PM Modi’s gift to the nation and the master stroke i.e. the 1st and 2nd wave of shutdown (better word than Lockdown) is now becoming negative due to the ill management by various states/UTs.
By Dr Suresh
At the time of writing, India’s corona +ve stood at 1.58 lakh with an active case of 86,000 and 67,691 recovered. PM Modi’s gift to the nation and the master stroke i.e. the 1st and 2nd wave of shutdown (better word than Lockdown) is now becoming negative due to the ill management by various states/UTs.
Let us see it at below:
1st shutdown gain lost: During the last 7 days, an average of 6,500 + new cases are added daily. From 606 total +ve on 1st day of the shutdown, it has now increased to 1.58 lakh. 72% of India’s total is in 5 states – Maharashtra, Gujarat, Tamil Nadu, Delhi and Rajasthan (maximum serial-wise). Convert it into cities: 62% of cases are in 11 cities. In the 1st and 2nd wave of shutdown when few patients were +ve and manageable, India should have applied the basic principle of Communicable deceases control i.e. — i) case finding by the house to house survey and lab testing of all population of Corona +ve cluster areas, housing complexes; ii) then given appropriate treatment; and iii) preventive measures.
Compulsory house to house testing and testing of all population of a +ve area/cluster etc. is a must as Corona is highly infectious. For the same reason, treatment of mild case can be done at designated quarantine centres and severe cases are treated at hospitals which have ventilators. There should ever be no home treatment in view of India’s poor congested homes. Preventive measures include total shutdown and quarantine (best), use of a mask (2nd best & most cost-effective), Physical distancing of 6 feet apart of the head to head count, frequent hand washing and other hygienic conditions.
Also read| Check Coronavirus latest updates here:
Death rate: Though death is only 4,531 giving a 2.85 % mortality rate, I will not take it as a good sign as indicated by many experts /commentators. When the caseload increases many folds, the fatality rate doesn’t reflect the true picture. Top 5 high fatality rates are –Bengal (7.06%), Gujarat (6.17%), Maharashtra (4.34%), Telangana (2.86%) and UP (2.86%). The doubling rate of death from 13th March to end of 1st shutdown was 4-6 days; the range now lies between 10-15 days from April 13 to May 20 (succeeding 5 wks). Authorities and many others claim it as a positive achievement; but, a practical Public Health doctor will never take it seriously. Maximum deaths were 194 on May 5th; then there was a sharp decline to 86 on May 12th followed by a gradual rise thereafter. This cumulative total has no meaning, it has to be cluster-wise and area-specific for proper monitoring.
Testing : Though India is on 10th number in infection world-wide, we have low death rate when compared with other countries. From testing 8,000 in 24 hrs. in 1st week of April, India can now test over 1 lakh per day, the cumulative total being over 3.3million. In spite of this, there is still a common feeling that growth of infections is far outpacing growth in testing rate thereby indicating that our tests are one of the lowest in the world.
Let us see some states- Maharashtra-13.5%; Delhi-8.1 %; TN-4.1%; Bihar- 4.7%; Telangana -8.5%; WB- 2.5%; Rajasthan-2.2%; Karnataka- 1%; Andhra Pradesh-0.8% etc. There is a lot of variations in these findings. Maharashtra which did about 3.9 lakh tests had 13.5% +ve rate whereas Tamil Nadu which tested 4.31 lakhs has 4.1% +ve. On the other hand, Delhi which tested less (1.78 lakhs) has more +ve rate of 8.1%.
Further, Andhra Pradesh which tested a good number of 3.22lakhs has only 0.8% whereas Bihar which tested very few (about 64,000) is having a 4.7% +ve rate. What I am trying to emphasis is that these are state-specific and region-specific and India’s cumulative total of the testing rate of whatever per cent has no meaning in the control strategy. It has to be cluster-wise and area-specific. Only then, a practical Public Health specialist can interpret properly for a control strategy. I presume people in authority knew that more testing not only gives the true picture of the spread but also prevents the spread of infection in the community by taking appropriate preventive measures.
Special train services: From May 1st Special/Shramik trains had started services on a limited scale. For the train services, though in the beginning there was some control with the basic check-up including medical certificates, now it is in a complete mess with no physical distancing ( better word than social distancing) and unhygienic condition & food, no medical certificate etc. It was stated that no person from the red zone would not be allowed to board a train. With shutdown not followed properly, it is reported that there is an increase of about 30% +ve cases after the return of migrants to their homes in Bihar. In my own state of Manipur, which was more or less corona free up to May 15th, also now has 50 active case after returnees came back by air, train and other surface transports. One can imagine the scenario when more than 50 lakhs are ferried home (Source, Union Railway Minister Piyush Goyal).
