On May 4, as India began to lift restrictions across red, green and orange zones, Lav Agarwal, joint secretary, ministry of health and family welfare, said it was prudent to refer to the current phase as “easing out 2.0”, rather than “lockdown 3.0”.
Agarwal’s comment was indicative of the Centre’s move to lift restrictions further in the coming days, given the economic crisis in the country. In his subsequent statements, however, Agarwal sounded a note of caution. “One mistake, and we will end up where we started,” he said, responding to queries on rising cases despite the 40-day lockdown period. As on May 3, 130 districts were in the red zone, 284 in the orange zone, and 319 in the green zone.
Experts said India’s epidemic curve has shown no signs of “flattening”—despite the health ministry’s confounding statements on flattening—and those monitoring and working on the health management strategy warn that lockdown or otherwise, the virus is here to stay.
According to some experts in the government’s Covid-19 taskforce, a second wave of infections is expected in the winter months. A government source said the key would be stringent implementation of the plan in containment zones, as well as avoiding mixing of those in the designated hotspots and the ‘cold spots’ or green zones.
“The virus is not going anywhere. But neither can we be in a lockdown forever,” said Dr Srinath Reddy, member of the Covid-19 taskforce. “What is reassuring, however, is that a majority of the cases, up to 80 per cent, have been mild, or asymptomatic. Having seen the numbers of SARI [Severe Acute Respiratory Infection] and ILI [influenza-like illness], it is clear that there is no big wave of these cases indicative of rapid spread.” Reddy is a member of the executive group of the Covid-19 steering committee of the World Health Organization.
He said it is unlikely that a surge, like in the west, will be seen in India. “Our hospitals will not be overwhelmed with severe cases like in the case of certain western countries. The effort now has to be to slow down the number of cases so that the health system can deal with them,” he said.
To contain transmission, social distancing measures, hand hygiene and wearing masks will further have to be reinforced.
Of course, the vulnerable and high-risk population, such as the elderly and those with co-morbidities, will need to be protected. To that effect, Kerala’s containment model has been regarded as the best in the country by the ICMR. The state has rolled out the ‘reverse quarantine’ plan. Said Dr B. Ekbal, “All those who are 65 years and older and have co-morbidities have been quarantined. About two lakh volunteers are going to take care of their personal needs. We will also be monitoring them at the local level very regularly.” Dr Ekbal is a public health activist, and member of the Kerala State Planning Board. He said, “When we discuss the ‘Kerala model’ we need to understand that we are only following the Centre’s guidelines, including opening up of businesses. The difference is that we implement them well.”
Each state would have its own challenge; in Kerala, for instance, Ekbal said the biggest challenge in the coming days would be the arrival of 60,000 Indians from abroad, who will have to be quarantined and monitored regularly.
Opening up would also mean that the testing capacity has to be enhanced, especially in the hotspots, experts said. Though RT-PCR tests remain the “gold standard” for diagnosis, antibody tests would also be added for surveillance. By month-end, the Centre has plans to conduct 1 lakh tests per day each for RT-PCR, as well as antibody. “Government laboratories alone have the capacity to run 1.25 lakh tests a day,” said Dr Raman R. Gangakhedkar, head, epidemiology and communicable diseases, ICMR. On May 2, Gangakhedkar said that 72,000 tests had been done in the country, and with 25 tests per positive person, India’s testing numbers were “adequate”.
In the days to come, corporates would have to ensure safety of their employees. Zoya Brar, CEO, and founder Gurugram-based Core Diagnostics, said further ramping up of tests has to be done. “Corporates will have to invest in multiple tests depending on what the regulator allows,” said Brar. These include serological or antibody-based tests (IgG and IgM antibodies). Among them, the ones that are done in a lab take longer, but are more accurate. The government would have to take the first step to allow these to happen.” As of now, antibody tests are recommended only for surveillance and not diagnosis.
When it comes to Covid tests, each has its limitation, said Brar. RT-PCR tests may not detect previous infection if done too many days after contracting infection, and antibody tests could throw up false negative in the early days of infection.
“The antibody-based tests will be crucial to ramp up our testing because if we use only RT-PCR tests, we will need more machines,” said an official with a private diagnostic chain. “We don’t have that kind of infrastructure. In recent times, my conversations with the biggest manufacturer of RT-PCR machines have revealed that they have been able to allocate only three machines for India. Manufacturers are bound to privilege the needs of their own countries first. Besides, our purchasing power is also low.”
Antibody kits will help us in knowing whether social transmission of the cases has begun, said Ekbal. “We will then be able to use them in hotspots, and based on results we can decide what our next step will be,” he said. However, the ICMR has said that the utility of these kits remains low. “They don’t help in early diagnosis as some people think. Considering they are first-generation tests, developed for this infection, they are not as perfect as those developed for say, HIV,” said Gangakhedkar. Besides, there is not enough evidence to say that the antibodies detected by these tests offered protection, or, for that matter, how long the protection would last. “In H1N1, for instance, even vaccine-generated antibodies offered protection for only about nine months,” said Gangakhedkar, “It is a new disease, and we are discovering new information every day.”