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COVID19 Surveillance: Post Lockdown Strategies and Options

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It is most likely that India will move to a post COVID 19 lock-down strategy that aims at reducing the rapid spread of the epidemic surge in hot spots (red zones) and mortality while at the same time reducing the economic consequences to poor communities who are maximally affected with loss of wages in the less affected and unaffected areas (yellow and green zones). The success of this strategy would largely depend on the type and intensity of surveillance activity in these three zones of the country. The article discusses the objectives and broad structure of this approach.
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20 April 2020 (Words 2860)
COVID19 Surveillance: Post Lockdown Strategies and Options
By
Thomas Kurien, Department of Medicine, Pondicherry Institute of Medical Sciences
Sudhakar Kurapati, Formerly with CDC, World Bank, and USAID
Ramesh Bhat, NMIMS University, Mumbai
Arni S. R. Srinivasa Rao, Medical College of Georgia, Augusta University, USA
Abstract
It is most likely that India will move to a post COVID 19 lock-down strategy that aims at reducing the
rapid spread of the epidemic surge in hot spots (red zones) and mortality while at the same time
reducing the economic consequences to poor communities who are maximally affected with loss of
wages in the less affected and unaffected areas (yellow and green zones). The success of this strategy
would largely depend on the type and intensity of surveillance activity in these three zones of the
country. The article discusses the objectives and broad structure of this approach.
Introduction
As we completed the 21 day national lockdown and started the extension till 3rd May 2020, the
question on every body’s mind is ‘What next?' We need to be clear about what we want to achieve in
the post-lock-out period. As of 20th April 2020, we have nearly 17656 confirmed cases nationally,
with nearly 559 (3.2%) deaths across the nation. These infections, to date have substantial geographic
variability. Currently, 35% of districts have a relatively very low prevalence of fewer than ten people,
3% have a high prevalence of more than 100 cases, and the rest 62% have moderate levels of disease.
Six percent of districts account for 71% of cases (see Figure 1). It is expected that more than 96% of
the affected recover with time as they develop antibodies against the virus, providing them immunity
against further infection. However, what we have not achieved at present is that almost 99% of the
population remains vulnerable to the virus with very low levels of herd immunity to prevent further
waves of COVID19 infection and surges in the community. There seems to be a consensus that we
will move to a differential strategy with the aim of reducing the rapid spread of the epidemic surge in
hot spots (Red Zones) and mortality particularly in more vulnerable people of the country while at the
same time reducing the economic consequences to poor communities who are maximally affected
with loss of wages and in the less unaffected areas (Green and Yellow zones). The success of this
differential strategy would largely depend on the type and intensity of surveillance activity in the
three zones of the country with the following objectives:
To identify emerging new infections in the community without delay so as to initiate
strategies to prevent surges and increase in mortality
To identify sub-populations in hot spots which are protected by immunity so that they can be
allowed to participate in normal activity and thus reduce economic consequences to affected
families
To identify the magnitude of herd immunity in the general population at different zones of the
country so as to stop emergency distancing measures instituted in the country and go back to
normal activities.
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The surveillance strategies must identify emerging new infections in communities without delay so as
to initiate strategies to prevent surges and increase in mortality. The differential strategy may focus on
the following:
1. Hot spots (Red Zone) Surveillance
These geographical areas have already been established as high prevalent areas of the country. It
is essential intensive distancing and lockout continue at these hotspots. The objective is, therefore,
to prevent surges and increase in mortality. Intensive tracking of infections in these areas is not
required since more than 20% of subjects with COVID are asymptomatic. Everyone should be
considered as likely COVID positive, and generalized and effective quarantine measures must be
the focus. It has been clearly shown during the lockdown period that this action can reduce the
surges of new cases and reduce mortality. However, to understand the progress of the epidemic,
low-level syndromic sentinel surveillance in health center/hospital will be required. In addition, in
selected areas, where access to health care is poor additional set-up to monitor pneumonia, and
pneumonia mortality must be established. Certainly, all cases with fever or upper respiratory
symptoms must be considered as COVID19 and subject to isolation and quarantine accordingly.
