By Dr. Anmol Kalha and Brig Arun Sahgal

The spread of COVID 19 the global pandemic remains unabated, impacting nearly 85 per cent of the globe. Surprisingly the worst affected are the developed economies of Europe and the United States, despite their advanced healthcare systems and a very favourable doctor /population ratios. Asian countries, on the other hand, have fared well in containing the spread of the ‘Contagion’. China is limping towards normalcy, South Korea and Japan have managed to contain the spread, while SE Asia is doing a reasonable job of managing the spread.

At the moment, all eyes are on India which went into 21 days locked down on 25th March 2020. There are concerns on how will the largest democracy in the world with a population of 1.3 billion copes with the lockdown and manage the spread of the virus. Questions include; is it an exercise in limiting the spread of the virus by flattening the curve by preventing community spread or is it an effort to create capacity and capability to meet the predictive jump to the community spread. It is important to underscore that India over the years has built reasonable capacities to cope with periodic disease outbreaks and has developed an effective integrated disease surveillance system. Question is, is it enough?

COVID 19 Prediction and Projection for India

To understand the calibrated Indian response so far it would be essential to look at the prediction modelling from two studies, one by Johns Hopkins and other by the ICMR. Essentially, the Johns Hopkin study released on 25th March 2020 has predicted a peak of 25 – 30 lakh infections by 25th April 2020. Their prediction for hospitalization by mid-May 2020 is between 15 -20 lakh people. The study is sceptical about the ability of the complete lockdown to impact the spread of the pandemic in India, highlighting that it would only create economic distress and panic. Inadequate testing has been seen as the most critical issue while recommending the need for additional critical care beds and requirement of one million ventilators progressively over the coming months. These are valuable input toward public health policy decisions.

The ICMR study (published in India Today) on an optimistic scale predicts 15lakh cases in Delhi, 5 lakh in the metros of Mumbai, Bengaluru, Kolkata in 200 days starting Feb 2020. In the worst-case scenario, the modelling predicts one crore cases in Delhi, 50 lakh cases in Mumbai in a peak starting 40 days from Feb 2020. It would be pertinent to remember that airport screening started only in March 2020. It is conjectured that approximately 15 lakh asymptomatic but contagious passengers could have slipped through. They are now being identified for testing. In any case, public concerns only started to mount in March once the news from China, Italy, Iran filtered in and more stringent measures were imposed on international travellers.

The main convergent points of both studies are that the numbers of cases are bound to rise, affecting a large segment of the population. Under the circumstances, the capacity to look after the most susceptible (over 60 years) with comorbidities will be crucial to be progressively built so that the entire healthcare system does not get swamped. The essential take away from two studies along with data coming in from China, Europe, Iran, USA and UK, following can be surmised as:

Even a moderate and optimistic spread of the virus will afflict a large portion of the population. Flattening the curve is not the endpoint of a “lockdown”, it is an important step toward affording time for building public health capacity to surmount a possible community outbreak. Test, Trace and Treat will be the mantra to verify the extent of the spread, the factors causing it as part of the deep learning on the pattern and path of the virus in our population.

How valid is the Indian Approach?

The lockdown was a crucial and essential first step. It was perhaps the most crucial decision for determined action to quarantine 1.3 billion people with a complete closure of all travel and enforced social distancing and isolation.

Surprisingly, the international policymakers did not see the simple logic of the proactive containment measures timed now: in three weeks the people infected would recover and become non-contagious even on the premise that it had already reached a community spread.

Additionally, globally the virus would have vented its destructive power and would be winding down as is evident in China. As long as we can prevent a fresh ingress of the virus from overseas, a test and trace initiative would define the spread of the virus in ethnic populations. China is currently banning all foreigners, and we might need to do the same or else have a rigorous protocol of screening and isolation in place for at least six months.

What Beyond 14th April?

