<p>For the first time in history, over 1.3 billion people were asked to stay locked up in their homes. Many did stay home and were able to cope relatively well thanks to the internet and technology that enabled them to work from home and shop from online grocery stores. For another significant section, however, it has been a rough ride. Their daily income has been disrupted and with no support for fulfilling their basic needs of food and shelter, many labourers and migrants have been left hungry and stranded.</p>.<p>With the economy dwindling, the government is loosening lockdown restrictions. Lockdown by itself was never a solution. It only bought us time to meet the goals of preparedness and gave us a way to prioritise them. The question that lies in front of us now is how to get out of the lockdown. Some often chide that it is like getting into a <em>chakravyuh</em>: We might know how to get in but the challenge lies in how to get out. Here we describe a tool that can be an effective path out of the lockdown. It is called surveillance.</p>.<p><strong>Strengthening surveillance in rural and urban areas</strong></p>.<p>Surveillance means a systematic collection of data for action. Strong surveillance is the need of the hour. It helps to monitor the extent of the circulation of the virus (SARS-CoV-2) in the general population. The World Health Organisation (WHO) recommends implementing testing for <a href="https://www.deccanherald.com/tag/coronavirus" target="_blank">COVID-19</a> via the existing national sentinel surveillance sites for Influenza-Like Illness (ILI) and Severe Acute Respiratory Infection (SARI). </p>.<p>In rural areas, ILI surveillance can be done by door-to-door visits by health workers. ANM and ASHA workers can visit the households with a simple checklist of symptoms, providing clear cut definitions for what constitutes a suspect case, a probable case, a confirmed case and contact is a must. By ensuring fast data reporting and analysis at the Public Health Centre and district level, we can detect new cases and identify clusters. Having more cases is the reality that we need to face and not detecting is what has turned out to be dangerous. One can look at Vijayapura and Davangere to understand the importance of this. Nothing happens all of a sudden. A strong surveillance system can detect cases early enough and prevent complications and deaths. </p>.<p>In the short term, the Karnataka government can engage medical institutes and public health institutes to strengthen the surveillance mechanisms in the state. The AYUSH workforce and volunteers can enable active tracing and screening of cases. Considering our huge population and the low human resource in the healthcare workforce, it is essential to have participatory surveillance where the public is also encouraged to self-report the symptoms. The goal is to detect and contain outbreaks among vulnerable populations, especially the elderly, people with disabilities, children in orphanages, who will not be able to seek help themselves etc. </p>.<p>In urban areas, it is important to engage civil society members, NGOs and other volunteers for strengthening the outbreak detection. Therefore, as an immediate measure, participation and coordination of multiple ministries and government bodies towards a common goal is important. </p>.<p><strong>District-level planning</strong></p>.<p>Preparing a district action plan similar to national immunisation plans must be the way forward with a robust review mechanism at multiple levels and with clear accountability for action. Adopting district strategies with a sharpened focus on high priority districts can help in addressing the needs of manpower, beds, high flow oxygen, ventilators, isolation facilities and drugs. </p>.<p>Any deaths anywhere in Karnataka should be investigated whether it is due to COVID-19 or not. Monitoring the trends in disease and death at the taluk and district levels will help in evaluating the impact of the pandemic on healthcare systems and society. This will also help to monitor long term epidemiologic trends and evolution of the COVID-19 virus. </p>.<p><strong>Keeping in mind local requirements</strong> </p>.<p>Public health authorities should review their local requirements and plan for an adequately-sized workforce of contact tracers. They should also involve private sector providers and NGOs for screening services, with clear segregation of affected areas. Capacity building of healthcare workers to conduct district self-assessments and healthcare workers for better communication have to be arranged through the online mode.</p>.<p><strong>Creating greater public awareness</strong></p>.<p>The public should be guided in the implementation of control measures like cough etiquette, physical distancing and seeking help in case of any symptoms. The various technological apps developed by the government like Kilkari, Divyang Sarathi and the agrimarket can be made use of by the government to convey messages about COVID-19 awareness. Engagement with the community and their religious and/or other influential leaders will ease the process of spreading the message and contact tracing.</p>.<p><strong>Adapting to a new normal</strong></p>.<p>Public gatherings, museums, nightclubs and daycare centres will have to still remain closed; wherever possible remote working has to be encouraged and public transport should have a minimum number of passengers. People will have to be vigilant, wear masks, maintain social distancing and go out only for essentials. Making use of the apps to track and maintain safe distance is very helpful and its widespread installation must be encouraged. </p>.<p>Thermal cameras have to be implemented at public spaces and over the counter sales of antipyretics without prescription must be strictly prohibited. Wherever possible, the contact information of the person and the prescribed doctor must be tracked. Many countries have come up with innovative solutions like face mask vending machines, staggered school days, wristbands that buzz if anyone advertently comes too close, technology apps etc.</p>.<p>Back to normal or the pre-COVID-19 era is not going to happen anytime soon. Physical distancing, maintaining cough etiquette and hand hygiene will have to become the new normal for the Indian society. Every district has a laboratory under the Integrated Disease Surveillance Project; a strong robust surveillance system should be the way forward. Karnataka can have a Centre for Diseases Control similar to what China and the United States have. Any temporary measure will only be reactive in nature. The long-term measure of public health emergency preparedness is the call for action now.</p>.<p><em>(Deepa R and Giridhara R Babu work at the life-course epidemiology unit, Indian Institute of Public Health, Bengaluru)</em></p>.<p><em>The views expressed above are the author’s own. They do not necessarily reflect the views of DH.</em></p>
