Click  here for english version Third update_Final_April 12_JSA & AIPSN

Jan Swasthya Abhiyan (Jsa) And All India People’s Science Network (Aipsn)

Third Update on the Coronavirus Pandemic (Update #3)

April 12th, 2020 

This is the third weekly update by JSA-AIPSN. It follows the Background Paper ( http://phmindia.org/wp-content/uploads/2020/03/Background-Paper-COVID19.pdf ) and first JSA-AIPSN Statement (http://phmindia.org/wp-content/uploads/2020/03/Statement-COVID19.pdf ) adopted on March 15th, 2020, the first JSA-AIPSN Update ( https://aipsn.net/2020/04/04/2nd-april-weekly-update-on-covid19-situation/) of March 23rd, 2020 and the second JSA-AIPSN Update (http://phmindia.org/2020/04/03/weekly-update-2-april-the-situation-and-the-peoples-health-movement-response-to-covid19/)of April 2nd, 2020. This update thus covers developments of the last two weeks. 

In this document we provide an update on the epidemiology of the corona virus disease (part I), comment on the new public health strategy unveiled this week by Government of India and then discuss the considerations going into the lifting of the lock-down and our position on it (part II). We then present the weekly update of our four working groups looking at: access to essential technologies (part III); health system preparedness (part IV); lockdown restrictions and concerns of rights and ethics (part V) and the crisis in livelihoods and government response to it (part VI).

Part I- Weekly Update on Epidemiology 

1. The current number of cases detected as of 10th April was 6412 (including deaths and cured) which is about 4.9 cases per million population. The number of deaths from COVID-19 is 199, which comes to 0.15 per million population. Reported deaths  are 3.1% of reported cases. . The number of deaths is low by international standards, but as pointed out in the last update, this is comparable to figures from many LMIC countries that have such outcomes despite weaker public health systems. (See Annexure 1 pg 15-16 for more details)

1. The lower figures in positive cases have largely been due to the lower levels of testing that India undertakes and the much tighter protocol on who can be tested. (All mild , moderate and even mostt severe symptomatic patients were excluded unless they had a histroy of contact or were healthcare providers). However here there is an apparent paradox. As of 9th April, a total of 144,910 tests have been conducted, among the lowest per capita in the world. Internationally, higher test positivity rates are associated with low levels of testing.  For instance, South Korea has lowest test positivity rates since it has the widest base of testing. But India’s test positivity rate is around 4.4% , very close to South Korea and well below that of both developed and developing nations. Within India, Kerala has the lowest mortality and test positivity rates. One explanation given for this is that the spread of the virus in India is very limited as compared to any other country, either due to the lock-down or due to perhaps to other hitherto un-determined resistance factors.. We have shown in the past weekly update that the lock down in India was not particularly early and other nations with early lock-down have fared differently. Moreover, the evidence to support resistance factors is very weak. 
2. A more likely explanation is in the large number of aymptomatic contacts that are tested plus a very low threshold for defining a contact, as well as the systematic exclusion of symptomatic persons with a loack of contact history from testing .. Even substantial numbers of hospitalized persons with severe acute respiratory Infection (SARI) were being excluded from testing. Also, all those who test positive must test negative twice before they are released and this could also add to the number of negative tests. We note that India mainly reports on number of samples tested and has stopped reporting on the number of individuals tested. We cannot be sure that this is the answer, but we suggest that to interpret test positivity rates the disaggregation by indication for testing should be included. 

1. We are also concerned about the definition being used by Government of India for ‘close contact’. As a result of the current definition, many doctors and nurses who have been transiently in the room are quarantined if a patient who visited their out-patient later tested positive. Or a social worker distributing food packets in a community kitchen is quarantined if one of the beneficiaries with whom they had no direct contact tested positive. In many countries close contact is defined as having been close for at leaast fifteen minutes at a distance of less than six feet and without use of a surgical mask. Singapore has defined it as thirty minutes. If the exposure is shorter than the prescribed limit, but more than two minutes, they can remain on job but would have to wear a mask and have twice daily temperature checks. Other brief incidental contacts are just asked to monitor themselves for symptoms. We are concerned that unnecessary and excessive quarantines will cripple health services and other essential services, while doing little to contain disease, other than the problem of interpretation of aggregated test results. There is an urgent need to rationalize this defnition of close contact, in line with evidence as available, striking an an optimal balance and minimizing quarantine to what is essential.  An analysis of the circumstances under which each contact who got the infection from an imported case can be done quite quickly . This was done in Kerala and we know that closed spaces are the highest risk situations. A/C cars, A/C transport and A/C rooms.Further such epidemiological studies are an essential component of any strategy.

1. One important unique epidemiological feature of the Indian pandemic is the gender ratio. In almost all nations in the world the ratio of affected men to women is 50%. The range could be 40% to 60%.  In India, 76% of those affected are men. The only other nation that has a similar feature is Pakistan with 72% of the affected being men.   

Part –II Containment Plan for Large Outbreaks – The new public health strategy

1. One major step forward has been the release of the “Containment Plan for Large Outbreaks” by the Ministry of Health and Family Welfare (MOHFW) and in tandem with the new testing strategy announced by ICMR on 9th April. 

1. The Containment Plan has several welcome features and marks a big step forward. Firstly it goes beyond the “Are we in stage 2 or stage 3?” discussions that had bogged the country down (see Update #2 of April 2nd for our comments on this) and calls for a scenario based approach- and these scenarios varying across the country. It talks of five scenarios instead of stages and lists them as follows: 

1. Travel related cases reported in India
2. Local transmission of COVID-19
3. Large outbreaks amenable to containment
4. Wide-spread community transmission of COVID-19 disease 
5. India becomes endemic for COVID-19

1. The Plan talks of large outbreaks without specifying whether or not this is community transmission- which, as we discussed before, is quite acceptable and then goes on to detail a strategy of response in this situation. Within this containment area it relaxes testing strategy to all symptomatic influenza like illness (ILI) cases. More importantly it would then limit strict lockdown to such clusters. There is considerable flexibility given to defining the cluster and the features of the lockdown required- allowing for better location-specific response. We note that the plan does not define how wide-spread community transmission situation is defined as compared to large outbreaks- but we can leave it at that. It is note dthat the exit point is being defined as India becoming endemic for the disease, which is realistic, rather than complete elimination. 

1. JSA-AIPSN calls on the government to build on this plan with the following suggestions and amendments:
   1. Clarify the strategic objectives and major interventions, not only in scenario III, but also in Scenario IV and V, and how each of these scenarios would be defined and distinguished from each other.  
   2. We demand that a vigorous Covid Disease Surveillance Programme (CDSP) forming a part of the Integrated Disease Surveillance Programme (IDSP) as called for in the first JSA-AIPSN  Statement and now elaborated upon) In synergy with a strategy of “Identify-Test-Isolate-Treat-Trace” (ITITT) would be the strategy in scenarios I, II, and V. We clarify that CDSP would be a part of the Integrated Disease Surveillance Programme (IDSP). 
   3. In scenario III and IV also the main strategy would remain CDSP and ITITT, but in addition there would be a small area lock-down in scenario  and a state-wide lock-down in scenario IV. It is noted that the measures that constitute “containment” are not limited to any one of the scenarios- but the scale and scope of containment would change. Even those districts and states in sceenario V could revert to one of the other scenarios and rquire containment again. 
   4. The governemnt is also cautioned on using geographic physical distance as measured in kilometers as the main criteria of defining the area under containment. This may have worked in Bhilwara where the main source of infection spread were medical doctors working in a healthcare outpatient department-. Patterns of health-seeking to behaviour are known to correspond to such simplistic circles. But this would not be true if a vendor in a market was the source of spread, or if a gathering of a community or an association was a source of spread, or if it were spreading in an occupational group, or even within a large slum like Dharavi. Thus social mapping would almost always be more important that physical distance as the basis. 
   5. The difference between physical distance mapping and social mapping could become a big problem during implementation. Social mapping to identify disease spread, would require interaction with the communities concerned, and would require social workers to enage in persuasion, negotiation and trust and  would further have to depend a lot on ITITT. Lockdowns based on physical distance alone is seen as best enforced by the police department and with the use of force and coercion. Though we concede that there is a considerable overlap between the two, a mechanical and exclusive reliance on physical distance would fail for both epidemiological and societal reasons. 

Core Strategy: Identify, Test, Isolate, Treat, Trace (ITITT)

1. Recognition on the importance of ITITT as the core strategy is near universal at the policy level. However, there is need to empasise that lock-down is not a substitute for it, but will be needed during and after this and further lock-downs. (Identify= actively seek out symptomatic cases; Test= Test for COVID 19; Isolate: All those who test positive must be placed in isolation, even while waiting to be tested; Treat = All COVID 19 patients who are symptomatic would require treatment based on their severity; Trace= the contacts of all COVID 19 positive patients must be traced based on the patients movement in last 14 days, but especially sine fever had developed and three days before it. These persons would need to be put on quarantining. The main purpose of tracing is on identfying those who need to be on quarantine. Isolation refers to COVID 19 positive patients or symptomatic suspects while waiting for testing. Quarantine is for  asymptomatic patients who have had contact and may or may not develop the disease)
2. Some states have teams of workers going around and looking for cases of fever and of recent travel outside the town of residence. This seems to be the best way to detect cases early. When fever is detected the team calls in on a line and an ambulance picks up the patient and takes them to a nearby center. If they test positive, they are isolated in earmarked beds and if severe, are taken to dedicated COVID 19 hospitals.. These are the states that are doing well. However, all states need to ensure that workers are protected through adequate PPE and training.
3. Some states do all of the above, but their emphasis is more on those with travel history, who they test even if asymptomatic. Unfortunately, those without travel history but with fever are ignored. Many states have even failed to test all those with signs of Severe Acute Respiratory Illness (SARI) if they have no contact or travel history. Often only if an X-Ray or CT scan indicates a problem, and sometimes only half of such patients, are tested even if all are such patients are hospitalized. This is completely unacceptable, but probably happening because these are the protocols currently in place for testing.  A combination of lack of testing kits and concerns about detecting high numbers of positive cases which would challenge the states narrative of a great control, combine to cause such deviation. 
4. A recent ICMR study has shown that in the 5 day interval of March 29th to April 2nd, the number of SARI patients testing for COVID-19 positive increased to 2.6% as compared to 0% in the first two weeks of March and about 1.8% in the latter two weeks of March. Further, of the 104 COVID-19 positive patients about 40% had no history of contact or international travel, which is clearly is community transmission as defined. We also note that the strategy of “large outbreaks amenable to containment” is implcitly an acceptance of communtiy transmission even if it is defined as happenning within a geographically defined hot-spot. 
5. We now know from case studies of severe patients that they have spent considerable time when they were mild and moderate visiting numerous healthcare providers using public transport, before they were finally diagnosed. The infection spread due to undiagnosed mild and moderate cases is considerable and the clearest reflection of this is the increasing number of healthcare providers who are not in the direct line of COVID-19 duties but are nevertheless coming down (and even one dying) due to COVID-19 infection which they may have got from their general out-patient care. Often it is due to co-morbidities like cancer that patients visit hospitals and pass on the infection to the care providers, such as in the case of the Delhi State Cancer Institute. 
6. We welcome the steps taken by the government to earmark beds for isolation purposes and hospitals for COVID-19 care in anticipation of a surge of cases. This is most welcome, though we are concerned that where arrangements are of poor quality  many patients prefer to escape. We are particularly concerned that train coaches would not be an adequate alternative. 
7. While steps taken by the Government to step up procurement of ventilators, oxygen supplies, PPE etc, these initiatives have been very late in coming, and also face huge challenges due to transportation disruptions arising from poor implementation of the lockdown. These problems are discussed in the next section. 