Laboratory testing in these cases is likely to go wrong as sensitivity and specificity of available
tests are still less (60-80%) than optimum.
2. Moderate Intensity (Yellow Zones) Surveillance
These are high-risk areas that can quickly turn into hot spots in the country if adequate and timely
interventions are not instituted without delay. Hospital-based surveillance looking at severe cases
and mortality will not suffice in these zones. The intensity of surveillance must be maximum in
these areas. Extensive laboratory testing of all symptomatic and even routine normal people using
'Testing Booths' will need to be instituted in these areas. Testing people coming for shopping and
travelling in buses, etc., in the region will give a handle regarding emerging new infections and
the trend of rising or lowering of the infections in the community. Active surveillance using
existing health infrastructure of health workers will be needed to monitor fever and pneumonia as
a priority in these geographical areas so that timely information is obtained, and appropriate local
strategies can be initiated to prevent spread. Workplace surveillance of symptoms can be
undertaken by companies and reported to public health authorities
3. Low Intensity (Green Zone) Surveillance
While the spread of COVID19 from high-intensity areas to low-intensity areas is prevented by
restrictions of human travel/contact to the maximum feasible. Care must be taken to monitor these
areas for emerging infections. At this point, low-intensity zones constitute the largest sections of
the country involving many villages of India with poor health infrastructure for intensive
surveillance. Therefore, technology-based surveillance of ‘Fevermay need to be given higher
priority than surveillance involving laboratory-based COVID testing methods on symptomatic
people. Potential outbreaks should be suspected and investigated if any geographical area shows
unusual fever outbreaks. Some innovative technologies have been identified in some countries
using Self-reporting thermometers and hand-held devices by health care workers in the villages.
Rumor registry is another mechanism that can be activated and used for monitoring unusual
events in the community.
4. Identify sub-populations in hot spots which are protected by immunity
It will be important to identify sub-populations in hot spots that are protected by immunity so that
they can be allowed to participate in normal activity and thus reduce economic consequences to
affected families in restricted areas. Antibody tests in high-intensity hot spots will be able to
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identify a protected population that have recovered from the infection. History of patient’s health
alone is not sufficient to detect this subpopulation since up to 25-30% of the population are
asymptomatic. This is particularly relevant in hotspots areas where a large number of people
have had infections. It will not be much useful in the very moderate and low-intensity areas.
Protected subpopulation can be provided working passes so that the economic impact in these
areas can be minimized.
5. Identify the magnitude of herd immunity
The identification of the magnitude of herd immunity in the general population at yellow and
green zones of the country so as to stop emergency distancing measures instituted in the country.
As we gradually reduce the restrictions on movement and work placed on our population for
reducing the spread of COVID19 infection, we need to understand a point in time when we can
go back to normal activity. It is possible that if more than 40-50% of the population are protected
by antibodies and not susceptible to further infection, it will be possible to wind down the
restrictions in the area. This objective is likely to succeed over a 6-18 months period in different
regions of the country if we go by the history of H1N1 epidemic. In high-intensity areas, it will
occur faster, and in lower intensity areas, this will occur over a greater time period unless a
vaccine becomes available. Information on herd immunity can be obtained by properly planned
repeated surveys on representative populations in these different geographical areas over 3-6
months interval. This can easily be done by public health departments in different government
and private medical colleges in the country under ICMR guidance.
Developing Effective Surveillance Response
Surveillance, by definition, is the collection of data for appropriate public health action. Any
recommendation on surveillance must be accompanied by specific actions based on the emerging
data. This graded response has been very well documented in the document, which has been in the
public domain (Report on Expert Committee on Strategy for Easing Lockdown Restrictions by
Government of Kerala ) and this seems appropriate as a corollary to this document on surveillance
(Refer Appendix 1 pages 16-23 of the report). The action plan clearly lists a three-phased approach to
reduce the distancing policy based on the risk profile of the districts. But it is evident that some sort of
distancing will continue all over the country till herd immunity develops in the population over time
or vaccine becomes available, or an effective intervention is identified to reduce case fatality of
COVID19 infection.
