Reoriented vaccine policy

• The foremost challenge in vaccination in India has been a supply deficit.
• Announcing a reoriented vaccine policy recently, the Prime Minister announced a coherent path forward.
• Starting from June 21, the Union government will take charge of 75 per cent of the total procurement, and provide vaccines to states at no cost.
• The government has reserved 30 crore vaccines with Hyderabad-based Biological-E by facilitating an advance payment of Rs 1,500 crore.
• Fortnightly updates on the supply of vaccines to states are being taken to ensure transparency and efficiency in planning.

Dealing with two complex challenges

• Two other complex challenges that need immediate focus are vaccine hesitancy and the much-discussed digital divide in the country.

1) Challenge of vaccine hesitancy

• Contextualised and curated approaches are crucial.
• The WHO has put forth the BeSD (behavioural and social drivers) vaccination model, which emphasises “motivation” as the vanguard of human psychology during a vaccination drive.
• Vaccination coverage could be increased by incentivising and motivating citizens.
• Unfortunately, in India, misinformation, disinformation and misplaced beliefs have led to fears about the potential harmful effects of vaccines.
• The diversity of India necessitates community engagement at the local level to counter this narrative of misinformation.
• A successful information campaign requires dissemination through mediums that invoke trust.
• Local languages and dialects should be used to engage people via local radio, television channels and regional newspapers.
• Another network that can be leveraged at the district level is that of the ASHA workers and the auxiliary nurse-midwives.
• These are trusted local figures.

2) Bridging the digital divide

• It is important to introduce solutions that bridge the digital divide.
• A toll-free helpline number 1075 has been activated for those without internet.
• Similarly, districts can explore missed-call campaigns, which could ensure that minimal infrastructure is being optimised for processing high-volume user requests.
• Even though the reported adverse events following immunisation stands at only 0.012 per cent, dedicated representatives can provide vaccine-related pre- and post-counselling to individuals.

Way forward

Startups could help bridge digital divide

• The devastating effects of the second wave in rural areas have prompted fintech startups to enable vaccine registration.
• PayNearby has helped over 8 lakh citizens register through its network of agents called “digital pradhans”, who are present in kirana, ration, mobile and hardware stores, frequented regularly by rural users. 

Use points of contact for publicising benefits of vaccine and registration

• Almost 81 crore beneficiaries, 75 per cent of whom are in rural areas, procure ration from 5,46,165 fair price shops across India.
• There are over 11 lakh business correspondent outlets in India working mostly in rural areas to advance the mission of financial inclusion.
• A network of around 1,54,965 post offices (as on March 2017) exists in India of which 1,39,067 are in the rural areas.
• Such points of contact can be leveraged as dedicated units for publicising the benefits of Covid vaccines and as physical locations for vaccine registration

Direct engagement with citizens

• The Prime Minister recently described district officials as “field commanders” in our efforts against Covid.
• This ambit should move beyond just the district bureaucracy to the extensive network of public services. 
• A stellar example of direct engagement also stems from the success of the Swachh Bharat Abhiyan.
• Direct engagement with citizens contributed greatly to the operational success of previous immunisation campaigns like the pulse polio programme.

Consider the question “What are the factors responsible for vaccine hesitency? Suggest the ways to deal with it.”

Conclusion

Thinking local and utilising established networks to create culturally resonant messages is the need of the hour to reduce vaccine hesitancy, bridge the digital divide and achieve vaccine saturation.

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The article contrasts the public healthcare system in South Asian countries with that of their Southeast Asian peers and highlights the shortcomings.

Subpar public healthcare system

• Super spreader events, a fragile health infrastructure neglected for decades, citizens not following health protocols, and logistical mismanagement were the factors responsible for the destruction in the second Covid-19 wave.
• What has exacerbated the situation is a subpar public healthcare system running on a meagre contribution of a little over 1% of India’s Gross Domestic Product (GDP).
• While the private medical sector is booming, the public healthcare sector has been operating at a pitiful 0.08 doctors per 1,000 people, World Health Organization’s (WHO) prescribed standard ois1:1000.
• India has only half a bed available for every 1,000 people, which is a deficient figure even for normal days.
• Bangladesh and Pakistan fare no better, with a bed to patient ratio of 0.8 and 0.6, respectively, and a doctor availability of less than one for every 1,000 people.
• While ideally, out-of-pocket expenditure should not surpass 15% to 20% of the total health expenditure, for India, Bangladesh and Pakistan, this figure stands at an appalling 62.67%, 73.87% and 56.24%, respectively.

