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Health experts to PM: Vaccines have no role in India’s COVID control

As India became the first country in the world to report more than 80,000 new cases of COVID-19 on a single day, the need for a safe and effective vaccine to prevent new infections of the novel coronavirus has been growing as well. However, healthcare experts say we may be overestimating a vaccine’s role in arresting India’s COVID-19 epidemic.

In a joint statement addressed to Prime Minister Narendra Modi, experts of the Indian Public Health Association (IPHA), the Indian Association of Preventive and Social Medicine (IAPSM) and the Indian Association of Epidemiologists (IAE) said, “Vaccines have no role in current ongoing pandemic control. However, whenever available, the vaccine may play a role in providing personal protection to high-risk individuals like healthcare workers and elderly with comorbidities.”

“It must be assumed that an effective vaccine would not be available in near future. We must avoid false sense of hope that this panacea is just around the corner,” they added.

This is the third joint statement issued by the same three groups. The last one was in May this year, wherein they accused the government-imposed as being “draconian” and called the state response incoherent. The IPHA and IAPSM put together a joint task force “of eminent public health experts of India” in April 2020 to advise the Centre on COVID-19 containment strategies. The IAE joined this effort later.

Their statement follows Union health minister Harsh Vardhan’s words last month that the country will have a vaccine by the end of the year. Modi had also said during his Independence Day speech that the country was ready to mass produce three COVID-19 vaccines, once scientists give the go-ahead – presumably a euphemism for clinical trials to conclude. These are COVAXIN, developed by Hyderabad-based Bharat Biotech; Ahmedabad-based Zydus Cadila’s vaccine ZyCoV-D; and Pune-based Serum Institute of India’s ChAdOx1-S vaccine developed by the University of Oxford and AstraZeneca.

The experts also highlighted the need to expedite the establishment of a dedicated, efficient and adequately equipped public health cadre at the Centre and across states – echoing a recommendation of various national committees and expert groups since 1946.

Background

COVID-19 pandemic in India has progressed at an unprecedented speed and scale bringing in its wake unimaginable humanitarian, health and economic consequences. It required decision making often based on weak or insufficient evidence. Fortunately, the global research community responded with robust and quick generation of evidence. Almost every day new evidence base is being added. Hence, many decisions taken during the early phase of the pandemic, with the benefit of hindsight, may appear to be inadequate or even inappropriate. However, as would be true of any evolving situation, we should be bold to effect course correction in light of the new and emerging evidence.

We appreciate that the health system’s response is often constrained by socio-political, economic, human resource and governance structure. This third statement makes recommendation based on evidence available till date and the existing circumstances. The overall objective of the third statement is to support the Government of India is formulating evidence-based policy for prevention and control of COVID-19 in India.

We strongly and unequivocally advocate for a “public health approach” for the novel coronavirus pandemic control, with the maximum possible good being done for the largest possible numbers. The ongoing pandemic is a public health problem that is fast worsening existing health inequities. It is not a law and order problem and should be dealt with empathy and meaningful community engagement. The way forward needs to take into account contextual constraints and community interests and design optimal interventions that require technical competence blended with good judgment, clarity and trust. The testing strategy needs to be pragmatic from a public health perspective, promoting differential/targeted testing of high-risk individuals and discontinuing universal testing at this stage. Vaccines do not have any role in current ongoing COVID-19 pandemic control in India. Vaccines with proven efficacy and safety, as and when available, should be administered according to the WHO’s “strategic allocation” approach or a multi-tiered risk-based approach.

Action plan

1. No lockdowns, only “cluster” restrictions of short defined duration to be imposed:

1.1. Lockdown as a strategy for control should be discontinued. Geographically limited restrictions for short periods may be imposed in epidemiologically defined clusters. Cluster restrictions should be considered only in areas with no community transmission. Even cluster restrictions should be imposed after weighing the impact of the same on the livelihood of target population. With adequate health system preparedness, including facility care for severe cases, cluster restrictions can be totally done away with and should be the ideal way to address this pandemic.

1.2. In Large cities (Y class) where already there has been substantial spread (can be assessed by the expert committee) there is NO advantage of creating containment zones and aggressive testing. The focus should be to prevent deaths from COVID-19 and not on containing the infection. IEC should advice people to watch for the symptoms and early reporting for testing on demand and contacting doctor for proper advice.

1.3. In Y class cities with moderate spread: Containment zones (CZ) should be revamped with clear roadmap and timelines for periodic review by expert committee, with the aim to test all suspects, isolate all infected individuals for proper treatment. All CZs should be de- contained in maximum of 14 days.

1.4. Small cities and rural townships with mild/limited spread: Existing testing and cluster containment strategy may be continued. Although testing strategy attached with mandatory isolation, needs to be reviewed in view of social stigma. In small cities this is a major factor preventing persons from coming forward for testing.

