Hyderabad: The speed and rapidity of the COVID-19 pandemic has deeply challenged the capacity of every country in coping with enormous increases in health service demand and access. Most countries have introduced at least some nation-wide measures aimed at containing the spread of the novel coronavirus pandemic. These include stopping/limiting international and domestic movement, closing educational facilities, banning public gatherings or enforcing quarantine, promoting handwashing and mask-wearing to name a few.
In addition, each country has responded – or is responding – to the COVID-19 threat with different measures and/or with different timings. This has resulted in variations in managing infection rates, differences in the epidemiological curve and in the societal and economic costs. Since different nations have different reporting standards, different healthcare capacity, different approaches to testing, and different approaches to tracing cases, one must exert caution in making general comparisons between them which can be misleading.
To enable more precise and targeted measures that are needed to stop transmission and save lives in both short and long term the WHO recommends six strategic actions which include:
- Expanding, training and deploying healthcare and public health workforce
- Implementing systems to trace every suspected case at the community level
- Ramping up capacity and availability of testing
- Equipping facilities to treat and isolate patients
- A clear communications plan and process to quarantine contacts
- Maintain essential health services to reduce mortality
While many countries in the South and South-East Asia region have managed COVID-19 containment and mitigation relatively well, there are few that stand out in offering specific lessons for the Indian context.
Applying the WHO actions above three countries from the region offer valuable lessons on COVID 19 management and preparedness to Indian states. The city-state of Singapore offers an excellent urban perspective in containing and preparing for the pandemic. Singapore was one of the earliest countries to detect Covid-19 by early February and by May-June was near the top of the confirmed cases list by territory.
However, at the point of writing this article, the number of cases now stands from 55,580 tested positive to 51,049 recovered and 27 deaths. Managing the pandemic involved the following deliberate steps involving- A whole of government response: Singapore used its previous experience from the SARS outbreak to prepare for COVID by involving multiple government agencies in coordinated planning and investing heavily in outbreak preparation, task-shifting health workers and building health care infrastructure capacity.
One example of essential inter-agency cooperation was between the contact tracing teams of the Ministry of Health and the Singapore Police Force along with auxiliary forces for enforcing social distancing and hand washing and wearing of masks. Mobilizing primary healthcare capacity through scaled screening using public health preparedness clinics. Since testing every citizen was not feasible and can overwhelm labs, one way to manage volume is to quickly identify and triage the highest risk patients. Singapore did this primarily through over a 1000 designated public health preparedness clinics that included both public and private providers across the country — that provided primary care physicians with additional training and preparation for outbreaks. Aggressive but targeted quarantine measures.
Like India, Singapore had a large influx of COVID positive cases among its foreign migrant workers who could not isolate. They were able to mitigate this with immediate aggressive targeted testing of this population and isolating them in specially prepared facilities along with quarantining close contacts of COVID positive cases in re-purposed facilities, which has limited or broken viral chains of transmission. Consistent public health communication that has been rational, transparent, and frequent, with uncertainties and gaps in knowledge specifically acknowledged.
Communication involved engagement between the public and leaders of civic society. The government delivers trusted information frequently and consistently to citizens via a national level WhatsApp group for one-way messaging, Finally, the most important take-away is support, mobilization and aggregation of the health workforce.
Throughout the epidemic, the health care workforce was augmented with auxiliary workers, volunteers from non-health sectors and supplemented with front line professionals from diverse health and municipal facilities. Both public and private sector frontline workers have been brought together for management of both COVID and non-COVID health conditions. Vietnam’s rapid response to the novel coronavirus has been one of the most successful in the world. Since mid-April, the country’s only cases of new infection were among people from overseas in quarantine after entering the country, although local infections have been growing in recent weeks. Vietnams strategy included again a - Whole-of-society approach: Early on, the Prime Minister prioritized health above economic concerns and Vietnam issued a National Response Plan with a National Steering Committee on Epidemic Prevention.
