Understanding the importance of testing for gaining control over what could be a runaway epidemic, Andhra Pradesh rightly focused on expanding access to free testing. It swiftly did three things: procured one lakh rapid kits from South Korea; put to use the PCR based TRUENAT technology; and issued a well thought out comprehensive testing strategy with the target of 15 lakh tests. The AP Testing strategy delineates persons to be tested in accordance with the level of risk – primary contacts living in red zones, elderly with co-morbidities, symptomatics, SARI and ILI cases, healthcare workers, fever cases, asymptomatics living in buffer zones, one person from every tenth household in the green zone and so on. A variety of mediums are being used – True NAT, RT PCR, Rapid diagnostic kits – each as per a laid down protocol.
Along with the analysis of deaths, the emerging data will provide AP information for formulating future strategies. Assessed over three parameters, AP is one of the better performing states: 1) fourth highest in number of tests done in March and April — as on 2 nd May, 1,08,403 tests were done compared to 1,44,159 tests by Maharashtra; 2) Doubling rate of infections has been encouraging, giving hope that the curve may finally be bending; 3) infection rate is better at 1.4% compared to 8% for Maharashtra, suggesting effective management. Of concern is the death rate at 2.1 compared to less than 1 in Kerala, indicating poorer quality of care. Besides, the majority of people dying or in critical care are 50+ age group with co-morbidities.
Data has enabled AP to categorize districts in terms of infectivity – five account for 80% of all infections in AP. Four rounds of fever surveys have been conducted among the 1.46 households providing information on the demographic and health profile of fever cases, enabling prioritization for testing and initiating containment measures. Epidemiological data is vital to target interventions for disrupting transmission. Absence of such vital data means fighting the battle blindfolded. Testing is the only means of getting a grip on the situation and the only means of providing confidence and credibility to assessments of future scenarios.
Decentralized approaches for Effective Implementation
Such rapid scaling up of the testing strategy and the effective implementation of welfare measures at the community level is as much a reflection of the political and administrative leadership as it is of the delivery structures provided at the village and ward levels by the current government. Envisioned by the Chief Minister, established for every 2000 households, the system consists of 8 qualified persons covering major sectoral activities and a volunteer for every 50 households. For Health, a qualified ANM has been appointed as the Village Health Secretary. All these 13 persons ensure programme delivery to households.
In the case of Covid, the volunteers, the ASHAs and the ANM together have been utilized for carrying out surveys, communicating preventive messages of staying home, washing hands, maintaining distance and using masks; organizing the quarantine arrangements; delivering rations and pensions etc.
Way Forward
AP has done well in keeping caseloads within its coping ability. Detailed action plans regarding availability of ICU beds, ventilators and PPE kits, masks etc. in public and private facilities to address any surge in caseloads have been readied. With the graded lifting of the lockdown from May 4, AP is now faced with a new round of challenges — ensuring the fresh wave of migrant returnees and restoration of economic and social activity does not undo the gains made. There are four areas in which
AP needs to pay attention:
1) Resume hospitals for treatment of non-Covid cases
Closure of hospitals to all care except emergencies has created unimaginable hardship to the sick and should have been avoided. With the diversion of personnel to Covid work, routine services — immunization, maternal care, provisioning of drugs to patients with chronic diseases like TB, HIV, diabetes, hypertension etc. could stand affected resulting in the emergence of drug resistance that is more difficult and expensive to treat. These services need to be immediately resumed and in order to avoid cross infections, the 104 services should be started and services for routine ailments, chronic patients, the elderly and those 50+ more vulnerable to Covid be provided at the village level. Besides, to avoid spiking of diarrhea and vector borne diseases, preventive action needs to be taken — spraying, distribution of bed nets, supply of drugs and kits to fieldworkers etc.
A stocktaking of the availability of essential drugs is necessary in the background of news that lockdowns have disrupted supply chains and manufacture of drugs by pharma companies.
Reports of an exponential rise in domestic violence and mental stress need to be investigated and addressed on priority. The social and economic disruption of the last six weeks is bound to leave deep scars resulting in depressions and suicidal tendencies. Experienced counsellors appointed in the HIV AIDS Control program need to be mobilized. There is an urgent need to enforce standardized treatment protocols and triaging patients for home treatment. Evidence suggests that 85% of patients do not require institutional treatment. Operationalizing this strategy would require assessing ability of the infected person’s ability to self-isolate, train family members on precautions, deliver medicines at home and monitor electronically.
2) Zoning
Government of India has directed states to lift the lockdown in a graded manner. Basically, it amounts to locking down the red zone – i.e areas having positive cases and in the rest, restore normal life. Such a balanced approach is necessary. But then, it also demands a more effective enforcement of lockdown in the red zones. AP needs to take two important steps. In slums and high density areas, there is nopoint in talking about physical distancing as five people cannot be cooped in a small hut in this heat. Social interaction being inevitable, not only must all supplies be provided at the household/basti level but masks, soaps and extra supply of water must also be provided. Inaddition, a mobile testing van be deployed for frequent testing of persons to identify any potential cases before they become super spreaders. Finally, it is essential to launch massive multimedia information campaigns – TV, newspaper, mikes on mobile vehicles etc. towards using masks and avoiding unnecessary movement. Behaviour change is difficult, but is the only way of protecting ourselves from the virus.
3) Promote civil society and NGOs
Covid is here to stay, atleast for two years. Cyclical lockdowns is an option but entails substantial trade offs and exhausts staff. It is therefore important to normalize the infection and learn to live with it. AP does not have many civil society organizations. It would be useful to strengthen those available and fully utilize the self-help groups and other community organizations in helping remove fear and stigma, encourage people to come forward for testing, managing quarantine centers; and building social solidarity and support systems.
Conclusion: The tasks ahead are immense. The challenge of coping with ensuring healthcare in the wider context of continued access to health determinants, namely food and incomes required for ensuring a healthy body, is overwhelming. Creating employment, mobilizing civil society, keeping transportation routes open, and restoring the social and economic life balance without allowing the infection to get the better of us would need granular planning done in constant motion factoring at every level of human interaction, physical distancing and use of masks. This requires imagination and innovation. The districts need to be asked to prepare micro plans, spelling out the pathways for ensuring appropriate sequencing of interventions and comprehensive approaches. Difficult but doable.
(K Sujatha Rao Former Union Health Secretary)