Flight Journey: Similarly, about 33% of flights had resumed from May 25th. The same is true of flight journeys in spite of Civil and aviation minister specially stating nobody from confinement zones be allowed to board. Though the flight journey has very good strict control measures, which is appreciable, one person tested +ve on the 1st-day flight in my state of Manipur. Similarly, one passenger of Chennai-Coimbatore flight was found +ve resulting in all Indigo crew being grounded for quarantine. In the same fashion, 6 passengers are found +ve in Chennai to Salem flight and another 14 Indigo passengers found +ve and so on. Though the Minister stated that no person from containment zones will be allowed to board, it is clear that many persons from red zones, as seen in the train, are boarding the flights. Those states doing the 14-day quarantine are sensible ones and have far-sighted common sense. Congratulations to them; those not doing so, are only contributing to more addition of +ve cases.
How 1st shutdown gain lost :
Negative gain: In the 1st & 2 waves of total shutdown i.e up to May 3rd, we had a manageable case of 40,000 caseload. There was complete shutdown; one factor contributing to that was fear psychosis as nobody wanted to die because of Corona. In this, our Prime Minister Modi’s appeal contributed the maximum. At that time, instead of applying the basic principle of communicable disease control, Team Modi was happy to do some limited control exercise and treating mild cases at home. Some states, particularly Delhi and Maharashtra did house to house survey and testing to a limited scale from around last week of March. As whole red zones were not quarantined properly, the local spread did occur. Also, home treatment of mild cases contributed to local spread. That was the beginning of the early stage of 3rd stage Community transmission. This piecemeal implementation of the basic principle of communicable disease control is still being applied throughout India. Hope responsible persons at PMO and Health Ministry listen to this.
Positive gain: We now have abundant testing kids, PPE, ventilators etc. Discard all these red, yellow, green zones, these are all confusing. Instead, declare +ve case areas as red zone and –ve areas as white zones. If even a single case is found, the area be declared as the red zone in view of the highly infectious nature of the virus. Then declare the containment area seeing the local geographical area as is done now by local administrators. Enforce the strict 14-day quarantine; apply the basic principle of communicable disease control enumerated above. Go to the basics as is done in Malaria, TB, Leprosy, Polio and other infectious diseases.
Community transmission: One important thing is clear now – In view of the heavy burden of the caseload, the states can’t implement the shutdown properly. The shutdown is ineffective now, we have to admit it. It is confirmed by many +ve cases seen in returnee train migrants and flight migrants. Over and above new +ve case from new neighbouring areas of red zone cities and urban areas, we will have 1000s from new villages/semi-urban clusters because of migrant returnees. India has to prepare for this. We are now in the middle stage of Community transmission (divide it as early, middle & late stage). We should try to avoid the uncontrollable late stage of Community transmission. We will have a few lakhs more in the coming 6 months. India will have no 2nd wave, 1st wave will continue in the sporadic form in many places including villages.
Natural resilience and immunity: We are lucky in one sense. Because of the exposure of India’s population to various infectious diseases since childhood due to poor socio-economic condition, we have an inbuilt strong immunity to any infectious disease. It is this resilience which is fighting corona giving many -ve results and a mild form of Corona. The same is true for our neighbouring countries. Let the experts go on researching about BCG, Polio, Measles etc. and spend billions and years. By that time, Corona will be wiped out from the earth and a new one will emerge.
Conclusion: In the early stage, we had that uncontrolled border fiasco at Delhi-UP border and Nizamuddin incident, Now we have these uncontrolled lines at many rail stations and uncontrolled flights. Theoretically, there are many good guidelines, but could not implement properly. I had recommended all these –including early border seal, use of mask, preventive use of Chloroquine derivatives and above all this basic principle of communicable disease control in my letters since March 22nd March to the PM.
Declare only red and white zone, do strict 14-day quarantine/shutdown in red hot spots and apply the basic principle of Communicable disease Control Programme. No need for a further lockdown of other areas, no need for worry, India will win!
(The author is MD, WHO Fellow (Holland, UK,) Chairman, Ex-Director Health, Manipur. Views are personal.)