Expert Speak Health Express
Published on Mar 16, 2020
A protean epidemic

The COVID 19 epidemic has been evolving by the day, opening new epicentres and rewriting previous assumptions. What began as a localised epidemic in Wuhan, in China’s Hubei province, rapidly crossed countries and continents. The speed of its spread, aided by the globalised nature of today’s world, has been unmatched in the history of epidemics. Response to the epidemic has differed between different affected locales. The progress of COVID 19 and response to it provides valuable lessons to policymakers and public health managers.

In 2002 China failed to acknowledge the SARS epidemic and inform the public leading to many avoidable deaths. It demonstrated how dangerous lack of transparency was to public health. Sadly, the same mistake was repeated when authorities did not act with the desired degree of urgency on the emergence of a new pathogen. For weeks together, after clinicians had reported the new virus in Wuhan city, no containment measures were taken and people were allowed to move freely within and outside the country. The mistake would prove very costly for China and the rest of the world. The virus that could have been limited to a few people now spread to other parts of the country and the world. Truth, however damaging it is politically, is a necessary ingredient to successfully managing an epidemic.

Before long the direness of the situation was obvious to the Chinese government. It almost posed an existential threat to the state and response at an unprecedented level was called for if the situation was not to get out of hand. In the past China had demonstrated their capability to mount stupendous efforts to contain diseases. Two examples are the Schistosomiasis containment and four bugs elimination campaign in the 1950s. The country brought to bear the same intensity in containing the spread of COVID 19. Contacts were traced and home-quarantined, and positive cases were isolated. Affected regions were isolated and travel in and out of severely affected regions was banned. Such measures appear to have succeeded in stopping the wild spread that had characterised the initial days of the epidemic. Italy has attempted to do a similar firewalling of affected regions. We will need to study the results and the costs to see if this is indeed the policy to be followed in mass epidemics in future.

By January, Chinese scientists had sequenced the genome of COVID 19, providing valuable insights into the nature of the virus and identifying the biological basis of the fast spread. (The coding of the receptor binding region COVID 19 was similar to SARS-CoV while rest of the sequences resembled less virulent strains). This was available in the public domain and was used to develop a real-time polymerase chain reaction (PCR) detection assay, PCR primers and probes. These facilitated fast and accurate detection of the virus and are supporting vaccine and pharma development across the world. The use of fast and accurate genomic sequencing and sharing of data was a major fillip to understanding and managing the virus. Excellent clinical research by Chinese clinicians has been a great support to care of patients in most parts of the world. Thus, science was a major contributor to the response.

Since, no medicines are currently available against the virus, only supportive care can be used to aid recovery. Till date, all the countries which have been severely affected have good health systems. While only 10 percent require intensive care and mortality is 3.4 percent, given the large number of persons infected, the absolute number of persons who need care have been difficult to cope with. While China has been justly applauded for adding additional facilities in record time, even that has proved inadequate. Since COVID 19 was attracting universal attention, there have been reports that persons with other serious conditions have been deprived of care. We will need to rethink planning for pandemics of this nature, including opening new centres by altering the use existing buildings to provide care and task shifting to lesser trained persons or lay volunteers. Comparing the experience of China and South Korea with Europe, it appears that free testing of all suspect cases and isolation of positive cases from the beginning provide better results. It would be a difficult for lower income countries to cope with the load that the current epicentres have had to manage.

India had the experience of dealing with H1N1 and Nipah crises in the past. So, as soon as the epidemic alert was received, advance preparation was done to screen and contact trace cases and isolate or home-quarantine high risk cases. This worked smoothly so long as the epicentres were few in number and India did not have close links with them.  However, that changed when new centres opened up in Europe and the Middle East. From then on, the number of cases has steadily gone up. Now it is a question of how many of the high-risk persons would be identified and tracked over time. Any positive case that is missed out would lead to a new cohort of contacts making contract tracing more difficult.

Next stage of the epidemic would start if and when community spread (persons who have never travelled out from their domicile or have connections with persons who have done so getting infected) starts. Since symptoms are indistinguishable from common conditions, cases would get ignored and till they become severe and the infection has spread to the larger community. Since younger persons are likely to be more mobile and therefore prone to picking up the infections fast, its impact will not be severe and they may not contact health care workers. But they would continue to spread the infection. Community spread would involve older patients who are at higher risk. This would increase the demand for intensive care including ventilators. Experience of Hubei and Lombardy regions provide an indication of the number of intensive care beds needed: roughly 10 percent of the total numbers infected. Creating the facilities take time. Government may need to identify buildings, procure oxygen cylinders, masks, cannulas and ventilators and recruit personnel immediately. This may at worst be wasted effort. But if support is needed and not provided, it could lead to avoidable deaths, loss of morale of health and anger in the community.

Governments have responded well to the epidemic so far. If the identification and isolation of high-risk cases and tracing contacts of positive cases is done well, India may be able to keep the number of infections and deaths low.  Barring a spike in community-based infections, the country may not face a major threat. But in public health it is always a good policy to prepare for the worst while hoping for the best. 

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Rajeev Sadanandan

Rajeev Sadanandan

Rajeev Sadanandan is former Indian bureaucrat from the Kerala cadre of the Indian Administrative Service and a healthcare policymaker. He has been working and researching ...

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