Lack of investment in healthcare

• Major public sector investments by the ‘big three’ of South Asia, i.e., India, Pakistan, and Bangladesh, are towards infrastructure and defence, with health taking a backseat.
• While India has the world’s third-largest military expenditure, its health budget is the fourth-lowest.
• Indian government in this year’s budget highlighted an increase of 137% in health and well-being expenditure, a closer look reveals a mismatch between facts and figures.
• In Pakistan, even amidst the pandemic, the defence budget was increased while the spending on health remained around $151 million.
• Not too far behind is Bangladesh, with decades of underfunding culminating in a crumbling public healthcare system.
• Major public sector investments by the ‘big three’ of South Asia, i.e., India, Pakistan, and Bangladesh, are towards infrastructure and defence, with health taking a backseat.
• A quick look at pre-pandemic sectoral allocations explains the chronically low status of human development indicators in the three countries.

Learning from Southeast Asia

• Southeast Asia has prioritised investments in healthcare systems while broadening equitable access through universal health coverage schemes.
• Vietnam’s preventive measures focused on investments in disease surveillance and emergency response mechanisms.
• Even countries like Laos and Cambodia are making a constant effort towards improving the healthcare ecosystem.
• All have done much better than their South Asian peers.

Conclusion

Learning from the devastation unleashed by the pandemic, South Asian countries must step up investment in their public healthcare sectors to make them sustainable, up to date and pro-poor; most importantly, the system should not turn its back on citizens.

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Breakthrough infection

• ICMR said that a small fraction of those vaccinated with either Covaxin or Covishield have tested positive (i.e. breakthrough” infections).
• However, these instances do not undermine the efficacy of the vaccines.
• The immune response begins to develop usually two weeks after every dose and there are variations within individuals, too.
• Of the 9.3 million who received the first dose of Covaxin, 4,208 tested positive; and of the 1.7 million who received the second dose, 695 tested positive.
• For Covishield, of the 100.3 million who received the first dose, 17,145 tested positive; and of the 15 million who got the second dose, 5,014 tested postive.

What explains infections after vaccination

• Healthcare and frontline workers, who were among the first to be vaccinated, were as a population far more exposed to the virus and therefore more susceptible.
• Secondly, the emergence of “the highly transmissible second wave (newer variants) ” may have contributed to instances of infection among those vaccinated.
• Several variants, which have mutations that have been shown to avoid detection by the immune system, and in some cases reduce the efficacy of vaccines, have been reported globally, including in India.

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The article suggests ways to deal with the second wave of Covid in India.

What explains the bigger second wave

• The size of any epidemic is a function of three things:
• 1) The size of the pool of the susceptible population.
• 2) The pattern of contact between the members of the population (frequency, mix, closeness and duration).
• 3) Probability of spread during that contact (infectiousness of the agent).

Let us have a look at these 3 factors in the current context

• As many people have already been infected in the first wave, the pool of susceptibles should be smaller.
• Serosurveys also support this as they found that about 25 per cent of people had already been infected nationally.
• However, this is an average and hides significant variations by state, age and place of residence.
• Populations with lower seroprevalence become the potential pool for the second wave.
• Given India’s large population base, the actual number of people are sufficiently large to enable multiple waves till we achieve a more even spread of protected people.
• The persistence of protectiveness of antibodies of those already infected and their cross-protectiveness to newer strains is not well established.
• Vaccination would reduce the pool of susceptibles.
• However, the current level of vaccination coverage is not sufficient to make a significant difference to this wave, given the fact that we are already riding it.
• It is a good strategy to prevent the next wave, if we can achieve substantial coverage with it.
• Vaccination also prevents severe disease, and hence reduces the death toll.
• With the removal of most restrictions, the probability of contact between individuals has risen sharply.

Way forward

• What can and should be avoided are super-spreader events like a crowded park, the Kumbh mela, election rallies, etc.
• A much stronger community engagement with a robust communication strategy and lesser emphasis on “criminalising” inappropriate behaviour is required.
• A nuanced communication campaign is the need of the hour and is conspicuous by its complete absence.
• What is urgently needed is a robust evidence-based communication campaign.
• Such a campaign would involve proactive serial assessment of the community perceptions and concerns, testing and refining messages through an evolving campaign.
•  A district-specific strategy of “test, trace, treat” along with containment measures (isolation and quarantine) is still the best way to deal with the situation.
• We also need to put a stop to political bickering; it erodes public trust and confidence.

