Novel Coronavirus Disease 2019 | Containment Plan for Large Outbreaks by MohFW

Background

On 7-01- 2020, Chinese authorities identified a new strain of Coronavirus as the causative agent for the disease.

The virus has been renamed by WHO as SARS-CoV-2 and the disease caused by it as COVID-19., which has now been spread to over 200 countries/territories.

As per WHO (as of 1-04-2020), there has been a total of 823626 confirmed cases and 40598 deaths due to COVID-19 worldwide.

In India, as on 2-04-2020, 1965 confirmed cases (including 51 foreign nationals) and 50 deaths reported from 29 States/UTs. Large number of cases has been reported from Delhi, Karnataka, Kerala, Maharashtra, Rajasthan, Tamil Nadu, Telangana and Uttar Pradesh.

Risk Assessment

When was COVID-19 declared as a pandemic?

WHO declared it a pandemic on 11-03-2020.

WHO advised countries to take a whole-of-government, whole-of-society approach to prevent infections, save lives and minimize impact.

Epidemiology

Etiological agent responsible for current outbreak of SARS-CoV-2 is a novel coronavirus closely related to SARS-Coronavirus.

In humans, the transmission of SARS-CoV-2 can occur via respiratory secretions.

Current estimates of the incubation period of COVID range from 2-14 days, and these estimates will be refined as more data become available.

Strategic Approach

India would be following a scenario based approach for the following possible scenarios:

  • Travel related case reported in India
  • Local transmission of COVID-19
  • Large outbreaks amenable to containment
  • Wide-spread community Transmission of COVID-19 disease
  • India becomes endemic for COVID-19

Scenario:

Travel related case reported in India

  • Inter-Ministerial coordination and Centre-State co-ordination been established.
  • Early detection through universal screening of all International passengers at Points of Entries.
  • Surveillance and contact tracing through Integrated Disease Surveillance Programme (IDSP) for tracking travellers in the community who have travelled from affected countries.
  • Early diagnosis through testing samples of suspect cases.
  • Buffer stock of Personal Protective Equipment.
  • Risk communication for creating awareness among public to follow preventive public health measures.

Local transmission of COVID-2019 disease

Local transmission will lead to clustering of cases.

Cluster containment strategy will be:

  • Extensive contact tracing and active search for cases in containment zone.
  • Testing all suspect cases and high risk contacts
  • Isolating all suspect / confirmed cases and providing medical care.
  • Quarantining contacts
  • Implementing social distancing measures.
  • Intensive risk communication.

Large outbreaks amenable to containment

Geographic quarantine and containment strategy will include:

  • Defining the area of operation
  • Active surveillance for cases and contacts in the identified geographic zone.
  • Expanding laboratory capacity for testing all suspect cases, high risk contacts and SARI cases.
  • Operationalize surge capacities created for isolation (COVID-19 hospitals/COVID-19 dedicated blocks) to hospitalize and manage all suspect / confirmed cases.
  • Implementation of social distancing measures with strict perimeter control.
  • Provide chemoprophylaxis with Hydroxy-chloroquine to all asymptomatic healthcare workers and asymptomatic household contacts of laboratory confirmed cases.
  • Further intensification of risk communication through audio, social and visual media.

Containment for large outbreaks through geographic quarantine

Geographic quarantine (cordon sanitaire) strategy calls for near absolute interruption of movement of people to and from a relatively large defined geographic area where there is single large outbreak or multiple foci of local transmission of COVID-19.

The stated strategy shall be applicable to such areas reporting large outbreak and/or multiple clusters of COVID-19 spread over multiple blocks of one or more districts that are contiguous.

Cluster Containment Strategy

It would be to contain the disease within a defined geographic area by early detection of cases, breaking the chain of transmission. Prevention of COVID-19 tp spread to new areas would include:

  • geographic quarantine
  • social distancing measures
  • enhanced active surveillance
  • testing all suspected cases
  • isolation of cases
  • quarantine of contacts
  • risk communication to create awareness

Large scale measures to contain COVID-19 over large territories have been tried in China. Mathematical modelling studies have suggested that containment might be possible especially when other public health interventions are combined with an effective social distancing strategy.

