As coronavirus positive cases near the 6000 mark countrywide, with certain cities and districts reporting high numbers, an immediate end to the nationwide lockdown on April 15 is very unlikely. Instead, states are looking at containment strategies to keep under total lockdown areas which are seeing a big spurt in positive cases, while relaxing some curbs in districts which have reported very few or no positive cases.
The basic guidelines for such a containment strategy were listed in an official “Containment Plan for Large Outbreak” formulated and released by the Ministry of Health and Family Welfare (MoHFW) on March 6th 2020.
So, what does this plan, which is the basis for the current actions by the state, say?
Though the plans, drawn up before the travel ban and national lockdown, lists five scenarios for a strategic approach to containment, the three most relevant scenarios today are:
- Large outbreaks amenable to containment: If cases under local transmission explode into larger outbreaks making clusters of cases and turning them into hotspots.
- Widespread community transmission of COVID-19 disease: Community transmission means a stage where the source of infection cannot be traced.
- India becomes endemic for COVID-19: The disease will become common in a particular area or region.
Bigger cities at greater risk, the H1N1 connection and the Bhilwara model
The plan makes a valid connection between the 2009 H1N1 influenza pandemic that spread more rapidly in the bigger cities with substantive population movement as compared to rural areas or small towns having poor air/rail/road connectivity. The document further notes that the transmission patterns of COVID-19 mimic the 2009 H1N1 influenza pandemic, and hence requires a differential approach and targeting of areas.
The identification of the hotspots remains the key in implementing the containment plan which talks about adopting a cluster-wise approach. The intensity of the containment strategy will depend on the targeting of the respective hotspot.
According to officials at the Integrated Disease Surveillance Programme, a cluster place is defined as any area where there are more than 10 cases. An area which has several such clusters is treated as a hotspot. Using this criteria, several states like UP, Delhi, Madhya Pradesh and Mumbai have declared several districts and areas as containment zones, sealing them off completely.
City administrations in China and South Korea had successfully adopted similar techniques to contain the virus spread. In India, the successful containment strategies implemented by district authorities in Bhilwara, Rajasthan is being considered a national model now. As a result containment plans in other states is largely based on the Bhilwara model.
Bhilwara in Rajasthan had suddenly become the hotspot of COVID-19 infection after the first case was reported on March 19th. Soon it reported the second highest number of cases in Rajasthan at 27. However, since March 30th, only a single positive case has been reported in the region. Mass testing and identification of potential clusters became the two prime poles of the Bhilwara District Administration’s strategy. An intensive door-to-door testing drive was initiated with almost 2,000 teams conducting door-to-door testing for 28 lakh people and home quarantining of those with flu-like symptoms.
Cluster or hotspot based approach: Geographical quarantining
The plan stresses the need for early identification of clusters and hotspots to lessen the risk of spread. For this, the plan advises geographical quarantining, which is what the states are doing now
So what if your area or locality is declared a hotspot? Here are a few key points:
- Any region declared as a potential cluster or hotspot will immediately be turned into a containment zone. The adjoining blocks or towns or villages of such containment zones will be considered buffer zone.
- No movement will be allowed in these zones except essential services and movement of government officials. An ID/pass system will be formulated and movements shall be strictly documented. No movement of any private vehicle will be allowed in this area. Borders will be sealed by the Police.
- Health workers at the exit points will perform screening functions. All vehicles moving outside the zone will be sanitized with sodium hypochlorite solution. Those entering the zone will be provided with a precautionary dosage of hydroxy-chloroquine. The District administration will also create awareness about the perimeter zone.
- Other steps will include cancellation of public gatherings, closure of schools, cancellation of public transport, issuing of public advisories and strict implementation of social distancing in the containment zone.
Tracing, testing and isolating – the plan’s three main mantras
Once a containment zone is declared, three key activities will be initiated within the zone: conducting extensive contact tracing in the hotspots and widespread testing and isolation of all suspected and confirmed cases within the zone’s perimeter.
The Integrated Disease Surveillance Programme (IDSP) will be deployed for implementing surveillance and tracing measures. IDSPs are armed with an Early Warning and Response System (EWRS) that will provide intelligence on increase in the spread or transmission within the zone. The moment an intelligence input is received, authorities will give a green signal for designated personnel to immediately initiate the surveillance and tracing plan.
The plan advises states and district authorities to ramp up testing infrastructure. The nearest network of VRDL laboratories and designated private labs will be strengthened and deployed to conduct the tests. Other labs, after quality assurance by ICMR, will also be roped in to perform tests.
The plan provides for managing the surge in testing capacity. If testing requirements exceeds capacity in any zone, cases will be shipped to other nearby approved labs. The plan also instructs on minimisation of turnaround time of test results to 12-24 hours.
All symptomatic individuals with recent travel history, symptomatic health care workers, all hospitalized patients with severe acute respiratory infection (SARI) and asymptomatic direct and high-risk contacts of a confirmed case will need to be tested once between day 5 and day 14 of coming into contact. The testing will continue till 14 days from the date tests declare the last confirmed case as negative.
For isolation, the plan advises that private health care units be roped in if additional capacity becomes necessary. Isolation will form an important part of the containment strategy in any particular cluster or hotspot. Ideally, the isolation will have to be in the individual’s ward. A minimum distance of one metre is to be maintained between the beds and patients must wear triple layer surgical mask at all times.
Mixing of cases from different containment zones is strongly discouraged by the guidelines which advises that designated hospitals be identified near to the affected zone. Patients from a containment zone ideally will be treated in a hospital nearest to his/her particular cluster or hotspot.
Protection for frontline workers and infection control practices at health care units
State governments must ensure adequate stock of PPEs for medical and other frontline staff. N95 masks, gloves, goggles, shoe covers and other PPEs are to be used as per the guidelines. States should promote rational use of PPEs.
Field staff for tracing, surveillance and other activities to be provided shelter within the containment zones in buildings like schools, hotels etc. and adequate catering arrangements to be made.
Ambulances to be sanitised on a regular basis with Sodium Hypochlorite Solution and drivers to be equipped with a triple layer surgical mask. The designated COVID hospitals will ensure that all healthcare staff is trained in washing of hands, respiratory etiquette, donning/doffing & proper disposal of PPEs and biomedical waste management. There shall be strict adherence to Infection prevention control (IPC) practices in all health facilities.
Legal framework for containment strategy
An exhaustive legal framework is available to ensure smooth execution of the containment strategy. The Disaster Management Act 2005, Epidemic Act 1897, Criminal Procedure Code and Indian Penal Code all give needed powers to police and health and other administrative departments to enforce public compliance. While at the Centre the health secretary is the empowered authority under the Disaster Management Act 2205 to decide on actions to be taken to contain the outbreak, states have been asked to delegate power to any authority.