How coronavirus can affect India
There could be successful containment; limited spread; or community transmission. Prepare well
Even before the World Health Organization (WHO) declared a pandemic, the world recognised the novel coronavirus (Covid-19) as a rapidly expanding global threat that raced across continents at startling speed. Perhaps, WHO delayed the declaration to prevent panic from hindering the evolution of effective health system responses in countries which had never encountered this virus before. Now the whole world has to deal with it, in terms of health and economic impacts.
India first recorded cases among Indians residing in Wuhan, where the virus emerged, followed by Italian tourists and others with international travel history or contact with infected foreign visitors. The initial response was to screen travellers from countries reporting cases and, as more countries joined that list, extending it to all international travellers. Case and contact tracing, with a 14-day quarantine, aimed to prevent spread within India. Entry to foreign visitors has now been shut for a month to keep out new sources of infection.
Will this be enough to shackle the virus or will it become a community infection with widespread transmission within India? It is difficult to predict now, but wise to prepare for all scenarios. Irrespective of which scenario becomes the dominant reality, there is no reason to let panic undermine organised response. It must be noted that Covid-19 is somewhat more virulent than its common cold-causing cousin, but far less virulent than the “bad boys” of the corona group (SARS and MERS), with an overall mortality of around 2-3%. It hands out its visiting card liberally, but serves the warrant of severe illness mainly on the elderly, persons with pre-existing diseases and smokers. We are unsure at present of its seasonality.
Scenario One: Containment measures will succeed, blocking new entrants harbouring the virus from entering the country till mid-April. This will enable our health systems to effectively deal with the in-country cases and contacts already detected, without fresh entrants expanding that list. By mid-April, we will better understand the course of the epidemic in other countries to define how immigration checks should be modified. Within-country transmission would have ceased by then.
Scenario Two: Evidence of community spread would appear in some places. Cases and contacts will be vigorously traced, quarantined, triaged for severity of illness and treated at home (if mild) or hospital (if severe). Since Covid-19 causes severe infection in about 15% of the people infected, the numbers needing hospitalisation would not be high and existing health care facilities would be adequate. Weaker state health systems will need to be reinforced, to prevent community spillage that can spread across the country. Immigration checks will continue to be rigorous to keep out new sources, so that the health system doesn’t need to deal with a thousand fires at once.
Scenario 3: The propensity of Covid-19 to sneak in undetected during the asymptomatic incubation period, and speedily spread thereafter, may result in a widespread community infection. While this will strain the health systems, the relative mildness of Covid-19 means that the majority of infected persons will recover without residual harm, under home quarantine. Because of the higher rates of diabetes, cardiovascular disease, air pollution, and malnutrition in our population, severely-affected cases may be around 20% of those infected. These cases will need hospital care under isolation. Some will need intensive care with respiratory support. Resources will need to be directed to case identification, assessment of clinical severity with apportionment to home care for the mild cases and hospital care for the severe cases. Strong primary health services should be able to supervise and support home care, while all available public and private hospitals will need to be mobilised for hospital care. Non-emergency patient care and elective surgeries can be deferred to prioritise hospital care for the sicker Covid-19 patients. Even hotels can be taken over if more isolation facilities are needed. The challenge will be in mobilising enough public and private health care providers. Equipment, such as respirators, too should be made available.
We do not know which of these scenarios will play out over the next three months. We should prepare for each, but alarmist predictions are unhelpful. Every health system in the world is being tested. We too will have to ramp up our health system efficiency to deal with this new threat. Strengthening of our health system, at all levels, cannot be a fleeting priority if we have to overcome this threat and avert or quell other health threats in the future.
If Covid-19 teaches us the importance of strong and adequately resourced health systems, the value of preserving domestic capacity for producing Active Pharmaceutical Ingredients (APIs) and essential drugs, and the imperative of backing away from the ecological despoliation that becomes the launch pad for zoonotic viruses, this frightening experience would have been worth it. Perhaps, if Covid-19 returns a year or two later, we will react with greater confidence and less alarm because more of us would be immune, there will be new drugs and possibly a vaccine, we will have better-prepared health systems and we will have a better estimate of how mild or virulent it is. Till then, let us deal with the new virus with situationally appropriate strategies and avoid self-defeating hysteria.
K Srinath Reddy is president, Public Health Foundation of India
The views expressed are personal