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Strengthening Disease Surveillance- CDSP as part of IDSP

1. One of the more inexplicable aspects of the government response is the non-use of the integrated disease surveillance programme and within that the flu surveillance programme to track and manage the COVID 19 epidemic. This system is designed to pick up and test for epidemics of respiratory viruses, and could have been easily geared to include COVID19 testing from early February.
2. The IDSP system has both event-based reporting and population-based reporting. It provides for suspect-reporting by para-medics, presumptive reporting on clinical crtieria by medical doctors and laboratory based reporting from 168 flu surveillance labs. The 1.5 lakh sub-centers submit S forms (Ssuspected cases) – and they should now be reporting any sudden increase of flu like illness (for which a definition has to be created- like more than 5 fever cases increase in the preceeding week) and any fever releated deaths. But more importantly, all PHCs, CHCs, DH and private cliinics and hospitals should be filling out the P form (Presumptive cases) which should now include a presumptive diagnosis of COVID19 based on clinical crtieria. Such criteria have been proposed by many specialists and are adequate for this purpose. And the laboratories for testing should be expanded from the current 168 to include one or more per district, especially now that rapid tests are available. In the malaria endemic areas, where the malaria surveillance is robust, this may be the preferred framework.
3. Any rises of presumptive cases must be followed by a field response team and a testing of a sample of cases if not all cases. In all areas, where COVID 19 is currently at zero levels at least 10% of fever cases must be tested by the rapid test kit with confirmation testing if they test positive. In areas which are reporting increasing COVID cases the testing must try to cover all fever cases. Testing as required for the ITITT strategy would continue. 
4. Where a lockdown is ordered the testing can include all those with fever and those who are contacts of COVID19, plus those who are asymptomatic and in that area even if they are not close contacts.
5. We understand that some states have not invested in their IDSP and many epidemiologist posts lie vacant. No state should consider a lock-down unless they have a minimum CDSP/IDSP in place. Norms for this should be rapidly reiterated and the center step in to close the gaps by transfers, fresh recurits  and on the job support as required. 

Box: Example of how a Clinical Case definition for presumptive diagnosis could be constructed (based on note by M.S.Seshadri & Jacob John)

Mandatory criterion: Fever of 3 or more days duration without other obvious localizing symptoms (such as dysuria, skin or soft tissue infections) 

Epidemiologic setting: Travel within the past 4 weeks to or from any other country or a big crowded city in the country; Visit within the last 4 weeks to a crowded place (bus stand , railway station, movie theatre, airport, place of worship etc)

Major criteria: 1.  Dry cough 2. Sudden recent onset Anosmia or loss of taste sensation  (anosmia due to nasal block and sinusitis to be excluded 3. Physical findings of crepitations on chest auscultation 4. Chest X Ray showing peripheral patchy infiltrate (not lobar pneumonia or cavitating lesion)

Minor criteria: 1. Diarrhoea 2.  Severe headache, body aches (Myalgia) 3. Normal or low normal  total WBC count and lymphopenia ( Lymphocytes < 20 % on differential count)    

Any persons with a mandatory critiria and at least one major criteria and an epidemiologic setting and/or one more major criteria or one minor crtieria can be taken as presumptive COVID 19. In COVID-19 active areas, this should be enough for isolation even if testing is not available. In other areas, one could self-isolate till testing is done. 

On lifting the Lock-Down & Hot-Spots for Containments

1. As the National Lock-down period comes to an end, the issue of continuation of lock-down has become the most important topic of discussion. The lockdown is imposing huge economic costs on the majority of the population. This economic shock that majority of the working people have to bear, combining with the virtual suspension of much of essential but routine healthcare could lead to a much greater mortality than the worst case scenario of a corona virus pandemic.  However we are concerned that the popular (largely elite and middle class) perception of lockdowns as reflecting strong and determined leadership may push states and the center to re-impose lock-downs all too readily. One view is that lockdowns are being preferred because they can be implemented through a single agency like the police. Many States do not have confidence in their administrative abilities for a multi-dimensional approach that includes rapid scaling up of public health services and manufacture as well as logistics for a variety of essential health commodities, like testing kits and PPEs. A case in point is Odisha which, for a total of 44 positives and one death has decided to lock up 4.6 crore people till April 30th. Only five out of 30 districts test positive but all 30 are locked down. They are the first to announce it and are receiving so much praise for the same. There can be relatively little doubt that deaths due to the withdrawal of other services and the continuing crisis for people’s livelihood would be high. There is also the great possibility that the disease will enter Odisha whenever the lockdown is lifted- say another month from now and peak thereafter. Many other states have also enthusiastically responded to continued lockdowns. Two state task forces/expert committees- Kerala and Karnataka- have recommended a phased withdrawal of lock-downs, but their understanding of phasing is different. The Kerala committee report has important contributions to make, especially with regards to the phased re-introduction of economic activity  and further the concept of phased withdrawal / re-introduction of public health measures including travel bans. The challenges are with regards to the criteria of phasing and the data on which this could be measured. 
2. It is worth noting that both in India, and world over a large number of epidemiologists and those with past experience of epidemic management, and those engaged with health systems strengthening have not quite shown the same enthusiasm for the lock-down. We also note that many nations went for later lock-downs and lifted it when transmission was low, and then returned to lock-downs in areas where transmission aceelerated. This was a part of their strategy, and not a failure of strategy. In this understanding lock-downs are most effective, and the best benefit to loss (pain to gain) ratio, when community transmission is widespread.. However effective a lock-down, whenever that lock-down is lifted, cases will start going up again and one must educate the public and poltiical leadership to understand that this will happen and can be managed. If however the rise crosses a threshold (as measured by a set of indicators that are agreed upon) further area- specific lock-downs could be considered, with adequate preparation and advance notice. But just extending this current lockdown and in general extended lockdowns, will take a huge toll on morbidity and mortality. For example many cancer patients and heart disease patients who needed elective surgery will possibly develop conmplications and start dying if surgey is further postponed. Deaths due to non-COVID causes would rise exponentially with each extension of the lock-down. 
3. We are agreed that the early lockdown as was imposed now was required for preparing health systems. We also agreed that this lock-down should have been much better prepared for and implemented- and not sprung as a surprise. We however DO NOT agree with the nation-wide extension of the lock-down or even across any State. We think that the current plan for “Large Outbreaks Amenable to Containments” its identification of hotspots is a good way to move forward and state-wide lockdowns should be considered only with wide-spread community transmission of COVID-19 (i.e scenario IV) and which is defined by multiple large outbreaks or clusters or hotspots in all regions within the state. 
4. Of course lock-down has to be lifted in a phased manner. But the manner of phasing and re-organization of work should have at its core a humane and poor-friendly approach. The arrogance that at times of epidemics we need “stern action” that necessarily will trample on the rights of the working people and the marginlised is often elite arrogance combined with bad public health understanding and is not acceptable. The main question is how to phase it so that it does not lead to a rush of migration and loss of all efforts at physical distancing. 
5. Re-imposition of lock-downs in a district or cluster of districts should require a rising number of new cases that indicate a R0 value of above an agreed upon threshold (A value of R0 of 1 or less is endemic disease). Disease incidence below that can be managed by ITITT approach alone. Lock-downs in smaller hotspots defined by a physical distance radius must be temporary till a house to house search is carried out, unless the nature of contacts made by the source necessitates it. 
6. To know the R0 level reliably, the Coronavirus Disease Surveillance Programme (CDSP), which would be part of the IDSP, should be put in place, almost immediately. The current numbers when used as the basis for setting lockdown thresholds are going to be very misleading as increasing numbers due to improved quality of surveillance and case reporting would be interpreted as an increasing epidemic.
7. Both state and central governments are trying for lockdown lifting criteria that pertain only to absolute rates of number of cases per million population and without reference to testing protocols and standards of testing and without any proposals as regards to establishing a CDSP.  We urge that a lock down should be considered only if there is a sustained increase in cases, and further that the increase occurs only in those who are not already in home or facility quarantine (and therefore indicative of community spread). This allows for withdrawal in an endemic situation, where there are steady new cases, but no accelerated increase in new cases. In other words, where there is still contagion, but there is no epidemic, i.e. we have reached an endemic scenario. This would be the immediate strategic objective. When lock-downs are lifted public transport and workplaces must be opened up in a responsible manner- and phased out carefully. (Reference: JSA-AIPSN statement on proposed extension of national lock-down)
8. Across all states and areas irrespective of COVID 19 status measures of physical distancing, ill persons required to wear masks, prevention of large gatherings ( above 20 initially) and basic rules of hygiene would be observed. We may also start testing and certifying for recovered patients who are now testing negative for virus and positive for antibodies and who can therefore be selected for certain tasks. 
9. The above strategy would hold good till a vaccine is introduced. 

Part III: On Access to Medicines and Essential Technologies

1. New testing guidelines: New Testing Strategy: The ICMR issued new guidelines on testing allowing rapid antibody based blood test for COVID-19. The ICMR is using this as a strategy for areas reporting clusters (containment zone) and in large migration gatherings and evacuees centres. Resident of areas designated as hot spots and which have reported a large number of cases may have to go through this screening test.   According to the guidelines issued by the ICMR, at the facility level, all symptomatic patients with influenza like illness (ILI) are to be tested using antibody tests. The ICMR has given a full treatment protocol regarding testing using antibody test as screening tool and RT-PCR as confirmatory test.  

2. The Antibody Test Kit: The government is in the process of procuring 5 lakh rapid antibody tests kits from various companies. These tests are useful for their speed as they can suggest whether a person is  has COVID19 antibodies within 15 minutes. In most clinical situations where we are testing symptomatic patients with mild, moderate or severe diseases, this test in combination with the clinical setting, would be adequate  for a reliable diagnosis that can lead to isolation and defnitive treatment and the use of PPEs by care providers. RT-PCR is desirable but isolation and treatment of the patient and tracing contacts need not wait for that. This also means that testing in clinically symptomatic cases can go down to PHC levels and this offers great advantage in reducing spread of disease ( as these patients would be visiting multiple health centers in search of care) as well as strengthen disease surveillance.

One problem that has been raised with this kit is that it is not useful to detect early cases in the pre-symptomatic phase and will give false negatives in first few days. Also in population studies or in asymptomatic patients a further viral  RT-PCR test would be required for confirmation. However after four days of fever (or number of days of fever as recommended after validation studies) in combination with the clinical picture it is very useful and this should be emphasized. 

The other problem with this kit is that after the patient recovers the test will remain positive. So it cannot be used for judging recovery. For that we would need a neative viral antigen test. The antibody test is  useful to measure past infection and therefore the main tool of population based sero-epidemiological studies.. 

Governments must report antibody positive patients with clinical symptoms as COVID 19 positive and isolate and treat them as such without waiting for a confirmatory viral antigen test. 

3. Procurement of Testing Kits: The entry of these rapid antibody testing kits into India would be a game changer. It is not clear as to how many Indian companies would manufacture them and at what scale and what proportion would be imported. These are cheap test at about Rs 400 per test and costs can be lowered further. Scaling up manufacture of this must be priority. The government has provided a list of approved 33 Indian suppliers Rapid / CLIA/ ELISA Corona Kits with condition that they must be first validated by NIV Pune.. All of these 33 are bringing in imported kits, one  from Israel, 2 from South Korea, and all the other 30 are importing from China, 

As of now though central government and states have placed import orders. The first batch was to have been delivered on April 8th, but as of now.no consignment has arrived, and this is attributed to failing quality tests in China. There are also issues with tendering and payment.

There are also 27 PCR mit suppliers approved. Of these only three are indigenous. Of the rest 10 are from China, 6 are from USA, 4 from South Korea, 2 from Germany and one each from Spain and UK. Given the high needs in their home countries, the actual supply remains to be seen. 

There are other cheaper viral antigen tests that have become available ( like the Viral NAT – which is a blood test for viral Nucleic Acid Amplification Tesing ), which is much cheaper than the current PCR test, especially if done on pooled samples. CRISPR-based tools have been developed as a viral tests to test COVID 19 within 30 minutes. These tests are simpler and easier than RT-PCR test with no need for bulky instruments and complicated operationsT This is another option that has to be rapidly explored and scaled up. 

The forecasting figures are also not clear. Our annual requirement may be upward of 10 million test kits- and this needs to be factored in when thinking of the manufacturing and import strategy. 