Conclusion

Dealing with the second wave should be based on the experience drawn from dealing with the first wave and complemented by a better communication strategy.

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The article delineates five areas in which partnership with the private sector is essential to deal effectively with the epidemic and ensure a whole-of-society response. Ensuring the participation of the private sector has been the recurring theme of many op-eds we have come across after the outbreak.

Significance of private healthcare in India

• According to the WHO, a critical lesson from the 2014-16 West African Ebola epidemic was that both the public and private sector need to work in tandem in responding to large-scale epidemics.
• In the COVID-19 response in India, the private sector has to play an even more important role, as it is the dominant provider of health services in the country.
• The private sector includes the for-profit and not-for-profit segments.
• The dominance of the private sector in India: The NSSO 71st round data on social consumption of health show that private hospitals, clinics and nursing homes provide over 70 per cent of healthcare.
• Data on the nearly 1 crore treatments received under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) corroborate this finding.
• AB PM-JAY data shows that over half of all treatments are being availed of from private providers, accounting for over 60 per cent of total disbursements.

UPSC asked about community-level healthcare intervention in 2018. So, pay attention to the significant role played by the private health sector in India.

Following five are the areas in which cooperation with the private sector will be essential-

1 Testing

• Creating a large and accessible testing infrastructure is the first weapon in the armoury.
• Countries like South Korea, Singapore, Germany and Japan have been successful at controlling the spread of COVDID-19 and reducing mortality through early detection and quick containment.
• This has been possible only through widespread testing.
• India has opened testing up to private labs.
• Testing has been included under the AB PM-JAY as well.
• We need to substantially expand testing capacity.
• This cannot happen without the active participation of the private sector.

2 Converting private hospitals into Covid-19-only hospitals

• As the government deepens its containment efforts, the country will need to rapidly surge the numbers of quarantine units, isolation wards and ICU beds in COVID-19-only
• It will also need to ensure increased and continued supply of essential medical products — from testing kits, masks and other PPEs to oxygen and ventilators.
• According to a recent ICMR study, around five per cent of those infected will need intensive care and half of those in intensive care units will need mechanical ventilation.
• These projections translate into large numbers that considerably exceed the capacity of the government health system.
• Private hospitals with adequate infrastructure will need to convert in COVID-19-only hospitals.
• There should be a clear policy framework of designated hospitals, reporting and referral systems and an appropriate payment system.
• With many government facilities being converted into COVID-19-only hospitals, a large number of non-COVID-19 patients will need facilities and providers to take care of their other urgent, critical or continuing healthcare needs.
• The AB PM-JAY has started a process to bring on board more hospitals to respond to such needs.

3 Protecting healthcare workers

• As more private providers join this fight, a major concern that will arise is keeping healthcare workers from becoming infected.
• In addition to being at a high risk of contracting the virus, healthcare workers are also potential carriers.
• Ensuring their protection is of paramount importance.
• Increasing the production: Companies manufacturing essential medical products such as ventilators, masks will need to crank up their production.
• Direct support from banks may be needed to keep production and supply chains going.

4 The private sector has to support the ecosystem driving health system

• The private sector will need to vigorously support the large ecosystem that drives the health system as the lockdown and ongoing epidemic restrict movement and normal economic activities.
• Activities such as the production of essential drugs and medical products, logistics to maintain smooth supply need to not only continue but also accelerate.
• Support for community activities such as night shelters and community kitchens will need to be strengthened.

5 Collaborate to share knowledge on the epidemic

• An adequate stage-wise response to the pandemic and its economic, social and political aftermath will require the rapid filling of the many knowledge gaps.
• Government, private and not-for-profit research institutions need to collaborate to understand the nature of transmission of the virus.
• They must understand the factors that slow its spread, the most at-risk communities, or the optimal quarantine period.

In 2015, UPSC asked whether the private health sector could help bridge the gap in providing universal health coverage. A question can be asked based on the same theme but in reference to dealing with the pandemic.

Conclusion

The fight against COVID-19 is not a race to a hilltop. It involves the continuous management of an evolving public health crisis that threatens to spawn economic and social crises. These multiple dimensions will require a whole-of-society approach that goes beyond the government alone.

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Context

The current COVID-19 crisis that India is battling has brought into sharp focus the public health system’s inadequacy to cope with it.

