A grassroots plan for India’s COVID-19 response

India’s daily new COVID-19 cases have crossed the 8,000-mark for the first time in more than 100 days. However, cases (moderate to severe) and hospital admissions related to COVID-19 are low. The spike in infections has raised some concerns about the start of a fourth national COVID-19 wave in India. From an epidemiological point of view, an immediate major national wave in India is unlikely. One reason for this is that the Omicron (b.1.1.529) variant is by far the only globally circulating variant of concern. The Omicron sub-lineage BA.2, which caused the third national wave in India, continues to dominate the country. Although two new Omicron sub-lineages, Ba.4 and Ba.5, have been detected globally and also reported from India, their share is small. Finally, there is no evidence that the BA.4 and BA.5 sub-lineages can cause a major nationwide surge in settings already exposed to the BA.2 sub-lineage. Clearly, while concerns about another national wave are unfounded, there is an ongoing demand for a fresh approach to the response to the COVID-19 pandemic in India.

epidemiological triad

Then, an important question is, if there is no new form of concern, why is there this rise in COVID-19 cases? The answer lies in an age-old concept of epidemiology that explains the ‘why’ and ‘how’ of a disease spread in any given setting: the ‘epidemiological triad’ of agent, host and environment. The spread of a disease is the result of a complex interaction of the agent (or pathogen, in this case SARS-CoV-2 and its variants), the host (human beings and their immuno-biological characteristics) and the environment (social and behavioral factors).

In the ongoing COVID-19 pandemic in India, the agent (Omicron version of SARS-CoV-2) has remained largely unchanged since the third wave in January 2022, with minor changes in the sub-lineage. As far as host factors are concerned, immunologically speaking, although antibody levels decrease over time and susceptibility to infection increases, the decline in immunity alone cannot be attributed to increased infection. Because neither previous infection nor COVID-19 vaccination protect against subsequent infection.

Rather, despite the increase in daily new COVID-19 infections, low rates of serious illness and hospitalization suggest that our immunity against SARS-CoV-2 is strengthening. It brings to the center stage the third component of the triad, i.e. the environment or external factors. Here, SARS-CoV-2 is very much around, as it was for the past several months, in all settings; And, it is not likely to go away. However, now travel has increased, economic activity has returned to or even higher than its pre-pandemic levels, there are regular social gatherings, and the wearing of face masks in crowded places is also noticeable less follow up. Clearly, environmental factors are driving the spike, more than the agent and host.

However, as likely to be around SARS-CoV-2, and as infectious disease experts and especially those who study the respiratory virus would argue, localized COVID-19 cases spike in many settings and for several months. are about to become a reality (and possibly years) to follow.

From an epidemiological point of view, COVID-19 infection in India is no longer a public health concern. The reason is that June 2022 is completely different from March 2020. At the time, SARS-CoV-2 was a new virus; No one had immunity to the virus, and everyone was equally susceptible. No vaccine was available and the risk of adverse outcomes following SARS-CoV-2 infection was unknown and unpredictable according to age and other characteristics. This was clearly a public health challenge.

About 27 months into the COVID-19 pandemic, most people have developed immunity either after natural infection (during the three national waves) or through vaccination (about 97% of the adult population has received at least one shot, While 88% have received two shots (Covid 19 vaccine). There is a better scientific understanding of who is at higher risk of serious outcomes (all in the over 60 years group and any age group with co-morbidities or weakened immunity), and the risks are known and largely predictable. Arguably, COVID-19 is less a public health problem and more a personal health problem.

a dynamic response strategy

Nevertheless, the increase in daily new cases should not be ignored. However, continuing with the five-pronged ‘test, track, treat, immunize and COVID-appropriate behaviour’ approach is no longer the best strategy for India and needs to be completely re-looked at.

First, urgently modify the indicators to monitor and track the COVID-19 situation. Daily COVID-19 infection and test positivity rates can be recorded, but have limited utility for decision making. Two operational surveillance indicators that should be used now may be daily new symptomatic COVID-19 cases and new hospitalizations.

Second, any setting that reports a spike in COVID-19 cases should be prioritized for advanced and expanded genomic sequencing, including sequencing of all hospitalized COVID-19 cases and a subset of asymptomatic and mildly symptomatic cases. Contains, so that one’s origins can be tracked. type. A strong link between health departments and the Indian SARS-CoV-2 Genomics (INSACOG) Consortium Network that conducts genomic surveillance is essential to correlate variants and clinical outcomes.

Third, from now on the risk of SARS-CoV-2 infection in India (or any setting around the world) is unlikely to be zero. Face masks and physical distancing have proven benefits in reducing transmission, but the benefits, at least in settings such as India, are now far greater at the individual level than at the population level. All social and economic activities (including schools) must continue to function to their full potential. Face-mask recommendations should be calibrated, targeted, context-specific and evidence-guided and should not be uniform for the entire population. Science communication and public education should be used to motivate high-risk population groups to adopt such behaviour. The requirement of compulsory face-masks for school going children (implicit or explicit) is unscientific and without evidence. Mask guidelines for school children should be voluntary without any indirect pressure, as is the case with some Indian states.

booster shots

Fourth, there is a known benefit of third shots of COVID-19 vaccines in select, especially high-risk population groups; However, the benefits of the fourth and fifth shots are modest and short-lasting, according to studies. Essentially, only one additional COVID-19 vaccine shot and potential protection is all that matters to get some increase in antibody levels. Due to hybrid immunity with two shots of vaccines and three national COVID-19 waves in India, which is unlikely to spare anyone, even with only two vaccine shots in India, protective immunity is provided by three vaccines. Might equal more than shots. with a low infection rate.

Therefore, Indian health policy makers need to be very strategic and pragmatic in the use of the third COVID-19 vaccine shot. Not every boom should result in renewed demand and a push for adults in all age groups to take booster doses. After all, if you only have to take a precautionary shot, there’s merit in delaying and keeping it for as long as possible and getting an asymptomatic vaccine shot. Similarly, there is no scientific rationale for rushing to vaccinate children under the age of 12.

Fifth, excessive attention to COVID-19 is not entirely harmless, but it diverts attention from other equally and even more pressing health needs such as tuberculosis, diabetes and hypertension, which constitute a large part of India’s population. affects the ratio. It is undoubtedly time Indian states draw attention to the long-standing health challenges and strengthen primary health care services.

what should be done

After the 1918–20 flu pandemic, the influenza virus remained in circulation and continues to exist today. Over the past 100 years, with regular mutations in influenza viruses, there has been a seasonal increase in cases, outbreaks and pandemics and two more influenza pandemics (1957–58 and 1968). Since then, there have been annual flu seasons around the world. Being another respiratory virus and an RNA virus with a tendency for regular mutation, SARS-CoV-2 appears to be on an influenza trajectory. Factoring in country-specific SARS CoV-2 epidemiology, the population-wide application of pandemic response in India could be converted to a focus on individual protection. India’s COVID-19 response strategy, in the days and months ahead, should focus on protecting the vulnerable; Promoting voluntary face-mask use; Strengthening COVID-19 surveillance, and using local COVID-19 data for decision-making. We are on a path of learning to live with COVID-19.

Dr. Chandrakant Laharia is a primary care physician, epidemiologist and public health specialist. He is the Founder-Director of the Foundation for People-Centric Health Systems, New Delhi