A Union health ministry plan has outlined how regions — cities, villages or neighbourhoods — with large outbreaks or multiple clusters of the coronavirus disease Covid-19 could be walled in, charting out what may be the first official road map to keep the disease in check by focussing curbs and surveillance on hot spots while other areas return to some degree of normalcy once the nationwide lockdown ends later this month.
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The strategy is based on lessons from the 2009 outbreak of the H1N1 influenza pandemic which, according to the report, had a bigger impact on “well-connected big cities with substantive population movement” while rural areas and smaller towns with low population and poor connectivity reported only few cases.
“The current geographic distribution of Covid-19 mimics the distribution of H1N1 pandemic influenza. This suggests that while the spread of Covid-19 in our population could be high, it’s unlikely that it will be uniformly affecting all parts of the country. This calls for differential approach to different regions of the country, while mounting a strong containment effort in hot spots,” said the health ministry’s containment plan for large outbreaks.
The road map is meant to tackle the third most serious scenario of the outbreak in the country. The first, and the mildest scenario, is when cases are limited to those who have travelled. Second is when cases are spread locally. The third scenario is when there are large clusters, while the remaining two are, when there is widespread community transmission and, the most severe, when India becomes endemic for Covid-19.
Actions for mitigation phase — a scenario when focus must shift to management of cases instead of containing the outbreak — will be dealt under a separate plan, the report added.
“The large outbreak in India is still amenable to containment. All states have put in place aggressive containment measures, and we haven’t reached that stage where the outbreak is uncontrolled,” said a senior health ministry official, requesting anonymity.
At present, there are 21 clusters in nine regions that are under a close watch for outbreaks. While there are no rigid thresholds set for what defines a “large outbreak” or how many clusters make the cut, an official aware of the plan cited Delhi’s Nizamuddin neighbourhood, Rajasthan’s Bhilwara and Kerala’s Kasargod as examples of what will be considered for the containment plan.
Nizamuddin is home to the Tablighi Jamaat’s headquarters, which has contributed about two-thirds of Delhi’s 445 infections. Bhilwara accounts for 27 of Rajasthan’s 200 cases and Kasargod 136 of Kerala’s 306 infections.
“That’s what is being done at the ground level from where a large number of cases are being reported. Most of our cases still can be traced back to international travel and the percentage where contacts have not been traced yet is too small to cause panic,” the official quoted above added.
According to the plan, a hot spot will be divided into zones: the quarantine zone and a buffer zone around it. The quarantine zone will be where most of the cases are focussed, while the buffer will include certain blocks or districts around it, as decided by authorities on a case-to-case basis.
For both zones, access– particularly outbound travel – will be cut off and all movement of vehicles and public transport will be halted, with exceptions only for those with special passes meant to enable essential services. “Thermal screening, IEC (inform-educate-communicate: a strategy to raise awareness on risks and consequences) shall be carried out at all entry and exit points,” the plan says.
Schools and colleges will be closed, mass gatherings will be banned and people will be encouraged to stay indoors for the first 28 days in both zones, the document states, adding: “based on the risk assessment and indication of successful containment operations, an approach of staggered work and market hours may be put into practice.”
These measures will be paired with increased disease surveillance: more random tests on hospitalised cases, testing of all suspected cases, isolation of patients and quarantine of contacts.
The testing criteria, however, remains the same. All symptomatic individuals who have undertaken international travel in the past 14 days, all symptomatic contacts of laboratory confirmed cases, all symptomatic health care workers, all hospitalised patients with severe acute respiratory infections (SARI) and asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in contact. The testing will continue till 14 days from the date the last confirmed case is declared negative by laboratory test, says the document.
According to experts, such strategies are crucial because it is not possible to keep a country as huge as India under perpetual lockdown and a blanket withdrawal is not advisable at this stage of transmission.
“The aim behind implementing the lockdown in the first place was to buy more time to better prepare the country for likely surge in cases, therefore, areas from where unusually high number of cases is being reported, what are called as hot spots, those should still remain under lockdown as these are sensitive areas that can change the entire scenario if left unattended. These are vulnerable pockets and need special government focus, else it can defeat the whole purpose behind country’s efforts towards flattening the transmission curve,” said Pradip Chakraborty, senior advisor, Centre for Public Health and Food Safety.
The containment strategy is similar to what has been used in China, the ground zero for the outbreak. Wuhan, a city of about 11 million people from where the virus is believed to have begun spreading in late December and affected the largest number of people within the country, was put under a strict curfew. The curbs were gradually relaxed, but movement restrictions have not been removed entirely.
Among some new measures, the health ministry report suggests local administrations must ensure “supply of enough triple layer masks to households in the containment and buffer zones to be distributed through visiting surveillance teams”.