1.5. Rural areas: syndromic surveillance by ASHA and village Nigrani Samiti and periodic review at PHC level could be done.

2. Quarantine and Isolation Policy: should be community friendly. The present policies, where:

2.1. Houses of all persons who test positive, are stamped, isolated by barricades is creating a fear in society. This practice should be abandoned immediately.

2.2. When majority of states / districts are affected, there is no rationale for quarantine of inter-state travelers who are required to be in mandatory facility (Hotel or health facility) quarantine (for 14 days). This should be stopped immediately. Citizen friendly measures like following home quarantine/isolation, which has been an effective strategy in many cities/states should be followed.

3. Pragmatic Testing as a control strategy: Universal scaling up of testing at current community transmission stage of the pandemic may not be an optimal control strategy and will divert attention and resources from control measures. With the availability of sufficient understanding of the natural history of disease and at-risk population, testing should be used with due diligence. Targeted testing of high-risk individuals, healthcare workers, elderly with co-morbidities, screening prior to surgical procedure etc. is recommended. However, areas in very early phase of pandemic (where zero or very few cases have been reported) testing may be used as a surveillance tool.

Suggested testing strategy

3.1. Cities and towns with high case load: (i) Consider all symptomatic COVID-19 cases and treat them at home or hospital depending on the clinical condition, as COVID-19 even without testing (syndromic approach); (ii) monitor symptomatic patients (even without testing), through phone, family members, and paramedics, and also through SpO2 values (either by supplying pulse oximeters individually or making these available through local paramedics) for early shifting to hospitals to reduce mortality; and, (iii) a reliable and accountable dashboard and central helpline for those requiring hospitalization (in coordination with ambulance services).

3.2. Towns/districts with low case load: Continue the practice of containment zones, identify the case and contain that area, conduct house-to-house survey, identify cases through testing, isolate all those cases preferably at some facility to avoid further spread or home quarantine if possible with strict instruction so that spread can be stopped.

3.3. Towns/districts with no case load: Continue surveillance activity and precautions; actively promote physical distancing, mask use and hand hygiene.

4. Immediate resumption of comprehensive health care services: Primary, secondary and tertiary health care services including outpatient and inpatient services including routine/emergency surgeries should resume as early as feasible, at least those areas that are progressing towards higher levels of immunity and in towns/districts with no cases. Adequate safety measures should be put in place for the safety of health care staff engaged with optimal PPE and testing of patients for COVID-19 as may be appropriate.

5. Protecting high-risk populations including elderly and those with co-morbidities: Elderly persons (>65 years) and those with co-morbidities (hypertension, DM, Cancer, obesity etc.) shall continue to restrict their outdoor activities as far as possible. Younger persons with co-morbidities should also exercise appropriate caution.

6. Continue preventive control measures of physical distancing face mask use, hand washing: All should continue to practice distancing (avoiding mass gatherings), face mask usage and hand washing to prevent and limit transmission.

7. ILI and SARI surveillance: Early detection of ILI and prompt management of SARI cases using a combination of syndromic surveillance and Test and Track strategy should be strengthened.

8. Periodic sero-surveillance survey for monitoring the pandemic: State and national level serosurveillance surveys need to be undertaken to monitor the pandemic and modify the control strategies accordingly. In future use of already existing sero-surveillance platform could be a cost-effective way to do the sero surveillance. All the sero surveillance must be supervised by trained public health specialist (MD Community Medicine) from local medical colleges, and public health institutions.

9. Opening of schools and educational institutions: It’s time now to move towards normalcy. Opening of school and other educational institutions could be started in graded manner. There should be a pragmatic approach, especially in areas where sufficient population is already infected with SARS-CoV-2 (As assessed by expert committee). Even in low infection areas, schools may be opened with due safety measures (social distancing, alternate work days, etc.), and with adequate surveillance for any outbreaks acceleration due to schools.

10. Role of vaccines in controlling ongoing outbreak: Vaccine have no role in current ongoing pandemic control. However, whenever available, the vaccine may play a role in providing personal protection to high-risk individuals like HCWs and elderly with co-morbidities. While being optimistic the prevention and control strategy should also prepare for the worst. It must assume that an effective vaccine would not be available in near future. We must avoid false sense of hope that this panacea is just around the corner.

11. Increase healthcare expenditure to 5% of GDP: Public health care should be significantly strengthened and enhanced with overall public expenditure to be increased to at least 5% of the GDP. The focus of increased health expenditure should be on primary health care and human resource and infrastructure strengthening rather than opening/strengthening tertiary care centres.

12. Public Health Cadre at national and state levels: The states like Tamil Nadu and Gujarat with existing public health cadre are relatively better placed in handling such public health crisis on their own. There is a need to expedite the establishment of a dedicated, efficient and adequately resourced public health cadre as Indian Health Service (IHS) in the centre and across states as recommended by various national committees and expert groups since 1946 on the pattern of Indian Administrative Service (IAS). – The Wire