Wisdom and intuition may see us through routine situations in our lives, but they are counterproductive to public health programs.
It is scientific evidence that should guide the decisions that ultimately save lives in a public health crisis.
Last year, India went into a national lockdown as it had 500 cases. In retrospect, the public health response was a wise decision, as the effective reproduction number (RT) – the number of people infected from infected people – was the highest (3.75) on 23 March 2020.
A year later, despite a lower RT of 1.65, more super-scattering incidents and poor adherence to appropriate behavior have resulted in the ongoing devastation we see around us ̵
I would think that the decision to lock in 2020 was based on evidence. Although intuitive, it helped avert a major national health crisis.
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Cut to February 2021: there was the red flag for rising RT quite early in the month.
Even as cases rose sharply in Kerala and Maharashtra, the country failed to prevent mass rallies at a time when it should have gone into state of war.
This inability to use data at this crucial time led us to obliterate our chances of limiting newer variants of the virus to a few areas.
India has some of the best minds and research laboratories to study genomic sequencing and discover new variants of Covid-19.
When the Indian SARS-CoV-2 Consortium on Genomics (INSACOG) – a group of 10 national laboratories – was set up by the Ministry of Health and Family Welfare on 25 December 2020, it was mandated to test 5% of positive samples from all states and 100% of positive samples from international travelers.
However, the government’s press release of March 24 this year shows that only 10,878 samples were shared by the states and UTs in three months, the same day the country officially saw over 50,000 positive cases.
Today, India ranks 102 when it comes to genomic sequencing of Covid (see table), even falling behind smaller countries like Australia and Denmark when it comes to the absolute number of positive samples sequenced.
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This is mostly due to the government’s poor resource allocation and lack of prioritization to identify the role of newer variants in the previous outbreak in Maharashtra. Much of the crucial time was lost as the state underwent an increase in cases. As a result of the delay, the variants may have spread to other areas.
As of March 27, the test positivity rate in India has jumped four times, from 5% to 21%.
Similarly, there has been a 12-fold increase in daily deaths per capita. Million of the population, from 0.2 on March 28 to the current level of 2.7.
Based on what we know about RT and the capabilities of the health care system, it is necessary for some cities, districts and states to stop the rate at which the virus is spreading through a focused lockdown and aggressive containment.
Instead, we ignore scientific data when it comes to developing a response to the second wave.
The National Center for Disease Control (NCDC) is a powerhouse for field epidemiologists. The National Institute of Epidemiology (NIE) in Chennai is the core of laboratory monitoring and training of health workers in epidemiology.
Ideally, the country would have benefited from our own Anthony Fauci – someone from the ICMR or NCDC, given autonomy to run a combined response against Covid-19.
But any attempt to review state performance using data is hampered by the tacit or poor reporting of numbers.
Those states that test at higher prices and have better reporting systems may also attract the necessary attention required to obtain more resources.
States like Kerala, Punjab, Karnataka, Haryana and Gujarat are experiencing an increase in RT compared to the previous week. Incidentally, these states also have the highest tests per Million (TPM> 1600).
In contrast, states like Uttar Pradesh and Bihar, which show a decline in RT, are directly correlated with having a relatively lower TPM compared to earlier in the week.
Using the database approach promotes equity, as detecting multiple cases through better testing strategy ensures that many vulnerable people get into the reach of services.
And this absence of an evidence-based approach is not only found in the public health response. Current clinical guidelines also include hydroxychloroquine, which has no evidence of benefit as prophylaxis against Covid-19.
In contrast, it was extremely confusing to see the approval of Coronil to fight COVID disease. Also, some of the drugs in the Ministry of Health management protocol required evidence to be cited from the randomized control trial or published studies. Combining non-evidence-based guidelines as part of clinical management has only confused the delivery of quality care.
The country could also benefit from a data-driven approach to vaccination.
The rate at which India started the vaccination program, even before the results of Phase 3 from Covaxin and Covieshield without building a bridge study, was not matched with the coverage rate subsequently.
The results from Phase 3 of Covaxin were recently published with vaccine efficacy of 78% (95% CI: 61-88) against mild, moderate and severe Covid-19 disease. The best time to fight the virus was when transmission was low in India while the other countries were witnessing the second and third wave.
Instead of increasing the vaccination rate, the country did not take extraordinary measures to facilitate foreign companies from outside to cooperate with Indian producers.
While delivery constraints still exist, more confusion is created by extending the age group to younger people without setting a clear date for when the process can begin.
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Native Americans are prone to cardiovascular disease at least a decade earlier compared to patients in the West. Young people with comorbidity should be included in the vulnerable group for vaccination. The government should have given priority to vaccinating them along with the existing 45 years and over.
India’s response to the pandemic has depended on an unscientific approach that relies on a system that was never built to meet the health needs of its citizens’ crore.
For example, one in three adults has hypertension. Nevertheless, the focus is on increasing public spending to reimburse reimbursements for complications due to high blood pressure neglected.
Similarly, more than 60% of the health needs are covered by the private sector. Yet there is no effort to relocate the patient base by building reliable and stronger public health systems.
By neglecting all data suggesting that expenses and treatment costs are growing out in private hospitals, the healing services are mostly outsourced to private health systems.
In a health emergency like Covid-19, the private health system is demonized, while the government’s rare issues are not prioritized by public health.
The way forward
First, the country has failed to exploit the full potential of those at the NCDC and NIE to control the Covid response. Researchers and public health experts should have complete autonomy to manage the pandemic.
The Office of the Chief Scientific Adviser has only enabled data access yesterday (May 1). The data from the NCDC and ICMR, when available to Indian researchers, can provide useful analysis and valid conclusions to guide our Covid policy.
India is proud of its computing capabilities, data analytics and is home to some of the best researchers in the world. Epidemiological evidence should be brought into line with genomic sequencing results to halt the virus’ attacks and prevent the spread of newer variants of concern.
India is a global leader in vaccination due to the strengths of the micro-planning and mobilization efforts. The expertise of the WHO-NPSP and UNICEF, which was used to combat polio, measles and rubella, was to be used as part of the coalition to rapidly expand vaccination coverage.
We can have specialists on each block in India and set up fully functional intensive care units with adequate oxygenated beds in each hospital at block level.
Is not it time to convert all hospitals at block level to 250-500 beds by population and to permanently employ the required qualified and trained staff permanently? Nor is it time to give them facilities and wages from the private sector, or what can be compared to the West?
Using evidence-based practices and guidelines and having well-educated workers is not a luxury but a serious necessity to meet the country’s public health needs.
(Giridhara R Babu is Professor of Epidemiology at the Indian Institute of Public Health, PHFI, Bengaluru)