Contradictory scenario between public and private healthcare delivery

• The contrast between public and private: Hospitals with state-of-the-art equipment rivalling five-star hotels in their facilities are mushrooming mostly in cities even as the overburdened public hospitals are valiantly fighting to cope. 
• Dismal picture in rural areas: As far as the rural areas are concerned, the community health centres and primary health centres and sub-centres present an even more dismal picture in terms of availability of medicine stock, trained para-medical staff, and doctors and nurses.
• However, it is not as if urban hospitals offer patients excellent care. A common and widely held general misperception is that the private healthcare system is better than the public one.
• Why private is not always better? Complaints of non-transparent billing, demanding exorbitant sums in advance even in a medical emergency, and cutting corners in services are all too familiar, as are cases of the denial of services.
• In semi-rural areas and towns, the private sector is not necessarily similar to hospitals in cities.
• The private hospitals in these areas are small and have basic infrastructure and limited medical and non-medical staff. Unlike the cities, the power and water supply in these areas also constitute a problem to the functioning of these hospitals.

Problems in the public healthcare system

• Within the public sector health system, there are a number of trends again that add to the dismal picture.
• A high number of patients: Doctors in the public hospitals deal with an overwhelming number of patients majorly from the poor and marginalised sections.
• Issue of contractual staff: Health activists have also pointed out that the growing trend of contractual hiring of paramedical and allied staff leads to an insecurity among them, and thus affects overall caregiving to patients.
• Consequently, the poor patients’ families, frustrated by the lack of infrastructure and services, turn their anger upon the doctors and nurses.
• What are the implications? The constant vilification of the public hospital staff coupled with starving these hospitals of resources has led to the view that the private hospitals are “much better” despite their exorbitant rates.

State-wise variation in healthcare

• States subject: Health is a state subject, and it is well known that the health delivery systems are not uniform across states.
• Kerala a role model: Kerala is often held up as a role model generally, and even now in the manner in which it has dealt with the COVID-19 crisis.
• The dismal system in North India: As it is, certain states in North India have abysmal healthcare systems, and a couple does not have any testing facilities, the media has reported.

Getting the private sector involved in COVID-19 testing

• Undoubtedly, at present, the private sector must be involved in screening, tests and treatment for COVID-19.
• The highly trained professionals in this sector can contribute enormously by helping scale up the testing efforts.
• Importance of large-scale testing: In South Korea too, it was large-scale testing that was instrumental in reducing mortality rates.
• The pricing issue: Services across sectors must not be priced differently at a time like this. The media has reported that there is a difference of opinion between the government and private sector on the price of COVID-19 tests flowing from the prices of test kits.
• Need for the protocol: A clear and non-negotiable protocol for the private sector must be established regarding the present crisis and how the government is going to help financially and otherwise in dealing with it.

Way forward

• Regulate the testing, screening and treatment facilities: The experience with the government offering subsidies to hospitals, especially in urban areas in terms of land and other concessions, has not borne out desired objectives such as better care for the poor.
• Taking a cue from this, the testing, screening, and treatment facilities must be regulated in terms of pricing and quality.
• Focus on strengthening the public health system: The Supreme Court has held healthcare to be a fundamental right under Article 21. The biggest lesson of the current crisis is that political will must focus on strengthening the public health system.

Conclusion

The finance minister has announced a package of `1.7 lakh crore to deal with this catastrophic situation. This is welcome, but long-term resource allocation to invigorate the public health system must be a continual and parallel process.

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Context

The COVID-19 pandemic has repercussions beyond the biomedical sector — it impinges on industry, transport, finance, banking and education sectors. All of them must act in unison.

Virus different from its nearest relative

• Comparison with SARS and MERS: The rapid spread of the zoonotic (transmitted from animal-to-human) coronavirus infection in Wuhan in China — several hundreds every day — in December 2019 and January 2020 was a clear signal that COVID-19 is drastically different from its nearest relative viz.-
  • the Severe Acute Respiratory Syndrome (SARS) coronavirus,
  • and its distant relative, the Middle-East Respiratory Syndrome (MERS) coronavirus.
  • The former spread slowly among humans in 2002-2003. It was checked globally within nine months by screening passengers and quarantining travellers from infected countries.
  • There have been no cases since July 2003. MERS coronavirus is, by and large, an inefficient spreader — it has been confined to the Middle-East.
• How COVID-19 is different? COVID-19 has assumed a pandemic form.
  • In less than three months, it has reached more than 180 countries and claimed more than 10,000 lives.
  • The disease has claimed more people in Italy than in the country of its origin.
  • Travel bans, screening travellers and quarantines are necessary to slow the spread of COVID-19.
  • However, there is a limit to the utility of these measures.
• Community transmission: When the infection becomes widespread, screening procedures will become inefficient — the virus will spread stealthily.
  • Indigenous transmission — the virus spreading within communities — has begun in many countries.
  • This is typical of viruses that spread from human to human through the respiratory system.

