Covid-19: India imposes lockdown for 21 days and cases riseBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1251 (Published 26 March 2020) Cite this as: BMJ 2020;368:m1251
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On 24 March 2020, Narendra Modi, Prime Minister of India, announced a 21-day nation-wide lock down, imposed under the Disaster Management Act, 2005, to prevent the further spread of COVID-19 . “India is at a critical stage and even a single misstep could lead to the deadly virus spreading like wildfire and put the entire nation in jeopardy. He said, if we continue to be negligent, India will have to pay a heavy price. Indian’s lockdown may rise cases the rises .
Amnesty International and the Human Rights Watch on 28 March 2020 urged police forces in India to act with restraining while maintaining law and order during CORONA virus lockdown . Avinash Kumar, Executive Director of Amnesty International India, said that India should take all the necessary steps to battle the COVID-19 pandemic. However, it is equally important that the interests of the most vulnerable communities be kept at the heart of every policy in battling the pandemic. The nation-wide lockdown has disproportionately affected migrant and daily-wage workers and those employed in the informal sector. In designing responses to COVID-19, the Government of India must ensure that the needs and experiences of these communities are not an afterthought.
According to the 2018-2019 Economic Survey of India, 93% of India’s workforce is employed in the informal sector which is largely characteristic of inadequate or limited social security benefits. As most of India’s economy comes to a gradual shutdown, millions of such workers have already lost their jobs. With temporary or insecure housing and inadequate food, shelter, and sanitation facilities, many have no option but to go back to their homes. Since the lockdown includes suspension of bus and railway services, many are compelled to walk to their homes, which in some cases are more than 1000 kilometres away. Restaurants and hotels remain shut, leaving them with fewer options to access clean food and drinking water as they walk back home. And to make it worse, the state police machinery is using repression, including ill-treatment, arbitrary detentions and unnecessary or excessive use of force on these workers for violating the lockdown.
The nation-wide lockdown has left millions stranded, struggling to search for food and water. Unfortunately for these people, the state machinery has become a larger threat than the COVID-19 pandemic. This is unfortunate and the Government of India must ensure that insensitivity and brute force be replaced by people friendly measures in battling the pandemic. Torture and other ill-treatment is absolutely prohibited in all circumstances, and can never be justified, including during public health crises.
Lockdown in India to battle the COVID-19 pandemic has left millions of migrant workers stranded and the poor struggling to access essential services across the country. The policies and schemes that are being planned and implemented to battle the pandemic by the Government of India must alleviate and not aggravate the hardships of the poor and marginalised communities in India.
The Government of India and various State Governments should take measures to widen access to social security which will reduce the hardships faced by those who have lost their jobs because of the nation-wide lockdown. It also urges the Government to respect and protect the rights of those under quarantine and ensure that people’s basic needs are met, including adequate shelter, food, water, and sanitation.
1. Gettleman, J, Schultz, K. "Modi Orders 3-Week Total Lockdown for All 1.3 Billion Indians". The New York Times. https://www.nytimes.com/2020/03/24/world/asia/india-coronavirus-lockdown...). (Accessed; 29 March, 2020).
2. Pulla, P. 2020. Covid-19: India imposes lockdown for 21 days and cases rise. BMJ, 368. (https://doi.org/10.1136/bmj.m1251 ). (Accessed; 29 March, 2020).
3. Amnesty International India. Battle against COVID-19 must not leave behind the poor and marginalized communities in India. (https://amnesty.org.in/news-update/the-battle-against-covid-19-must-not-...). (Accessed; 29 March, 2020).
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Epidemiological, public health, and ethical considerations in the evolution of India’s COVID-19 testing strategies.
India is highly susceptible to the COVID19 pandemic due to the limited health infrastructure, dense population, significant proportion of people living in poverty, and a large elderly population in absolute terms with high prevalence of comorbidities like diabetes, obesity and undernourishment that significantly accentuate the risk of mortality . As of 28 March 2020, India has reported 987 COVID-19 cases and 19 deaths, after conducting approximately 35,000 tests .
The World Health Organization has recommended testing every suspected case for coronavirus infection, isolate the positive cases, trace all contacts, and test those who are symptomatic, to prevent the spread of the disease . However, extensive testing requires adequate availability of testing kits and skilled human and material resources for sample collection and designated laboratories that have appropriate safeguards for infection control and safety.
