Surveillance as the way out

Lockdown Exit

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 to fulfill their basic needs of food and shelter, many labourers and migrants have been left hungry and stranded.

With the economy dwindling, the government is loosening lockdown restrictions. The lockdown by itself was never a solution. It only bought us time to get prepared. The question now is, how to get out of the lockdown. Some say it is like getting into a chakravyuh: We might know how to get in, but the challenge is getting out. Here we describe a tool that can be an effective path out of the lockdown. It is called surveillance.

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 Covid-19 via the existing national sentinel surveillance sites for Influenza-Like Illness (ILI) and Severe Acute Respiratory Infection (SARI).

In rural areas, ILI surveillance can be done by door-to-door visits by health workers. ANM and ASHA workers can visit households with a simple checklist of symptoms. Providing them 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. The reality is that we have more cases than we know, and not detecting them is turning out to be dangerous. One can look at Vijayapura and Davangere to understand the importance of this. A strong surveillance system can detect cases early enough and prevent complications and deaths.

In the short term, the Karnataka government can engage medical institutes and public health institutes to strengthen surveillance 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 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.

In urban areas, it is important to engage civil society members, NGOs and other volunteers to strengthen outbreak detection. The participation and coordination of multiple ministries and government bodies toward a common goal is important.

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 address the needs of manpower, beds, high-flow oxygen, ventilators, isolation facilities and drugs.

Any death anywhere in Karnataka should be investigated whether it was due to Covid-19 or not. Monitoring the trends in disease and death at the taluk and district levels will help evaluate 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.

Public health authorities should review their local requirements and plan for an adequate 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 for better communication have to be arranged through the online mode.

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 apps developed by the government like Kilkari, Divyang Sarathi and the agri-market app 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.

Adapting to a new normal

Public gatherings, museums, nightclubs and day-care centres will have to still remain closed; remote working must 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 helpful and its widespread installation must be encouraged.

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 prescribing 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, apps, etc.

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 Indian society. Every district has a laboratory under the Integrated Disease Surveillance Programme; a strong robust surveillance system should be the way forward. Karnataka can have a Centre for Diseases Control similar to what China and the US 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.

(The writers work at the life-course epidemiology unit, Indian Institute of Public Health, Bengaluru)