On 10 May 20, the Indian government sent a Naval ship, which carried medical teams, essential medicines, and food items to the countries like Maldives, Mauritius. Similar international support was given to India during the oxygen crisis during the second wave.
Make in India in COVID
From indigenous COVAXIN to indigenous personal protective equipment (PPE) production, to made-in-India Ventilators, the COVID crisis seems to provide a boon to Government Make in India drive. Harnessing all national resources is a swift and cost-effective approach.
During the COVID-19 pandemic in India, Finance Minister announced an amount of Rs1.70 Lakh Crore relief package under Pradhan Mantri Garib Kalyan Yojana for the poor. The government launched various rehabilitative measures for migrants, daily wagers, farmers. An increase in public spends on health care from 1% to 2.5%–3% of GDP can decrease the out-of-pocket expenditure from 65% to 30% of overall health-care spend and this would be a transformational shift. The government will provide Rs 35,000 crore for COVID-19 vaccination.
In India, vaccination drive using two vaccines Covisheild and Covaxin was started on 16 January 21 in a phased manner. On May 1, government started vaccinating the younger population above 18 years of age. At present, almost 87 crore population is being vaccinated. The government updated guidelines on May 19, 2021, in which vaccination allowed for lactating mothers, the gap between COVISHIELD second dose increased to 12–16 weeks. All COVID cases need to wait for 3 months before vaccination. The Russia-made Sputnik vaccine will be available shortly. Phase 2/3 clinical trials permission has already been given to COVID Covaxin vaccine for the 2–18-year age group. India has approved the World's first DNA vaccine for anyone aged 12 years and above.
Key challenges during the pandemic
Many people especially poor, migrant workers, and farmers faced a greater challenge with drastic economic losses. The functioning of other national health programs including routine immunization programs was adversely affected. To provide basic and essential health services government-initiated telemedicine, however, there were connectivity issues in certain remote, hard to reach, rural areas. States and Union territories were monitored by the government to check for their preparedness regarding isolation wards, contingency plans, and availability of PPE and masks. However, there was great variation between states because of existing health infrastructure, medical workforce, etc., Moreover, there was the challenge of stigmatized infected Corona warriors given the already shortage of existing manpower.
Is Lockdown effective in the control of spread? Full nationwide lockdown strategy is still a matter of debate, especially in resource constraint countries like India, with a large number of poor, migrants, daily wagers already affected to a large extent with lockdown having long term social, economic, physical, and mental health effects. Even localized lockdown would be useful if the time is utilized to augment medical infrastructure permanently, as there is an imminent threat of other emerging and re-emerging diseases.
Are large-scale testing and aggressive contact tracing of any use in the present situation? Contact tracing being labor intensive and a multistage process needs to be utilized effectively and with caution when there is already community transmission going on.
COVID wave is described as a rapid surge in several cases, India had a rapid surge of cases till Sep 20 described as the first wave. The end of the first wave may be attributed to COVID appropriate behavior of the community, and the immediate immunity of the infected population. After almost 8 months later, there was a rapid surge of cases (Second-wave), which may be attributed to COVID fatigue, a mutation in the viruses (Variance of concern and interest), and various super spreader events that happened at that period.
As the virus is evolving and mutations are being influenced by added drugs and vaccines, the third wave is looking imminent as many susceptible populations, especially the young and pediatric age group seem to be a vulnerable population. Capacity building in form of provision of oxygen plants, augmentation of intensive care unit beds, especially for the Pediatric population needs to be targeted. Routine Non-COVID care including antenatal care and regular immunization of children should also be given due care. Arrangements must be made to obviate discontinuation or irregular availability of non-COVID care. The threat of the Mucormycosis epidemic needs attention. Latest reports suggest Maharashtra has reported more than 2500 cases, Tamil Nadu 236, Kerala 36, and Andhra Pradesh 768 cases. Capacity building to tackle this epidemic along with correct administration of steroids in form of dose and requirement and proper diabetes management is the need of the hour.
Decentralized and aggressive testing, contact tracing, isolation of infected, and precautionary self-isolation of contacts are critical in reducing the number of new cases. These interventions must be balanced with getting back to normal life and everyday activities to the best extent possible until a reversing the trajectory of the pandemic is traced. Telemedicine needs to be implemented effectively. There is a need for strengthening surveillance systems, especially in the field of zoonotic diseases, emerging, and remerging diseases. Focussing on an Ecosystem surveillance system and one health approach may help in creating an early warning system. Transparency, confidentiality, correct, and timely reporting should be given due importance.
Vaccination seems to be the most potent weapon. However, supply issues being bottleneck should be planned with strict monitoring on differential pricing and commercial focus. There is an urgent need of approving and deploying a broader mix of vaccines and Ramp up manufacturing capacity. Addressing vaccine hesitancy is equally important. Grassroot workers, community leaders should be effectively utilized to address the same.
A positive change in the behavior of the communities in implementing nonpharmaceutical intervention (NPIs) is a prerequisite. There is a need to learn from the success obtained by TB and HIV programs by engaging civil society. NPIs mainly hand hygiene, respiratory hygiene, and social distancing shall be the major elements to prevent and contain COVID-19. All these require sustained public cooperation.
Finally, we do not recommend a blanket national or state lockdown, as opposed to localized, phased restrictions or closures. A targeted and focussed cluster containment strategy is the need of the hour. We recommend a mandatory 7-day institutional quarantine for all visitors arriving from other countries. Special focus should be given to rural areas in respect of health-care infrastructure strengthening and workforce resource management. There should be a ban on mass gatherings and venues for large congregation's Public advocacy campaigns on mask-wearing and safe behavior should be given due importance.
| Conclusion|| |
From overall perspective preventive measures such as hand hygiene, social distancing, facial masks were a norm across the nation in the pandemic. Full lockdowns and early border closures appeared to lessen the peak of transmission and thus prevent health system overcapacity. However, these measures had an impact on the lives of people as well as the economy of the countries. Capacity building and addressing issues related to vaccination drive along with cluster containment strategy seems to be the way forwardCapacity building and addressing issues related to vaccination drive along with cluster containment strategy seems to be the way forward. This study may help in preparing for future pandemics from the lessons learned from the response of the central government as well as states.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]