Country-wide Containment Strategies for Reducing COVID-19 Cases in India
The COVID-19 pandemic in India has now reached devastating proportions with widely publicized shortages of hospital beds and oxygen in many locations. Reported deaths have crossed 3000 each day, and it is widely believed that this itself is an under-estimate. Therefore, the immediate priority is to decrease the number of deaths prior to the downturn in cases, which is still expected to take a while. In this document, we present a checklist of actions that cumulatively can be taken, beyond the current binary discussion of lockdowns to reduce this burden.
India’s effective reproductive rate (R) for COVID-19 stands at 1.44 as of April 25, 2021. At this rate, each infected individual is infecting another one and a half persons. The rate of increase in reported new cases averaged 6.8% for the month of April nationwide, while the rate of increase in reported new deaths averaged 8.3% over the same period.1 With over 2.7 million active cases, the healthcare system is under severe strain. It is imperative, therefore, to reduce the continuous rise in new cases.
There has been much discussion around the world on the efficacy of lockdowns, and the relative tradeoffs between controlling the spread of the pandemic and the economic costs of shut down.2 We do not believe there are binary choices to be made, or that there is one single policy option of a complete lockdown. A series of actions are needed. Some of these require closures; some require targeted containment; others need effective public messaging to influence individual behaviors. These choices also depend on the state of the pandemic in a country. In the case of India, R is greater than 1 in every state of the country (except for Chhattisgarh). This means that containment measures are critical to reduce the spread of COVID-19 in every state.3 It also means that India needs a coordinated response across all states in a systematic, synchronized manner. The exact steps taken may differ based on local contexts. In areas where infections are spreading rapidly, short, severe closures may be required; where case counts are low, containment measures may be appropriate. Specific action may differ at the district level. But it is critical that all states act in unison, and as part of a coordinated strategy, spearheaded by the Government of India. No state is safe until all states work together.
We outline a series of steps as part of a checklist in the attached table based on the state of the pandemic. This table can be used at the state or district level to identify specific actions relevant for a specific situation based on key epidemiological trends. We specifically recommend that the following variables are considered: new cases per day (7-day moving average), rate of increase in new cases per day (2-week moving average), test positivity rates per day (2-week moving average), number of tests per million per day, and utilization rates of ICU beds. Suggested thresholds are based on global trends, Government of India guidelines, and epidemiological research. We advise that states and districts be categorized as low risk, medium risk, and hot spots based on the criteria above, and an appropriate mix of steps be taken from the list below. And finally, we recommend that all steps with significant economic consequences, be taken after a) in-depth consultations with all stakeholders in society; and b) ensuring that there are programs and safety nets in place for the most vulnerable and for those that will bear the brunt of the economic costs of closures.
This checklist also draws on recommendations of the Lancet Commission on COVID-19 Task Force on Public Health Measures to Suppress the Pandemic.4 The note below provides evidence and discussion of the priority actions needed immediately, recognizing that some actions are common across all risk levels, in a bid to stem the spread of the infection to currently low risk geographies.