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Addressing Immediate Challenges in Controlling COVID-19 in
India
Thomas Kurien, Department of Medicine, Pondicherry Institute of Medical Sciences
Ramesh Bhat, NMIMS University, Mumbai
Arni S. R. Srinivasa Rao, Medical College of Georgia, Augusta University, USA
Sudhakar Kurapati, Formerly with CDC, World Bank, and USAID
For correspondence. email: ramesh.bhat@sbm.nmims.edu
Words: 2442
Introduction
Corona Virus Pandemic has to date spared India from a massive onslaught of death and
destruction, similar to what we see in China, Europe, and the United States of America. As
on date, India has reported 3072 COVID-19 cases and 91 deaths
1
. The Government of India
(GOI) has taken many proactive steps to control the epidemic, including the total lockdown
of the nation to flatten the epidemic curve and reduce the case fatality rate. India has chosen a
strategy of large-scale quarantine and limited testing and not extensive testing and limited
quarantine. This is because we have a large population of 1.3 billion, and many states in India
have the comparatively limited testing capacity to deal with a large-scale epidemic. The
timeline that we get by flattening the curve should be urgently utilized to plan and implement
interventions that help preventing further spread of the disease. This is important as we will
need to withdraw before long the nation-wide lockdown to reduce the economic impact and
resultant suffering of the poor and vulnerable population of our country.
The containment efforts in the country started with the testing of foreign travellers and their
contacts. Subsequently, persons with severe respiratory infections were also included in the
testing strategy. While contact tracing is a significant task which some states in India seem to
have done better than others. Data indicates that the infected individuals currently hail from
170 of the 640 districts of India. Within these districts, based on the number of infected
persons/or frequency, 27 high burden districts can be identified as hotspots (see Exhibits 1 to
3). About 4% of districts account for 43% of the burden, require immediate and focused
attention1.
In this setting, what we do in the immediate future has to be based on the existing spread of
the disease and projections based on mathematical modelling. Three main factors need to be
taken into consideration as we plan future strategy: (a) Even if we may decide to extend the
nation-wide lockdown for some more time, it cannot be extended for an indefinite period as
the economic consequences of a prolonged shutdown will be too high. (b) The pattern of the
spread of the virus is not uniform across the nation but concentrated in select hot spots in the
country. (c) The countrywide lockdown has produced some very unfortunate consequences
due to massive-scale migration of population across the country with resultant human
2
suffering and a potential threat to the spread of the virus in the source and destination of these
migrant populations. (d) Even though an effective vaccine is a long way away, there is some
indication that Hydroxy Choloroquine (HCQ) and BCG vaccination may provide some
benefit to reduce the infection, severity and virus load
2
.
At this point, incident data on COVID-19 cases suggests that India has succeeded to some
extent to flatten the epidemic curve. However, it seems inevitable in the light of large scale
conglomeration of migrants in many places; there will be a need to monitor the situation
continuously to determine geographical areas and districts which emerge in the future as
high-risk regions in the country particularly at the source and destination points of migrants.
Differential Approach to Social Distancing and Testing Strategies
The efficient use of preventive strategy, as seen in other health programs, will require
differential allocation of resources and focus based on the disease spread rather than across
the nation. The monitoring of high burden districts based on prevalence needs to be continued
to identify and designate hot spots in the country. The degree of the lockdown and social
distancing can be graded after the lockdown period. As migrant infections rise as expected
over the next few weeks, additional hotspots may arise in source and destination points. It is
anticipated, therefore, that three levels of social distancing strategy need be adopted to tackle
the epidemic while allowing some degree of economic activity to be initiated in shallow
prevalent areas of the country to mitigate the economic consequence of the epidemic. The
disease burden in each hotspot may show different timeframes, based on the cumulative
effect of the viral spread. In such situations, it will be essential to keep a flexible approach in
terms of timeline and how long do the district admin/health staff need to monitor the
epidemic. As time goes, we will be required to define the sort of an endpoint/threshold that
would enable us to return to routine work. At the same time, we may need to develop
mechanisms or initiate necessary steps to keep watch and try to avert a second wave later in
the year using three-pronged strategy:
1. In the identified hotspots current level of the mandatory shutdown will need to be
continued. A wide-spread testing strategy can be initiated in these areas to identify
positive cases that need to be quarantined. At the same time, newer diagnostic tests using
antibody titre can identify subgroups of the population who have recovered from minor
infections, and these can be allowed to perform normal functions within these
geographical hotspots. It is essential to ensure the availability of personal protective
equipment, ventilators, isolation wards and short-term orientation or training of
personnel, etc. It will be important to address the strategy of testing at high-risk districts
(hot spots). Given the remoteness of many districts, what level of logistics support
required for managing the testing activities? In the next couple of days, it will be
important to define the inclusion criteria for the testing and management of these cases at
the district/hotspot level, and also what kind of training and facilities may have to be
provided, timeframe for monitoring and surveillance in the identified areas.
2. Moderate level geographical areas can adopt a less stringent lockdown avoiding large
gathering, limited movement, and more freedom to initiate economic activity. These
populations need to be monitored closely based on a random sampling of the population
3
to understand the spread of disease and mounting appropriate responses to the epidemic.