India adopted a graded, testing strategy for COVID-19, that initially restricted testing to only symptomatic patients who had recent international travel history, and all the symptomatic contacts of laboratory-confirmed cases. Subsequently, the testing strategy has been expanded in the 3rd week of March. The current guidelines now recommend additionally, the testing of all symptomatic healthcare workers, all hospitalized patients with Severe Acute Respiratory Illness (SARI), i.e., fever AND cough and/or shortness of breath, and asymptomatic direct and high-risk contacts of a confirmed case . Testing is available free of cost in designated government facilities, but only when meeting the testing criteria. However, it involves a significant out of pocket expense in undertaking testing in a few private labs that have been approved for the purpose.
The number of people tested for COVID-19 per million population in India is among the lowest in the world. Some experts have considered this as being inadequate in identifying the magnitude of the actual burden of COVID-19 due to the likelihood of missing a significant proportion of positive cases . Moreover, the unidentified cases can further spread the infection to their contacts and increase the risk of community transmission with an exponential increase in cases.
Nevertheless, inferences drawn from the available testing data, suggest that the testing strategy was appropriate for the following reasons.
(1). The proportion of patients testing positive for the coronavirus infection is currently < 2.6% in India, despite the expansion in the testing strategy. This persistently low rate of infectivity despite the restrictive testing criteria is also indicative of the lack of community transmission. Further testing individuals at lower risk of coronavirus infection (not having travel or COVID-19 patient contact history) will cause this proportion to reduce further. It is true that states like Kerala and Maharashtra that tested more patients also found more cases , but the larger denominator was due to a larger diaspora population mainly from the Middle East that traveled back to India belonging to these states, that obviously met the eligibility criteria for testing.
(2). Symptomatic patients with mild symptoms (notably, without shortness of breath) that don’t meet criteria for COVID-19 testing criteria were recommended self-isolation in homes and avoiding contact with other family members, and following hygiene measures. This is because even in the less likely scenario of a mildly symptomatic patient with COVID-19 being missed due to lack of testing, patient beneficence would be limited due to high chances of recovery in the absence of preexisting comorbidities and the absence of curative treatment. Consequently, an infected undetected patient with mild symptoms practicing self-isolation in household settings is unlikely to be negatively impacted due to the lack of confirmation of his/her COVID-19 status.
(3). Mass testing in Indian health settings is challenging due to a large population, limited testing capacity, and lack of effective airborne infection control measures. Infected patients in waiting queues and the queuing area of the health facilities, and during travel if using public transport, or when not using a mask could also increase the risk of infection transmission to the non-infected patients. However, the original testing strategy restricted access to COVID-19 testing. The expanded testing strategy additionally allows any individual to test for COVID-19 in select private labs, based on his/her capacity to pay, which raises concerns over equity.
(4). Several reports of home quarantine violations by Indian residents having international travel history were reported in the media, including cases of suppression of fever symptoms by use of antipyretic agents, and some of these cases were later diagnosed having COVID-19 . A more comprehensive testing strategy that tested all asymptomatic patients with travel history would have provided a higher yield of COVID19. However, the question arises as to the extent of behavior modification for self-isolation, which could be reasonably expected among the mild symptomatic, non-comorbid patients originally exhibiting social deliquescence in the counterfactual event of them having been tested and diagnosed earlier.
(5). The initial restricted testing strategy could hypothetically have missed out on COVID-19 infected SARI cases that were recommended testing by the treating physician but were not tested by the government lab if they did not meet the travel or contact history criterion. The current testing strategy has rectified this significant omission since all hospitalized patients having SARI are now required to be tested, private labs are open for testing, and testing can be conducted based on the physician’s recommendation .
Based on the available data and trends of the COVID-19 epidemic in India, the restricted testing strategy has evolved to become robust, ethical, and adequate. India is currently observing a three-week lockdown to interrupt the chain of transmission and flatten the curve. Post lockdown antibody testing in random cluster and community samples could provide valuable evidence as to the extent of spread, development of herd immunity, and infection prevalence in the community. This would ultimately determine the validity of India’s testing strategy in the management of the COVID-19 epidemic.
1. Fauci AS, Lane HC, Redfield RR. Covid-19 — Navigating the Uncharted. N Engl J Med. 2020;382(13):1268–9.
2. Government of India. Ministry of Health and Family Welfare. [Internet] [Cited 28.3.2020] Available from: https://www.mohfw.gov.in/
3. WHO Director-General's opening remarks at the media briefing on COVID-19 - 16 March 2020. [Internet] [Cited 29.3.2020] Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-re...
