Featured image: Medical workers are seen outside a government hospital, where six people were tested positive for COVID-19, in Karad, Maharashtra, Friday, May 1, 2020. Photo: PTI
This is the second of a two-part analysis of Maharashtra’s COVID-19 epidemic. Read the first part here.
Based on analysis of development of the COVID-19 epidemic in Maharashtra, the Public Health Analysis Group has proposed a set of strategies to upgrade control measures in the state. We acknowledge the wide range of efforts being carried out by the Maharashtra health department for epidemic control, and have offered suggestions with these efforts in mind.
1. Ensuring two tracks of action
Overall, moving beyond primary focus on fire-fighting in existing hotspots, we suggest a two-track strategy to contain the epidemic across Maharashtra. This involves dividing districts of Maharashtra into four categories, based on numbers of COVID-19 cases and likely nature of epidemic transmission:
A two-track strategy would deploy differential measures.
Track 1 (For category A cities, high transmission areas in Category B districts): Here, community transmission seems to be underway. Existing approaches including certain restrictions on population movement are likely to be necessary for some period of time. However, these would be accompanied by extensive testing, identification of maximum cases at an early stage followed by isolation, contact tracing and home quarantine, upscaled testing of high risk sub-groups, and providing effective treatment at an early stage by ramping up hospitals and ensuring good quality clinical care, thus minimising deaths due to COVID-19.
Track 2 (For majority of Maharashtra including low transmission areas in category B districts, and entire category C and D districts – which would together cover around two thirds of Maharashtra’s population): In these areas, where large-scale community transmission is not yet underway, critical components of the intensive Kerala strategy need stronger emphasis:
- wider testing to detect maximum cases, followed by isolation and early treatment,
- meticulous contact tracing for all known cases (possibly 20 to 50 contacts per case),
- stringent home quarantine of all contacts, support to home quarantined persons, and
- testing of all contacts and suspects, leading to early identification of further cases.
While these measures are mentioned in the national containment strategy, implementing these as an integrated package with high effectivity is essential. A few weeks from now, even that chance might have been lost in Track 2 areas. Maharashtra has missed the first bus in COVID-19 epidemic control, let us not miss the second bus, for this may be the last one.
While COVID-19 testing has been considerably expanded in Maharashtra in the recent period, testing needs to cover additional categories of people. While following the ICMR criteria for COVID-19 testing, community-based testing on a sample basis and preemptive testing among symptomatic elderly persons and those with existing morbidities should be added on priority basis, to detect early and reduce deaths. For ramping up COVID-19 RT-PCR testing facilities, pooling of samples for testing can significantly upscale testing capacity.
2. State-specific evidence for better epidemic control
Analyses of existing data and rapid studies would greatly improve our ability to control the epidemic in Maharashtra. To understand the current prevalence of COVID-19 infection in the general population, including asymptomatic cases and dynamics of transmission, we need rapid community studies in few areas.
Detailed analysis needs to be conducted concerning all persons who have died with COVID-19, disaggregated according to various parameters. If certain areas and hospitals have lower fatality rates after adjusting for other factors, these could be further analysed to improve case management.
Further, we recommend formation of a state public health advisory group with multi-dimensional public health expertise for analysing information, developments and scientific updates, and advising the health department for refinement in epidemic control strategies.
3. Upgrading health system preparedness to deal with COVID-19
This is a major area which the public health group would deal with separately, however a few points will be noted here. Presently, expanding the capacity of public hospitals to deal with expected serious COVID-19 cases is high on the state government’s agenda. In this context, we need to estimate the number of cases requiring hospitalisation and critical care at the peak of the epidemic.
In the context of Maharashtra’s ‘hard lockdown’, figures projected by the CDDEP for peak COVID-19 hospitalisations are in the range of 1.81 lakh. We can estimate that around 5% out of these, meaning at peak around 9,000 cases might require ICU support. Keeping such scenarios in view, the healthcare resources estimated in Maharashtra to deal with serious COVID-19 cases are as follows.
