Even as the second wave of the Covid-19 pandemic seems to be receding in the country, the fears of an impending third wave loom large. Irrespective of declining active case numbers, the devastation caused by the pandemic over the last year is brutal and irreversible. As a country, if we want to lessen the adverse effects of the next wave, the time is ripe to look at the past few months, identify weak links, and proactively solve for them.
Between April and May, our team supported the Union and two state governments in different aspects of their pandemic response. Closely working with both levels of government gave us an insight into the key levers that can shape the effectiveness of a Covid-response strategy--information, execution and capacity. Government officials need access to relevant and reliable information to make timely decisions, those decisions have to be executed effectively, and finally, the system’s capacity to execute decisions has to be bolstered.
Information:
1. Use of data and technology for COVID management: The necessary condition for any government to be able to mount a response to a crisis is visibility into the scale of the current crisis and the ability to gauge its severity in the near to medium term at the minimum. In the case of Covid, this translates into data on active cases at an aggregate level, at the level of administrative units (districts, blocks), hospital beds, all relevant medical infrastructure (oxygen support, staff, medicines, ambulance), home isolation cases, citizen grievances, etc. Across the country, different states maintain this data with different levels of sophistication. From registers, white boards, Excel sheets, Google sheets, to online data systems. It is of paramount importance that all states develop integrated data systems that pull relevant data points from COVID hospitals, health and care centres, testing centres, citizen grievance helplines, so that they are empowered to identify the most pressing issues and respond in a timely manner.
To this end, we supported the Delhi government in developing an Integrated Command and Control Centre to enable data-backed routine COVID response and prepare for potential future outbreaks. This data can help the government identify triggers when containment measures and lockdown protocols need to be enforced.
2. Surveillance strategy: The most critical lever to curb cases from spiking is surveillance, based on the three pillars of timely testing, contact tracing and containment. At the peak of the second wave, testing labs across different states were hard pressed for resources and unable to conduct RT-PCR tests and report results in a timely manner. Before the third wave hits, states should assess their testing capacity at the peak of the second wave and the actual demand, identify the shortfall and ramp up capacity accordingly. Alternative testing strategies like self-testing kits, leveraging RAT in public places, airports, railways stations etc, while continuing use of RT-PCR for confirmatory testing in case of symptomatic patients, should be leveraged more actively.
As per Health department, Government of NCT Delhi data, only 33% of all contacts were traced within 72 hours in Delhi during the second wave. To minimize the spread of the virus, 30 contacts per COVID-positive patient need to be traced within 72 hours of confirmation. This would require close monitoring of district surveillance teams and community mobilisation to enforce curbing movement of identified contacts. It is also important to ensure that district surveillance teams capture GIS data of positive cases, traced contacts and containment zones to share with District Collectors.
For instance, in Alwar and Bhiwadi, open-source tools were used extensively for mapping COVID case data that helped in identifying COVID-19 clusters. This information was further shared with district administration to facilitate quick decision-making and execute tailored strategies and containment measures. Based on GIS data on COVID case spread, micro containment zones can be formed immediately based on the outcomes of targeted contact tracing.
A similar approach has been adopted by the Delhi government in preparation of the third wave, called the “Graded Response Action Plan”. Our team supported the government in developing this plan which would empower officials to take containment measures in accordance with “colour codes, also known as alerts--yellow, amber, orange and red--based on the Covid-19 positivity rate on two consecutive days, cumulative figures of fresh infections over a week and the average oxygen requirement for a week”.
Execution:
3. Case management protocol: In the second wave, in many states it was the patient or patient’s family which decided when hospitalisation was required and which hospital to go to. There was no reliable information on availability of beds or an effective channel to triage people and recommend treatment based on severity of symptoms. This left millions in the lurch, relying on personal networks and social media to get critical, life-saving information.
Mumbai’s case management model offers important lessons in this regard. The Brihanmumbai Municipal Corporation (BMC) mandated testing labs to not give Covid reports to patients directly. Instead labs released reports to BMC at 12 am each night, then a BMC team worked on these reports overnight to filter people by severity (remove COVID negatives, remove those who have been positive for beyond 10 days, etc). At 8 in the morning, filtered results would be handed over to wards. The triaging team in these wards would inform the patients, visit their residence to assess their condition and then depending on severity, isolate the person or get them admitted to a care centre / health centre / hospital as needed. In case of severe emergencies, the visiting doctor determined the type of medical facility needed by the patient (non-oxygen bed, oxygen bed, ICU bed) depending on symptoms. This reduced the patient burden on all health facilities and ensured timely care.
Capacity:
4. System capacity: For case management protocols to work effectively, it is important to ensure that the system has enough resources to tackle the crisis. States should evaluate and bolster system capacity in terms of 4 key resources: human resources, oxygen, medicines and ambulances. Final year MBBS students and nursing students can be trained to provide teleconsultation support to home-isolated patients, conduct triaging by visiting patients. Nursing students can also be trained for ICU management to support senior nurses in managing critical patients. Pharmaceutical students can also be directed to support districts in COVID management. States should use the current time, when the health infrastructure is not as stressed as it was in the last two months, to ramp up on essential medical supplies.
Simultaneously, states need to keep track of the needs of serious non-Covid patients, such as those who are either battling Cancer or are on dialysis, suffering from tuberculosis, pregnant women who require prenatal care, etc. From an administrative perspective, state governments should retain civil servants, who were closely involved in managing the second wave, in the same positions, or leverage their experience if and when a third wave hits. This would ensure that governments are ready to spring into action as soon as warning signs emerge, rather than having a new set of officials start afresh.
These are some of the basic elements of a Covid response strategy that we should prioritize immediately. If we can get these right, then we might be able to lessen the impact of Covid-19 in the coming months.