How India’s health management systems deals with the disease burden?

• Medicine consists of three components —
  • universal healthcare,
  • public health, and
  • research to constantly contextualise solutions to local problems.
• Reaction after falling ill: Many of us in India believe that disease is a matter of fate or karma and disease prevention is not always in human hands — we only react after falling ill.
• No focus on prevention and control: Therapeutics and surgeries — healthcare interventions — are valued much, but not disease prevention and control.
• Cultural beliefs matter: Attitudes and cultural beliefs do matter. If victims are somehow regarded as responsible for their maladies, universal healthcare is perceived as an optional service — not mandatory.

Good reasons to change the attitude

• There are good reasons for such thinking to change.
• Every person who contracts a communicable disease stands the risk of spreading it to others.
• Prevention of disease is states’ duty: At the same time, the state, too, is responsible for the spread of diseases by not mitigating the environmental and social risk factors or determinants. Prevention of disease is the state’s duty.
• Investment in health and its implications: Healthy people create wealth. For example, every year, uncontrolled tuberculosis drains India’s economy of the equivalent of the GDP of roughly 2 million people.
  • Investment in health, therefore, can have implications for the country’s economy.
  • But Indians have never really demanded an effective public health system.
  • Healthcare has never become a political slogan. That’s one reason for the sorry state of India’s public health system.
• Absence of effective public health system: The country does have international obligations to control TB, malaria and leprosy, and eliminate polio.
  • Ad hoc measures: In the absence of an effective public health system, the country has depended on fulfilling these obligations through ad hoc measures that are targeted towards one disease.
  • Need for robust health system: Robust public health systems are needed to prevent typhoid, cholera, dysentery, leptospirosis, brucellosis, water-born hepatitis and influenza.
• Overburdened healthcare system with communicable disease: The absence of an effective preventive element means that healthcare services in the public sector are over-burdened with uncontrolled communicable diseases.
  • The entry of the private sector: This encourages private sector healthcare providers to step in, which brings in problems related to unregulated profits.
  • Questions are often raised over the quality of service.
  • COVID-19 could compound the systems problems: Moreover, uncontrolled communicable diseases vie with the non-communicable ones for the healthcare provider’s attention. The COVID-19 outbreak could compound the system’s problems.

One step ahead of the virus

• SARS and Nipah in Kerala: The SARS and Nipah virus outbreak in Kerala in 2018 were crises that required short bursts of professional activity. Our healthcare systems coped with them.
  • But endemic diseases, even influenza, that has a vaccine, require sustained interventions.
• Test for the country’s healthcare system: Herein lies the test for the country’s healthcare system.
  • It has often been seen that the system is not able to sustain its initial momentum.
  • There is a possibility that COVID-19 could follow the path taken by the HINI influenza – after the epidemic died down, the disease became endemic.
  • The country’s healthcare system has to prepare for that. In other words, it has to be one step ahead of the virus.

Way forward

• Equipping district hospitals: Every district hospital must be equipped to diagnose infections caused by serious communicable diseases — these affect the lungs, brain, liver and kidneys.
  • The system should also ensure that healthcare personnel do not get infected.
• Allocate 5% of GDP to health budget: The country needs to allocate 5 per cent of the GDP to the health budget to have a health management system that can take care of public health emergencies such as the COVID-19 outbreak — and its aftermath.
• Unified control machinery: A unified command and control machinery, under the prime minister’s guidance, to control the spread of COVID-19 is overdue by at least six weeks in the country.
• Define the tasks of various authorities: The tasks of the Directorate-General of Health Services, National Centre for Disease Control, Indian Council of Medical Research, National Health Mission and state health ministries must be clearly defined.
• The mechanism for coordination: Most importantly, a mechanism for coordination between these agencies should be set up to deal with the COVID-19 threat.