National health profile 2018 states that Maharashtra currently has 51,446 public hospital beds, which is less than 30% of the expected peak hospitalisations (1.81 lakh) required for COVID-19 management in the projected hard lockdown scenario.
Similarly, 2572 public health system ICU beds might be able to manage only around one-third of the roughly 9,000 critical COVID-19 cases. And obviously, all public hospital beds cannot be devoted exclusively to COVID-19 treatment since routine illnesses, emergencies, deliveries etc. would continue to occupy a large number of beds.
Linked with expanding physical infrastructure, top priority must be given to addressing health human power issues including filling long-pending vacant posts in the health department, which has now been promised by the health department. Provision of adequate PPE (personal protective equipment) to health staff involved in dealing with suspected and confirmed COVID-19 patients is also important, linked with adoption of a graded PPE policy.
During the epidemic surge, if all patients are to be adequately treated, then a large proportion of cases will need to be managed by insourced, regulated private facilities. In this context, two recent initiatives by the state government are significant. Firstly, the Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) insurance scheme for free hospitalisation care has now been extended to cover all citizens. Secondly, the government has invoked the Disaster Management Act and Epidemic Act, capping the fees of COVID-19 treatment in all private hospitals.
Building on these positive measures taken in the epidemic situation, there is need for a comprehensive policy dealing with the role of private healthcare sector. This concerns the management of COVID-19 cases, dealing with continuation of routine healthcare, surveillance, testing and treatment of COVID-19, including temporarily taking over private hospitals for COVID-19 care.
The policy should also include comprehensive protocols for COVID-19 management and protective measures for staff to be rigorously monitored, and ensuring free COVID-19 testing by private labs with a fair and timely reimbursement mechanism.
4. Developing a responsive lockdown reversal strategy for Maharashtra
A wide range of public health opinion tells us that a lockdown is a relatively ineffective instrument for slowing down COVID-19 transmission. Blanket restrictions at best give an opportunity to implement much more effective tools of widespread testing and isolation, tracing of contacts and quarantine, which must be the main epidemic control strategy.
Keeping in view this public health context as well as major social impacts of a generalised lockdown, there is an urgent need to formulate a lockdown reversal strategy for Maharashtra. We recommended that in track 2 districts, upscaling of intensive strategies could be accompanied by progressively relaxing the lockdown within the district, while restrictions on entry to the districts and careful monitoring of numbers of cases continues.
Such a policy shift can strike a balance, progressively lifting restrictions while also effectively controlling the epidemic. The Maharashtra government should engage diverse experts and social networks through online consultation for drafting such a strategy.
5. Catalysing widespread public awareness and participation for COVID-19 control
Pending a vaccine or treatment to eliminate infection, all current approaches to deal with COVID-19 revolve around modifications in social behaviour. Hence, epidemic control including the intensive strategy mentioned above are possible only through active social participation.
Such participation needs to be catalysed by involving panchayat representatives, women’s groups and civil society organisations in each area. This can be initiated in an appropriate manner even in conditions of lockdown through the use of mobile phones and online communication.
While ASHAs can carry out expanded contact tracing, other social actors can shoulder tasks of supporting people in home quarantine. Decentralised initiatives such as the colour-coded pass system implemented in Chandrapur district to ensure social distancing should also be encouraged. A systematic state-civil society interface needs to be set up in each district, engaging diverse civil society networks and organisations to support epidemic-related measures, as well as facilitating organised community-based feedback.
Maharashtra today faces a double crisis – health impacts of COVID-19 and social impacts of a lockdown. We need to control the epidemic through upscaling intensive strategies, while also lifting restrictions in a graded manner. The state must partner with civil society, enabling Maharashtra to move beyond both the lockdown and the COVID-19 epidemic.
This article is drafted by Abhay Shukla based on a recent report prepared by Maharashtra Public Health Analysis Group. Along with Abhay Shukla, members of the group include Shweta Marathe, Muneer Mammi Kutty, Archana Diwate, Harsha Joshi, Pooja Chitre, Neha Naik, Mayank Sharma and Dipak Abnave. Several group members are associated with Jan Swasthya Abhiyan.