Indian modelling studies predicted positive benefits of social distancing
3
and similar
measures were also recommended in other population too
4
,
5
. A recent study conducted by
Harvard School of Public Health researchers suggests staggered intervals of social
distancing may be more beneficial in saving lives than the one-time social distancing in
the USA. The team proposed “intermittent” social distancing, in which authorities enforce
distancing when cases rise above a set threshold and then lift measures when cases fall
below a set threshold
6
.
3. In a large number of very low-risk regions in the country, regular economic activity can
be restored. However, these regions must ensure social distancing norms in all their
routine activities, which may need to be continued until herd immunity develops
gradually in the population.
There are emerging studies on using newer technologies and methods of disease surveillance
in low-risk populations. A study has shown that the heart rate data can be exquisitely helpful
for picking up a flu outbreak before it actually happens. There is also a study which suggests
using body temperature with a smart thermometer and such cases can be digitally tracked
with some probability to pick-up the outbreak before it happens and ensure isolation and
prevent that exponential growth in that community
7
. It is also possible to identify the clusters
using smart thermometers, social site postings pattern, spurt in low lymphocytes count noted
by labs in an area, spurt in bilateral pneumonias noted by Radiologists in an area
8
.
Treatment Options using HCQ and BCG vaccination
Flattening the epidemic has given India some time to initiate some definitive treatment
strategies in addition to social distancing. There is some indication that Hydroxychloroquine
(HCQ) reduces infection rate, severity, and viral load. The final results of Randomized
Control Trials initiated by WHO may be available in 1-2 months. Meanwhile, ICMR has
given preliminary clearance for its use in COVID-19 affected individuals in India. FDA has
cleared the use in the USA also. BCG vaccination has also been noted to have some
protective effect by boosting immunity in individuals. India must get ready to initiate without
any delay in both HCQ and BCG in health workers and high-risk populations to reduce the
spread and prevent infection as soon as results become available from ongoing studies.
Migrant strategy
Migrant workers, daily wagers, low-income group families have become shelter-less and lost
their livelihoods as a consequence of a complete lockdown announcement. With no-access to
livelihood and nutritional needs, these groups have no other option but to move out of their
current dwelling units in the cities/towns and proceed to their native villages, which are
located in faraway places. In the process, several thousands of people congregated on roads,
exits points, transit areas and borders, railway stations, so on, and so forth. This has resulted
in a chaotic situation, and these groups have faced severe hardships for food, water, and
shelter. Unfortunately, if some individuals who are infected with COVID-19 are among these
groups, then there is an enormous possibility of exposure to the virus. Therefore, these groups
will have to be handled carefully at source, transit, and destination points
9
. Containment and
4
mitigation efforts need to be taken on a high priority. What could be possible interventions to
handle this situation:
• Responding to workers in distress due to the lockdown through the Labour Helpline
(1-800-1-800-999)
• Involve the civil society partners participating in the migrant interventions (many of
them are part of NACO program for the selected geographical regions
10
• Prepare a package of COVID-19 impact mitigation services and delivery mechanisms
• Access the database or information available about the migrant populations
• Reach out to the migrants at source, transit, and destination points11
• Use the networks established by the migrant targeted interventions in the NACO
Program (TI NGOs) and piggy-back on their efforts to provide the COID19
mitigation package of services.
• Closely monitor the activities through a supervisory mechanism and facilitate
coordination among the states/districts etc.
• Provide communication and stigma reduction BCC materials
• Provide counselling services as required
Administration and Coordination of COVID19 Prevention activities
Containment and mitigation strategies need to be simultaneous and well-coordinated. But at
present, these efforts by the national and sub-national governments are way below the desired
levels. The responsibilities of administrative and programme functionaries and the level and
magnitude of preparedness required for such a nation-wide intervention have not been clearly
understood. This has resulted in a great deal of confusion and chaos among the population,
particularly the migrant workers and their families. Several inter-state border issues have also
come up.
What should be the action plan to address these emerging challenges? The administrative
units need to work on the following:
• Map and identify high-risk districts which require higher levels of intervention
• Establish a district coordination committee with Collector as the Chairperson
• District Medical and Health Officer (DMHO) should be the convenor.
• Key district officers, civil society representatives, should be the members. We can
follow the DAPCU coordination Committee model that was developed in the
HIV/AIDS Program11.
It will be important to come up with an essential package of services for current and future
COVID19 waves. Once designed, this essential package kicks in whenever there is a
semblance of a COVID19 outbreak.
Developing District-wise Model-based Predictions
There is a need to urgently develop mathematical models informing us about the gravity of
the situation and, more specifically, identify emerging hot spots and potential spread based on
determinants of virus spread identified. Wavelet theory could help predict the future hot
5
spots, likely spread of infection in a given area in the absence of social distancing or other
preventive measures
11
.