4. The Scaling up of Testing Services and Payment for Testing: The JSA – AIPSN statement had clearly articulated the need for “free-to-patient” testing. While the government made it free in the public sector it allowed private sector to charge Rs 4500 per test. Fortunately the Supreme Court in an order this week mandated free testing even in the private sector but left modalities undecided.  This has forced the government to consider what it should have done in the first place, namely the rate of reimbursement to the private sector for testing. They could negotiate the rate with government based on a quick costing analysis but the private sector would have to provide it free to the patient. Problems of delays in payments can be overcome by giving an advance amount and then refilling it as and when 80% of it is exhausted. The private sector has objected to limiting testing to only those samples/cases which government approves. On this issue, we recommend that the private sector should be allowed to test anyone who by the standard protocol deserves to be tested – and that should definitely include all mild and moderate cases. In the current context, of government limiting its testing to align with its narrative, this autonomy to the private sector to be responsive to the need as certified by its doctors must be respected. 

The number of labs doing testing for COVID was only one laboratory even in February. This is now reported to have increased to 223, of which 157 are in the public secor, and and 66 in the private sctor. Daily testing rates were low but now have reached about 10,000 per day. 

5. PPE: The government statements indicates an order for 1.74 crore PPE sets and N95 and masks. That there is a huge shortage in N95 masks, coveralls and other PPE is too well known to need reiteration here. Doctors, nurses, sanitation staff and other auxiliary staff have been complaining regularly about this, to the extent that gag orders have been issued by government but to no avail since the problem is so severe and threatens the lives of these health care personnel and their families. There is not only a large gap between need and supply, but also a gap between the government’s assertions about plentiful supplies and the reality that most numbers referred to relate to orders rather than actual availability on hand.. There is both lack of transparency and a lack of preparedness. Media reports supported by documentary evidence suggest that most orders for PPE (34 out of 39), were placed only after announcement of the lockdown, a full two months after COVID-19 made its appearance in India, and 24 of these were placed in April 2020. Deliveries both imports and domestic are lagging far behind orders, production against some of which have barely begun. Domestic manufacturers have faced massive pin transportation bottlenecks due to extremely poor implementation of government instructions on the ground, in this case exemptions granted for transport of essential commodities. It is to be noted that public sector undertakings (PSUs) are supplying most of the requirement, despite many years of debasement and under-valuation of their capabilities. Government requires to do its utmost to immediately resolve transportation and supply chain bottlenecks, and extend support to manufacturers to enable rapid scaling up of domestic production.    
6. Ventilators: The government has announced that it has placed orders for 49,000 ventilators, most of  which 10,000 are from BEL, DRDO and the Railways, with some private companeies working with automobile majors. The exact deliverey dates are uncertain.. 
7. Oxygen: A six fold increase in supply of oxygen purposes since February 1st is reported. There is no news on oxygen concentrators. 
8. Drugs: The government did a flip-flop on Hydroxychloroquine by first banning its export and then hastily withdrawing it in response to US bullying. Consdering the government’s and manufacturers’ statements that there is enough for Indian needs and considering that India commands the market for this medicine, there is indeed a requirement that we help other nations like US and Brazil that have asked for it. We hope we have got a quid pro-quo for import of ventialtors, PPE and testing kits from these nations. On other drugs, it is good news to note that India has joined the WHO solidarity trial. 
9. Costs of emerging COVID-19 medicines: Many clinical trials are underway looking at efficacy of various drugs for treatment of COVID-19. Prof. Andrew Hill of the University of Liverpool, United Kingdom has published a paper in Journal of Virus Eradication titled “Minimum costs to manufacture new treatments for COVID-19” in which he and his team have calculated costs of these drugs which are repurpose drugs, normally indicated for other diseases. His results show minimum estimated costs of production are US $0.93/day for remdesivir (produced by US multinational corporation Gilead), $1.45/day for favipiravir, $0.08/day for hydroxychloroquine, $0.02/day for chloroquine, $0.10/day for azithromycin, $0.28/day for lopinavir/ritonavir, $0.39/day for sofosbuvir/daclatasvir and $1.09/day for pirfenidone. Costs of production ranged between $0.30 and $31 per treatment course (10–28 days). Going forward, we need to keep a tab on their costs as some of them will be used for COVID-19 depending on the results of clinical trials.

Part IV. Health Systems Strengthening

1. On 7th April, the MOHFW issued a Guidance Document on appropriate management of suspect and confirmed cases of COVID-19. The dedicated COVID centres have been divided into 3 types:

1. Dedicated COVID Care Centres (CCC) for mild suspected and confirmed cases. These are makeshift facilities. They may be set up in hostels, hotels, schools, stadiums, lodges etc., both public and private. 4000 raliway coaches are also reported as having been readied for the purpose. If need be, existing quarantine facilities could also be converted into CCC. It must also have a dedicated Basic Life Support Ambulance (BLSA) equipped with sufficient oxygen support on 24x7basis
2. COVID Health Centres (DCHC) for moderate suspected and confirmed cases. These should either be a full hospital or a separate block in a hospital with preferably separate entry\exit/zoning. These hospitals would have beds with assured Oxygen support. They must have a dedicated BLSA equipped with sufficient oxygen support for ensuring safe transport of a case to a Dedicated COVID Hospital if the symptoms progress from moderate to severe.
3. Dedicated COVID Hospitals (DCH) for severe suspected and confirmed cases. It should either be a full hospital or a separate block in a hospital with preferably separate entry\exit. These hospitals would have fully equipped ICUs, Ventilators and beds with assured Oxygen support. 

2. The official government statement is that it has now readied 520 dedicated COVID hospitals, with nearly 85,000 isolation beds, and 8500 ICU beds. At the next level they also have prepared another 5570 additional health facilities, another 197,400 isolation beds, and a further 36,700 beds. Another 40,000 isolation beds have been prepared from 2500 railway carriages. 
3. There are reports from every state of such designated centers being created at two levels- for isolation and for ICU care. States are now having to empty out their busiest and most functional of public hospitals and government medical college hospitals to put a DCH in place. The effort to bring a private sector hospital as a COVID19 fell through in many states like Chhattisgarh. But we are not hearing much on the corresponding increases in HR, minor equipment, and major equipment and skills. Moreover, this threatens to have a crippling impact on provision of other routine essential health services, especially in the tertiary level public hospitals. 
4. While the aggregate numbers of orders placed and hospitals planned are encouraging, reports from many states show a large number of district hospitals which have yet to establish ICU beds and have the necessary equipment and skills for the same. There is concern that in large number of districts, bottlenecks in human resources, skills and supply chains may be inadequate to meet the challenge. Years of lack of preparedness and under-investment cannot be corrected overnight, but at least we can welcome the fact that the government is now seized with the issue. 
5. Private sector involvement has been varied. Bringing some private hospitals under public authority has been mooted but not done. COVID 19 testing and treatment has been included in PMJAY package but not clear whether this has been availed of.  In some states like Tamil Nadu and Mumbai some private hospitals have been accredited for COVID 19 patients but allowed to charge and reports are of very high charges. There are also reports of many accredited hospitals not seeing any COVID 19 likely patients and making no special arrangements to refer them to COVID 19 hospitals. Finally there are also reports of private healthcare having to shut down all services because of healthcare providers becoming infected. There is a clear need to bring select private hospitals completely under a public authority and where they are operating on their own bring them under PMJAY reimbursement  protocol for all COVID 19 cases and all cases of SARI. They must be monitored to ensure that their staff is protected and that they do not deny patients the care that is needed. 
6. One major problem arising is the major decrease in access to essential healthcare services. These include all patients with non-communicable diseases unable to access essential medicines or the care they need from public hospitals and private hospitals, and therefore at much higher risk for complications and mortality. The more critical the patient, like in the case of cancers, renal dialysis, the more severe the problem. On communicable disease front also, postponement and suspension of immunizations services, and difficulties in access services for HIV, TB etc are being reported. Out-Patient and In-Patient services for non-Covid-19 patients in both public and private have been substantially reduced.  The decreased access to services is due to four factors:
7. a) active elective suspension of services as part of the lock-down- and stay at home instructions. 
8. b) shifting of staff essential for routine services to COVID 19 related work-especially in states with weaker healthcare systems.
9. c) Lack of public transport to reach these services
10. d) Many doctors and nurses who are NOT on COVID 19 duty getting COVID 19 infected due to exposure to general patients in whom cases of mild or moderate COVID 19 are intermingled. Once someone tests postive all the staff get isolated or quarantined- shutting whole hospital or much of it down. 

The morbidity and mortality due to the decreased access to essential healthcare services is going to increase sharply and exponentially as the lock-down continues. This should be obvious enough, or else such healthcare servies would not have been seen as a fundamental right, but we are yet to come across a modelling exercise that has factored this in.. We had warned against such a situation at the beginning of the lockdown period. However we are seeing the situation getting worse (Ref. Press Statement by JSA Delhi on Denial of Healthcare to Critical Patients and Sudden Discharge from Hospitals without Alternate Arrangements).

Part V: Stigmatisation and Rights violations under the Lockdown 

• Stigmatisation and the communalisation of the pandemic: In midst of the ongoing crises, the members of a community who participated in a religious congregation are being hounded and criminalised by the state, police and media. While there may have been lapses by participants of the gathering (such as not reporting that they had visited a Covid-19 affected country), there are instances of people from other communities who have also failed to  isolate themselves after coming to India from other countries and have passed on the infection to others. Further, there are reports of religious gatherings of other communities that have taken place as well, some even after the specific congregation11 12 (from rt 2 food). The targeting of Muslims has led to diverting public attention away from the safety precautions that need to be taken to prevent the spread of the virus. Rather than focusing on safety measures, the government, media and the public are instead busy blaming the Muslim community. The attempt to extrapolate the stigma of COVID infection to an entire community, i.e. the Muslim community in India, is nothing short of targeted vilification in a public health crisis.  It is also in contravention of the World Health Organization’s advisory issued on 6 April, 2020 that “Countries should not profile novel coronavirus disease (COVID-19) cases in terms of religion or any other criteria”, asking “governments not to politicize the issue and stop profiling people on religious basis.” The advisory also requested people to “never spread names or identity of those affected or under quarantine or their locality on the social media”.  This kind of victim-blaming, religious profiling and stigmatising could significantly undermine the public health efforts in Covid-19 epidemic.

• Stigmatisation and suicides and social ostracisation: Even without the above event, this pandemic has become highly stigmatized due to the highly moral tone attached to social distancing and individual responsibility. This pandemic has therefore seen an incredible level of stigmatization, similar to that seen in HIV pandemic or even worse. There are a number of suicides reported because of testing positive or even the fear of testing positive. There are cases of ostracisation by villages and families. There are many reports of people hiding their disease and their symptoms. 

• Stigmatisation and attacks on health workers: There are widespread reports from across the country of attacks on health staff and even doctors. Doctors themselves afraid to pass infection to their loved ones are staying away from home, even sleeping in their cars. Resident associations are refusing accommodation to doctors and even turning them out. Doctors and other health workers working with Covid-19 positive patients have been assaulted by people blaming them for spreading coronavirus in their area. The large mobilizational event by government of lighting a lamp and earlier of applauding the health workers for their work by clapping has not made enough difference at the local level where the hate and stigmatization generated by the sub-text has dominated. Health workers are also more at risk due to lack of PPE. When doctors and nurses complain against this, strict gag orders are passed and there are instances of suspension of health workers. 

JSA-AIPSN calls for an active end to stigmatization. This requires a major change in media strategy where not only the need but the limitations of social distancing are pointed out. Neither individuals nor communities must be blamed for either getting infected or passing along infection. Social distancing helps but is no guarantee. There have to be active efforts to reach out to aggrieved communities. 

• Rising violence on women, girls and children during lockdown: In planning responses to the lockdown, its impact on girls, women and gender-diverse persons has largely been invisible. The burden of domestic and care work which is borne by women has been exacerbated by the lockdown. Given the extreme curtailment of movement, girls and women find no respite affecting their physical and mental health further. Violence – verbal, physical, psychological and economic – against women and girls within homes and institutions are reported to have worsened due to the lockdown, also leading to adverse physical and mental health outcomes. The National Commission for Women reports a sharp rise in number of cases of domestic violence against women and of child abuse. The total number of complaints by women increased from 116 in the first week of March to 257 in the last week of March. In 11 days the Childline India helpline got more than 92,000 SOS calls from children asking for protection from abuse and violence. Reports indicate that police is even more unsympathetic and resistant to registering or acting on complaints. In the Press Release on World Health Day we have urged the government to immediately make arrangements for responding effectively to counter violence related to the pandemic and its control. Calls to the phone helpline should be responded to immediately; a local response team including for providing first aid, counseling should reach the survivor and coordinate all necessary steps and requirements as per the needs of the girl/woman. For example, transport to a safe space or shelter, as may be identified by the girl/woman. All support services, one-stop centres should be functional.  