4. ICMR. Strategy of COVID19 testing in India 17/3/2020. [Internet] [Cited 28.3.2020] Available from: https://icmr.nic.in/sites/default/files/upload_documents/Strategy_COVID1...
5. Coronavirus | Testing is the easiest thing to do, says community health expert Gagandeep Kang. [Internet] [Cited 28.3.2020] Available from: https://www.thehindu.com/news/national/coronavirus-testing-is-the-easies...
5. States That Are Testing More Are Detecting More Cases, Data Show. [Internet] [Cited 28.3.2020] Available from: https://www.indiaspend.com/states-that-are-testing-more-are-detecting-mo...
6. COVID19. Govt warns of action under IPC for violating quarantine. [Internet] [Cited 28.3.2020] Available from: https://economictimes.indiatimes.com/news/politics-and-nation/covid-19-g...
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Re: Covid-19: India imposes lockdown for 21 days and cases rise :Adequate supply of PPE, N95 Masks,Gloves, handsanitizer,Medicince for all workers in government /private hospitals by the India governments is must to fight covid-19 pandemic war
World Health Organization designated the coronavirus(covid-19) diseases a global pandemic. As number of cases in India continued to grow (as on 28.03.2020 up to 2 pm number of positive covid-19 cases 908 and death 21:while in West Bengal state number of positive cases 15 and death- 1) inspite of declared and imposed lockdown from 22.03.2020 midnight to 14th April 2020 so far announcements by the government of India and home quartine, practice of social distensing, frequent hand washing with soap and hand 70% alcohol based hand sanitizers to slow down the rate of transmission, so that flattening of curve of new infection, but the covid-19 positive cases raising steadily day after day. This will demand in very short duration (as India is very close to move from phase 2 to phase 3 when cases will be more and more detected from community if tests are done for every symptomatix cases ) numbers of beds equipped with ventilators,(for covid-19 cases), medicine, n95 masks, Personal Protection Equipment (PPE) as defined by CDC and FDA for the health care workers. But the country is in fact presently facing inadequate supply of n95 respirators, PPE which are very crucial for the first line health care workers including for all clinicians in OPD and indoor , pathologists, microbiologist and n95 masks for the patients who have bronchial asthma, COPD, chronic bronchities, Chronic heart failure and patients with other co morbid diseases like diabetes, hypertension, immunosupressed, cancer patients, transplants patients or taking immunosuprssive drugs, radiation etc
There was a great panic for buying n95 face masks to spread faster then corona virus just before lock down announced in 22nd March 2020 in Kolkata . Face masks had been sold out and now been in short supply throughout India including in West Bengal and probably in many countries in world, despite WHO remain stick against healthy peoples wearing any masks. The government hospitals (besides those who are in durect contact with covid admitted patients and related with RT PCR detection in biosafety lab) and common people are now wearing clothes face masks or medical mask
The use of face masks and N95 respirator for the protection of health care workers have renewed interest following 2009 influenza pandemic and emerging Infectious disease such as avain influenza, middle east virus and Ebola virus. Various types of masks are now been used to protect health care workers. These are disposable medical /surgical mask (bilayered or trilayered masks ), cloth masks and respirator masks. In high resources countris selling disposable surgical mask /medical masks replaced the use of cloth masks which are also in short supply there likely . But cloth masks are widely used globally including in Asian countries, West African countries particularly in emerging Infectious Diseases in the context of shortage of PPE and N95 masks for all health care workers
Wearing a medical /surgical masks is one of the preventive measures to combat soread of Infectious viron and certain respirator (N95) decrease spread of 2019 ncorona virus. It may act as protective measures when the infection is through aerosol generation . But masks alone is insufficient to provide adequate level of protection and other equally protective measures must be taken like PPE kit, hand washing with soap frequently for health care workers and for community N95 masks when covid-19 virus spreads in community. Will cloth masks be at all replace medical or surgical mask in community. I don't think it so.
A study by CRaina Macintyre(1)et all in a RCT trial cautioned the use of clothes masks that influenza like illness statistically& significantly higher in cloths masks (Relative risks 13% higher rate, 95%CI-1.69-100.7) and laboratory confirmed virus significantly higher in cloths masks group compaired with trilayered surgical mask. Penitration of cloths mask by particles was almost 97% and medical masks is 44%.