A metaphor of war (the battle against the coronavirus) was used in public messaging to unite citizens against the virus. This was critical to coordinate the actions and communications of relevant actors at different levels of government. A mitigation and containment strategy was swiftly deployed with the help of the military, public security services, and grass-root organizations, which was done through three measures - Rapid containment: Strict containment measures were gradually adopted, including airport health screenings, physical distancing, travel bans on foreign visitors, a 14-day quarantine period for international arrivals, school closures, and public event cancellations.
Wearing of masks at public venues was strictly enforced, even before the WHO recommendation, along with requiring hand sanitizers in public areas, workplaces, and residential buildings. Non-essential services were shut down nationwide, and strict restrictions on movements imposed across most of the country.
Aggressive and control at primary health levels: While costlier mass-testing strategies were attempted in more advanced economies, Vietnam focused on high-risk and suspected cases and ramped up testing capacity quickly, from 2 to 120 nationwide sites by May. Learning from the SARS outbreak, Vietnam implemented mass quarantines in suspected hot spots based on evolving epidemiological evidence over time and around 1,000 people per confirmed case were tested, the highest ratio in the world. As soon as an infected person was identified, he or she was placed in a state-owned facility such as a university dormitory or military barracks. All close contacts of the infected person were also placed on "stand-by" in these facilities, even if they were asymptomatic at the time. In parallel, there was extensive contact tracing, isolation and quarantining, up to third-tier contacts. People who lived near confirmed cases, sometimes an entire street or village, were swiftly tested and isolated, limiting community transmission.
Nearly 450,000 people have been quarantined (either at hospitals or state-run facilities or self-isolation. Clear, consistent, creative public health messaging: proved to be crucial in inculcating a community-based response involving multiple stakeholders. From an early stage, communications about the virus and the strategy were transparent. Details on symptoms, protective measures, and testing sites were communicated through mass media, government websites, public grass-root organizations hospitals, offices, residential buildings and markets, via text messages on mobile phones, and as voice messages. This well-coordinated multi-media approach and consistent news strengthened public trust and helped society adhere to protective and containment measures in which every citizen felt inspired to do their part, whether that was wearing a mask in public or enduring weeks of quarantine.
Closer to home we have Sri Lanka a much smaller island nation who has managed to contain the pandemic relatively well. Sri Lanka’s healthcare system ranks high in the region, with a network of accessible hospitals around the country, highly qualified medical staff, and local governments with dedicated public-health inspectors.
However, the lack of institutional capacity to manage a mass outbreak required strict virus-control measures, where the military has shouldered the responsibility for the national response—from overseeing quarantine centre’s to contact tracing—while the police have managed the curfew, responding to reports of violations and arresting suspected violators.
The government adopted other strict measures, including suspension of inbound flights and regularly disinfecting marketplaces and public transport stations, all of which earned the military and police forces praise for limiting the rate of transmission. There are two consistent lessons Indian states can take away from this country the first being an - established system of disease surveillance.
Having learnt from its past experiences with numerous communicable and non-communicable diseases, Sri Lanka has invested in strong public health surveillance which has proven to come in handy during the current coronavirus pandemic. The country had already developed a surveillance system based on the Open Source DHIS2 platform in early 2020 and closely monitored the pandemic's movement right after the first case appeared in January, tracking any potential COVID-19 suspects.
The government ensured that public health surveillance was activated to find any cases with respiratory illnesses. Once the cases were identified, we conducted the needed diagnostics so that we were able to rule out any suspected COVID-19 cases. The second was Sri Lanka’s consistent reliance on its primary health network. While public health clinics were shut during outbreaks, the government instead started delivering routine health checks and medication directly to the homes of patients. A hotline was created to allow non-COVID patients to seek advice from healthcare worker addressing non-COVID conditions as well.
There is an interesting analogy where country health systems are compared to team sports like football, where many players collectively contribute to scoring a goal and winning a tournament. Similarly, healthcare provision and access during COVID -19 will require a diverse set of actors to come together to anticipate, mitigate, contain and respond to healthcare and disease-related challenges at different levels. The more coordinated and well-aligned the team is the better able to devise a strategy to combat disease outbreaks and produce good health outcomes for populations. These targeted actions have helped reduce the pressure on the health care system and bode well for Indian states as they move to the next phases of containment.
Also read: Health Ministry issues guidelines for preparedness & response to COVID-19 in urban areas