The objectives of the surveillance policy would be to differentially allocate resources to strengthen
care and support of the affected population in high prevalent zones at the same time reduce the
economic burden of the population in the less affected zones of the country without increased risk of
epidemic surges and change in the status of the epidemic category of districts from lower to higher
levels of prevalence.
Integration and Coordination of Surveillance Activities for COVID19
A wide range of surveillance systems has been developed in India over the past few decades, which
can be used effectively to keep track of COVID19 epidemic in India. By pooling the resources,
involving the field and laboratory personnel and management systems, COVID19 surveillance system
can quickly be established and operationalized immediately. As an integral part of the country's
response to COVID19, this activity needs to be given the highest priority and necessary support.
Resource requirements for this will need to be identified as a priority, particularly for rapidly
strengthening IDSP in all states in India.
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Integrated Disease Surveillance Programme (IDSP)
IDSP is primarily meant to detect and respond to emerging epidemics like COVID19. It is a
decentralized program having both syndromic and laboratory-based surveillance components. It is IT-
enabled with focus at district and state levels to monitor disease trends and respond to outbreaks in the
early rising phase through trained Rapid Response Team (RRTs). However, the programme has not
been uniformly successful in all the states of India. The established components of surveillance
activities are particularly needed for COVID surveillance. Other disease surveillance systems can be
integrated at this point with IDSP to monitor trends of COVID in different settings. For example, HIV
Sentinel Surveillance (HSS) system which has extensive coverage of many high-risk populations
where sentinel surveillance can be used to detect change COVID prevalence in hotspots and the
National Polio Surveillance Project (NPSP) has an excellent laboratory component and can be used in
COVID confirmation in all districts.
Develop and establish COVID19 Sentinel Surveillance (CSS) system
Additional surveillance for COVID19 is needed to collect data from the special group, particularly
asymptomatic people who may not be detected by usual disease-based surveillance systems. These
units must conduct active surveillance asymptomatic carriers who cannot be identified through
existing systems to get laboratory confirmation. COVID surveillance must be established in places
where people gather and get together like bus stations, religious places, malls, schools, and
educational institutions and construction sites. This is particularly important in medium-prevalence
zones to prevent them from becoming new hot zones of infection.
Management System to Improve the Efficiency of Surveillance:
There will be a need to put a management system in place which may constitute a district-level
coordination committee under the leadership of District Magistrate/Collector with District Medical
and Health Officer (DMHO) as the convener. Representatives of ICMR, vertical disease control
programs, medical colleges, health NGOs, civil society networks, IMA, etc., must be part of this
coordinating body as envisaged under IDSP. The key role of this committee would be to map and
identify high-risk areas that require a wide range of intervention and work closely with key district
level officers, local self-government members, civil society representatives. The district-level
committee would also be empowered to plan and coordinate for 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.
Conclusion
The mantra echoing in all social media and many scientific circles is 'Test, Test, and Test'. But testing
to collect data is only one part of the necessary surveillance activity to guide health policy. The
efficiency of testing to control the epidemic will improve if the type of differential testing is tailored
based on the levels of prevalence in the geographical region strongly linked to specific predetermined
public health action. Different types of COVID tests are needed for different regions, and it includes
test (a) to diagnose and isolate affected individual, (b) to detect protected individuals so they can
resume normal activity and (c) to determine the pattern of involvement and magnitude of herd
immunity as a measured to go back to normal social activity for the population.
It is essential to integrate all surveillance activities in the country to tackle this pandemic. This can be
achieved by strengthening the Integrated Disease Surveillance Program, which has already been
established for this specific purpose of epidemic control in all states in India. Data collection and
response should be decentralized at the district level and will need to be different based on the
prevalence of the disease in the area during the post lockdown period and beyond. As coronavirus is
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going to remain a threat in times to come, strengthening the structure and operational aspects of the
surveillance system now will help not only the current crisis but also in the post-vaccine surveillance
phase. Certainly, the surveillance system will be pivotal for monitoring the safety and efficacy issues,
vaccine immunization distribution, and adverse events reporting, At this critical juncture of COVID19
pandemic, the country must take this opportunity to increase investments on surveillance by
strengthening IDSP across the country for not only addressing the immediate public health challenges
but also for long term benefits which will accrue over the years.