<p>For the first time in history, over 1.3 billion people were asked to stay locked up in their homes. Many did stay home and were able to cope relatively well thanks to the internet and technology that enabled them to work from home and shop from online grocery stores. For another significant section, however, it has been a rough ride. Their daily income has been disrupted and with no support for fulfilling their basic needs of food and shelter, many labourers and migrants have been left hungry and stranded.</p>.<p>With the economy dwindling, the government is loosening lockdown restrictions. Lockdown by itself was never a solution. It only bought us time to meet the goals of preparedness and gave us a way to prioritise them. The question that lies in front of us now is how to get out of the lockdown. Some often chide that it is like getting into a <em>chakravyuh</em>: We might know how to get in but the challenge lies in how to get out. Here we describe a tool that can be an effective path out of the lockdown. It is called surveillance.</p>.<p><strong>Strengthening surveillance in rural and urban areas</strong></p>.<p>Surveillance means a systematic collection of data for action. Strong surveillance is the need of the hour. It helps to monitor the extent of the circulation of the virus (SARS-CoV-2) in the general population. The World Health Organisation (WHO) recommends implementing testing for <a href="https://www.deccanherald.com/tag/coronavirus" target="_blank">COVID-19</a> via the existing national sentinel surveillance sites for Influenza-Like Illness (ILI) and Severe Acute Respiratory Infection (SARI). </p>.<p>In rural areas, ILI surveillance can be done by door-to-door visits by health workers. ANM and ASHA workers can visit the households with a simple checklist of symptoms, providing clear cut definitions for what constitutes a suspect case, a probable case, a confirmed case and contact is a must. By ensuring fast data reporting and analysis at the Public Health Centre and district level, we can detect new cases and identify clusters. Having more cases is the reality that we need to face and not detecting is what has turned out to be dangerous. One can look at Vijayapura and Davangere to understand the importance of this. Nothing happens all of a sudden. A strong surveillance system can detect cases early enough and prevent complications and deaths. </p>.<p>In the short term, the Karnataka government can engage medical institutes and public health institutes to strengthen the surveillance mechanisms in the state. The AYUSH workforce and volunteers can enable active tracing and screening of cases. Considering our huge population and the low human resource in the healthcare workforce, it is essential to have participatory surveillance where the public is also encouraged to self-report the symptoms. The goal is to detect and contain outbreaks among vulnerable populations, especially the elderly, people with disabilities, children in orphanages, who will not be able to seek help themselves etc. </p>.<p>In urban areas, it is important to engage civil society members, NGOs and other volunteers for strengthening the outbreak detection. Therefore, as an immediate measure, participation and coordination of multiple ministries and government bodies towards a common goal is important. </p>.<p><strong>District-level planning</strong></p>.<p>Preparing a district action plan similar to national immunisation plans must be the way forward with a robust review mechanism at multiple levels and with clear accountability for action. Adopting district strategies with a sharpened focus on high priority districts can help in addressing the needs of manpower, beds, high flow oxygen, ventilators, isolation facilities and drugs. </p>.<p>Any deaths anywhere in Karnataka should be investigated whether it is due to COVID-19 or not. Monitoring the trends in disease and death at the taluk and district levels will help in evaluating the impact of the pandemic on healthcare systems and society. This will also help to monitor long term epidemiologic trends and evolution of the COVID-19 virus. </p>.<p><strong>Keeping in mind local requirements</strong> </p>.<p>Public health authorities should review their local requirements and plan for an adequately-sized workforce of contact tracers. They should also involve private sector providers and NGOs for screening services, with clear segregation of affected areas. Capacity building of healthcare workers to conduct district self-assessments and healthcare workers for better communication have to be arranged through the online mode.</p>.<p><strong>Creating greater public awareness</strong></p>.<p>The public should be guided in the implementation of control measures like cough etiquette, physical distancing and seeking help in case of any symptoms. The various technological apps developed by the government like Kilkari, Divyang Sarathi and the agrimarket can be made use of by the government to convey messages about COVID-19 awareness. Engagement with the community and their religious and/or other influential leaders will ease the process of spreading the message and contact tracing.</p>.<p><strong>Adapting to a new normal</strong></p>.<p>Public gatherings, museums, nightclubs and daycare centres will have to still remain closed; wherever possible remote working has to be encouraged and public transport should have a minimum number of passengers. People will have to be vigilant, wear masks, maintain social distancing and go out only for essentials. Making use of the apps to track and maintain safe distance is very helpful and its widespread installation must be encouraged. </p>.<p>Thermal cameras have to be implemented at public spaces and over the counter sales of antipyretics without prescription must be strictly prohibited. Wherever possible, the contact information of the person and the prescribed doctor must be tracked. Many countries have come up with innovative solutions like face mask vending machines, staggered school days, wristbands that buzz if anyone advertently comes too close, technology apps etc.</p>.<p>Back to normal or the pre-COVID-19 era is not going to happen anytime soon. Physical distancing, maintaining cough etiquette and hand hygiene will have to become the new normal for the Indian society. Every district has a laboratory under the Integrated Disease Surveillance Project; a strong robust surveillance system should be the way forward. Karnataka can have a Centre for Diseases Control similar to what China and the United States have. Any temporary measure will only be reactive in nature. The long-term measure of public health emergency preparedness is the call for action now.</p>.<p><em>(Deepa R and Giridhara R Babu work at the life-course epidemiology unit, Indian Institute of Public Health, Bengaluru)</em></p>.<p><em>The views expressed above are the author’s own. They do not necessarily reflect the views of DH.</em></p>