• Rising number of FIRs and police violence for violation of lockdown: Throughout the lockdown we have seen shocking visuals of brutalities against those going out for essential work and there are far too many reports of persecution. Whereas a middle class looking person is likely to have his reason for stepping out accepted, the law is much less flexible with a poor or marginalized person stepping out. Instances of FIRs and police action against such sections including arbitrary actions like seizure of vehicles also abound. We demanded that the government should take strict action against any form of police excess on migrant workers, wage labourers, vendors, the health care workers and others who out of sheer necessity need to break stay-at-home restrictions. (Ref. JSA-AIPSN statement on lock down brutalities)

• Quarantines undermined by poor facilities: There are many reports of conditions of quarantine being so poor that persons break quarantine surreptiously or openly. On hearing about these conditions many deny history of travel or having fever or take paracetomol to hide it- to escape not only stigmatization but also the poor conditions in which they are kept. The risk of infection under such conditions rises for those who are quarantined. We demand that adequate facilities should be provided to those under quarantine, and that the basic rights of the person to food, water, clean sanitation, hygiene, electricity and good health care facilities should not be breached.  (Ref. JSA statement on concerns with regard to isolation and quarantine for COVID-19)

• Privacy concerns regarding Apps for surveillance and monitoring during Covid-19

The central Government and many State governments have, or are soon planning to, release mobile Apps as part of their strategy in the fight against the COVID-19 epidemic. This has presumably been done following other countries that have set up similar systems, such as South Korea and Singapore. While in South Korea concerns around privacy and invasive nature of this surveillance were underplayed through a nationalism discourse, Singapore on the other hand was concerned about these issues, and assured users it would not use compile or use data for any purpose other than contact tracing. The various Apps developed and at various stages of being deployed in India seem to be following the South Korean model, believing perhaps that the Indian people and regulatory agencies, maybe even the judiciary, would allow privacy concerns to take a backseat to control of the epidemic. 

The Central government’s Aarogya Setu App is supposed to track movements of Covid-19 positive cases and those under quarantine, and even perhaps all people in hotspots and sealed areas. The Aarogya Setu App seeks all personal information such as full name, address and so on, assigns a unique identifier to each user’s phone (with a proposal to also seed it with the Aadhaar number). If a person tests positive, then all her/his contacts are notified and other App users notified if the Covid-19 positive person is nearby. The same company that has provided the Centre and several State governments with facial recognition software for police and other surveillance is providing inputs to integrate such features with Apps being developed in India. While the Aarogya Setu App’s privacy policy states that the data will exist only on anonymised data bases, it would not be difficult to recreate the original data. The policy also states that the data will be retained only for 30 days, but there is the danger that it could easily be available on back-end servers virtually in perpetuity. 

State governments are gradually starting to introduce these Apps and also making them compulsory. The Delhi government has decided to use Apps for quarantined persons and for the hotspot containment zones, with the Chief Minister even announcing he is contemplating making use of the Apps compulsory. Punjab has started the COVA App and made it compulsory for companies such as Google and Apple and all social media players to push their customers to download it.

There is little clarity or transparency about which agencies would be running and sharing the App’s data, who can access this data and how long they will be available for. The Indian Apps have little transparency as regards to their privacy policy or potential use of this surveillance data much after the Covid19 epidemic is over and for purposes that have nothing to do with the epidemic. Whatever its supposed immediate benefits during this epidemic, this surveillance trend is deeply worrying for its harmful future potential, especially given India’s steady drift deeper into authoritarian rule.

• Condition of prisons and prisoners: In a joint Statement, JSA and AIPSN expressed deep concern regarding the preparedness of Indian prisons to meet the challenges of the Covid-19 pandemic. (Ref. JSA-AIPSN Recommendations for Prisons in light of the Covid 19 pandemic). JSA and AIPSN made recommendations on decongestion of prisons and for those who cannot be releases, to make COVID related changes and set up a detailed contingency plan.

The Supreme Court is hearing the petition on the issue of overcrowding of prisons and the infrastructure therein. Court has already passed an order that arrangements for transportation of prisoners to their homes or to temporary shelters should be made.  

Part VI: Crisis in Livelihoods and the Government Response

Government figures now establish that nearly 50 million short term migrant workers as having lst their work. According to an affidavit filed in the Supreme Court over one million migrant labourers are stuck in shelter homes because they could not make it back home. A mass movement home and then back to their place of work would have to be anticipated once the lock down is lifted. This would need to go along with measures of a minimum wage and a pressure to ensure that these workers are re-employed. Govrnment has announced no plans of how they would reach their homes and how families disrupted and separated by the suddenness of the lock down can re-unite. Clearly the problems of migrant workers continue to be an after-thought. JSA and AIPSN have previously issued a statement on the Economic Package and Demands and deals with the background of the issues mentioned in this section. (Ref. JSA-AIPSN statement on the economic package announced by the government)

• Government relief measures: A number of states have announced relief measures but they are highly inadequate and there are huge gaps in reaching them to those who need it. At the time of writing this, the vast majority may have received little relief except those who got food in shelter homes and community kitchens. Instead of setting up systems for relief measures, the government has left it to the NGOS. In a submission made to the Supreme Court the government stated that in 13 states, NGOs provided food to more people than the state government. A large proportion of migrant and rural workers are expected to further fall below the poverty line due to the Corona virus pandemic that is exacerbated the already existing agricultural and economic crisis. A rapid assessment of the impact of COVID-19 lockdown on migrant workers was undertaken by Jan Sahas who found that the migrants were in near destitute conditions, with high debts and hardly any resources to fall back upon. To overcome the economic slowdown imposed by the lockdown and boost up industrial production, the Government of India is planning to increase the daily working hours from 8 hours to 12 hours as reported by media. Trade unions, like CITU have already expressed their concern that on the issue. Such a move may relieve the employers from paying overtime for extra-working hours, but it would add to the distress of millions of working people in the country, who have been already hit badly due to the lockdown.

The Right To Food Campaign in its latest update it has cited a thread of new reports of atleast 45 deaths, which includes deaths due to hunger, exhaustion and accidents of people walking back to their homes, police atrocities, inability to access medical services and suicides. Along with the migrant workers and rural poor, urban slum dwellers across states are struggling to get access to food and ration as often they do not have ration cards. JSA has endorsed the Right To Food Campaign’s demand to government that PDS should be expanded to cover every individual, irrespective of whether they have a ration card, with 10kg of grain, 1.5kg pulses and 800gms cooking oil per month per person for atleast six months.

• Greater fiscal support to state governments: The central government has notified the release of Rs 11, 092 crores to the states under the State Disaster Risk Management Fund for combating Covid related relief measures. However, the state wise distribution of the funds shows that there is discrepancy in allocation if determined on the basis of number of Covid cases. Maharashtra with highest number of cases has been allocated Rs 1611 crores, while Kerala which had the second largest number of cases till the 3 April received only Rs 157 crore.  There have been repeated demands for providing greater fiscal support to the state governments, who are at the frontline of dealing with the situation on the ground. 

• Release of foodgrains and pulses: The central government announced in its economic package that ration to priority households under the National Food Security Act would be raised to 10 kg of rice or wheat, and 5 kg of pulses. Issues concerning the policy have been raised in the statement of the Economic Relief Package. According to the latest PIB statement a total of 2 million metric tonnes of food grains have been unloaded by states during the lockdown, while, there was a surplus of total 77 million tonnes with the Food Corporation of India.  The pulse reserve with the National Agricultural Cooperative Marketing Federation is also finding it difficult to transport the surplus to the states due to lacking transportation and private milling facilities. The demand for further opening up the food reserves to take care of the food security needs of the growing number of vulnerable people has never been greater. Recently the government has announced that ration would be extended to non-NFSA beneficiaries with ration cards issued by state governments. News coming from the ground shows that this criterion too leaves scope for exclusion. Our demand, as stated above, is for government to provide ration to all who need it. 

In conclusion: 

We have flagged many of these concerns to the government in our Press Release of April 7th. Now in parallel with the release of this weekly update we shall be releasing three statements which would contain the main demands and recommendations that flow out of this understanding:  

1. 1. Proposed Extension of Nationwide Lockdown: Concerns and Demands by JSA and AIPSN ( http://phmindia.org/2020/04/12/proposed-extension-of-nationwide-lockdown-concerns-and-demands-by-jsa-and-aipsn/ )
   2. Press Statement on the communalization of the pandemic (in draft stage)
   3. Press Statement on adverse impact of stigmatization and what must be done to counter this (in draft stage)

Follow for regular updates:

Website www.phmindia.org www.aipsn.net

Twitter @jsa_india

Facebook @janswasthyaabhiyan

click here for pdf English

Weekly Update on COVID19 situation

JAN SWASTHYA ABHIYAN (JSA) AND ALL INDIA PEOPLE’S SCIENCE NETWORK (AIPSN)

Dated 2nd April, 2020

1. Making Sense of the numbers:: Where are we in the epidemic curve
2. The lock-down and its sheer brutality
3. Do lock-downs work?
4. Health system preparedness
5. The peoples movement response

Part I. Making Sense of the Numbers

In India the COVID19 epidemic has reached the 64th day since the first case was reported on January 29th. The number of cases crossed the 100 cases mark three weeks back, on March 14th. At the start of the lockdown India was at 648 cases, which doubled (close to 1251 cases) within six days. .

As of 1st April the total COVID 19 positive cases are 2012. The growth rate since 24rd March is 252% and the daily growth rate from 31st Mar to 1st Apr is 23% (see chart below).

Globally there are now 801,064 cases which translates into an average of 102 COVID positive cases per million population. The total deaths reported are 37,815, which works out to a mortality rate of 5 per million population.

India in contrast has a case rate of only 0.9 million per million population and a death rate of 0.02 per million. Does this mean that we are doing well for this stage of the epidemic, or is it too early to tell? To analyze this, our weekly update looks at cross country comparisons, our testing protocol and case definitions and the entire narrative on ‘stages of the epidemic’.

Table : Cross-Country Comparisons

Sources:

1. Data for USA testing rates is from https://covidtracking.com
2. Data for testing rates for India, Bangladesh and Pakistan is from Wikipedia
3. Data for testing rates for all other countries is from https://ourworldindata.org/covidtesting
4. Data for dates of 100th case and number of cases since lockdown is from https://coronavirus.jhu.edu/map.html

1. Cross Country Comparisons:

 While the first case in most nations occurred at about the same time,- but as the table above shows, there has since been a big divergence between the experience of the high income countries (HIC) and a selection of relatively high population low or middle income emerging economies (LMICs) (https://www.worldometers.info/coronavirus/#countries)

Between these two groups, the divergence in both incidence and mortality is huge. High-income nations appear to have a much higher infection rate and even a much higher mortality rate. Iran and Thailand are outliers in the middle-income countries group since they have relatively higher infection rates. But they are also known to have more universalized health care systems.

Within the high-income nations too the experience can be very different. But on the whole they have much higher infection rates than the LMICs irrespective of the date of first infection or the date of lock-down. One probable reason is the testing protocol followed (whether mild and moderate cases or all asymptomatic cases are tested) and the capacity to deliver these services, both in terms of test kit availability and access to testing. The more one tests, the more one uncovers positive cases. The alternative to such an explanation is to believe that LMICs on the whole have a higher resistance to the spread of infection. But that does not seem to protect nations like Thailand and Iran who are known for both better health systems and better health sovereignty.

Absolute Mortality rates is a true reflection of the health burden imposed by the disease and here there is a clear difference between the different nations. Case Fatality rates are important, but at this point of time could be misleading. We need to adjust for testing rates and protocols. They could be appearing high in Italy and Spain, and certainly in UK because tests were not offered to many of those with mild or moderate symptoms, whereas in South Korea it may appear low since more persons were tested. We will know for sure only later, when studies measure the total proportion of those who were infected- and calculate the proportion that were asymptomatic, mild or moderately symptomatic, and the proportion with severe symptoms, and fatality.

