To ease Covid-19 curbs, rely on decentralised/district-level guidelines
Since the Covid-19 pandemic hit India, our response strategy has been around the mantra “test, test, test”. India has increased its testing capacity by using RT-PCR and Rapid Antigen Test kits, along with an innovative combination of different platforms. These strategies helped us reach 1.2 million tests per day in September 2020 and a further peak of 2.2 million tests per day in May. This was also accompanied with the introduction of two India-made vaccines in January.
Now, with India in the midst of a second surge, the state governments have implemented restrictive measures. While these have mostly been successful in curbing the spread of infection, restrictions cannot be a sustainable solution. So, what then should constitute an evidence-based response to the situation? What can be considered as a neither too-late nor too-early easing of restrictions, as each option has its associated consequences?
The answer lies in a decentralised pandemic response that focuses on three pillars — district-level test positivity rate, vaccination coverage, and a bottom-up decision-making process. During the first wave, centralisation, to some extent, was critical — since we were dealing with a novel virus and regulatory processes had to be set up. But now, with wide heterogeneity in disease transmission between states, these decisions need to be more decentralised and contingent on local-level data. Restrictive measures on movement, mass gatherings, and social events are being governed at the district level. We need to further engage districts to make these recommendations based on district-level data and trends. But while monitoring is key, evaluation tools should be easy to use, shunning a long list of asks that keeps delaying the decision to ease things. Instead, what we should focus on are three key parameters.
Pillar one should focus on districts with a test positivity rate (TPR) of less than 5%. TPR reflects the percentage of all Sars-CoV-2 tests performed that are positive. This will continue to be the key indicator for making informed decisions. As per the World Health Organization (WHO), the epidemic should be considered under control, when the positivity average over two weeks is less than 5%. Districts should liaise closely with state government on TPR, ensuring quality of restrictions and make recommendations accordingly.
Pillar two rests on adequate vaccine coverage for priority and vulnerable groups, and should be a parameter while considering opening up. Vaccinations among the most vulnerable population groups need to be ramped up to ensure that there are fewer deaths, even if the cases surge. The reality is that the supply of vaccines will take a few months to reach the level of adequacy in terms of doses. However, the judicious use of what is available now, and ensuring their administration where they are needed most (frontline workers, including health care professionals, those above 60 years, and those who are above 45 years and with co-morbidities) need to be prioritised. At least 70% of these priority groups need to be covered while a district is working its way out through restrictive measures to reach the TPR threshold of less than 5%.
Pillar three is community ownership. Without community ownership — where people follow Covid-appropriate behaviour such as masking up and maintaining physical distance — all administrative measures are bound to fail.
The pandemic has forced us to think differently about the norms that govern responses to it. While we live in silos and ask for continued restrictive measures or new treatment and prevention to be adopted every day, we must consider the impact of these on lives and livelihoods. Therefore, our response to the pandemic must be driven by local data, and executed and monitored by a flexible administration and an empowered community.
Dr Samiran Panda, head, epidemiology and communicable diseases division, Indian Council of Medical Research (ICMR) and director, ICMR-National AIDS Research Institute, Pune.Professor (Dr.) Balram Bhargava, director-general, ICMRThe views expressed are personal