India has now crossed 50 lakh COVID-19 cases of which 21% are currently active and around 1.7% have resulted in fatalities. So where do we go from here and what are the interventions we should focus on during this phase of the epidemic? Five key themes emerge from the analysis of state- and district-level trends.
1. Focus on Containment, Health Infrastructure in Smaller Cities and Towns
To begin with, the spread of COVID-19 cases was largely concentrated in a handful of metropolitan cities like Mumbai, Delhi, Chennai and Kolkata. Over time, however, the epidemic has also spread to some of India’s Tier 2/Tier 3 cities and towns.
Currently, 24 districts out of the top 30 with the highest number of active COVID-19 cases have a total population size of less than 10 million.
The initial spread beyond metros happened in neighbouring districts eg Gautam Buddha Nagar and Ghaziabad in the vicinity of Delhi; Chengalpattu and Thiruvallur in the vicinity of Chennai as well as North 24 Parganas and Howrah in the vicinity of Kolkata.
Given that the health infrastructure in smaller urban centres could get stressed more quickly compared to the large metros, containing COVID spread should remain an important goal. Alongside testing and tracing, this necessitates a strong focus on isolation, especially regular monitoring of individuals under home isolation. Additionally, ensuring adequate numbers of oxygen supported and ICU beds in these areas is also critical for the management of patients with moderate or severe symptoms.
2. Managing COVID Spread to Rural Areas
Given that the COVID epidemic in India is still in the growth phase, concerns about the infection moving into rural areas are valid. Physical distancing can happen somewhat more organically in rural areas compared to densely populated urban centres which might prevent the infection from spreading as rapidly in our villages. However, there is no room for complacency. Some states have developed models for managing the return of migrant workers to villages which can be customised and replicated elsewhere too.
For instance, Odisha activated its Panchayati Raj Institutions and engaged with Sarpanchs who took an oath to take care of migrant labourers upon their return to the state. Community-based monitoring was carried out by Gram Panchayats and Urban Local Bodies.
Powers of the district collectors were delegated to Sarpanchs in Gram Panchayats within their jurisdiction. Returnees to the state as well as their friends and relatives were required to register with the Gram Panchayat. Quarantine facilities were provided free of cost for a period of 14 days. Upon completion of the requisite quarantine period, returnees were offered a monetary incentive. Local communities were engaged to facilitate the identification of returnees who had not registered with a Panchayat-level quarantine facility.
Further, awareness campaigns need to be undertaken in rural areas through engagement with Gram Panchayats, mobilisation of community-based organisations like self-help groups as well as utilisation of local communication channels such as community radios.
3. Bringing Down Test Positivity Rate to Below 5%
While the use of rapid antigen tests is a part of the overall public health strategy for screening large numbers of people relatively quickly, it is important for states to be aware of the limitations of this approach. In particular, individuals who have COVID-like symptoms should be tested again using RT-PCR tests even if their rapid antigen test result is negative.
Moreover, while several states are doing well on tests conducted per million population, the daily test positivity rate (number of people detected as COVID positive from the daily pool of samples tested) is still above the WHO recommended threshold of 5%. This indicates that testing in these states is not keeping pace with the spread of the infection and needs to be expanded further.
4. Minimising Fatalities
At an all-India level, the case fatality rate has been falling over time and is currently at 1.7%. In some states, however, both the case fatality rate as well as the total deaths per million population are significantly higher than the national average. Intensified efforts need to be made to bring the case fatality rate below 1%, if not lower. This requires regular monitoring of individuals in home isolation through the use of technology as well as equipping them with pulse oximeters for tracking their oxygen levels. Early infusion of oxygen in patients with moderate or severe COVID symptoms can prove to be a life-saving intervention as evidenced by the experience in several districts.
In Noida, for instance, even though COVID cases were surging a few weeks ago, the district was able to maintain a low fatality rate because of measures like equipping surveillance teams with pulse oximeters, checking the oxygen levels of patients visiting fever clinics and keeping individuals with oxygen saturation levels below 96% in high-dependency units where infusion can be initiated immediately, if required. For senior citizens and patients with comorbid conditions like hypertension, diabetes and chronic kidney disease, the focus must be on ensuring that they reach a health facility well in time after a COVID positive diagnosis so that their condition can be observed closely and timely action can be initiated in case of any worsening of symptoms.
5. Addressing COVID Fatigue
Across the world, COVID is yet to show signs of slowing down and it is natural for fatigue to set in among health workers as well as citizens. In India, too, we are increasingly witnessing signs of behavioural fatigue with people perhaps becoming less conscious about maintaining physical distancing and wearing face covers in public places.
Of course, given that COVID is here to stay at least for the time being, people need to get on with their lives but this should not happen at the cost of following COVID safe behaviours. With different sectors of the economy now opening up, employers must ensure that standard operating procedures are adhered to at places of work. Additionally, a large-scale behaviour change campaign should be undertaken to alert people about taking due precautions, especially ahead of the upcoming festival and wedding season. Finally, states must also pay greater attention to health worker fatigue by ensuring rotation of shifts and allowing adequate time for rest.
(Urvashi Prasad is a Public Policy Specialist with NITI Aayog. She's writing this in her personal capacity. She can be reached at @urvashi01. The views expressed in the article are the author’s own. The Quint neither endorses nor is responsible for the same.)
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