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.
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