 

Factors affecting large outbreak cluster containment

  • Number and size of the cluster/s.
  • Effectiveness of geographic quarantine.
  • How efficiently the virus is transmitting in Indian population, taking into account environmental factors especially temperature and humidity.
  • Public health response in terms of active case finding, testing of large number of cases, immediate isolation of suspect and confirmed cases and quarantine of contacts.
  • .Population density and their movement (including migrant population)
  • Ability to ensure basic infrastructure and essential services.

Action Plan for Geographic Quarantine

Legal Framework

Central Government /State Government should review the existing legal instruments that provide legal support to implement the containment plan.

Acts/ Rules for consideration could be:

(i) Disaster Management Act (2005)

(ii) Epidemic Act (1897)

(iii) Criminal Procedure Code

(iv) State Specific Public Health Act.

States may invoke the provisions under Disaster Management Act, 2005 or under the Epidemic Act,1897 to delegate powers to identified authority to act in such a manner to control or contain the outbreak.

Indian Penal Code, 1860 under Section 270 provides power to act against those indulging in spread of disease. Section 144 of the Code of Criminal Procedure, when invoked, prohibits gathering of people.

Institutional mechanisms and Inter-sectoral Co-ordination

At the Union Government level

Group of Ministers (GoM) under the Chairmanship of Union Health Minister will be the apex body to take policy decisions.

Union Health Minister will have an advisory Group.

Public Health Working Group under Secretary (H) and Joint Monitoring Group under DGHS will provide technical inputs.

At the national level,

Co-ordination with health and non-health sectors will be managed by National Crisis Management Committee (NCMC) / Committee of Secretaries (CoS), on issues, flagged by Ministry of Health.

At the State level

Concerned State will activate State Crisis Management Committee or the State Disaster Management Authority.

Institutional arrangement at the operational level

District Collector would be the nodal person for all preparedness and response activities within his jurisdiction.

He/she will keep ready all administrative orders for social distancing, restriction of rail/road/air transport, perimeter control and continuity of essential services.

A compendium of all the administrative orders required for enforcing the non- pharmaceutical interventions would be prepared well in advance and kept ready to be executed during response phase.

Trigger for Action

Epidemiological intelligence on increase in the incidence of a COVID-19 cases occurring within a defined geographic area will be trigger for action. This will be provided by IDSPs early warning and response (EWAR) system. Routine laboratory based surveillance of SARI cases is another trigger for action.

Rapid Response Teams (RRT)

Emergency Medical Relief (EMR) division, Ministry of Health and Family Welfare will deploy the Central Rapid Response Team (RRT) to support and advice the State.

Identify area under geographic quarantine

Large outbreak is defined as localized increase in the incidence of a COVID-19 cases occurring within a defined geographic area.

Area under geographic quarantine will be defined.

There shall be

(i) containment zone, surrounded by (ii) buffer zone

Boundary for geographic quarantine will be defined based on :

(i) geospatial distribution of each cluster contained within,

(ii) largest administrative unit containing all clusters occurring within a state (with a minimum of 1 district),

(iii) feasibility to implement strict interruption of movement of people,

(iv) joint assessment by State and Central RRTs.

Buffer Zone

Adjoining blocks of the affected district or rural districts of the affected city will be considered as the buffer zone.

Surveillance

Surveillance in containment zone, including contact listing, tracking and follow up shall be carried out.

Precise mapping of the outbreak shall be carried out.

Passive Surveillance shall be enhanced all throughout the area. All hospitalized patients with Severe Acute Respiratory Illness shall also be tested for COVID-19.

Perimeter Control

Perimeter control will ensure that there is no unchecked outward movement of population from the containment zone except for maintaining essential services.

Thermal screening, IEC shall be carried out at all entry and exit points.

All vehicular movement, movement of public transport and personnel movement will be stopped. For personnel and vehicles requiring regular movement, a pass/ID card may be issued with details recorded and communicated.

District administration will post signs and create awareness.

Details of all persons moving out of perimeter zone for essential/ emergency services will be recorded.

Those entering such geographically quarantined areas shall be given a chemo-prophylactic dose of hydroxy-chloroquine.

Vehicles moving out of the perimeter control will be decontaminated with sodium hypochlorite (1%) solution.

