COVID19: Think and Act Differently

In late of December, 2019, COVID 19 pandemic initiated in the form of a cluster of pneumonia cases of unknown origin in Wuhan city of Hubei province, China.^[1,2,3] The outbreak very rapidly crossed geographic boundary of China and affected several countries including India within a short span of time.^[4,5] Presence of SARS-CoV-2 in India was first identified in a student returning from China on 30th January, 2020. ^[6] ‘ Deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction,’ World Health Organization declared it as Pandemic on 11th March 2020.^[7]

World faced Corona virus pandemic earlier in form of SARS^[8] & MERS^[9] in 2002-03 & 2012 respectively. SARS-CoV-2 has high infectivity and less fatality as compared to SARS & MERS. Basic reproduction number, which indicates the number of people a patient can directly infect in a healthy population, was 1.7-1.9, 0.7, and 2-2.5 for SARS, MERS & COVID 19 respectively.^[10] It is reflected with absolute numbers related to these pandemics, number of identified cases for SARS & MERS were restricted only to few thousands, whereas COVID 19 by now already crossed one crore. Case fatality rate on confirmed cases was 9.5%^[10], 35%^[10,11] and 4.55%^[12] for SARS, MERS and COVID 19 respectively. It is found to be much less in India, only 2.69 as on 10th July 2020.^[13] If hidden cases which are mostly asymptomatic or mildly symptomatic, in the community, is considered, fatality rate which is termed as Infection fatality rate (IFR) might come down to even less than 1.^[14] In a study of China, it was found that out of total identified patients, more than 80% have mild symptoms, and less than 5% was found to be critical.^[1]

Many therapeutic & nontherapeutic measures are suggested by WHO to clinically manage the COVID 19 cases and reduce transmission from time to time.

Government of India declared country-wide lockdown as a speed-break measure to halt transmission on & from 25th March 2020. It was extended in consecutive 3 times up to 31st May 2020. Unlock phase-1 continued from 1st June to 30th June, 2020 when lockdown was restricted in containment zones only. Unlock 2nd phase started with more relaxation on & from 1st July 2020.

Lockdown was able to slow down transmission to some extent. It seems to have favorable effect on effective reproduction number. During unlock phase, chance of transmission of the disease is likely to have increased, which is evident from the present trend of disease occurrence. As on 10th July, 2020 number of cases and deaths in India were 8.22 lakhs & more than 22 thousands respectively. More than 25 thousands of new patients are added daily.^[13]

India is now passing through the transition of local to community transmission. For local transmission containment strategy is applied. As the numbers of cases are rapidly increasing, number of admissible cases is also increasing proportionately. Priority will be shifted gradually from containment strategy to mitigation aiming at reducing number of deaths by ensuring quality of care. So, facilities including infrastructure (Hospital, bed strength, ICU with ventilation facilities), consumables and skilled manpower are to be strengthened adequately to manage critical patients.

It appears that sometimes health care providers are not free from fear of getting infection, which has a negative impact on the quality of care. Negligence and deprivation of treatment are reported time and again. It is also observed that in many facilities, particularly in non-COVID hospitals, care providers are tested positive for COVID 19, and consequently a sizable numbers of providers are sent to quarantine, thus patients’

care being grossly compromised. Referral system after COVID situation became complicated, and appears to be not clear to common people.

We still did not accept COVID 19 as a disease like many other diseases endemic in our country, neither at community level nor at the level of heath care providers. It is becoming stigmatized which is evident from many incidences published in newspapers & electronic media. People, sometimes, are behaving adversely like social boycotting, when one person is getting infected in the locality. Health care providers attached to COVID or SARI hospital sometimes are ill-treated by the local residents. It is because of non-acceptance. We experience 4.2 & 3.2 lakhs of annual deaths from tuberculosis & diabetes, we do not fear, whereas only 0.22 lakhs of death toll from COVID 19 has shocked us tremendously. It is due to fear from unknown & uncertainty, and fear wave generated by media through hammering with statistics round the clock, which is traumatizing our brain & emotion constantly. Whatever measure we take, it is difficult to check upward trend of the disease in our country with such a diversity in social & economical life until a herd immunity is developed either by natural infection or vaccination or by both.

