The threat of community transmission of coronavirus looms large
“If community transmission doesn’t happen in the next 30 days, we may be on a good wicket,” said Dr Balram Bhargava, director general of the Indian Council of Medical Research on Friday evening, when India had confirmed 81 cases.
Between then and Sunday night, coronavirus disease (Covid-19) cases have jumped to 107. At this rate of increase, the number of cases is set to double by midweek.
India is on a very sticky wicket.
With several instances of at-risk travellers and their contacts evading screening, refusing to stay home quarantined for two weeks, or slipping out of isolation wards across the country, the threat of community transmission of Sars-Cov-2, the viruses that causes Covid-19, is likely to happen sooner than later.
Community transmission is said to occur when Covid-19 is diagnosed in someone who has not travelled to a country with an ongoing outbreak and has not been near a confirmed case or their close contacts.
It is far more difficult to contain because anyone and everyone could be infected or infecting others, as is happening in China, Italy, Iran and South Korea, which would mean everyone with fever and cough will need to be home quarantined for Covid-19.
“We can’t stop community spread, but we can delay it and slow it down to space the demand on health services so that everyone gets the medical care they need,” said Dr K Srinath Reddy, president, Public Health Foundation of India.
Fewer new cases “flatten the curve” on the graph and indicate the infection is spreading slowly, which puts less pressure on India’s overstretched healthcare infrastructure. A high curve means the Covid-19 is spreading quickly and many may not get the medical care they need, which is likely to raise the number of people dying.
Public health measures that help slow infection are treating cases in isolation, screening, contact tracing and quarantining suspected cases, social isolation and frequent hand washing.
“India has a very robust surveillance network that tracked each and every case of flaccid paralysis across states to end polio. This has been further scaled up, and we have a network of labs. We have a graded response mechanism in place. As Prime Minister [Narendra] Modi told Saarc [South Asian Association for Regional Cooperation] leaders today, ‘We are careful to not underestimate the problem, but also to avoid knee-jerk reactions,’” said Union health minister Dr Harsh Vardhan, to HT.
The virus has spread to 156 countries and 13 states in India, where it has shot up from three cases on February 2 to 107 on March 15.
India is still on stage two of the outbreak, when there is local transmission from imported cases (stage 1) to one or more close contacts.
Stage 3 is community transmission, as is happening in Iran, Korea, US and many parts of Europe, with then last stage being an epidemic, which devastated China.
“Examples from around the world show that mounting a rapid and comprehensive response to delay transmission must be followed by a rapid shift from a containment to a mitigation approach as cases surge, failing which the healthcare system will collapse under a sudden increase in numbers of critically ill patients needing care,” said an advisor to the World Bank, requesting anonymity.
According to a study of 191 Covid-19 patients in two hospitals in China found that the median duration of viral shedding in survivors was 20 days, with the virus being detectable till death in non-survivors.
The longest observed duration of viral shedding in survivors was 37 days, which means they remained infective for a long time, which would require extended isolation.
The study also found that 48% patients had chronic illnesses, with hypertension affecting 30% patients, followed by diabetes (19%) and coronary heart disease (8%, with the median time from the start of symptoms to being admitted in an intensive care unit (ICU) was around 10 days.
In India, the challenge will be treating such patients who need hospitalisation and ICU support, given the huge shortage of health workers.
The average Government allopathic doctor to population ratio is 1: 10,926, according to the National Health Profile 2019, with there being just 2,048,979 registered nurses and registered midwives in 2017 to treat 1.35 billion people.
“There are not enough ICU beds in India, which is needed for about 5% of Covid-19 cases, who on average need four to six weeks of ICU admission. Given that we don’t have enough beds to treat existing diseases, it will be a challenge to build capacity if there’s a sudden surge in numbers,” said Dr G Arunkumar, director, Manipal Institute of Virology, Karnataka.
“My concern is the emergence of large clusters of cases, of which around 20% will need hospitalisation, and 5% will develop severe pneumonia that will need ICU support.
“In such cases, the challenge will be scaling up treatment capacity with stringent infection-control protocols, as Covid-19 deaths in health workers in China, and in Canada during the Sars 2002-03 outbreak, was disproportionately high,” said Dr Arunkumar.