How India must prepare for a second wave of COVID-19

India has so far escaped the worse of the COVID-19 pandemic at about 33,000 confirmed cases and over 1070 deaths by the end of April 2020. But as the country looks at easing lockdown restrictions in the coming weeks, it seems important the public health machinery braces for a potential second wave of infections.

Some key lessons learnt from the first wave of COVID-19 could help shape future strategies.

To begin with, India’s early physical distancing strategy has paid dividends, helping to bring the crisis to a manageable level. A complete lockdown, isolation of cases and quarantining the contacts of the COVID-19 infected across the country has relatively successful in the past five weeks. These measures have also raised awareness of COVID-19 and instilled a sense of cough etiquette and hygiene, which should serve the country well in the future.

Statistics suggest that these mitigation efforts may have helped “flatten the curve” and minimise the spread of COVID-19. Even as the number of coronavirus-infected cases continues to rise, the numbers suggest a stable situation. The growth of the infection rate has been more or less linear and not exponential , according to figures made available by India’s Ministry of Health and Family Welfare, although testing has not been sufficiently rolled out in the country to provide accurate numbers.

A number of factors could be at play for India’s low mortality rates, which is less than 1 per one million people – compared to 416 in Spain, 316 in Italy and 215 in the UK as of 18 April 2020. The age of our nation is one factor: as COVID-19’s mortality risk is disproportionately higher among people over 60, in India only 3.4 per cent of the country is over 70 (compared to 16 per cent in Italy). Pre-existing seasonal coronavirus antibodies may exist in certain populations in India, offering partial protection or leading to milder or asymptomatic disease. Research is still underway to determine this more clearly.

When the potential second wave hits

With a large at-risk population among India’s 1.3 billion, now is not the time to be complacent. To stay ahead of the epidemic curve and prepare for a potential second wave, India needs to plan future steps on three levels: the family, the community and the hospital.

At the family level, the emphasis must be on protecting the vulnerable: individuals over 60 and those with underlying medical conditions or children with low immunity. Families will need to shoulder this responsibility, helping to ‘reverse quarantine’ the elderly and vulnerable. This would mean keeping them away from the public, minimising interaction with them, reducing the number of visitors and promoting physical distancing.

At the community level, the lockdown needs to be lifted in stages as planned, to ensure a livelihood for India’s poorest people who are currently living through a humanitarian crisis. But the government needs to continue scaling up testing, to provide an accurate view of the epidemic growth once the lockdown is lifted. Authorities will also need to continue strong public health messaging in terms that all levels of society can understand. This includes education on personal hygiene measures such as frequent hand washing, avoiding unnecessarily touching one’s eyes, nose and mouth, and cough and sneezing etiquette. In hotspot areas, the government will need to encourage social distancing and isolation while discouraging large gatherings.

At the hospital level, steps need to be taken to reduce transmission. Triaging at hospital entry, lowering the threshold for testing, isolating and cohorting of patients, particularly with co-morbidities, ensuring adequate personal protective equipments (PPE) for healthcare workers and offering preference for ventilatory and other life-support equipment for individuals with a better chance of survival if health systems are overwhelmed, are crucial strategies that should be adopted.

As we focus on treating COVID-19 patients and protecting health care workers, managing people with other diseases has become challenging. Complete or partial suspension of care in hospitals may be fatal for some. The move towards telemedicine or mobile integrated health care, to treat patients virtually at their homes, will probably not be nearly enough to provide adequate health care to a population of 1.3 billion. Additional steps need to be considered.

To tame the pandemic, India has many valuable assets. That includes advanced pharmaceutical expertise and manufacturing capabilities, and a government which seems to be fast-tracking research to develop low-cost rapid diagnostic test and vaccines. India is home to many experienced vaccine makers, some of whom are racing to develop vaccines against the novel coronavirus. Several clinical trials are underway to test the efficacy of various treatments, including convalescent serum therapy.

But these impressive and necessary efforts will only go so far without coordination and collaboration. Standardised treatment protocols and development of a national database to inform decisions and evidence-based management guidelines is badly needed and international cooperation is more important than ever.

For this reason, a group of scientists, physicians, funders and policy makers from over 70 institutions from 30 countries launched a COVID-19 Clinical Research Coalition in early April 2020. The coalition, armed with an open innovation model, will help research institutes in low and middle-income countries to quickly launch high-quality clinical research and rapidly find answers on COVID-19 prevention, diagnosis and case management. The coalition has set up a web-based platform to help researchers pool resources, protocols and research data, and to quickly find partners for funding, materials, and technical expertise – including know how to tide over logistic hurdles and regulatory approvals.

Such collaboration is essential. It will provide the government with the necessary data to inform its decisions about how to respond swiftly to the next wave of the pandemic. The government must encourage such public and private collaboration in scientific research, secure more investments, and ensure that the benefit of these scientific endeavours benefit everyone.

Only this effort, combined with adequate responses at the family, community and hospital levels, will arm India to survive this crisis with the least possible suffering.

(*George M Varghese is the head of the Department of Infectious Diseases at Christian Medical College, V ellore, India and ** Suman Rijal is the Director of Drugs for Neglected Diseases initiative, India.)

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