Dense urban communities such as slums, old city areas under containment need to be broken into units with physical separation (like a floor of a chawl with common sanitation).
By Sharad Verma, Vikram Janakiraman & Saurabh Chhajer
India imposed a nationwide lockdown on March 24 to curb the spread of Covid-19. This gave us time to prepare our healthcare response. Now, controlled return to a ‘new normal’ is a priority. We propose a set of India-specific actions to constrain further spread of the disease and commence economic activity.
Two vector approach for testing
The current test methodology in India largely focuses on symptom carriers and those in contact with the infected person. It aims at individual-level actions and should continue as the primary approach. To strengthen this, we should increase testing levels in states (districts) that are low on testing (say, <1,000 tests per million) or have high incidence rate (% positive tests >5%). In districts where self-reporting of cases is low and contact tracing and quarantine enforcement is weak, we need to do more proactive testing. Given that some patients are asymptomatic and pre-symptomatic transmission has been observed, periodic tests should be undertaken in high risk areas (like wholesale vegetable markets) and high risk populations (say, medical professionals). This would allow us to identify transmission chains outside the symptomatic test and trace protocol to detect an outbreak early.
This primary approach needs to be complemented with another vector for testing that randomly tests a representative sample of people and helps determines statistically reliable incidence rates over time for individual districts. Taken together, this will provide a more robust testing mesh. Insights derived from this approach can be used to segment districts and decide timing and extent of easing lockdown measures, like districts where actual incidence is low and can be opened up. It will also help direct actions to augment healthcare and testing capacity where needed. For the second vector to yield statistically significant results, a random sample of 5,000 tests per district (where incidence rate is expected <1%) and 1,000 tests per district (where incidence rate is expected >1%) would allow us to establish a clear baseline. This would form the basis for clear district classification and hence drive consistent decisions on ease/enforcing more containment measures. While the first vector will operate daily, the second can be repeated on a periodic basis.
Adopt a more granular approach towards containment
As the lockdown lifts, we need to shift focus of the unit from a district that is too dispersed to smaller, easily demarcated containment areas. These areas remain under lockdown (with essential activities allowed) rather than the full district. This will allow vital economic activity to commence in parts of the district where there is no case detected. However, this should be done in districts where sufficient testing has been undertaken and a baseline incidence rate established. Enforcing restraint to limit people transfer across containment borders will be critical.
We should add healthcare readiness as a metric for segmentation, in addition to incidence rate. A district that is well prepared to handle patients (available healthcare capacity defined as critical care/ICU beds that can absorb new cases at current growth rates) can allow for gradual easing of lockdown measures. Districts with limited healthcare facilities need to augment capacity and convert local hostels or hotels to dedicated Covid facilities and deploy mobile quarantine units.
Specific solutions for high-risk populations and locations
Front-line groups such as medical staff need constant monitoring for symptoms and periodic testing. Beyond that, testing should be undertaken in the local community rather than have people come to hospitals. Clear separation of testing facilities and quarantine centres from pure Covid hospitals is essential to reduce infection and pressure on critical care facilities.
High-traffic locations such as wholesale vegetable shops need a clear protocol to minimise interactions; for example, suppliers coming from outside the city come early in the morning and then leave, followed by local suppliers, then by local vegetable vendors and finally end-consumers accompanied with basic checks such as fever screening, sanitisation tunnels, etc, and periodic testing.
Dense urban communities such as slums, old city areas that are under containment need to be broken into units with physical separation (like a floor of a chawl with common sanitation facilities). If a case is detected, the individual needs to be taken out to a separate area outside the community identified for isolation. Facilities for institutional quarantine need to be created as effectiveness of home quarantine is limited given the population density in these areas.
As we open up the economy, more customised measures will need to be devised for each type of activity; for example, plants with discrete manufacturing, assembly lines, continuous processing plants, etc. Industry-specific teams along with healthcare professionals will need to determine the best set of norms by sector partnering with trade bodies to share learning amongst its members.
Exiting the lockdown requires a phased approach established on a new segmentation framework and augmented testing methodology that would facilitate opening up the economy without crippling healthcare. All of us will need to make an effort to learn quickly and replicate at scale successful measures to minimise the risk of cycling in and out of lockdowns. This is critical to saving lives and restoring livelihoods.
Verma is MD & senior partner, Janakiraman is MD & partner, and Chhajer is principal, BCG. Views are personal