Conclusion

The COVID-19 pandemic has repercussions beyond the biomedical sector — it impinges on industry, transport, finance, banking and education sectors. All of them must act in unison.

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Context

China’s handling of coronavirus, in contrast to SARS, has been effective, should be a template for others.

Why lockdown of Wuhan is a big deal?

• A move without precedent: China’s lockdown of roughly 60 million people in Wuhan and other cities in Hubei province for more than a month now is without precedent in the history of public health.
• Best way to stop the virus from spreading: The best way to stop a virus from spreading from person to person, is to give it no place to spread to.
  • This is achieved by isolating those who are infected and quarantining those who might be infected.
• Cordon sanitaire: In China, though, the control has moved beyond traditional quarantine to a cordon sanitaire-an exclusion zone people cannot travel into or get out of.
  • In most countries, this simply would not work for a period this long and a population that large.
• Inconceivable move in other places: Wuhan is a city of 11 million people, slightly larger than Chennai or Bengaluru. It would be inconceivable to think of cutting off transportation in and out of these cities or asking people to stay at home for even a day, let alone a month.
  • No political control nor administrative mechanism: Like India, most countries in the world have neither the political control to impose their will on people this way nor the administrative mechanism to enforce this degree of control.

Human cost and ethic of the lockdown

• The human cost: The human cost of such a strategy is immense.
  • Feeling of being unable to escape: The fear induced by being unable to escape from a place where a new virus is circulating is immense.
  • The worries and stresses of everyday life multiply one hundred-fold when everything from shopping for food to occupying children stuck at home becomes a challenge.
  • The slightest cough, cold or fever can trigger panic.
• Ethics involved in the move: The ethics of the cordon sanitaire in Wuhan, as well as the quarantining by Japanese authorities of the cruise ship Diamond Princess, will be debated for years after this particular outbreak is over.
• Slowing the spread: But whatever its human and financial cost, China’s actions in the first month of the outbreak helped to slow the spread of the virus within the country as well as internationally.

How China’s response this time is different from the SARS

• On December 31, the Chinese government informed the WHO, and the world, of the existence of a form of pneumonia of unknown cause
  • It also told the people of Wuhan to wear masks if they had symptoms and seek medical attention.
• Virus identification: For the world, the big breakthrough from China came on January 7, when researchers in Wuhan identified the virus as a new coronavirus.
• Sharing of the genetic sequence of the virus: Two days later, China shared its genetic sequence with the world.
  • How genetic sequence helped? The sharing of the genetic sequence allowed labs all over the world to develop testing kits to detect the disease.
  • It also put countries on the alert for travellers with the disease, without which the new coronavirus would have spread much quicker and farther than it has so far.
• China’s response to SARS: The Chinese response to SARS in 2003, in contrast to this, was a cover-up.
  • The disease circulated for nearly three months, enabled by government secrecy and censorship.
  • Spread of disease without warning: When travellers from China brought the disease first to Hong Kong and from there to other cities across the globe, there was no warning.
  • It was only after the disease spread in Hong Kong, that scientists and public health experts began to decipher this new virus.
  • Lessons learned: China, fortunately, learned the lessons for SARS and put together systems to identify and respond to this new disease quickly.

What India can learn from China

• Infrastructure with speed: Public health officials all over the world, including in India, should study the speed with which China put together an infrastructure to deal with this new disease.
  • Modern, well-equipped hospitals dedicated to coronavirus patients were constructed in weeks.
• Centralised information and logistic system: Centralised information and logistics systems and systems to ensure coordination between multiple levels of government -from the central government to provincial and municipal governments, were put into place.
  • All the systems seem to have worked reasonably smoothly, given the chaotic and complex atmosphere of a disease outbreak.
• Unique approach: The way China has tackled this disease has been an “all of government, all of the society approach”, in the words of Bruce Aylward, the leader of the WHO team that recently spent two weeks in the country.
  • It was, as he described it, “a very old-fashioned approach”, but one that had “prevented at least tens of thousands, but probably hundreds of thousands of cases.”

Conclusion

• In all probability, it is only a matter of time before India sees new cases. The Indian health system, as in China, is multi-layered. Some states like Kerala have strong public health infrastructure and a strong response capability. Many other states like Uttar Pradesh and Bihar do not have strong public health systems. They will find it difficult to respond and will learn that diseases, like the revolution, can be brutal.