That being said- after adjusting for testing rates we find that some countries such as US, UK and Belgium have a much higher proportion of positive cases and others like South Korea and Australia have lower positivity rates.

Moreover, even for a certain level of incidence- certain countries like Germany, Scandinavian countries, Japan and South Korea had much less mortality. What we can conclude: One can comment on true incidence of COVID 19 only when testing rates conform to a protocol where ideally a) all symptomatic cases are tested and b) all asymptomatic contacts of COVID 19 positive cases are tested. If the testing protocol fails to test the above, the incidence rates must be adjusted accordingly by modeling or computation, assuming that the proportion between asymptomatic, mild, moderate and severe is the same universally. Similar adjustment is required for commenting on mortality too. However, in nations where accurate cause of death reporting is universal, such as in most HICs and countries like Thailand, absolute mortality rates would also be indicative. However this is not the case in India and the increment mortality that COVID19 may cause, may not be readily visible.

2. Comparisons between states:

The following charts show the number of COVID-19 infections and related deaths across 15 States with the highest numbers (See charts below). Maharashtra has the highest number of infections and deaths.

3. Testing Protocols in India:

          The current testing protocol in India could seriously under-estimate the number of COVID 19 positive patients in India by about 80%. India has allowed testing only for severe acute respiratory infections where a) the age is over 15 years there is fever and one respiratory symptom- cough and shortness of breath AND requires hospitalization; b) OR has traveled abroad c) OR been in contact with a confirmed case of COVID-19 positive case in last 14 days, d) OR any health worker admitted with severe acute respiratory infections (SARI).

Further, it also stipulates that if the history of travel and contact is not there, then only half of those admitted patients would be tested. While this may be good enough for a research study, the hospitalized half not tested actually has an equal chance of having COVID 19 and therefore could infect the entire staff and patient attendees. Further, if there is no increased number of cases- and there is just the same number of cases as was already there in the previous 15 days, no one however serious and typical of COVID19 infection, needs to be tested.

Informally and anecdotally, reports from across the states indicate difficulties in getting it tested even where ICU mortalities have occurred. There is almost an unwritten order within the system to keep the numbers low.

4. Case Definitions in India:

            Current case definitions in use for mild or moderate case of COVID 19 need to be examined. The WHO case definition of a mild case is: “Patients with uncomplicated upper respiratory tract viral infection, who may have non-specific symptoms such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache. Rarely, patients may also present with diarrhoea, nausea and vomiting (3, 11-13)”. The Public Health England definition is even wider. In India however, the case definition emphasizes fever AND cough AND shortness of breath. If there was only fever with sore throat and limited cough or nasal congestion this would not even be considered as suspect.

When by definition all mild and moderate cases are excluded from testing, – we should then assume that prima facie over 80% of all COVID 19 cases will not be picked up and interpret our figures with that important caveat. Our numbers are therefore well designed under-estimates.

5. ‘Stages’ of the Epidemic in India- an ICMR innovation?

In India, ICMR has created a narrative built around epidemic stages, which is widely adopted by the media and now also by very many reputed clinicians who are briefing the media. Indeed, this was first announced in a well-attended media briefing.

The narrative goes like this: India is at stage 2 of the epidemic and this is a manageable stage. A lock-down is meant to prevent it from going to stage 3, which is a terrible stage to be in, where we lose all control and an irreversible and terrible situation has set in. Thanks to our lock-down we are remaining in stage 2 and have been saved from stage 3. Stage 2 is characterized by the fact that we can trace back every case to a case of international travel. This is therefore called local transmission. Whereas in stage 3 we cannot do so- and therefore will be called community transmission.

There are many problems with this narrative. Firstly, WHO does not use such stages nor are we aware of such stages in any major public health texts. WHO does talk of four phases- the third being amplification and fourth reduced transmission- but containment, control and mitigation are overlapping concepts.

Secondly, though local transmission traceable back to an international travel contact is important and may be the exclusive form of case identification in an early stage of the epidemic, it has no relevance at this level of disease incidence. We know that a large number of travelers have entered in whom symptoms develop late, or they were from nations, which were then not known to have transmission. Further there are very many asymptomatic carriers of the disease who will never even know they have it and therefore transmission without a known contact is happening. Indeed such transmission is widely reported, but the government is not willing to give up its narrative, and ad hoc explanations appear- “oh this is only a small minority of patients”, or “we are still tracing the contacts”. That is not the meaning of the term “community transmission”. Further, whether a contact is identifiable or not is also dependent on subjective factors like patient recall, or skill in contact tracing. And then most importantly, we do not allow for testing anyone without contact history- therefore creating by design an absence of evidence to detect community transmission and then touting such data as the evidence for its absence.

Finally there is no big break-point between these two stages. Stage 3 is just as reversible as stage 2 and stage 2 just as likely to continue to generate cases. What matters is the rate of increase of incidence of infection, and if it is increasing exponentially, the action that is required. At this moment we cannot predict in whom the fresh cases are likely to occur, and instead we are tracing back to find out from where they got it. Whereas, we have already reached the stage where the main strategy should be identify all likely cases, isolate, test, treat and trace their contacts for further testing and isolation.

The probable reasons why the narrative of ‘stages’ is being maintained could be the sense of triumph in the declaration of still being in stage 2 and the sense of horror created by the threat of entering stage 3 are necessary to justify and manufacture the consent that is required for this brutal lockdown in India. We could live with this, except for the fact, that maintenance of this false, misleading and irrelevant epidemic stages, leads us to justifying the exclusion of mild and moderate cases from testing and well planned isolation. This is also leading to a huge amount of victim blaming when each instance of the disease can be traced back to some transgressor- where the accountability of the government is only in not being authoritarian enough. Recently this has also taken a communal turn. Governments filing FIRs or taking other action against such offenders follow this, with a large section of media applauding it. On closer examination most such charges are without merit.

Further, these mild and moderate cases are being handled in our regular outpatients as non-COVID ARIs and even 50% or more of our severe and hospitalized COVID 90 patients are being examined and treated by healthcare providers without any personal protective equipment (PPE) whatsoever. Recognizing this, the government has made all symptomatic healthcare workers eligible for testing and further allowed an as yet under-investigation drug Hydroxychloroquine for chemo-prophylaxis- but this is not quite the way to go.

            The call from people’s movements to the government is to drop this narrative of stage 2 and stage 3, and instead talk of immediately initiating the isolate, test, treat and trace- as the main strategy in readiness for the lifting of lock-down on April 14th. The lockdown has bought the system valuable time to prepare for the epidemic and was to some extent inevitable due to the weight of scientific opinion as was available then to the government, but now that we have the experience, and also understand the collateral damage it causes we could review this strategy and learn the lessons so that we do not have to repeat this in the future. We should also stop misleading comparisons we make with European nations which have different contexts and note that our figures are more comparable to much of Africa and the more economically and socially disadvantaged countries of every region.

Part 2. The Lock-Down and its brutality

The other major feature of this week was the lock-down. In sheer scale and scope few nations have seen anything like this. The program theory that justifies lock-down is that the measure of the contagiousness of a disease is dependent, not only on the virulence of the organism which we can do nothing about, but also to the number of contacts between an infected person and a non-infected person. It is an extreme and enforced form of physical distancing.

The lock-down was anticipated to cause economic slow-down, and personal hardships and some curbs on individual rights, but the rationale was that this was the price the country and its people had to pay for safeguarding us from losing anywhere from an estimated 0.5 % to 3 % of our population which could be many millions and if we go by the lower estimates it would still be thousands of deaths.

As expected, the lock-down did cause hardships to all- but very disproportionately. When the lockdown was introduced the hardships presented in the media either related to corporate concerns like economic slowdown, or middle class concerns like inability to buy groceries, boredom, managing with maid-servants etc. In hindsight it appears that there was absolutely no recognition or consideration in policy circles of who the majority of the country were and the conditions of their life. There was neither planning nor messaging related to problems like farmers having standing crops ready for harvest, or fishermen who could not go to sea, or the millions of daily waged migrant labour who live on the brink with no social security whatsoever. The immense tragedy that has followed, in terms of mass migration and hunger, was clearly unanticipated by government. It made clear the real social distance between the ruling elite and the majority of the people. It also made a mockery of the efforts at physical distancing. The large movement of people after the lockdown means that the key objective of the lockdown failed and has in effect rendered it as ineffective. The lockdown has created conditions suitable to transmission of COVID-19 infection. Moreover, the number of deaths due to such distress, hunger, lack of transportation and lack of access to healthcare for other diseases, may in fact be many times more than the deaths due to Covid-19 infections.

The social, economic and human cost being paid by the poor is enormous. Relief measures were not announced in parallel with the lockdown announcement. Two days later the government announced a very incomplete and inadequate package of measures that could not win the confidence of the people or stem the huge surge of migration all across the country, as fearful working people made a desperate bid to get home. Instead of responding with utmost sympathy to this distress migration, and strengthening relief measures, the government response was brutal, insensitive and at the end of the day- ineffective as well.

There are many contenders for the most shameful of the orders passed or measures enacted to prevent this migration and to enforce the lock-down. One example that shocked the nation was that of a group of migrant workers being sprayed with chemicals. Another is the Haryana government order creating temporary jails and calling for the arrest of migrant families walking on the road with luggage and young children as “jaywalkers.” In a series of press releases and public statements the peoples health movements have protested such brutalities and unethical behavior of the state and of communities. (See JSA-AIPSN statement on state obligations during the lock down (http://phmindia.org/2020/03/29/government-responsibilities-during-lockdown/ ) and JSA-AIPSN press release protesting criminalization and use of coercion and violence against the movement of migrants (http://phmindia.org/2020/03/31/press-release-retract-notifications-that-criminalize-use-coercion-against-the-movement-of-migrants/) )

The fear and victim-blaming that was rampant in all official messaging on the epidemic has also led to a huge degree of stigmatization and hatred within communities. One form, which it took, was doctors and nurses engaged in the struggle being thrown out of homes and refused entry into residential areas, as fearful residential colonies locked-down. Another was the hostility shown to those on whose houses quarantine notices had been stuck. Such public naming and implicit shaming and measures like public circulation of names of those who had been on international travel and of COVID patients- all in sheer violation of all ethics related to privacy and confidentiality- did not help the cause of physical distancing (See JSA_AIPSN statement protesting breach of confidentiality and privacy (http://phmindia.org/2020/03/23/jsa-statement-on-breach-of-confidentiality-around-coronavirus-cases/   ) and JSA-AIPSN statement regarding concerns on isolation and quarantines (http://phmindia.org/2020/03/24/jsa-statement-on-concerns-with-regard-to-isolation-and-quarantine-covid-19/  ) ). Clearly the perpetrating authorities were unaware of centuries of public health experience in epidemic management that teaches us how fear and stigmatization lead to families hiding the episodes or illness and circumventing rather than following the requirements of quarantine and physical distancing.

It was not only the migrant workers who were affected but all working people- especially farmers, agricultural labour, fisher folk, tribals, construction workers, sex workers and other unorganized sector workers. The relief measures were often a re-packaging of items already on the budget or very small tokens of relief. The JSA-AIPSN has brought out a statement explaining the inadequacy of the proposed measures at economic mitigation and articulating people’s demands for relief and mitigation (See JSA_AIPSN statement on the economic package announced by FM with respect to COVID19 pandemic and the lockdown (http://phmindia.org/2020/04/02/statement-on-the-economic-package-announced-by-fm-with-respect-to-covid19-pandemic-and-the-lockdown/ ) ).

One important component of this litigation is the urgency to prevent hunger and starvation. The Right to Food Coalition has issued a statement in this regard (Right to Food Campaign- statement on urgent Steps for Mitigation of Impact of Covid-19 on the Poor and Vulnerable during the lock down and coronavirus pandemic (http://phmindia.org/2020/03/20/letter-to-the-pm-demanding-for-urgent-steps-for-mitigation-of-impact-of-covid-19-on-the-poor-and-vulnerable/  ) ). Another important component was the way the lock-down hurt access to essential healthcare services. Partly this was due to lack of transport, but in part because essential health services were shut down or diverted to make way for services to address the epidemic.