Laboratory support

All test results should be available within 12-24 hours of sampling. ICMR along with the State Government will ensure that there are designated agencies for sample transportation to identified laboratories.

Designated laboratory will provide daily update (daily and cumulative) to District, State and Central Control Rooms.

Testing criteria

(i) All symptomatic individuals who have undertaken international travel in the last 14 days

(ii) All symptomatic contacts of laboratory confirmed cases,

(iii) All symptomatic health care workers,

(iv) All hospitalized patients with SARI and

(v) Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact.

Hospital care

Persons testing positive for COVID-19 will remain hospitalized till such time as two of their samples are tested negative as per discharge policy. About 15% of the patients are likely to require hospitalization, and an additional 5 % will requires ventilator management.

Three tier arrangement for managing suspect/ confirmed cases will be implemented to decrease burden on the COVID Block/ hospital.

  • mild cases will be kept in temporary makeshift hospital facilities by converting hotels/ hostel/ guest houses/ stadiums near a COVID-19 hospital.
  • Moderate to severe cases, who require monitoring of their clinical status (patients with radiological evidence of pneumonia) will be admitted to COVID hospital.
  • Some of the severe cases may progress respiratory failure and /or progress to multi-organ failure and hence critical care facility/ dialysis facility/ and Salvage therapy [Extra Corporeal Membrane Oxygenator (ECMO)] facility for managing the respiratory/renal complications/ multi-organ failure shall be required. If such facilities are not available in the containment zone, nearest tertiary care facility in Government / private sector needs to be identified, that becomes a part of the micro-plan.
Surge Capacity
If situation warrants, surge capacity of the identified hospitals will be enhanced, private hospitals will be roped in and sites identified for temporary hospitals will be operationalized.

Pre-hospital care

Ambulances need to be in place for transportation of suspect/confirmed cases, shall be manned by personnel adequately trained in Infection Prevention and Control (IPC), use of PPE and protocol that needs to be followed for disinfection of ambulances.

Infection Prevention Control Practices

There shall be strict adherence to Infection prevention control (IPC) practices in all health facilities.

Designated hospitals will ensure that all healthcare staff is trained in washing of hands, respiratory etiquettes, donning/doffing & proper disposal of PPEs and bio- medical waste management.

Medical personnel working in isolation and critical care facilities where aerozolisation is anticipated, will wear full complement of PPE. Support staff engaged in cleaning and disinfection will also wear full complement of PPE.

Clinical Management

Suspect cases with co-morbid conditions, if any, will require appropriate management of co-morbid conditions.

For patients with Severe Acute Respiratory Illness (SARI), having respiratory distress may require, pulse oxymetry, oxygen therapy, non-invasive and invasive ventilator therapy.

Psychosocial support

National Institute of Mental Health and Neuro Sciences (NIMHANS) will be the nodal agency to plan and execute psycho-social support. NIHMANS will prepare a Psycho-Social Support plan and implement the same in the COVID affected areas.

Pharmaceutical interventions

There is no approved specific drug or vaccine for cure or prevention of COVID-19.

Hydroxychloroquine has been recommended as chemoprophylaxis drug for use by asymptomatic healthcare workers managing COVID-19 cases and asymptomatic contacts of confirmed COVID-19 cases.

A combination of Hydroxychloroquine and Azithromycin has been advocated for use in severe cases of COVID-19 under medical supervision.

Non-Pharmaceutical interventions

Preventive public health measures

There will be intensive social mobilization among the population in geographic quarantine zone for adoption of community-wide practice of frequent washing of hands and respiratory etiquettes. The community will also be encouraged to self-monitor their health and report to the ASHA/Anganwadi worker visiting home or to nearest health facility.

Quarantine and Isolation are important mainstay of cluster containment. These measures help by breaking the chain of transmission in the community.

Quarantine

Quarantine refers to separation of individuals who are not yet ill but have been exposed to COVID-19 and therefore have a potential to become ill.

Those above 60 or with co- morbidities will be shifted to designated quarantine facility. This will help identify early development of symptoms among them, their testing and shifting to isolation facility.

Isolation

Refers to separation of individuals who are ill and suspected or confirmed of COVID-19.