So adequate supply of N95 mask, quality PPE (not rain coats like or surgical gowns, instead of PPE), quality gloves, face shields for the front line health workers, laboratory personnel doctors (pathologists microbiologists clinicians) nurses, technicians, sweepers, carrying Viral transport mediums containg specimens are very important. Surgical /Medical/cloths masks are not protective for health care workers at least who are workings as front line soldiers in covid19 pandemic war. Both PPE and N95 are for once use and next to throw. A guide line from the WHO and CDC should be for consideration of re use of these PPE and N95 masks after gamma ray or UV rays radiation and sterilization for some hours and the government should dieect the manufacturing private /government companies those have expertise to make n95 masks, PPE, gloves as per criterion of FDA
1)C Raina Macintyre, Holly Seale, Than chi Dung, NguyenTran Hien etal A cluster Randomized trial of cloth masks compared with medical masks in health care workers BMJ open 22nd April 2015 e006577 doi 10.1136/bmjopen-2014-006577
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I am quite relaxed knowing that India finally imposed complete lockdown for 21 days on 24th March 2020 but I argue with the timing of the Lockdown. Being one of the biggest democracies in the world, India is also home to many scientists, researchers, academicians, epidemiologists and public health specialists. I believe, India failed to initiate appropriate steps which were required to adjourn the immediate effects of the growing pandemic.
As the Covid-19 epidemic broke out in Wuhan Province of China, India was just a mute spectator. The borders India share with China, International business relationships, foreign trade and travel should have been suspended for the time being till the initial outcome of the local epidemic in China was known. Instead, nothing such was done, which led to the entry of travelers to India fleeing from China to save their lives. A sort of initial screening was done at international ports which were mostly escaped by many being asymptomatic at the time of screening. The healthcare infrastructure system of India was not such tailor made and prepared to quarantine all those with a travel history from China. At later stages, many were quarantined, but the quarantine facilities were themselves prone to epidemic outbreaks due to lack of space and poor sanitary and hygienic conditions. Most cases reported from India had an International travel History.
On 31 January, 2020, when India reported its first case from Kerala, that was the second chance India had in hand to call off further International trips both ways but again failed to do so. Instead, more and more Indian travelers were invited back home to safety. Not knowing that Covid-19 had already conquered and put its traces on many countries, with each International flight the virus was unknowingly imported from other countries more and more within the home. Further, the delay in cancelling visas to foreign travelers was a key point decision and a final chance for India which could have averted this tragedy as the initial spread of the Covid-19 was found among 17 international travelers from Italy, the country this time in most agony and pain. Cancellation of all International flights and visas would have restricted the entry of SARS Cov-2 virus in the population. As we know, India is one among the most populous country of the world, finding a Covid-19 suspect is like finding a needle in a haystack. This not only made the job tiresome for the authorities but easier for the virus to spread.
Many days recorded no new Covid-19 positive cases but actually the virus was multiplying from two to four, from four to eight and so on. Slowing the virus enhanced its grip in some states and people started migrating from these to other states to save themselves. The news from many countries was devastating and scientists were clueless with no treatment or vaccine in hand. The tension and anxiety was growing with news of covid-19 deaths everywhere. Calling off interstate trains and domestic flights and sealing interstate borders could have still offered a last chance to India, but unfortunately they misinterpreted the silent nature of the Covid-19. India should have forecasted those numbers at the first instance what they predict today, like incidence and deaths from covid-19. People were rushed into lockdown with no prior preparations, knowing that most of the people belong to socio-economically poorer sections.
Complete lockdown is a gamble, and India has dared to play it. A bit late, but still I believe it will be somehow useful in containment of the virus and will prove to be an effective strategy only when coupled with active surveillance, contact tracing and rigorous testing of suspects. After the lockdown, there has been a sudden surge in positive cases which has a mixed kind of reaction from the experts. Some are of the view that the lockdown may just flatten the curve, others that the burden will be there. I believe, lockdown if observed with letter and spirit, the already covid-19 suspects and their contacts will turn out with symptoms within the longest incubation period. Which is most likely happening this time, resulting in the surge? Surging Stage “S”. Another Peak Stage “P” will follow, when the cases will peak, depending upon the infected covid-19 cases in the community (which will depend on the initial spread before the lockdown). That will be followed by another deflate Stage “D”, when the cases will slowly reduce.
For this to happen, India has to follow complete lockdown and maintain social distancing as much as possible. Authorities need to home deliver basic food stocks, support work from home initiatives, enhance IEC activities through electronic media and engage people in health promotional activities. Meanwhile, the frontline workforce doctors, paramedics and other essential departmental employees must be equipped with personal protective equipment, hospitals be ready to face any emergencies, and facilities be furnished and hygienic to board people for quarantine.