The JSA has documented the crisis in access to essential health services due to the lockdown and written to the government demanding that such services must be continued through this period, with special arrangements made for the sick to access services during this period (See JSA-AIPSN statement on lockdown and suspension of essential healthcare services (http://phmindia.org/2020/03/27/statement-against-closing-essential-health-services-during-lockdown/) ).

We also note that among working people themselves and in civil society there are also outstanding individuals and organizations who have come out, sometimes at great risk to themselves to help those in such great distress. These have to be built on- but cannot substitute for the obligations of the government under a lock-down. Individuals have obligations which most follow to the extent it is feasible for them- but the big question we ask is whether the government is able to fulfill its obligations. The JSA and AIPSN have released a number of statements that highlight the consequences of the lock-down and immediate action that government must take to ameliorate this crisis.

Part 3. Do lock-downs work?

One of the big questions that have arisen is whether lock-downs work. Firstly it must be noted that much of the scientific justification for lock-downs lies in a combination of mathematical modeling and the assumptions it makes as well as expert opinion. There is very little hard evidence. The problems with the models are many.

Most models never factored in the social costs and collateral economic damage and reduced access to health care. None of the models even attempted to model for equity and the differential impact that a lock-down would have on different sections of society in different nations. The working people in a nation where most of the workforce is in the organized sector, where universal healthcare is a reality and where social security covers all sections like the North European and Scandinavian nations, is clearly less likely to suffer such damage as compared to a nation like India, where most of the workforce is in the unorganized sector progress towards universal health care is minimal and where for the vast majority there is no social security. It is not only economic outcomes one is worried about- it is also health outcomes. Of course most of the increased mortality that would result from the lock-down will be on the poor, whereas at this stage of the epidemic, arising as it is from international travel and their contacts a major part of the morbidity would be on the more affluent. Had all of this been factored in, the least the experts could have done, was to give a week time for people to get home and better arrangements to be made. The logic of announcement of demonetization or an enemy strike is one thing, but the logic of shutting down all of people’s social and economic life is quite another.

Models also never factored in how the epidemic plays out in different context of immunity, vulnerability and virulence. They also did not factor in what would have happened in scenarios where the lock-down was more focused on hotspots and vulnerable sub-sections like age, and the identification of these hotspots guided by testing. Finally, the reasoning for the lock-downs has not quite figured out what happens after a lock down is lifted, the number of days the infection will take to reach back to the same level of spread as now.

On the other hand there is clearly one major benefit of the lock-down that there is a consensus on- that it flattens the curve- i.e. delays the peak of the epidemic and prevents a huge surge of cases giving time for health systems to prepare themselves. Even on this, we need to keep an open mind- since in practice the level of physical distancing achieved may be negligible because of the problems of implementation and because preparation in such short times is really not feasible. If South Korea and Japan and Germany have done better, these were precisely the three nations who had the technological capacity to scale up testing based on indigenous capacity plus also had the highest bed to population ratios and ICU bed to population ratios even within the developed world.

The best time to have started preparation was actually at least 15 years back- but failing that, the next best time would be now.

Given these very many uncertainties about the benefits of a lock-down and the very certain ill-effects the least we can do is to measure its effectiveness and in a gradual and phased manner, starting now, lift the lock-down and make arrangements so that it is not needed again after 14th April.

Part 4. Health system preparedness:

Irrespective of its narrative on stage of the disease or the effectiveness, health system preparedness to meet this pandemic is essential.

We note that there are several major very welcome developments in this area- and we list these below:

1. The finance minister announced a fund of Rs 15,000 crore to strengthen the health systems to meet this challenge. This was much needed. Such an amount should anyways have been part of the annual budget, in fulfillment of the government’s own policy commitments to the health sector. But given the fact, that this is coming after years of under-financing, it would be inadequate to close the gaps. Further, much of the strengthening of health services- whether it is by hiring more human resources or by increasing ICU beds and ventilators cannot and should not be seen as a transient measure. What would have helped and could still help the state governments in utilizing this amount effectively, is a clear commitment by MOHFW to retain this amount in future budgets as well.
2. The government has sanctioned three companies last week for production of test kits for COVID2. These three promise to reach a capacity of about 30,000 kits per day. Another 11 companies were in the queue for approval, and by now are probably approved. But some of these are importers and importing now may be impossible. The government aim is to reach a testing capacity of 60,000 per week, which may seem a big target now, but in practice is still too low. The way forward would be for the government to support private companies with both financial resources and imported technical support (perhaps from the South Koreans) to accelerate indigenous production to close to 1 lakh per day, and bring the costs down to Rs 300 per kit or less. With the availability of kits, hopefully the protocols for testing would be changed. However by the time of the lockdown we may reach only about 30,000 kits per day. As we go to release this we have disturbing news of a crisis in the availability of reagents. Though the government action on this has been very delayed, it is welcome, There are many concerns regarding the impending severe shortage of APIs for essential drugs, issues of Intellectual Property Rights related to new drugs , medical kits and vaccines and on the government’s approach that the JSA, AIPSN and AIDAN have written to the government about (See JSA-AIDAN_AIPSN letter to prime minister on scaling up access to free testing and treatment for COVID 19 (http://phmindia.org/2020/03/25/letter-to-the-pm-addressing-issues-of-scaling-up-access-to-free-testing-and-treatment-for-covid19/ ))
3. The government has passed an order stopping the export of ventilators in the second week of March. Further it has placed an order for 10,000 ventilators to become available before mid-April and another 30,000 to become available in one more month. The government has taken note of some private hospitals to buy and hoard ventilators and of private companies to sell at higher prices to them. Ventilators must be now declared an essential commodity, and government should ensure proper allocation and deployment of these as and when they become ready. We note that 40,000 ventilators in a month is optimistic, especially when the orders are yet to be finalized, but here the government is on right track.
4. The government has identified a number of sites in larger cities; largely student hostels, guest houses, and sports facilities, which it can use for quarantine and potentially for isolation of COVID 19 patients who do not need hospitalization. We have no clear information about how many such student hostels and sports facilities have been so requisitioned.
5. The government has also identified one or two hospitals for each cluster of districts that can be brought under a public authority for exclusive use in management of COVID 19 severe cases and critical care. In some large hospitals it has identified wards and/or sections of the hospital for such use.

6. The government passed an order stopping export of personal protective equipment (PPE) in early February. Since then it has placed an order, including emergency imports for PPE through the government owned company HLL Lifecare limited. It is also in the process of giving sanction to Indian manufacturers of the same. Though these are steps in the right direction, we have concerns about the adequacy of these arrangements, on which we have written to the government. This could be another major bottle-neck. This could also be contributing to the pressures to identify less number of cases. The JSA-AIPSN will be writing to the government in this regard.
7. There are many areas where many states are not making enough efforts. Only one or two states have made moves to address the gaps in ambulances and patient transport systems that would be needed. Many states have large gaps in human resources and in supply chain management systems that they are not addressing. Training is also behind schedule in most states. Most states have also not begun efforts to prevent hospital acquired COVID19 infections. The JSA-AIPSN has written to the government on many of these gaps in health system strengthening and what corrective actions that states must undertake as a priority (See JSA-AIPSN letter to government on health system preparedness (http://phmindia.org/2020/04/03/letter-to-secretary-health-which-encloses-our-statement-on-health-systems-preparedness/ )). We are also monitoring the efforts to rapidly build up health systems and collecting more details on ongoing health system preparedness as happening in the states.
8. In conclusion, though in denial of the extent of spread and very delayed and inadequate in scale in preparedness, this last week has seen a series of policy initiatives that address most requirements for health systems preparedness, backed by the funds needed to achieve this. There is also rise in seriousness across states though some states are still slow to begin, or focused on only one or two dimensions of preparedness. An useful collation of orders by state governments (including state Health Departments) is being updated and made available here covid-india.in
9. One priority area where the plans of the government are not clear or consistent is the strategy for mild and moderate case who could be as much as 20 to 30% of the entire population. Even if we assume that these patients are in homes due to the lock-down, as soon as lock-down lifts, those they have infected would be moving freely in the population- and their family members and primary healthcare givers would be unaware and unprotected. This would be a major source for spread of the infection. Our suggestion is that there must be an intensive effort, with help of community and voluntary team to identify all those with mild and moderate symptoms, test them for the disease, and if positive offer institutional isolation to them. Only if they are in a position to practice home isolation effectively or if in that district it is not possible to arrange institutional isolation should home isolation be preferred. For such a strategy there is are two requirements- (a) expand access to testing, and where possible try to organize sample collection from home in response to a call to a help-line call (with all necessary safety precautions) or for patient transport to designated sample collection centre. And (b) identify a large number of spaces that could be considered for institutional isolation and plan the systems required to set these up and manage them when the need arises. If the government is not ready to undertake this, we must understand that the government is opting for a strategy where the majority get infected and recover, giving rise to herd immunity, while government only takes care of the very sick. But if that is the plan then such a huge all out lock-down should not be resorted to.
10. We are also concerned about some recent reports of strategies of containment that have no basis in evidence or the science of public health. One such innovation is to define a 5 km radius around a COVID-19 hotspot as a danger zone and a further 3 km as buffer zone and lock down everyone within these zones as well as universal masks etc. This appears like another whacko modeling effort gone wrong, where physical distance is being interpreted literally and not along the lines of a social distance defined by the economic activity and production and social relationships in that area. When efforts are made at modeling, there is an urgent need to see that there are social scientists and public health expertise as part of the team.
11. One area where innovation would help is point of care diagnostics to identify those who are immune to the disease and no longer infective- for these would make much more effective volunteers, requiring less protection and be able to serve in the different frontlines. If the epidemic plays out as per current projections the government is going to require a large number of volunteers.

Part 5. The Response from Peoples Movements and Communities:

1. This week has also seen the build-up on a major response across people’s health movements, people’s science movements, women’s organizations, trade unions and associations of working people, civil society organizations and community based organizations. These organizations have also sought and got support from a number of progressive intellectuals and scientists and public health experts.
2. The JSA and the AIPSN have been holding consultation on Skype and have tried to understand the developments, critically review and in consultation with domain experts brought out a number of papers and statements that can inform their own membership and the general public. They have also articulated demands for better COVID 19 control and for better mitigation of the social and economic costs of the lock down through a charter of demands and a number of press releases and petitions to the government.
3. In addition to these statement, the JSA and AIPSN have launched campaigns to inform its own members and the general public of the dangers from this epidemic, how to keep the community, themselves and the public safe and to counter fake news, stigmatization and victim blaming messages that emanate both from sections of the government and communities. (See PHM Advisory for Families and Communities, and PHM FAQs on the COVID 19 pandemic (http://phmindia.org/2020/03/28/advisory-for-workers-cleaning-hands-in-low-resource-settings-and-protection-in-crowded-places/ ). There are also short videos and WhatsApp posters that are available.)
4. Because of the lock down, extensive field level mobilization and community support action has not been possible, though in many states, organization who are part of this network are engaged in organizing community kitchens. Once the lockdown lifts, a major effort at social bonding and mobilization to counter hate campaigns, and provide support to affected families and communities, is being planned.
5. We would be sending this weekly update along with a special press release that would  a) demand a review of the lockdown and an phased withdrawal of the same; b) an acceleration of work in preparing the health systems for the epidemic through a more comprehensive approach and c) a call for much more participatory and less authoritarian approach to controlling and mitigating this pandemic.

For further information, please contact:

T.Sundararaman – 9987438253

D.Raghunandan – 9810098621

Sarojini N. – 9818664634

Sulakshana Nandi – 9406090595

Follow for regular updates:

Website www.phmindia.org  www.aipsn.net

Twitter @jsa_india

Facebook @janswasthyaabhiyan

11-JSA-AIPSN statement on PPE_v1

On the Personal Protection Equipment (PPEs) for Healthcare Workers in the Light of Increasing Numbers of COVID-19 Patients

Joint Statement by Jan Swasthya Abhiyan and All India Peoples Science Network

The JSA and AIPSN draw the attention of the public and the media to the major crisis that has developed in health worker safety due to the lack of PPEs. Not only will the healthcare staff be at higher risk of getting the infection, widespread infection in healthstaff would sharply decrease the capacity of the country to delivery health care services in both the public and private sector. 

