COVID-19: An Indian Scenario

Ajay Prasad Hrishi P., MD, DNB, DM
Associate Professor, Division of Neuroanaesthesia, Department of Anaesthesia
Sree Chitra Tirunal Institute of Medical Sciences and Technology (SCTIMST)
Trivandrum, India

Girija Prasad Rath, MD, DM
Professor, Department of Neuroanaesthesiology and Critical Care
All India Institute of Medical Sciences (AIIMS)
New Delhi, India

Ajay Prasad Hrishi P., MD, DNB, DM

Girija Prasad Rath, MD, DM

It was not very long ago when on 31 December 2019, the WHO was informed about a pneumonia of unknown cause, in the city of Wuhan, China. Unforeseen to us on New Year’s Eve, waiting to welcome the fabulous year 2020, was the fact that this was going to shake the world from its roots, causing political, economic, and social instability. It was the genesis of the novel coronavirus (nCoV). When the cases were reported from five WHO regions in a month’s time, the WHO declared the 2019-nCoV outbreak a ‘Public Health Emergency of International Concern’ on January 30, 2020. The disease was named COVID-19 and research started intensifying in the areas of infection control and prevention, clinical management, surveillance, and risk stratification. Judging by the rapid and alarming rates of disease spread, WHO called COVID-19 a ‘pandemic’ on 11 March 2020.

The Indian Course of Battling the Menace
India confirmed its first positive case in the southern state of Kerala on 30 January 2020 when a student of Wuhan University came home (Kerala) on a college break and by 10 March the numbers rose to 50. As the number of positive cases increased to 500, Prime Minister Narendra Modi, asked all citizens to observe 'Janata Curfew' (people's curfew) on 22 March. Then the Government of India (GOI) ramped up its efforts in combating the disease from opening a 24x7 helpline to the executive decision of the largest lockdown of the nation starting on 25 March; the WHO mentioned it as being “tough and timely”. The lockdown restricted people from stepping out of their homes, as of 13 May, there are approximately 74,281 confirmed cases with 2,415 death. The infection rate has been reported to be 1.7 which is significantly lower than in the worst affected countries across the globe.

Meanwhile, the swift action of GOI brought back smiles on the faces of parents of 324 students who were flown from China in a special Air India flight. The humanitarian gesture of GOI was appreciated when it promptly lifted off its ban on export of hydroxychloroquine (HCQ) on April 7 to help the USA and 53 other countries.

Apex Medical Body on Growing Demands
On 17 March 2020 when India had only witnessed imported cases of COVID-19, the Indian Council of Medical Research (ICMR) came up with its strategy for testing all symptomatic people who had an international travel history or contact history with laboratory-confirmed positive cases, and healthcare workers managing patients with respiratory distress were screened for COVID. These testing strategies were revised over time with inclusions of rapid antibody tests and use of pooled samples for molecular testing of COVID-19 for surveillance purposes. It was reiterated that these tests might not replace the RT-PCR tests for diagnosing COVID-19 but could be used as a tool for surveillance depending on the situation on the ground. The latest ICMR-revised advisory authenticates that RT-PCR throat/nasal swab test as the best for diagnosis.

The Existing Health Care Facility: Is It Falling Short of The Demands?
The researchers at the Center for Disease Dynamics, Economics and Policy (CDDEP) estimated that India has approximately 1.9 million hospital beds, 95 thousand ICU beds, and 48 thousand ventilators. Most of the beds and ventilators are concentrated in only seven states such as Uttar Pradesh (14.8%), Karnataka (13.8%), Maharashtra (12.2%), Tamil Nadu (8.1%), West Bengal (5.9%), Telangana (5.2%), and Kerala (5.2%). The disease as of 13 May 2020, had infected 74,281 people and killed 2,293. Will the rising numbers incapacitate the Indian health system? With the fragmented healthcare facilities, at present India could possibly contain the pandemic efficiently by thorough preparedness. Hospitals decided to suspend elective and non-essential surgeries. With quarantine and isolation being the cluster containment mantra, what is the fate of rural communities without any hospital infrastructure? To meet this challenge, railway coaches were turned into isolation wards. The Indian railway’s capacity to reach more than 700 districts across the nation was leveraged.

The Kerala Model: Leadership on Display
During the initial stages of the pandemic, the states of Kerala and Maharashtra topped the list of the highest number of COVID cases. Kerala by then had one-fifth of the total cases, despite having only 2.5% of India’s population. Through stringent measures of a very rigid quarantine system and lockdown, Kerala, which has approximately the size of Kingdom of Bhutan, was successful in flattening its curve ahead of other states of India. The state machinery was successful in effectively enforcing the lockdown measures. This was further sustained by the time-tested strategy of case isolation and contact-tracing through a robust surveillance system. The robust health infrastructure of the state was successful in managing the infected cases with a case fatality rate which is one of the lowest globally 0.1%. The credit goes to the entire medical team for the recovery of the 93-year-old man and his 88-year-old wife at the Government Medical College Hospital, Kottayam, with the man being India’s oldest COVID19 survivor.