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Context

With multiple cities in China under a public health lockdown, global supply chains of various essential products and consumer goods are likely to be affected. This should be particularly worrisome for India, which has a roughly $93 billion total trade and about $57 billion trade imbalance with China.

Cause of worry turned into a reality

• Public health experts have worried most about an animal virus-
  • That gets into humans.
  • Causes human-to-human transmission.
  • Has high infectivity and a range of clinical severity.
  • With no human immunity, no diagnostic tests, drugs or vaccines.
• An emerging virus, called the 2019 novel coronavirus (2019-nCoV), appears to be just that.
• With the World Health Organisation declaring it a Public Health Emergency of International Concern (PHEIC), this outbreak is now a pandemic.

What is coronavirus

• Group of animal virus: Coronaviruses are a group of animal viruses identified by their crown-like (corona) appearance under a microscope.
• SAARS connection: The 2019-nCoV belongs to this group of viruses, six of which, including the 2003 Severe Acute Respiratory Syndrome (SARS) and the 2012 Middle East Respiratory Syndrome (MERS) viruses, were earlier known to cause disease in humans.
  • Genetic similarity with other viruses: Genetic sequencing of the virus from five patients showed it to be 5 per cent identical to the SARS virus.
• Bats as hosts: Since the SARS outbreak in 2003, scientists have discovered a large number of SARS-related coronaviruses from their natural hosts-bats.
  • Previous studies have shown some of these bat coronaviruses to have the potential to infect humans.
  • Genetic sequencing showed it to human coronavirus to be over 96 per cent identical to a bat coronavirus.
  • Thus, 2019-nCoV clearly originated from bats, jumped into humans either directly or through an intermediate host, and adapted itself to human-to-human transmission.
  • Bats are a particularly rich reservoir for viruses with the potential to infect humans.
  • Examples of these include viruses such as Hanta, Rabies, Nipah, Ebola and Marburg viruses, and others that have caused high levels of mortality and morbidity in humans.
  • India has 117 species and 100 sub-species of bats, but we know little about the viruses they harbour and their disease potential.

India’s response

• India’s response includes-
  • Surveillance of arriving passengers at airports.
  • Awareness drives in the border states.
  • Designation of hospitals with isolation wards and the availability of protective gear (e.g. masks) to health workers.
  • SOP: There are clear operating procedures for sample collection and its transport to the National Institute of Virology, Pune, which is the nodal testing centre.
  • A self-declaration mechanism is in place and a 24×7 telephone helpline has been set up.
• Two areas of concern
  • 1. Promotion of untested medicines: There is mixed messaging promoting AYUSH products that are untested and of questionable efficacy.
  • 2. India- a hot zone of zoonotic pathogens: India has been a “hot zone” for the emergence of new zoonotic (animal-derived) pathogens for over a decade.
  • But we continue to lack the capacity to quickly identify, isolate and characterise a novel pathogen.
  • Example of China: China is a good example of how investments in research and public health will allow it to take a lead on developing diagnostic tests, vaccines and drugs for this new virus. We must do the same and prepare for the future.
• Disruption in global supply chains and concerns for India
  • With multiple cities in China under a public health lockdown, global supply chains of various essential products and consumer goods are likely to be affected.
  • This should be particularly worrisome for India, which has a roughly $93 billion total trade and about $57 billion trade imbalance with China.
  • Disruption in medicine supply: The Indian pharmaceuticals industry imports about 85 per cent of its active pharmaceutical ingredients from China.
  • Any disruption in this supply chain would adversely affect the availability of medicines in India, which would be required in an outbreak situation.
  • Need to support local pharma. industry: India must, therefore, take steps to correct this imbalance and support the local pharmaceuticals industry in reducing its dependence on China

Possible scenarios

• Public health experts estimate that the epidemic will peak in three months.
• From here on, there are a few possible scenarios, but which of these would play out is hard to guess.
• 1^st possibility: There could be very large numbers of cases and global spread of the virus with a low CFR of 0.1-0.5 per cent, like the bad flu. Or the same with increased CFR, which would lead to significant mortality.
• 2^nd possibility: It is also possible that the outbreak spiralled in China due to a combination of factors not present elsewhere, such as population density, food habits and the Chinese New Year, which sees large population movements.
  • It is also possible that the pandemic may not sustain outside China and die out like the 2003 SARS outbreak.
• Whatever be the case, surveillance and sensible public health measures will be needed over the next few months.

