Lockdown checked speed, not cases. Unlock was date, not data, driven

Lockdown checked speed, not cases. Unlock was date, not data, driven

01.01.2021

No country has found a winning formula to contain the SARSCoV2, the virus causing the Covid-19 disease. India has also tried to build the ship while sailing on a rough sea. As the sun sets on 2020, let us look back. Could India’s response have been better? In hindsight, yes.

Between January and March, India focused exclusively on minimising the risk of importation. Se l ec tive screening and travel restrictions to begin with, and universal screening later with mandatory quarantine, could not adequately counter this risk. Had quarantine been instituted right from the beginning, the impact would have been different.

In the last week of March, lockdowns were imposed primarily to slow down the epidemic, the final phase lasting till the end of May. The announcement of lockdown came abruptly, without giving time to people, sparking fear, anxiety and panic. It created major uncertainties of livelihood and food for the poor. Millions of workers started their journey home, frequently in overcrowded conveyance, which threatened to push the virus deeper into rural India where it would be challenging to test and provide healthcare. Lockdowns were often enforced with coercive methods, spending more effort in containing the people rather than the virus.

The other rationale of lockdowns was to buy time to prepare the system to respond to the epidemic – from ramping up testing and quarantine facilities to arranging enough personal protective equipment for healthcare personnel. But this took more time than the lockdown periods.

The ‘pre-emptive, proactive, graded response’ failed to check the rising number of cases. When the lockdown was announced, there were 564 cases and 10 deaths with a doubling time of 3.4 days. On April 19, when graded relaxation was allowed, there were 17,656 cases, 559 deaths and a doubling time of 6.2 days. The lockdowns slowed the speed of spread of the infection, but not the number of cases, which kept increasing. India has occupied number 2 position in the number of cases reported globally. Lockdown is a blunt tool to flatten the peak of the epidemic, and not very efficient in interrupting the chain of transmission.

Testing and quarantining – the sharper tools – coupled with rigorous measures of masking, physical distancing, containment and mitigation would have flattened the curve and also reduced infection rate. The lockdowns were followed by a gradual seven-stage unlocking, which was date-driven rather than data driven.

It was a mistake to limit the initial testing to a few specific high-risk groups. Testing criteria were restrictive and testing rates were low, underestimating the cases.

The situation of the epidemic was informed by a set of data released by the government. It focused on numbers tested, numbers positive, recovery rate, doubling time, etc, not forgetting to highlight that the case fatality ratio in India was lower compared to other countries. While this data subtly hints that the government’s efforts have resulted in keeping the ratio low, it might have more to do with the proportion of the population older than 70 years, the prevalence of cardiovascular diseases, chronic respiratory diseases and other lifestyle conditions.

The rest of the official data has been closely guarded, only a few details have been released. Had the district-wise, demographic-wise case statistics and anonymous contact traces been released in the public domain, reliable model forecasts of disease spread and targeted regional lockdown protocols could have been generated.

Data to calculate infectiousness of SARS-CoV2 (basic reproduction rate) is important to tailor contact-tracing and quarantine strategies. Without access to data, no secondary analysis has been possible. There have been delays in sharing and full disclosure of national sero-survey data.

The government has also been quick to accord emergency-use authorisation to several repurposed medicines for treatment of Covid-19, such as hydroxychloroquine, Remdesivir, favipiravir, itolizumab, tocilizumab, etc. Sharing the science and uncertainties that informed these decisions would have been helpful to build public trust.

The response to the SARS-CoV2 epidemic should have been driven by a public health agency. We could have had different groups of experts, bureaucrats, etc to advise and guide, but the lead should have been given to a public health agency, trained to control epidemics. In this most serious public health crisis of our times, the absence of public health agencies on the national scene was conspicuous.

India’s variegated epidemiological, social and systemic vulnerabilities make its pandemic response difficult and complex. Some approaches have worked well, while others needed better planning.

Kant was head of the department of epidemiology and communicable diseases, ICMR.

Dr Lalit Kant AGAINST

The situation of the epidemic was informed by a set of data released by the government… The rest of the official data has been closely guarded, only a few details have been released