By Kiran Mazumdar-Shaw, Executive Chairperson, Biocon
The first COVID-19 case in Karnataka was reported on March 9. Strict containment measures ensured the total number of cases were contained to approximately 3,200, with 1,950 active cases and just over 50 deaths till May 31 when the nationwide lockdown started to be eased. Since then the situation has exploded. Karnataka’s total case count crossed 44,000, with ~26,000 active cases and over 840 deaths on July 15. Within a span of 45 days, the state has, on average, added over 900 cases a day. In the first two weeks of July, it witnessed a jump of 2,000 cases daily. COVID-19 cases in Karnataka are growing at the fastest pace compared to other states. The doubling time of cases is less than 10 days for the state versus more than 21 days for India as a whole.
Simultaneously, the state’s fatality rate at 1.82% is inching towards the national level of 2.64%. The test positivity rate for Bengaluru, the state capital, surpassed India’s average rate of 9.8% for the week of July 6-12.
From a safe haven in May to being the state with the fourth highest caseload of COVID-19 in India, the situation seems to be spiralling out of control. Yet, Karnataka has important lessons for the rest of India.
To prevent a worsening of the COVID-19 situation in India as well as the states the top three priorities should now be: contain the spread of the virus, control the mortality rate and cascade responsibility.
With several parts of India, including Bengaluru, bringing in a second lockdown the 5T model of ‘test, trace, track, triage and treat’ needs to be strictly enforced.
India needs to relook at its testing guidelines, given the Indian Council of Medical Research’s (ICMR) estimate that 70-80% of coronavirus patients are asymptomatic. Everyone should be able to get a test done as India is now producing enough testing kits. The government should allow companies to test employees who are reporting on site.
The Ministry of Health should quickly activate its plan of conducting sero-surveillance nationwide to evaluate a larger swathe of the population for SARS-CoV-2 exposure.
Comprehensive contact tracing is key to slowing the spread of COVID-19. Up until May, the Karnataka government was doing a thorough job of tracing and quarantining. For every positive case, Bengaluru was tracing 47 contacts compared to Mumbai’s ratio of 1:3. It helped prevent the rapid spread of the novel coronavirus infection in the initial days. With the easing of the lockdown, complacency seeped in, contact tracing reduced to immediate family and cases started multiplying.
Active clusters should be completely sealed off and the Dharavi Pattern of ‘chase the virus’, which helped bring down COVID-19 incidence in Asia’s largest slum, should be emulated throughout the country.
Containment through increased testing, efficient contact tracing and proper quarantining is only one part of the story. The government also needs to be able to predict where the next outbreak is likely to happen through data mining and analysis so that they are prepared to nip the problem in the bud.
One way of doing this is by testing those with a ‘high risk’ profile, based on the frequency of work travel, use of public transport, presence of co-morbidities such as diabetes and hypertension etc.
Containment, prediction and preparedness will be key in avoiding a COVID-19 catastrophe in the country.
Control Mortality Rate
The mortality rate is a good indicator of a country’s ability to prevent COVID-related deaths. While it is heartening to know that this has dropped from 3.28% at the beginning of May to 2.64% now, we need to bring it below 1%.
An alarming shortage of hospital beds across the country is putting at risk the lives of patients with serious COVID-19 complications. To prevent hospital infrastructure from getting overwhelmed, the government will need to triage COVID-19 cases into mild, moderate and severe categories. Patients with mild symptoms should be home quarantined, while moderate cases treated in government quarantine centres or paid hotel quarantine facilities. The staff at hotel-turned-quarantine centres should be equipped with proper personal protective equipment and trained to provide contactless services to ensure their safety.
Only severe cases with complaints of breathlessness, blood oxygen saturation levels of less than 90% and other complications should be admitted to designated COVID-19 hospitals.
The government should target to bring down the number of COVID-19 patients seeking hospitalization to less than 5% from the current 15%.
To bring down mortality, ICMR should update clinical management guidelines for the use of available treatment options along the continuum of care. For example, Hydroxychloroquine and Favipiravir can be used in the initial asymptomatic and mild treatment stage, while Remdesivir and Methylprednisolone can be administered immediately after hospitalization. Immunomodulatory drugs like Tocilizumab and Itolizumab can be used to treat moderate to severe patients to address the building cytokine storm and prevent them from needing critical ventilator support. Protocols for convalescent plasma therapy and corticosteroid medication such as Dexamethasone should also be specified. Metrics that measure the reduction in ventilator need will directly correlate to the effectiveness of standard of care delivered.
A decentralised approach is critical to tackle public health emergencies like COVID-19. Responsibility needs to be cascaded down to the smallest administrative unit. The ward councillor and the sarpanch of the gram panchayat should be tasked with preventing any resurgence in infections in the areas they administer through greater testing, quarantining, zoning and sero-surveillance.
Time is running out and India will need to pursue a technology and protocol led approach to avert the looming COVID-19 crisis with stakeholder collaboration and administrative accountability.
‘An abridged version of this piece was published in the Mint on July 17, 2020’