The greatly increased need for PPE: 

 COVID-19 cases are growing in India with every passing day. It falls on the frontline healthcare workers to treat and care for them. However, the lack of proper protection in the form of Personal Protective Equipment (PPE) is preventing health workers to make effective interventions in the containment of COVID-19. It is putting lakhs of health workers including sanitation and other frontline personnel tasked to treat patients and clean premises of health facilities and other public spaces at the risk of contracting the virus.  

Healthcare workers across the spectrum have been hit by the lack of masks, gloves and gowns. Four thousand Community Health Volunteers (CHVs) in Mumbai have been directed to search for suspected COVID-19 affected patients without being given enough protective gear and sanitisers. We have learnt about instances in private hospitals where the nurses are working in Intensive Care Units (ICUs) without masks and where the private hospital is treating Severe Acute Respiratory Illness Patients who have not been tested for COVID-19.  

We are also privy to many reports that any doctor or nurse managing any general out-patient  unit anywhere in the nation is now at increased risk of getting exposed to COVID 19 patients and developing the disease- since mild and moderate cases are not identified and isolated in India’s approach to managing the epidemic. Indeed the past week has seen an alarming increase in healthcare providers who are so effected

 The doctors across India have been demanding PPE to go ahead with their work uninterrupted. The fact of their higher risk for infection, instead of bringing support has often exposed them to violence and hostility as sources of infection into the community. On 21st March, Doctors Association Kashmir sent a letter to the advisor to lieutenant governor of the UT of Jammu and Kashmir citing acute shortages of personnel protection gear especially N95 Masks, PVC coated gowns and goggles. There are similar reports from all states. 

As the spread of COVID-19 increases, providing PPE at all levels of care – community as well as hospitals , to those seeing COVID patients and those managing general patients– is of paramount importance.   And to rationalize the use, those at higher risk like those collecting samples or those in the frontline of care provision have far more extensive and stringent requirements of PPE as compared to others. 

Unpreparedness of Indian Hospitals for Infection Control: 

The Indian healthcare system has long neglected infection control in its health facilities. Studies show that not more than 20-30% of hospitals have Infection Control and Prevention (IPC) guidelines in place. Fewer follow them diligently. After SARS epidemic and then due to the increased focus on antibiotic resistance and drug-resistant tuberculosis, IPC started to gain currency in policymaking circles with ICMR and NCDC revising their guidelines for hospital acquired infections. 

Despite the guidelines, hospitals have never invested in procuring PPE for their staff, letting them suffer on the way. COVID-19 has brought this historical neglect to the fore. Had the Indian health system been investing in protective gear for its staff from before, we would not be facing the crisis to the extent that we do today. 

Delays, and inadequacy of government efforts on  procure PPE : 

The role of the government over the past two months is also baffling.. The first case of COVOD-19 was registered on 30th January in India. Taking cognisance of the seriousness of the issue, the government issued an order prohibiting export of all PPE. But it was amended on 8th February allowing export of surgical masks and all gloves except NBR gloves. The restrictions were further relaxed to include more items on 25th February. 

TheWHO issued an interim guidance regarding PPE on 27th February noting that there is going to be a global shortage of PPE and hence came up with a document on its rational use. Taking cue from this, the government should have moved fast to prohibit export of domestically produced PPE and raw material so as to ensure its availability in the country. But that order came only on 19th March. 

Current government efforts at procurement are far too little, and very late, making it unlikely that we would have adequate PPE anytime soon. The government has placed the order of 7.5 lakhs body overalls to be supplied by May. However, the need could be upto 5 lakhs of body overalls a day. Similarly the order of 60 lakh N95 masks and one crore three ply masks will be grossly inadequate in the current scenario. 

Barriers to scaling up production: 

We also understand that there are many constraints to scaling up of production  to desired levels. A few of the PPE components are not manufactured in India and there is an import dependency. Also, there is shortage of the required raw material in the country making increased manufacturing a problem. Further there is is disruption of supply chains, making  the availability of these equipment from import markets difficult. Now when the orders are placed, many manufacturers find that due to the lock down immediate procurement of raw material or hiring and deployment of labour are both very difficult. 

Part of the barriers are in the past and relate to our economic liberalisation program, which  has eroded the manufacturing base of even low technology content products and created import dependency. Though our potential capacity in required technology, in our hour of need, we find that our past policies have compromised our self reliance in this secor, and therefore oour health security. Considering the huge demand from many countries for PPE India cannot depend on the import to meet its demands. Therefore the government has to scale up the production and maintain this in the future also

Recent Welcome Moves to address the crisis: 

We welcome the letter of NPPA to all states to find out the inventories and available production capacity. During the initial days there was no mechanism to find out the inventory and manufacturing capacities existing in the country. 

We also appreciate the government’s effort to place PPE components like mask and hygiene product like hand sanitisers and the raw materials for their production as essential commodity and imposing price control over them. However, it  is important to ensure uninterrupted supply. While the export restrictions are an important step to ensure the domestic supply, it is also important to enhance the production capacity to also supply to many countries who are in need of these products. However, such export should be at the government-to-government level to avoid profiteering at the cost of public health and also to ensure domestic supply.  

To fulfil its needs the government has placed a number of orders and is is now supervising the manufactures, 

More steps  required to achieve required production capacity. 

However the number and output would be very low compared to the demand.. To close this gap, government should instruct select large scale manufacturing companies to start production of the important elements of PPEs. Further, though specificiations are provided, government would also need to transfer designs and other blue prints to new actors to initiate manufacturing. Further, government should directly procure these specified raw materials and supply to the end-product manufactures who are supplying the government. These steps  would be urgently required to enhance the efficiency in the supply and production of PPE. 

Re-examine specifications:

Another important issue we noticed is that the Indian PPE requirement specifications as well as guidelines for use are higher than the WHO prescribed standards. We are afraid that such higher standards would create scarcity of prescribed PPE and result in the failure of the real purpose. Another important issue is the guidelines to be framed for the reuse of Hazmat Suits after autoclaving. At the moment the supply is limited to disposable PPE kits which are in limited supply. The government should set up an expert committee to arrive at these specifications and guidelines which are more conducive to the Indian context and to meet our immediate needs. The expert committee should be tasked with constantly revising the decisions as new and better data arrive. We have done some preliminary exercise in this regard that we can share on request. 

To increase production of PPE and ensure safety of healthcare workers, we make the following demands from the government: 

1. Urgently ensure availability and free supply of PPE to all health workers. directly or indirectly providing care for COVID 19 patients at per their level of risk.  Towards this end government should revisit its specification and guidelines for use. 
2. Private hospitals should be directed to follow the guidelines and not put their staff at risk.
3. Include all health workers seeing general outpatients as also at higher risk due to unidentified mild and moderate and even asymptomatic cases in circulation and develop recommendations on PPE for them.
4. Scale-up the production of PPEs within the country. Government should identify the products that are not currently manufactured in India and within a short deadline seek proposals and technically and financially support the manufacturing of those components in a decentralised manner so all states have at least one manufacturing unit. 
5. In order to enhance the number of manufactures, government should publish the designs and blue prints along with the specifications and  convert largescale apparel production firms to start the immediate production of PPE components. 
6. In order to expedite the procurement and supply of PPE equipment, government should involve more public sector establishments.  Currently, the government has given HLL Lifecare Limited, a government-owned company, rights for procurement of PPE. Approval for more public sector institutions in the procurement would speed up the procurement and supply. 
7. Issue guideline for the appropriate disposal of PPEs used by health workers as well as face masks that public use 
8. Ensure transparency with regard to the procurement prices and suppliers and the number of procurement.  
9. Set up an Expert Committee to establish PPE requirement specifications as well as guideline for use in the Indian context. Its role should include constant revision in light of new and emerging data.

08 JSA advisory on health systems preparedness Apr 2 v1

From Jan Swasthya Abhiyan (JSA)                                                                 April 2, 2020

&

All India Peoples Science Network(AIPSN):

To

Secretary,

Department of Health & Family Welfare,

Govt of India, Nirman Bhavan,

Dear Sir/Madam:

Subject: Advisory to State and Central Governments

On strengthening health systems to manage the COVID 19 pandemic

Please find enclosed a detailed note prepared in a participatory and consultative manner by a number of organizations and concerned citizens who are part of our network of civil society organizations and peoples movements

We note that the country is going through a lock-down which has brought immense hardships to the majority of the people. The only justification for such suffering is to give time to the health systems to prepare for the oncoming epidemic.  We have noted the significant number of measures that government has announced to step up the supply of testing kits, and PPE and ventilators, but we are worried that it would be little and late.

From our interaction at state level, we are deeply concerned that the preparations are patchy, slow, and selective. In our enclosed advisory, we have put together the very many aspects on which all state governments and the state governments needs to take immediate action. We demand that urgent action be taken on each and every one of these suggestions. We also call on you to include representatives of our organizations in monitoring the pace and comprehensiveness and quality of preparation.

We are also releasing this statement to the media so that they can also be informed on what, in our view, requires to be done. This would promote early identification of gaps and this would strengthen the effort at preparation.

We are also issuing an advisory to people and communities on what they require to do to protect themselves and to be of assistance to frontline staff of the department and all others who are working in partnership to help combat this epidemic. We would also be working to ensure social solidarity in this time of crisis.

T.Sundararaman

Sulakshana Nandi

N. Sarojini

D. Raghunandan

On behalf of  JSA and AIPSN

Advisory to State and Central Governments

On strengthening health systems to manage the COVID 19 pandemic

INTRODUCTION:

The lockdown implemented across the country only buys the government time to prepare the health systems for the coming epidemic.  As, informal workers and poor people are paying an immense price in terms of suffering and even deaths; the urgency and moral obligation to prepare each state’s health system is even more.

We in people’s health movements, people’s science movements and in all movements of working people are seriously concerned by the lack of clarity on what is required in terms of preparation. Different state governments are prioritizing one or another aspects, failing to address the rest. We therefore call on governments to take immediate note of all the elements of preparing health systems that we list below:

These are based on the March 25th, 2020, briefing of the Director General of World Health Organization:

“ We call on all countries who have introduced so-called “lockdown” measures to use this time to attack the virus. You have created a second window of opportunity. The question is, how will you use it?»

The six key actions that we recommend are:

1. First, expand, train and deploy health care and public health workforce;
2. Second, implement a system to find every suspected case at community level
3. Third, ramp up the production, capacity and availability of testing;
4. Fourth, identify, adapt and equip facilities to manage risk, treat and isolate patients;
5. Fifth, develop a clear plan and process to quarantine contacts;
6. And sixth, refocus the whole of government on suppressing and controlling COVID-19.