Conclusion

India escaped the 2003 SARS and 2012 MERS outbreaks largely unscathed. This may still be the case with 2019-nCoV, but the laws of probability are likely to catch up soon. It would help to invest, build capacity and be ready.

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Context

In some ways, China is setting the standard for a public health response that may become a way of life in the 21st century.

Origin of the outbreak and deadly it could turn out?

• Outbreak of unknown virus: In December 2019, an outbreak of viral pneumonia of unknown etiology emerged in Wuhan, a city in the central Chinese province of Hubei.
• Discovery of novel coronavirus:  A few weeks later, the World Health Organization (WHO) and Chinese health authorities announced the discovery of a novel coronavirus, known now as 2019-nCoV, as being responsible for the pneumonia.
• Important questions: The two most important questions asked in a fast-evolving pandemic of this nature are:
  • 1) How deadly is the disease, and;
  • 2) Can it be contained?
  • The latest available figures suggest that the death toll in China is 304 and 14,411 have been infected. The current fatality rate estimate of 2% is unstable and is likely to fall as more cases are detected.

Containment attempts by China and spread to the other countries

• Unprecedented attempt by China: The attempt at containment started late, but has never been attempted in the fashion that China has gone about it.
  • Wuhan lockdown: Belatedly, on 23 January, China locked down Wuhan and 12 other cities, quarantining 52 million people in one sweeping action.
  • This is the first known case in modern history of any country locking down an entire large city.
• Reports of confirmed cases from other countries: Confirmed cases have since been reported from Hong Kong, Macau, Taiwan, Thailand, South Korea, Japan, Singapore, Australia and the US.
  • India reported its first case from Kerala of a medical student from Wuhan University, followed by two more.
  • Singapore and the US have now banned foreign nationals who have recently been in China from entering the country.
  • Russia, Canada, the UK and India have begun evacuating citizens from Hubei province.

Research on coronavirus so far

• Coronaviruses (CoVs) are characterized by club-like spikes that project from their surface, an unusually large RNA genome and a unique replication strategy.
  • CoVs cause a variety of diseases in mammals and birds, ranging from enteritis in hoofed animals to potentially lethal human respiratory infections.
  • Genome sequence: The 2019-nCov genome was sequenced in China in early January and reported in The Lancet last week.
  • It suggests that the original host of this coronavirus was a bat reservoir, though it is unclear whether there was an intermediate host.
• A recent entry to the human host: The uniformity of the sequenced genome suggests that the virus has entered human hosts very recently.
• Recent emergence from the animal reservoir: Several other countries, including the US and France, have sequenced the RNA of the 2019-nCoV as well. These sequences and their similarity to the initial samples from China suggest a single, recent emergence from an animal reservoir.

Tests and vaccine development

• How is the virus tested? Testing for 2019-nCoV requires a reverse transcription polymerase chain reaction test (RT-PCR) which converts RNA into DNA, making study and comparison easier.
• No vaccine yet: There are no vaccines yet for this virus, but promising paths have been identified, borrowed from the SARS related vaccines.
  • Development of an effective vaccine may only come after the 2019-nCoV is contained, but it may still be useful if there were to be a subsequent outbreak.
  • The frequency of future outbreaks is only likely to increase because of climate change, global travel and fast mutating viruses.

What lessons can India learn?

• Develop framework and capacity: For India, this global health emergency should serve as an eye-opener.
  • If lockdown turns out to be a useful tool to prevent the spread of a deadly virus, India will need to develop the framework and capacity to implement such a drastic measure.
  • Under-equipped municipalities: Our municipalities are hopelessly under-equipped to implement strict isolation and containment strategies.
  • We will need to develop the capacity to build large facilities for housing patients in isolation wards.
  • Use of pre-cast: This will require India to accelerate the use of construction methods like pre-cast technology.
• Protocol and instructions: The National Centre for Disease Control (NCDC) has been proactive in updating its protocol related to the 2019-nCov and has clear instructions for reporting and assay preparation.
• Develop capacity in geographically diverse regions: Samples in India need to be sent to the National Institute of Virology in Pune.
  • While the public health and epidemic escalation framework appears capable of handling a small number of cases well, it is not clear how it will stand up to a large number of cases in a specific geographic region.

Conclusion

“Nothing happens quite by chance. It is a question of accretion of information and experience,” said Jonas Salk, the virologist who developed the polio vaccine, in some ways, China is setting the standard for a public health response that may become a necessary way of life in the 21st century. India must use this as a guidepost to greater preparedness.

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