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It is of concern about the rising cases of COVID 19 in India. The present system of screening of COVID 19 affected individuals only measures the tip of the iceberg where only persons with raised body temperature are detected. There are instances where individuals have reportedly consumed paracetamol during the flight to suppress their febrile status and got passed through thermal tests. People have the tendency to hide their history of travel abroad during which time they might have passed on the virus to unsuspecting close contacts. After the announcement of complete lockdown in India since 24th March 2020 midnight scores of migrant labourers stranded at their workplace have embarked on different means to reach their homes. Many of them have hid inside trucks carrying vegetables or essential goods, even inside milk tanks of milk vans. A large number of them even have started walking on the roads to reach their destinations. Such measures only show how people do not obey rules and flout the norms.
In fact, for an effective identification of suspect cases, the need of the hour is to appeal to people so that they do not hide their travel history, self declare about their close contact with any suspect or confirmed case so that they can be isolated or adopt home quarantine measures. Fromm the health sector side, intensive measures to identify, record fever cases with or without cough or breathlessness by simple history taking and using thermal thermometers on a daily basis in their health facility or in the community during home visits should be done. People should be informed to report to the health facility if they have any doubt of infection from coming in contact with either a suspected or a confirmed COVID 19 case. While measures for home quarantine of suspected cases for at least 14 days may be simple to announce, the problem in actual implementation needs to be looked at by constant monitoring by neighbours or resident welfare associations.
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It is quite clear now that that the process of self-isolation/lockdown only flattens the curve. The area under the curve remains the same. In other words, the same number of patients will fall sick but over a longer period of time. So, the current plan is to reduce the load on the health services only. Perhaps try and push part of the curve towards summer and hope for the best.
Basically, an effective medicine or a vaccine is needed.
Also, as viruses are relatively unpredictable, it might decide to mutate and disappear. This is the imponderable or unpredictable. That is where prayers come in.
But the developing world, where I live and practise, presents its own challenges.
We must remember that in the developing world we are not able to save patients with high injury severity scores under normal circumstances. In comparison this is a greater challenge in numbers and perhaps in severity.
Naturally, under such circumstances, our triage threshold will become significantly lower. This is worrisome because of the numbers that we are talking about in the subcontinent.
Most of the hospitals in our part of the world are not aware of their surge capacity. It needs drills and assessment and planning in ‘peacetime’. I have a sneaking suspicion that we, in the developing world, might already be working above our hospital surge capacity on routine days.
One might suggest some means by which the pandemic might be combated better in our circumstances.
1. Clear plans of management and clear chains of authority at the hospital, state and country levels. We might have leaders who are obeyed by most people. At the same time, we certainly have many doctors especially public health specialists and infectious disease specialists who could explain the future course of the disease better. It is a difficult choice. Should the popular figures speak or the more inherently knowledgeable ones? Perhaps it is time to share the stage.
2. As India and Pakistan apply opposing strategies to combat the virus, a lockdown appears to be the better bet at this moment. However, how does a country exit the lockdown without risking another surge? Perhaps it is important to allow some geographically isolated states to come out of the lockdown first whilst deploying medical resources there. This model could be applied to the rest of the regions gradually. After all herd immunity is the only exit strategy at this moment.
3. Religion. It is the only thing that will keep doctors and paramedics working at the frontlines. A significant number is scared. As part of the healthcare system here one feels a palpable sense of dread in a part of the medical community, especially considering the figures coming out of Italy. Heroes are good, as long as they are on the other side of the fence in these circumstances.
4. Rather than go for spectacular innovation in ventilators and high-end equipment as many propose, it would be better to innovate in low end personal protective equipment. This would include innovation in plastic barriers between a suspected patient and the screening doctor, low cost plastic mask frames, plastic shoes and coveralls.
5. Finding and instituting best practices. In an era where social media can ferment riots, the barrage of forwards causes great confusion in the average medical practitioner. It is important to have a single source at the state level which can provide relevant information and address pertinent issues. This should be constituted by a mixture of medical specialists and bureaucrats. The bureaucrat heavy approach can be tangential at best. At present social media is adding to the confusion in the midst of an avalanche of information. It feels like drinking from a fire hose.
6. Involving psychiatrists. The era of rumours seems to be back. The primitive response of trying to save oneself at a visceral level is visible in the areas where the patients or the doctors at the forefront of this fight reside. It is important to put forward the viewpoint of the patient. The public should know that there is a huge difference between Isolation, quarantine and ostracization.
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