These measures are the best way to suppress and stop transmission, so that when restrictions are lifted, the virus doesn’t resurge. The last thing any country needs is to open schools and businesses, only to be forced to close them again because of a resurgence. Aggressive measures to find, isolate, test, treat and trace are not only the best and fastest way out of extreme social and economic restrictions – they’re also the best way to prevent them

The eight measures we set out before are what state governments must do in the immediate to achieve the above objectives:

• Arrangements for Testing
• Arrangements for Isolation and Treatment of Mild and Moderate cases
• Arrangements for Treatment of Severe Patients and for Critical Care
• Addressing Human Resource Requirements
• Addressing Human Resource Rights and Safety
• Ensuring Supply Chain Management
• Ensuring Ambulance and Patient Transport
• Engaging community Volunteers

• Arrangements for Testing:

1. Expand testing protocols to include all patients where the health care provider thinks it to be a clinically suspect case of Covid-19, based on clear, scientific standard protocols. This is required for both public health planning and because everyone who tests positive must be isolated. This is central to control of the epidemic – now and in the future. Denying testing to those with mild symptoms is a failure to isolate the main sources of infection and any amount of physical distancing will not make up for this. We note that he rate of testing in India is very low at around 20 tests per million compared to about 7000 tests per million in South Korea[1]. Though India has much less resources, there is clear need for very rapid increase in the number of tests being done.  The main reason for this is restricting testing to contacts, foreign travel, which means that by protocol we are excluding the majority of COVID-19 patients who are mild and asymptomatic. This is leading to a false complacency as well as many clusters of infection growing unnoticed. It is also leading to all healthcare providers, even those not addressing COVID19 specifically getting infected. It is also required to guide areas where case searches and preventive measures have to be intensified.
2. To achieve the above, hospitals need to ensure designated collection centres of samples in every district or preferably in every block. Immediately identify and train the concerned personnel in using PPE and collecting samples properly.
3. Consider small mobile teams with adequate training and appropriate PPE collecting test samples from home in symptomatic patients in response to a phone call to a designated number. This will reduce infection when they come by public transport to the facility, and reduce infection at the facility when they wait to be tested. One possibility that the government can explore with due precautions is to use a number of volunteers who have recovered from the disease and therefore immune. To be safe they should have been tested to ensure that they are positive for antibodies and negative for the virus. Where distances are very big, and public transport very crowded this may be the only option.
4. All testing must be free. All test results should be uploaded to an open repository with due care taken for privacy considerations. This will ensure that the test results can be checked publicly. A number that is linked to them could identify patients. So repeat testing can be followed up. Charges are to be considered only if the patient has come out of own accord with a doctor’s prescription for the test. Even that can be allowed only when the availability of test kits becomes much better than it is now.
5. The testing protocol should ensure that all suspect mild moderate and severe cases are tested, and the necessary testing kits, equipment and reagents for this should be available. Asymptomatic contacts of COVID19 patients should also be tested on the 5^th and the 14^th day of the contact- but this could be included only when necessary test kits to test the symptomatic patients are in place..
6. For the purposes of surveillance all these testing results should be anonymized, aggregated and reported to a central and state authority. In addition carefully selected surveillance sites should test a well drawn sample of the entire population to monitor true infection and case fatality rates, as well as the development of immunity. Antibody tests which are available would also be essential to test for asymptomatic infection and herd immunity.

2) Preparing for the Management of Mild and Moderate Cases

1. In many nations there is an effort to hospitalize all mild and moderate cases so as to ensure good quality of isolation. Considering the large numbers that will be involved, private nursing homes, hostels and hotels will require to the requisitioned to serve as isolation hospitals. These are «hospitals» from the perspective that their occupants are sick persons, requiring a basic level of care that nurses and paramedics could provide. However some supervision by medical staff is required to identify those turning severe and referring them early.
2. District administration should therefore earmark and prioritize the order in which beds would be requisitioned and deployed – for the first 100 patients, and then in further increments of 100. We note that there are plans to convert railway passenger trains into isolation center. Though as a desperate measure this may be a good idea, the average period of isolation would be anywhere from 10 to 14 days- and a railway compartment would be very restrictive. The recruitment of sports facilities and hostels and guest homes and hotels would be preferable.
3. In districts where the public and private sector capacity to do this is weak, some of these centers could be managed by civil society organizations or local community based organizations or local self-government institutions- like municipalities and panchayat. These are then community managed institutional isolation sites with largely supportive care- food, water, symptomatic medicines, being organized and isolation being enforced.
4. In all the above situations the working staff, should have adequate PPE.
5. In many nations in the world even this has not been possible and home isolation has been resorted to. This is easier in middle class and privileged populations where housing has the necessary space. But in all circumstances it would require to be backed by good outreach services and monitoring.
6. There should be a helpline in every state where people with symptoms can approach and be guided for whether to test, where to test, and transport for testing and/or isolation.
7. The current approach of de facto denying the very existence of mild and moderate cases through a calculated strategy of non-testing and inaction will drive the epidemic forward.

3)            Management of Severe Cases and those requiring Critical care and ventilatory assistance:

1. For severe cases with signs of pneumonia confirmed by X-rays, hospitalisation should be ensured. Dedicated wards in existing health facilities should be utilised for this. In all such wards oxygen should be available, isolation should be possible and working staff should have PPE. Oxygen concentrators and pulse oximeters and consumables as required for acute respiratory illness with respiratory distress would also be needed in adequate numbers. Managing oxygen supplies is often a critical bottle-neck and this must be attended to.
2. For critical cases, given the high requirement in skills, equipment, PPE and isolation it would be preferable to centralize management of severe and critical care patients in a dedicated COVID-19 hospital. Either requisitioning or recruiting a private sector hospital, or using a public hospital should achieve this. The existing caseload in that hospital should not be left without alternative. This is a reason why, in many states, a large under-utilized private hospital would be best commandeered. In many nations, entire hospitals have been built at short notice. This is may be required in some of the northern states where both public and private infrastructure is most inadequate.
3. When planning for critical care and ventilators, we suggest a norm of one such bed and ventilator for about 30,000 population. However the requirement may increase if there is a surge (the curve did not get flattened) or where a big cluster of cases got established. It would decrease if there is higher mortality rate (about 90% of those on ventilators dying within two or three days) and increase if survival is better (patients may need 10 to 20 days of ventilator support). Sharing of such ventilators is possible to a limited extent. Efforts should be made to prevent the spreading out of ventilators across multiple hospitals. Ventilation in this disease requires a much more sophisticated equipment and a higher level of training. Ventilators should be pooled in one or two hospitals identified as nodal hospitals to treat COVID 19 patients. In cases where ventilation is required, we caution that any ventilator will not do.

1. For the overall management of all COVID 19 patients in a district or a cluster of small districts, there should be one medical command centre for ensuring the preparation and allocation of resources, creating the necessary beds at different levels of care and allocation of patients accordingly. Proper guidelines should be set in place to prevent nosocomial or hospital-acquired infections. Care should be taken to ensure the separation of COVID-19 cases from routine patients in all health facilities.
2. The orders required for requisition of private hospitals and nursing homes for isolation and treatment when the need arises should be issued now. Clear guidelines on costing, administration and treatment protocols should be laid out and finalized as soon as possible and before a crisis situation emerges.
3. All treatment should be free. A few private hospitals that are undertaking COVID-19 care on their own, can be permitted to do so but treatment fees should be capped.

4) Human Resources for Combatting the Epidemic:

1. To close the gap in human resources – the first and most immediate measure is to immediately fill existing vacancies by employing those who have applied for employment and are waiting at different stages of recruitment. Online interviews and video conferencing, as done in Kerala, is a feasible option. Those employed on short-term contracts and contracted through third party agencies are at risk of discrimination with regard to access to personal protective equipment, leave and other safeguards. Additional care has to be taken to ensure that they are involved and/or covered by all the necessary procedures.
2. Put in place on-line training programs on COVID 19 for the entire medical workforce in the country, facility based training for the entire workforce in the each facility, including ASHA and community-based health workers attached to different health posts.
3. The medical professional at the nodal hospitals should be given training to manage ventilators in case of Acute Respiratory Distress Syndrome (ARDS) arising out of COVID 19 infection. Web-based training is a start- but on the job mentoring by experienced domain expertise would be required.
4. The entire staff in all COVID-19 earmarked hospitals, ICU units and isolation centers should have proper training and this should include both guidelines and protocols for COVID-19 care, as all as personal safety, infection risk management and the use of personal protective equipment. The government should provide guidelines for these procedures to be followed in private facilities.
5. For work such as contact tracing, outreach support to those in home quarantine or isolation, develop a policy of health care auxiliary workers- not only ASHAs, but also including volunteers.
6. States should ensure that the logistics to supply equipment and material for hospitals and health centres is not hampered due to the lockdown.

5) Ensure health workers rights and safety

1. The rights of all health workers should be protected. Wages should be provided as per existing government norms, and extra hours remunerated as per the law. Considering that health workforce in private facilities will also be involved in responding to the epidemic, and facing higher risks that what health workers face in their usual settings, state governments should ensure compliance with the Supreme Court Recommendation related to wages in private healthcare facilities In many situations a special risk allowance could be considered. Special paid leave in case of Covid-19 related sickness and quarantine should be provided, including to workers on short-term contracts and employed through a third party.
2. Health workers undergo considerable stress during this period. Therefore counseling and mental health support should be made available. Breaks and time-off should be maintained, as healthcare workers’ burnout aids spread of virus. Health workers displaying Covid-19 like symptoms should not be asked to continue attending to work. Health workers’ right to opt out of work when they are not provided with a safe working environment and adequate protective equipment should be respected. Health workers working in high risk areas, such as isolation wards, have to be provided the option of adequate hostel accommodation so that they can avoid going home where there are old relatives or young children whose health they are concerned about.
3. For health worker safety adequate availability and training to use the necessary Personal Protective Equipment (PPE) is essential. These guidelines should be clearly displayed and followed. Those who refuse to work because of violation of these guidelines should not be penalized. These guidelines should apply and their implementation monitored in private health facilities too A monitoring system should be put in place so that health workers can raise concerns about violation of guidelines and action taken accordingly by the relevant government.
4. Maintenance of and adequate supply chain for PPEs and safety equipment for health workers is one of the key challenges before governments and they should be held accountable for this. Government of India should examine the feasibility of its rigid criteria for PPEs and adopt the more practical, yet adequate, WHO guidance on the same. The inability to follow unnecessarily
   demanding guidelines should not become an excuse to avoid strict implementation of the WHO guidance (see PHM Advisory in this regard).
5. Training should be given on infection risk management and on how to use PPEs. All health workers should be provided with communication materials on the use of PPEs. Guidelines should clearly mention as to who are at what level of risk and the adequate PPE requirement for different workers. The government should engage with trade unions of health workers to ensure that the guidelines effectively reach = all concerned health workers. Facility management should facilitate an active role of health workers’ representatives in determining safety measures and safeguards of their health.
6. Free access to health care for health workers dealing with the Covid-19 outbreak, even in events that do not lead to hospitalization, has to be ensured for all health workers, including those working in facilities under the central and state government, but also municipal and local bodies, in the private sector, and health workers with informal employment conditions.

6) Supply Chain Management:

• The pandemic management is going to require a very high degree of efficiency and time-lines and quality controls to ensure that the necessary testing kits, medicines, and PPE are available where they are needed, when they are needed, and in adequate quantity and quality.
• States like Tamil Nadu, Rajasthan and Kerala have already robust systems in place for doing this, but even they would find it difficult. States, which have not established such systems, must immediately put together a state level authority, which can manage this using the guidelines from the exemplar states. In consultation with center, where the funds are from the center, procurement procedures must be simplified to meet the situation.
• Given that manufacturing capacity is the key bottleneck, both states and center should set up task forces which will look at the choice between manufacturing within the state and/or purchasing from outside, make forecasts of the requirement, identify and address potential barriers and then place orders well ahead of the peak of the epidemic. The center has to ensure that patent and trade barriers do not come in the way.
• Ambulances and Patient Transport:
  1. There would be the need to designate some ambulances with advanced life support for shifting patients in need of ventilation and many other patient transport vehicles for shifting patients suspected of COVID 19 for testing, or of confirmed cases for hospitalization, isolation etc.

1. The number of ALS ambulances and patient transport vehicles required would vary with the surge and clustering of cases. Norms can be developed. In states where the number of public ambulances under the 108 and related services is well below requirements, order for more ambulances should be placed NOW.
2. Mechanisms for sterilization of the ambulances, training and low risk PPE for drivers and training with high risk PPE for accompanying emergency technicians, should also be put in place.

8)            Community Volunteers and Community Participation.

1. Ensuring community participation is essential. We will need volunteers to do surveillance and tracing. These volunteers can be enrolled from within the community or through community based organizations.
2. People who are discharged after COVID-19 treatment can be a useful resource and they should be encouraged to volunteer. They will be able to help in home isolation and their experience of encountering the disease will help in changing the perspective around it. They would also help in tasks like institutional isolation, home and institutional quarantine, contact tracing. Some of them, especially if from within the health workforce could be useful for testing.
3. The availability of antibody testing for past infection and immune status is expected to become available. Given the way we have managed mild and moderate cases, this “individuals who have recovered from infection” may be useful asset as community volunteers.
4. Community Organizations would need to be deployed widely for many tasks including relief and welfare measures to reach most the vulnerable sections, management of home and institutional quarantine, monitoring of human rights issues, campaigns against stigmatization of the disease and public education, as required.

In conclusion:

The State and district level units of peoples health movements and peoples science movements and of a wide variety of civil society organizations and trade unions and workers associations stand ready to help the government and communities in combatting this pandemic and the humanitarian crisis that both the pandemic and measures to contain it have led to. The government must make use of this resource.

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                        ^[1] https://www.icmr.nic.in/