The Bhilwara Model: Ruthless Containment of COVID-19
On 21 March 2020, the BBC called the town of Bhilwara in the state of Rajasthan, “India's Italy” in the making. The ruthlessly efficient district administration had something else in mind. One of the first moves made in parallel to the medical interventions was to get the people off the streets. Being an industrial hub with large industries involved in textile manufacturing, the administration swiftly shut down the trades. This put the lid on the entire industrial activity and employment in Bhilwara. Government officials communicated with all the employers and urged them not to entrench workers and to ensure part payment of their wages during the lockdown. On the same day, ‘Corona Fights’ teams were formed in each village, which included Accredited Social Health Activists (ASHA) and local officials. These teams ensured that the people who were advised to self-quarantine did not venture out of their residences. Meanwhile, the medical machinery was successful in conducting door-to-door survey and screening of suspects in up to 92% of the population and limiting the cases to 27 with no new cases reported after 3 April 2020.

Lackluster Economy: The Downside
The lockdown has brought to light the plight of millions of poor Indians who migrate from villages to cities in search of livelihood (migrant laborers) and who are now stranded far away from home, with no livelihood nor income. The lockdown has ravaged the rural economy, pushing villagers to money lenders. The disruption of the rural market has become a bigger threat than the virus itself. Production has been curtailed in factories and services have suffered losses. The Indian economy is reeling under the impact of coronavirus.

The Research Front
These are times to demonstrate the power of science. Indian researchers have responded quickly rising to the occasion. Low-cost, easy-to-use portable ventilators were developed to meet the ever-increasing demand. The government of India along with private partnership has sprung into action in the manufacturing of 100,000 low-cost ventilators and creating an additional stockpile of at least 100,000. Robots are deployed at entrances of buildings and other public places to dispense hand sanitizing solutions as well as deliver public health messages. In an attempt to curb the spike, the latest initiative by the Ministry of Electronics and Information Technology is the ‘Arogya Setu App’. This phone-based application informs its users if they cross paths with a person who has been tested positive for corona. This tracking system is based on Bluetooth and the location on GPS. It can identify hotspots, and thus, deal with the community spread.

Multiple manufacturers have begun developing indigenous rapid diagnostic kits which are based on detection of proteins in COVID-19 virus or human antibodies. The state-of-the-art technology GENE LAMP-N by the scientists of Sree Chitra Tirunal Institute of Medical Sciences and Technology (SCTIMST), Trivandrum picks up the gene sequences which are unique to the SARS COV-2 virus. The method by which it concentrates the viral RNA to give faster results is very innovative with a sensitivity and specificity of 100% in the trial testing. Against the 20 samples tested per day in the routine PCR-based machines, this device is expected to test up to 500 samples per day at 20% of the cost (of PCR-based).

World’s Largest Repatriation Exercise
With over a million Indians stranded around the world, the GOI is planning to reunite them back to their families in a phased manner by air, land and sea. People with compelling emergencies will be given priority. The phase one of the mission to repatriate over 300,000 registered Indian expatriates is planned between 7-13 May 2020 as a joint operation of the Indian Air Force, Air India, and the Indian Navy. These exercises named as ‘Vandhe Bharath Mission’ and ‘Operation Samudra Setu’ will be etched in the modern history as world’s biggest ever repatriation exercise. Indian Navy also has embarked on ‘Mission Sagar’ to help its neighboring countries in the Indian Ocean region by supplying medical equipment, medicines, food and essential goods to overcome this pandemic; it is in line with India’s role as the first responder in the region.

Evolving Social, Economic Scenario in Post-COVID India
Though in the initial stages, the COVID-19 pandemic bogged down the vibrant Indian social and economic diaspora, now the pace has been accelerating back to near normalcy. Known as the country which is home to an ever-innovating population, the country has managed to stay ahead of the disease in the past two months of lockdown. India, which is globally acclaimed for its schooling system, is back on its feet, conducting online classes for as young as five-year-olds to the graduates attending medical colleges. The technology industry, which is the backbone of the Indian economy, is back in the scene with millions of employees working online from home. The emotional well-being of the population also is on a high with families getting quality time to spend at home. Yoga, India’s gift to the world is playing an essential role in the upkeep of physical and mental well-being.

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