From March 25, India initiated the most extreme step in the mitigation strategy of COVID-19 control: the lockdown. This is a very courageous step by the Indian government, and as responsible citizens we need to abide by its instructions. If we are instructed to remain at home, we need to!
Most countries follow the containment, delay and mitigation stepwise strategy to control COVID-19.
In the very early stage, people who had recently travelled to other countries tested positive. This is the ‘stage of imported cases’. India followed the ‘containment strategy’ at this stage: we isolated these patients, tracked their contacts and quarantined them.
Then we had the second stage, of ‘local transmission’, wherein contacts of the patients developed the disease. At this stage, Indian public health officials continued contact-tracing and also instituted the ‘delay measures’ in the form of social-distancing, and closed offices, schools and colleges and advised against large gatherings like weddings.
Next, India expects the stage of ‘community spread’. In this stage, people with no history of contact with visitors from foreign countries or with their contacts acquire the COVID-19 infection. In the community spread stage, we need to concentrate on delay and mitigation strategies by strictly implementing social-distancing.
The last and most extreme stage is the epidemic phase, where we can have hundreds or thousands of patients with the disease within the country. In this stage of the epidemic, the most reliable control measure is an extreme mitigation step known as ‘suppression’ or ‘lockdown’. Most countries, including France, Italy and the US, initiated a lockdown at the epidemic stage. But by this time, several hundred patients were already dead in these countries.
India has followed the same strategy of containment, delay and mitigation. But the difference is we followed a quicker transition from one stage to the next relative to those in other countries. India hasn’t yet confirmed the presence of community transmission of the new coronavirus but we can’t definitively rule out this stage either. The government has already taken the extraordinary step of implementing a lockdown, the extreme mitigation measure, at a very early stage of the outbreak. Unlike other countries that initiated a lockdown at the epidemic stage, our country initiated a lockdown at the local spread stage itself.
In effect, we rapidly changed our strategy from containment to delay to mitigation. We have learned from the failure of other countries. Initiating a lockdown at the threshold of the epidemic stage will be less fruitful. We are convinced that if we decide on a lockdown, we need to do it sooner rather than later.
This said, a lockdown has its downsides. A three-week lockdown in particular will have significant economic consequences for any country. That is the reason why many countries initiated a lockdown later. We have considered the economic consequences but considered the lockdown an unavoidable mitigation measure.
There are some strategies with lower economic consequences. For example, a few countries are following a strategy of building herd immunity. In this case there won’t be any lockdown. Instead, vulnerable individuals such as the elderly will be quarantined and the younger and fit individuals will be exposed to the virus while they continue with their routines. The logic behind this idea is that by exposing younger people to the virus, most individuals in the community will develop immunity, and this ‘herd immunity’ will subsequently protect the vulnerable population.
The pitfall of this strategy is the possibility of a large number of vulnerable people succumbing to the disease, overwhelming the healthcare system and potentially resulting in a catastrophic scenario. The United Kingdom initially followed the herd immunity strategy but later realised its impracticality and quickly moved to delay and mitigate.
The Netherlands is following a strategy similar to herd immunity. Though the Netherlands has closed schools, colleges, and offices, there is no lockdown and there are no restrictions on the people’s movement. Sweden is also following this strategy.
So is the Indian strategy the right one? Yes, we believe in the containment, delay and mitigation strategy similar to most other countries. But unlike most other countries, we quickly transitioned from containment to delay and then from delay to extreme mitigation. We believe our strategy will help our country reduce the impact of the COVID-19 outbreak. As responsible citizens, we must follow all the measures our government has recommended.
Dr Abdul Ghafur is an adjunct professor and consultant in infectious diseases at the Apollo Cancer Institute, Chennai, and coordinator of the Chennai Declaration on Antimicrobial Resistance.