THE NOVEL DISEASE PREPAREDNESS – IS INDIA READY?

-Dr. Priyanka Manghani, Post Graduate Student, Prasanna School of Public Health

 

2 am, Department of Internal Medicine, Government Hospital, Delhi.

A 40-year-old diabetic patient is admitted with symptoms of cough and has a cardiac arrest. He was resuscitated but is still hypoxic to 15%. The patient was on maximum ventilator settings, arrested multiple times and eventually died all within a few hours.

JR1:  What did we do wrong? We could not save him!

JR2:  His reports just arrived. He was COVID-19 Positive.

JR1: I don’t know when this will stop. How long can we sustain this? We aren’t testing enough, and we are not prepared to handle such a major surge in cases.

JR2: I am worried about the same. My co-residents and I haven’t slept and eaten well in days, we don’t have adequate PPE and most of us are at risk. Staff from Unit 2 have also been tested and are positive for COVID19. How will we cope with the burden if the cases keep increasing? We don’t have enough ventilators, not even for the elderly, let alone the young.

JR1: Hmm, I too have been thinking about that. When Italy doesn’t have enough for the population and isn’t giving ventilators to people above 60 now, what will we do? This is truly the fall of global health arcades. This is so distressing.

This is the current scenario in all hospitals throughout the nation. Healthcare workers are overburdened, at risk of infection, and we have so many people exposed to people with a travel history. Where does this place us? Will India lose to COVID 19? Let’s rewind back to early January when the outbreak was confirmed in Wuhan, China. With just few cases initially, the rampant spread shocked the world. Was this another repeat of SARS, or something worse?

While initially we didn’t consider it a global agenda of priority, we are now paying the price for it. Majority of the cases have a history of travel and we aren’t testing enough. People who don’t have any symptoms aren’t being quarantined seriously, even when there is reason to do so, and there is no testing at domestic airports and railway stations. The circle of exposure is varied and all contacts within it need to be screened. 

The bigger question here is – are we really prepared for an epidemic? This is a highly contagious disease with the virus having a high reproductive number. What can we do to improve the situation and achieve emergency preparedness in the future?

  1. Let’s accept it – everything is Public Health!
  • While Community Medicine and Public Health is a branch looked down upon by many, let’s accept that when it comes to strengthening health systems and outbreak investigation, epidemiologists have a crucial role to play in containing the outbreak. We need to invest more in public health infrastructure and build more hospitals catering especially to infectious disease and with a large bed capacity. Even general hospital needs a minimum of 2 such wards with a large bed capacity, in each city. While this may sound overambitious for a developing country like India, the truth is there is such a need and we are going to have to figure out a solution to develop this plan. Along with improving public health infrastructure, we need to also build a resilient health-care system in terms of human resources, finances and collaborations to address global health emergencies. We need to increase the GDP allocation for healthcare and the seats for medical courses along with providing specialized training to public health workers in epidemic intelligence, while also working on intersectoral and global collaborations to address emerging and re-emerging infectious diseases, especially those having a zoonotic origin.

 

  1. Research into Emerging Infectious Diseases:
  • We need to focus more on research by not only allocating an increasing fiscal amount into the same, but also by working on better equipping more research labs to work on studying mutating viruses and investigating strains of the disease.  At this stage, we have a triple burden of disease – communicable, non-communicable and emerging infectious/zoonotic disease. We need to take steps to address all three, else India will be on a spurious growth curve in all 3 domains. All three need equal investment and evidence-based policy, and fiscal decisions need to be made to each sector. We need this and we need it now! Let’s not wait for another Corona to come knocking on our doors!

 

  1. Preparedness at both Facility and Community Level:
  • In terms of preparedness, we need both facility and community level preparedness. This includes health worker safety in terms of PPE as well as isolation and quarantine measures at both the health facility and in the community.  Stronger infection control measures coupled with reporting of cases regularly to surveillance teams is also needed. Many a times fever goes reported as Pyrexia of Unknown Origin. This needs to be addressed and a detailed investigation into such cases needs to be done. Medical officers should be sensitized to the early warning signs of a potential epidemic and the need to report cases regularly to the surveillance department.

 

  1. Laboratory Preparedness: 
  • We need to invest more in specialized laboratories to address such an outbreak. Currently, we have only 3 BSL-4 labs for a population of over 1.3 billion. BSL-4 (Biosafety Level 4) labs are at the highest level of biosafety and are needed to work on agents that are easily aerosolized during procedures, cause fatal disease and against whom no current treatment or vaccine is available, for e.g. COVID-19. The inadequacy of such labs needs to be addressed and more funding needs to be given for setting up such specialized labs which play a massive role in epidemiological surveillance. Labs have a huge role in public health from being at the cornerstone before the outbreak in terms of early warning signals and outbreak detection as well as in confirming cases along with trend monitoring, and monitoring control progress.

India currently has over 900 cases of COVID19. With the lockdown in place, we hope the numbers don’t spike more which could be the case due to the selective screening adopted previously. Social distancing does help, but this move should have been implemented much earlier. While states like Kerala have been active in quarantining people who have arrived from abroad, many other states need to learn from Kerala’s dedication considering their previous experience with NIPAH and good health indicators. We hope that officials implement a more stringent plan and testing strategy and the cases and case fatalities decrease.  Wake up India, let’s beat this and ensure we don’t have to endure a novel disease again to teach us that we need to build a more resilient health system! Lockdowns are necessary, but there are not enough to contain the cases. We need to ensure a lot more to flatten the epidemic curve.

Sincerely, 

A public health enthusiast.

[The Author would like to thank a variety of clinicians and public health specialists from India and US whose inputs and case notes have been used for this commentary.]

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