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Exhibit: The matrix of activities showing COVID19 surveillance options
Surveillance
Objectives
High Prevalent
(Red)
Moderate Prevalent
(Yellow)
Low Prevalent
(Green)
A
To identify new
infections in the
community without
delay so as to initiate
strategies to prevent
surges and increase
in mortality.
All preventive
measures to continue,
including lockout in
Red zone areas. So
diagnostic surveillance
is less important. Only
syndromic surveillance
is required at Sentinel
sites in Medical
College. Labs of IDSP
to detect reducing
trends when it occurs.
Yellow zones will
require maximum
surveillance to detect
the emerging disease
while partial activities
are continued.
Syndromic surveillance
through IDSP through
Private Practitioners,
ANMs, Anganwadi
workers, Medical
colleges, and private
hospitals.
Here laboratory
confirmation is
mandatory in all
symptomatic people,
and all test +ve people
will need to be isolated
to prevent the spread
of disease and to
prevent change into a
hot spot.
In addition,
asymptomatic
surveillance, as
described in Row D
since 20% of COVID
patients do not have
any symptoms.
Active Fever
surveillance by
ANMs and
Anganwadi workers
under IDSP
Rumour Registry to
be activated
IDSP Rapid response
team will investigate
for confirmation of
emerging sites in
the low prevalence
areas and take
preventive steps.
B
To identify sub-
populations in hot
spots who are
protected by
immunity so that
they can be allowed
to participate in
normal activity and
thus reduce economic
consequences to
affected families.
Rapid tests identifying
people who have
recovered from the
disease and having
adequate IgG titre will
need to be identified,
and they can be put
back to work even in
hot spots, thus reducing
the economic burden.
Polio Surveillance
program
IDSP Lab Surveillance
Workplace surveillance
if a patient develops
symptoms so that
people with immunity
can be allowed to work
Nil
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Polio Surveillance
program and IDSP Lab
Surveillance
C
To Identify the
magnitude of herd
immunity in the
general population at
yellow and green
zones of the country
so as to stop
emergency
distancing measures
instituted in the
country.
Repeated cross-
sectional surveys
once in 3-6
months. If herd
immunity
develops for more
than 40-50% of
cases, normal
activity can be
resumed.
Medical Colleges
ICMR
NCDC
Repeated Cross-
sectional Surveys once
in 6 months. If herd
immunity develops for
more than 40-50% of
cases, normal activity
can be resumed.
Medical Colleges
ICMR
NCDC
Repeated Cross-
sectional Surveys
every 6 months
Medical colleges
ICMR
NCDC
D
Surveillance of
Asymptomatic
population for
Covid19
Not required
Since Lockout is
gradually reduced
Asymptomatic persons
visiting shopping areas,
places of worship,
schools/colleges,
weekly market activities
will need to be
monitored to prevent
the spread of disease.
This requires
confirmation by lab
tests.
This can be a special
activity of the IDSP
team with help from
Polio laboratories and
Medical college
laboratories.
Test and Isolate COVID
patients
Not required
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Figure 1: 39 District Profile of Cases
(Source: https://www.covid19india.org/ 16th April 2020)
1,756
1,534
586
492
483
351
307
270
232
219
204
167
167
150
127
126
122
115
109
87
86
84
82
79
78
76
75
71
70
65
65
59
59
59
58
56
56
53
51
0200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000
Mumbai
Delhi
Indore
Ahmadabad
Jaipur
Pune
Hyderabad
Thane
Maharashtra Unknown #
Chennai
WB Unknown #
Bhopal
Kasaragod
Agra
Vadodara
Coimbatore
Guntur
Jodhpur
Kurnool
Bengaluru
Surat
Kota
Gautam Buddha Nagar
Tiruppur
Kannur
Srinagar
Lucknow
Tonk
Erode
Dindigul
Meerut
Tirunelveli
Banswara
S.P.S. Nellore
Mysuru
Bandipore
S.A.S. Nagar
Saharanpur
Nizamabad
39 Districts Account for 71% Cases
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