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Wisdom and intuition can lead us through routine situations in our lives, but they are counterproductive for public health programs.
This is scientific evidence that should guide the decisions that will ultimately save lives in a public health crisis.
India entered a nationwide lockdown last year when it had 500 cases. In retrospect, the public health response was a wise move as the effective reproduction number (RT) – the number of people infected by those infected – was at an all-time high (3.75) on March 23, 2020.
A year later, despite a lower RT of 1.65, multiple super-spreading events and poor adherence to the appropriate behavior, resulted in the continued devastation we see around us – cases of Covid reaching a new high every day, an increase in deaths and a shortage of drugs. and oxygen.
I want to think that the decision to go into lockdown in 2020 was based on evidence. Even though it was intuitive, it helped avert a major national health crisis.
Read: Indian economy slows, Covid-19 vaccine is best bet
Cut-off until February 2021: there was the red flag of the increase in RT fairly early in the month.
Even though cases have risen sharply in Kerala and Maharashtra, the country has failed to prevent mass gatherings at a time when it should have gone into war mode.
This inability to use the data at this crucial stage has seen us wipe out our chances of restricting new variants of the virus to a few areas.
Genomic sequencing
India has some of the best minds and research labs to study genomic sequencing and detect new variants of Covid-19.
When the Indian Consortium SARS-CoV-2 on Genomics (INSACOG) – a group of 10 national laboratories – was created by the Ministry of Health and Family Welfare on December 25, 2020, its mandate was to test 5% of samples from all states and 100% of positive samples from international travelers.
However, the government press release of March 24 of this year says only 10,878 samples have been shared by states and UTs in three months, the same day the country officially recorded more than 50,000 positive cases.
Today India ranks 102 in genomic sequencing of Covid (see table), even falling behind smaller countries like Australia and Denmark in absolute number of positive samples sequenced.
Read: Scientists mobilized to fight the Covid-19 pandemic
This is mainly due to the misallocation of resources by the government and the lack of prioritization to identify the role of the new variants in the previous outbreak in Maharashtra. Much of the crucial time was wasted when the state suffered from the spike in cases. Due to the delay, the variants may have spread to other regions.
Since March 27, India’s test positivity rate has quadrupled from 5% to 21%.
Likewise, the number of daily deaths per million population has increased 12-fold, from 0.2 on March 28 to the current level of 2.7.
Based on what we know about RT and the capacity of the health system, some cities, districts and states need to stop the rate at which the virus is spreading through targeted lockdown and aggressive containment.
Instead, we ignore the science when it comes to evolving a second wave response.
The national center for the fight against the disease (NCDC) is a center of epidemiologists in the field; Chennai National Epidemiology Institute (NIE) is the nucleus for laboratory surveillance and training of health workers in epidemiology.
Ideally, the country would have benefited from our own Anthony Fauci – someone from ICMR or NCDC, given the autonomy needed to lead a combined response against Covid-19.
But any attempt to examine state performance using data is hampered by the silent or poor reporting of numbers.
States that test at higher rates and have better reporting systems may also gain the attention needed to secure more resources.
States like Kerala, Punjab, Karnataka, Haryana and Gujarat register an increase in RT compared to the previous week. Incidentally, these states also have the highest tests per million (TPM> 1600).
In contrast, states like Uttar Pradesh and Bihar, which show a decrease in RT, are directly correlated with a relatively lower TPM compared to the start of the week.
Using the data-driven approach promotes fairness, as detecting more cases through a better testing strategy ensures that many vulnerable people come within the scope of services.
And this lack of an evidence-based approach is not only found in the public health response. Current clinical guidelines also contain hydroxychloroquine, which has no evidence of being beneficial as a prophylaxis against Covid-19.
On the other hand, it was extremely confusing to see the approval of Coronil to fight the COVID disease. In addition, some of the drugs in the Department of Health’s management protocol required that evidence be cited from the randomized controlled trial or published studies. The combination of non-evidence-based guidelines in clinical management has confused the provision of quality care.
Vaccination
The country could also benefit from a data-driven approach to immunization.
The speed with which India started the vaccination program, even before the results of Phase 3 of Covaxin and Covieshield without a transition study, was not compared to the speed of coverage afterwards.
The results of phase 3 of Covaxin were recently announced with a vaccine efficacy of 78% (95% CI: 61-88) against mild, moderate and severe Covid-19 disease. The best time to fight the virus was when transmission was low in India as other countries experienced second and third waves.
Instead of stepping up the pace of vaccination, the country has failed to take extraordinary steps to help foreign companies from outside work with Indian manufacturers.
While supply constraints still exist, further confusion is created by expanding the age group to younger ones without setting a specific date on which the process can begin.
Read: Seven states see symbolic start of 3rd phase of Covid-19 vaccination campaign
Indians were prone to cardiovascular disease at least a decade earlier than patients in the West. Young people with co-morbidities should be included in the vulnerable group for vaccination. The government should have given priority to their vaccination with the 45 years and over.
India’s response to the pandemic has taken an unscientific approach, relying on a system that was never designed to meet the health needs of millions of its citizens.
For example, one in three adults has high blood pressure. Yet, by neglecting its detection and treatment, the focus has been on increasing public spending to fund reimbursements for complications resulting from high blood pressure.
Likewise, over 60% of health care needs are met by the private sector. Yet no effort is made to shift the patient base by building reliable and stronger public health systems.
Disregarding all the data suggesting an increase in spending and treatment costs in private hospitals, curative services are mostly contracted out to private health systems.
In a health emergency such as Covid-19, the private health system is demonized, while the government’s inability to prioritize public health is rarely questioned.
The path to follow
For starters, the country has not used the full potential of those in the NCDC and NIE in managing the Covid response. Scientists and public health experts should be given full autonomy to manage the pandemic.
The office of the chief scientific adviser only allowed access to the data yesterday (May 1). NCDC and ICMR data, when made available to Indian researchers, can provide useful analysis and valid inferences to guide our Covid policy.
India prides itself on its skills in calculus, data analysis and is home to some of the best scientists in the world. Epidemiological evidence must be aligned with the results of genomic sequencing to stop the attack of the virus and prevent the spread of new variants of concern.
India is a world leader in immunization because of the strengths of micro-planning and mobilization efforts. The expertise of WHO-NPSP and UNICEF, which has been used in the fight against polio, measles and rubella, should be used as part of the coalition to rapidly expand immunization coverage.
We can have specialists in every block in India and create fully functioning intensive care units with sufficient oxygen beds in each hospital at the block level.
Isn’t it time to convert all block hospitals into hospitals with 250 to 500 beds depending on the population and permanently hire all the qualified and trained staff required? Also, is it not time to offer them amenities and salaries that are those of the private sector or what is comparable in the West?
Using evidence-based practices and guidelines and having well-trained workers is not a luxury but an absolute necessity to meet the public health needs of the country.
(Giridhara R Babu is Professor of Epidemiology at the Indian Institute of Public Health, PHFI, Bengaluru)
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