Ideally, patients can be isolated in individual isolation rooms or negative pressure rooms with 12 or more air-changes per hour.

Under no circumstances these cases should be mixed up.

Social distancing measures

For the cluster containment, social distancing measures are key interventions to rapidly curtail the community transmission of COVID-19 by limiting interaction between infected persons and susceptible hosts.

  • Closure of schools, colleges and work places
  • Cancellation of mass gatherings
  • Advisory to avoid public places
  • Cancellation of public transport (bus/rail)
  • Enforcement of Geographic quarantine.

Material Logistics

State Government has to ensure adequate stock of Personal Protective Equipment (PPE). The quantity required for a containment operation will depend upon the size and extent of the cluster and the time required for containing it. States will also ensure that the PPE are being used in accordance with the guidelines on rational use of PPE.

Stay arrangements for the field staff

Field staff brought in for the surveillance activities and that for providing perimeter control need to be accommodated within the containment zone.

Communication channels

During house to house surveillance, ASHAs/ other community health workers will interact with the community for:

(i) reporting symptomatic cases

(ii) contact tracing

(iii) information on preventive public health measures.

Awareness will be created among the community through miking, distribution of pamphlets, mass SMS and social media. Also use of radio and television (using local channels) will ensure penetration of health messages in the target community.

Media Management

Central level, only Secretary (H) or representative nominated by her shall address the media. At the State level, only Principal Secretary (H), his/her nominee will speak to the media. At the District level DM/DC will address the media.

Regular press briefings/ press releases to keep media updated on the developments and avoid stigmatization of affected communities.

Information Management

A Control Room (if not already in place) shall be set up at State and District headquarters. This shall be manned by State and District Surveillance Officer (respectively) under which data managers (deployed from IDSP/ NHM) responsible for collecting, collating and analyzing data from field and health facilities. Daily situation reports will be put up.

Aggregate data on daily basis on the following (for the day and cumulative):

  1. Total number of suspect cases
  2. Total number of confirmed cases
  3. Total number of critical cases on ventilator
  4. Total number of deaths
  5. Total number of contacts under surveillance

A Control Room shall be set up inside the geographic quarantine zone to facilitate collection, collation and dissemination of data from various field units to District and State Control Rooms.

Alerting the neighboring Districts/States

Also suitable provisions shall be created for enhancing horizontal communication between adjacent districts, especially for contact tracing exercise and follow up of persons exiting the containment zone.

Capacity building

Large human resource requirement will be there to manage:

(i) Field activities including surveillance,

(ii) Clinical care at hospitals,

(iii) laboratory testing and

(iv) support staff to provide support services.

Training content

Trainings for different target groups shall cover:

  • Field surveillance, contact tracing, data management and reporting
  • Surveillance at designated exit points from the containment zone
  • Sampling, packaging and shipment of specimen
  • Hospital infection prevention and control including use of appropriate PPEs and bio- medical waste management
  • Clinical care of suspect and confirmed cases including ventilator management, critical care management
  • Risk communication to general community and health service providers

Target trainee population

Various sections of healthcare workforce and workforce from non-health sector. Training will be tailored to requirements of each of these stated sections.

The training resources available at IGOT platform of GoI may be utilized.

Replication of training in other Districts

Unaffected Districts are also trained along the same lines so as to strengthen the core capacities of their RRTs, doctors, nurses, support staff and non- health field formations. These trainings should be accompanied with functional training exercises like mock-drills.

Financing of containment operations

Funds will be made available to the district collector from NHM flexi-fund. The SDRF funds can also be used as per notification issued by Ministry of Home Affairs.

Scaling down of operations

Operations will be scaled down if no secondary laboratory confirmed COVID-19 case is reported from the geographic quarantine zone for at least four weeks after the last confirmed test has been isolated and all his contacts have been followed up for 28 days.

If the containment plan is not able to contain the outbreak and large numbers of cases start appearing, then a decision will need to be taken by State administration to abandon the containment plan and start on mitigation activities.

To read the official document, please click on the link below:

Containment Plan for COVID-19


Ministry of Health & Family Welfare

[Document dt. 04-04-2020]

Join the discussion

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.