Conclusion
The government has adopted a strategy of largescale quarantine and limited testing to flatten
the epidemic curve and reduce the death rate. This note suggests the timeline should be
urgently utilized to plan and set in action to prevent further spread (second wave) of the
disease. Currently, 49 high burden districts account for 62% of the burden, require immediate
and focused attention. The efforts will require significant coordination of administrative
activities and exploring and finalising treatment protocols, including HCQ and BCG. District
level COVID-19 Prevention Committees (DCPC) using the existing structure of District Aids
Prevention and Control Units (DAPCU) may be activated. The role of these units will be
significant in behaviour change and communication and various migrant management
strategies. Once we have reasonable data on tests and number of cases, wavelet analysis of
district data may be considered to inform the prevention and control strategies.
6
Exhibit 1: Number of New and Total Cases1
Exhibit 2: State-wise Number of Cases 3494 as on 4th April 2020 09:30pm1
0
500
1000
1500
2000
2500
3000
3500
01-Mar
02-Mar
03-Mar
04-Mar
05-Mar
06-Mar
07-Mar
08-Mar
09-Mar
10-Mar
11-Mar
12-Mar
13-Mar
14-Mar
15-Mar
16-Mar
17-Mar
18-Mar
19-Mar
20-Mar
21-Mar
22-Mar
23-Mar
24-Mar
25-Mar
26-Mar
27-Mar
28-Mar
29-Mar
30-Mar
31-Mar
01-Apr
02-Apr
03-Apr
New Cases
Total Cases
10
10
14
18
20
22
25
32
53
65
84
92
108
144
154
190
200
227
229
306
445
485
537
0100 200 300 400 500 600
Chhattisgarh
Andaman and Nicobar Islands
Ladakh
Chandigarh
Odisha
Uttarakhand
Assam
Bihar
West Bengal
Punjab
Haryana
Jammu and Kashmir
Gujarat
Karnataka
Madhya Pradesh
Andhra Pradesh
Rajasthan
Uttar Pradesh
Telangana
Kerala
Delhi
Tamil Nadu
Maharashtra
7
Exhibit 3: District-wise Number of COVID-19 Cases 4th April 2020
27 Districts Account for 1490 Cases (43%) of Total Cases
4% of Districts Account for 42% of Cases1
247
65
25
25
91
43
37
33
27
26
142
50
58
44
25
36
55
27
27
32
32
26
112
51
78
45
31
050 100 150 200 250 300
MUMBAI
PUNE
THANE
SANGLI
CHENNAI
DINDIGUL
TIRUNELVELI
COIMBATORE
ERODE
SOUTH DELHI
KASARAGOD
KANNUR
GAUTAM BUDDHA NAGAR
AGRA
MEERUT
HYDERABAD
JAIPUR
EVACUEES
BHILWARA
S.P.S. NELLORE
KRISHNA
GUNTUR
INDORE
BENGALURU
MYSURU
AHMADABAD
GRUGRAM
8
References
1
https://www.covid19india.org/ 4th April 2020 10:15 pm
2
Aaron Miller, Mac Josh Reandelar, Kimberly Fasciglione, Violeta Roumenova, Yan Li, and Gonzalo H. Otazu.
Correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19: an
epidemiological study. https://doi.org/10.1101/2020.03.24.20042937
3
Mandal S, Bhatnagar T, Arinaminpathy N, et al. Prudent public health intervention strategies to control the
coronavirus disease 2019 transmission in India: A mathematical model-based approach [published online ahead
of print, 2020 23rd March]. Indian J Med Res. 2020;10.4103/ijmr.IJMR_504_20.
doi:10.4103/ijmr.IJMR_504_20
4
Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal
role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med.
2020;27(2):taaa020. doi:10.1093/jtm
5
Choi SC, Ki M. Estimating the reproductive number and the outbreak size of Novel Coronavirus disease
(COVID-19) using mathematical model in Republic of Korea [published online ahead of print, 2020 12th
March]. Epidemiol Health. 2020;e2020011. doi:10.4178/epih.e2020011
6
https://www.thecrimson.com/article/2020/3/31/coronavirus-intermittent-distancing-study/
7
https://healthweather.us/?mode=Atypical
8
Email Communication from CMAAO IMA HCFI CORONA MYTH BUSTER 29, Dr K K Aggarwal
President CMAAO, HCFI and Past National President CMAAO dated 1st April 2020
9
Many civil society organizations in the filed such as Aajeevika Bureau, Shram Sarathi, Basic Health Services,
Prayas, INAAF, Saath, Yuva, CRH, and Prabasi Shramik Sahayata Manch have started collaborating on several
areas to handle the emerging situation (communication from Pavitra Mohan and Rajiv Khandelwal
10
National AIDS Control Organization (NACO), MOHFW, GOI, (2010): Policy, Strategy and Operational Plan
– HIV Intervention for Migrants
11
Rao, ASRS, Krantz S.G., Kurien T, Bhat, R, Sudhakar K (2020). Model-Based Retrospective Estimates for
COVID-19 or Coronavirus in India: Continued Efforts Required to Contain the Virus Spread, Current Science,
118, 7: 1023-1025. https://www.currentscience.ac.in/php/forthcoming/2020/COVID-19.pdf
