Can normal life resume after the 21-day nationwide lockdown? Will three weeks be enough in the fight against the novel coronavirus? How many more people will be infected by SARS-CoV-2, the virus responsible for the pandemic? These are burning questions that everyone - public health officials to persons now confined to their homes - are asking.
In an email interview to TNM, Bhramar Mukherjee, a professor of biostatistics and epidemiology at the University of Michigan and a co-author of the study ‘Predictions and role of interventions for COVID-19 outbreak in India’, emphasises that the nationwide lockdown is not a “magic potion” and the virus is not going to disappear. The lockdown, she says, buys more time for the government and healthcare workers to prepare for the long fight ahead. She also highlights the need to do more testing, to ramp up production of personal protective equipment and urges the government to send out a message to not stigmatise COVID-19 patients.
1. India has begun a 21-day lockdown. Do you believe that this 3-week period of social distancing will be enough for the virus/transmission to burn out?
The lockdown is not a magic potion. From a public health point of view, learning from the many countries that have now experienced this pandemic, aggressive measures are needed early and they are most effective when the number of cases have not exploded. The associated costs of a lockdown are severe in social and economic terms, for every country, and of course for India. But if a lockdown had to be implemented at some point of time during the course of this pandemic, it is best to do it early. We have to remember this is not a "cure all" solution. The virus is not going to disappear. This just buys us time so that we can prepare our army to go on a war. The war is still on, and we should use this time and operate as if on war-footing. Expand testing capabilities, set up a nationwide task force for contact tracing, set up COVID-19 care centers, produce and acquire protective equipment for front-line health care workers. In the meantime make sure there is economic and social immunity and subsidy for the people of India who are most vulnerable. It is a long strategy to conquer this epidemic and requires partnership of the public, government, health care sector, private sector and scientific experts. There is no time to waste. This is actually true for the whole world. We are all connected in this process.
2. With the 21-day lockdown period in force, how many cases can we expect in India? How many deaths are we looking at in the next few weeks?
We are working on models to study the effect of lockdown under various scenarios. I would be able to answer this question better in the next couple of days when I have studied the projections. I would like to iterate something I have said in various interviews. The numbers from each epidemiologic model (there are many) are variable, with large uncertainties. The takeaway message is more consistent though. We cannot be complacent. We cannot think in terms of discrete tactics. We need comprehensive long term strategies. Even after the lockdown is over, we should practice social distancing, ban large gatherings, be adherent to hand hygiene. We need a punctuated and careful return to normalcy. In spite of the gloomy projections we know that China and South Korea have turned the course around. That should give us hope. But the public health officials and government are still working diligently to expand testing, protect frontline health workers and set up treatment facilities.
3. One of your calculations in the study shows that if travel ban + distancing comes into force, we can expect the cases to taper down by May. Is this what we can expect then?
Those figures and models are run under the assumption that by creating a lockdown and social distancing, you are able to reduce the probability of an infected individual meeting a susceptible individual and it stays at that low rate as we progress in time. But what will probably happen is that when the lockdown is lifted this transmission probability may go up again. But hopefully at that point the number of new cases have been contained, testing and contact tracing task forces have been set up, health care facilities and mobile labs for testing and treatment are better prepared, other public spaces have been repurposed into temporary care facilities, we have more ventilators, and we all are adherent to the hygiene recommendations. That is why we have to be cautious with any such forecasting and prediction, as they are wrinkled with many assumptions about human behavior. The healthcare system in India is already overstretched, these three weeks enable us to set up our long term strategy and do better at testing and treating. We need to make sure during the lockdown that the food supply chain is maintained, essentials are provided, poor have support and we all as citizens do our part to provide support and guidance to daily wage earners in our own households and circle. We have a tremendous role to play in this war as citizens.
Just as an example, South Korea has much less fatality, 131 out of 9241 cases (1.4%) because they could arrest the spread early and prepare their healthcare system. Compared to countries where lockdown was later imposed, where fatality rate is 3-5%. India has acted early so I am hoping and praying for the best.
4. Italy also has been under lockdown since March 9. But we see no slowing down of cases or deaths. Is it fair to make a comparison to Italy?
If you have looked at the data, there is approximately a period of 14-18 days when the number of new cases start going down after aggressive intervention, Deaths will go down at a longer lag. The number of "true" cases is a composition of the number of unreported/untested infected people and the ones that are confirmed. We will never know the "truth" unless we test more. The rise in the reported numbers could be due to more testing becoming available. We will have to watch the next few days carefully for Italy.
5. How vulnerable are India’s healthcare/frontline workers given that resources are overstretched? There are already reports emerging from Delhi of a doctor being infected, and transmitting the virus to his family.
This is a very serious concern. Not just in India, we are seeing so many fatalities in the US as well. These heroic individuals are taking care of COVID-19 patients and getting sustained exposure. China and other countries who are on the mend have donated protective gears, large scale production of these equipments should start now. Industrial sectors need to pitch in, India has brilliant scientists, inventors and everyone should think about increasing production capacity. COVID-19 patients and caregivers should not be stigmatized or sacrificed.
6. What do you believe the Indian government still needs to do?
I mentioned this in my response to the first question. But here are some concrete thoughts:
a. Test, test test: Testing and contact tracing cannot stop and needs to expand. Make it easy to get tested and prompt return of results
b. Set up disease surveillance. Monitor admission due to respiratory illness in hospitals, healthcare facilities, insurance claims
c. Send strong message not to stigmatize COVID-19 patients, adhere to quarantine rules, provide guidance on hand hygiene
d. Distribute food, hand soap, thermometers.
e. Arrange supply of protective gear for health care workers, ventilators, treatment
f. Set up hospitals for COVID-19 patients
g. Reduce non-essential medical care but ensure critical care patients are not afraid to seek care. You do not want excess deaths from other causes.
h. This is a hard time for everyone in the world. We need to send some positive messages as we have seen countries arresting the growth as well by doing the right thing.
i. Long term surveillance and management of the COVID-19 crisis is needed with not just public health in mind but the economic, social and psychological trauma that it will leave on humanity. there are no easy solutions to the defining crisis of our time.