The question haunting the country is what happens post 14th April 2020? There is no clarity on the issue coming from either the Health Ministry or the ICMR. Two distinct scenarios are possible which warrant a discussion.

Scenario 1. Continue the lockdown beyond 14th April 2020?

If the present decision was arrived at based on containing the replicative cycle of the virus through containment and isolation of India, then a continuation of the lockdown is not likely to bring any deterministic outcomes, it would only enforce the social distancing, isolation of those at higher risk etc. The possibility that spread to the community would have burned itself out with a majority recovering from a baseline infection, 15 % hospitalized, and a death rate of 3 %. While the numbers may seem alarming, the peak of this cycle is likely to be reached in the next couple of days. The resource depletion created by continuation will create a chain reaction with serious consequences. An open question will be if the cure is harsher than the disease, with little additional control over the contagion.

Scenario2: Partial lifting of the lockdown

This scenario is more realistic, with a minimum of four months of directed and targeted containment. The return to manufacturing will be possible, albeit with essential and new workplace norms; like rotational staff work rosters, work at home where possible and maintain social distancing. Large congregations, sporting, public and religious events will need to be deferred. The data and deep analytics will reveal the higher risk groups for whom the containment may be enforced longer. This virus has to burn itself through 60% of the population for herd immunity to limit its spread. The expedited introduction of a vaccine may be the only other alternative to contain this contagion

Management Perspectives

Ramping up the intensive care facility is critical. We need to develop capacities to add 2000 ICU beds per day as suggested by Dr Devi Shetty (TOI Editorial 26th March 2020). The death rate is directly related to the number of ICU beds. In Italy, which has a bed to population ratio of 13: 100000, the death rate is roughly 10%, Germany with a ratio of 29:100000 has a death rate of 3 %. India, which has 2.3: 100000 bed – population ratio will need a million ventilators to cope with the current predictions of the spread. Development of health capacities must remain the most critical priority of the government in which industry must give a helping hand. The creation of exclusive COVED19 hospitals is the need of the hour. Existing medical/dental colleges in states provide a viable option. Each of these institutions, which have approximately 400/100 bedded multispecialty hospital, presents a unique opportunity for scaling up of resources. Almost 300 recognized dental colleges alone with 100 bedded hospitals could be a useful resource for adding ICU beds and providing quarantine facilities. All that would be required is oxygen supply and ventilators. Next is workforce challenges, particularly internists, critical care specialists, pulmonologists, trained doctors, nurses, OT and anaesthesia trained ICU technicians for manning ventilators. As Dr Devi Shetty has suggested, 50,000 specialist doctors waiting to appear for the final exams can be added to the system with some changes in the process of qualifying exams and board certification. Retired health care personnel are already being recalled and will be a valuable augmenting resource. Also, the dental workforce can be redeployed as is being done by the NHS in the UK. This too can help in augmenting beleaguered health care system in India. All dental surgeons are trained in general, medicine, surgery and can function under supervision in the ICU and to assume routine administrative and logistics support. The Armed Forces Medical Services (AFMS): The AFMS has both capability and capacity that can be deployed at short notice. The COAS has already announced that the Indian Army can deploy at least 28 field hospitals at short notice. Another unique opportunity is for the states to coordinate with the AFMS for emergency training of healthcare personnel in basic tenets of biologic containment (training of service personnel to NCB situations is integral in the AFMS).

Conclusion:

In this article we have attempted to outline the Indian approach, in the backdrop of two predictive models for the spread of Corona virus in India, highlighting possible post 14th April contingencies, outlining crucial management perspectives to deal with the disease. It is important to underscore that India is at war; we need to unite and put all our resources together at this critical juncture. The economy will take a major hit; it is incumbent to ensure the well-being of the socially marginalized as also to kick start manufacturing. India is being tested, and it cannot fail.

Dr. Anmol Kalha, Associate Director and Advisor, Max Health Care and Brig Arun Sahgal, PhD, is a Senior Fellow at the Delhi Policy Group.