Health care system at different levels starting from village to tertiary level is well visible in our country. It is required to make it well organized and oriented in this pandemic situation. When community transmission is inevitable, behavior change communication (BCC) for prevention & control of COVID 19 is the need of the hour for community. Syndromic management approach might be applied at PHC/BPHC level while screening the patients. Influenza like infection (ILI) can be managed at home following certain guidelines and maintaining strict isolation, where possible. In our society, even if family level, overcrowding is grossly prevalent. In that case ‘ Safe home’ approach is an encouraging alternative to manage the cases more efficiently, but with minimum investment in terms of availability of skilled manpower or costly equipment.

Every hospital starting from Rural Hospital/Community health Centre should have dedicated isolation wing for management of fever patients with shortness of breath including swab collection facilities. If the patients are tested positive, they should be sent to designated COVID hospital, following appropriate protocol while transferring. Care is to be taken so that treatment is not denied or delayed unnecessarily even for a single patient from any health facility as he or she is showing COVID like symptoms (suspect). Middle tier hospitals should be prepared in full strength so that they can shoulder effectively the responsibility to manage moderately severe cases of COVID 19. Thus, we will be able to keep higher centers ready for critically ill patients.

Implementation of infection prevention & control (standard precaution, droplet/respiratory precaution & contact precaution) should be followed religiously everywhere in hospital settings. It will save health care provider not only from COVID infection, but many other infections also like drug resistant TB, HIV/AIDS, Hepatitis, meningitis etc. Moreover, this skill will strengthen the system to face boldly an epidemic like COVID 19 in years to come.

We have to modify our life-style favouring hand hygiene social distancing & use of mask. It will reduce transmission of COVID 19 & many other diseases. By practicing hand hygiene we can prevent water borne diseases spreading through faeco-oral route like diarrhoea, cholera, typhoid and water washed diseases like trachoma & conjunctivitis, and hand-foot & mouth diseases. Practice of mask use in outside environment is able to reduce transmission of infection which spread through droplet & air like influenza, diphtheria, meningitis, pertussis, rubella, streptococcal throat infection, pneumonia etc. and also prevent diseases related to air pollution like asthma & COPD. Observation of social distancing will check droplet transmitted diseases as well as diseases which spread by the direct contact like leprosy, fungal skin diseases, pediculosis, HIV/AIDS etc. This message should be incorporated in IEC/BCC strategy so that community can understand greater benefits out of these practices.

Fear and anxiety are quite common not only among common people, but equally prevalent in health care providers. The Secretary General of WHO correctly pointed out in his speech that we should keep aside ourselves from unnecessary news about COVID 19. Instead people should modify life-style in positive direction including social communication with friends and relatives through distant modes, reading favorite books, listening to songs, engaging in indoor games, exercises, meditation etc.

We should be sensible enough about the dignity of a person passing away as a victim of COVID 19. Nearest & dearest ones should have right to show their last homage properly. A strict protocol is being followed for dead body disposal of COVID 19 patients, whereas for non-COVID patients (not tested for COVID), traditional approach is observed. Some of these non-COVID patients are likely to come out as positive, if routine test is done. A dead body cannot speak, cough or sneeze, nor can it touch anybody, so why we are being so afraid of it. Following protocol, adequate covering to avoid spillage of body secretion, disinfection and safe distancing are the precautions which we should follow irrespective of the testing status.

A great threat we are going to face in near future is the generation of enormous amount of PPE material. If necessary care is not taken for its proper management following biomedical waste management rules, the environmental health will be at stake.

We cannot win the battle against COVID 19 without participation, in good confidence, of the community, and Panchayat Raj Institutions (PRI) in particular.

Lastly, I think that the community medicine experts and as a body of the experts, IAPSM, appear to be kept aside, and not properly utilized in full potential in this Pandemic. The right person in the right place and time will be always helpful to win the battle in the long run.

In conclusion it can be said that we have to accept COVID 19 as many other diseases endemic in our country. This acceptance will definitely reduce stigma now being attached to the disease. The earlier we can shed the stigma off; the better will be the outcome. We must keep ourselves ready to face the pandemic boldly with courage with the weapons so far we are availing through scientific development.