Delhi at an inflection point in Covid battle

The Capital is at a crucial stage where it needs to act swiftly before the growing number of Covid-19 cases builds into a second wave, top health experts in the country believe, identifying the period from now till the festive season in October as a crucial window for infection control measures.

There were 1,693 new cases reported on Wednesday, taking the average number of new cases over the last seven days to 1,375 -- the highest since the seven-day period ending in July 15. The proportion of samples turning positive has also been the highest it has been since then.

“Delhi is at the crux where the rise in the number of cases can be controlled, if it is not controlled now, we can enter a second wave in a few months. People are fed up, and have become casual about using masks and maintaining social distancing, and we have to factor this in when planning a response to prevent resurgence,” said Dr Randeep Guleria, director, All India Institute of Medical Sciences (AIIMS), Delhi.

“I would say 3,000 cases daily will indicate resurgence, we have to keep the number of daily cases between 1,000 and 1,500. Delhi’s R-naught (R0) has gone up, which suggests the disease is spreading. R0 has increased to over 1 from a low of 0.71 on July 27, Delhi should focus on keeping the R0 below 1, anything approaching 2 is a huge concern,” he said.

R0 is the reproduction number that indicates the number of people infected by a single person. If the number is above 1, it implies the outbreak is growing. Once it breaches 2, the growth can become exponential.

“With opening up, cases will rise, this is the only way as life has to go on. Around 30% people have antibodies, which means 70% are still vulnerable, and the only protection is wearing a mask. There are no short cuts as we don’t know how protective these antibodies are as these are not neutralising, which offer longer protection,” said Dr SK Sarin, director, Institute of Liver and Biliary Sciences, New Delhi.

“There is bound to be some daily fluctuation … but the positivity rate is also rising, which is a cause for concern,” said Dr K Srinath Reddy, president, Public Health Foundation of India.

REOPEN SLOWLY
The experts said that encouraging discipline during the festive season – a period when people socialise and shop – will be crucial. “We should bring the R0 down to 1 to have stable numbers. Delhi has certainly done well, but opening public transport will pose a huge challenge. We all have to assume that everyone is infected and can transmit to us, and we can transmit to others. Keeping that in mind, we must use universal precautions,” he added.

The strategy must focus on addressing economic considerations as well. “We need to have a relook at the strategy keeping in mind human behaviour, economic activity, and newer interventions, including partial lockdown being implemented in many states like Kerala, Tamil Nadu, Karnataka and West Bengal,” said Dr Guleria.

He added that now is not the time to reopen schools and more public transport. “Opening public transport further is not a good idea as the festive season is about to begin, where people begin meeting family, friends and markets and public places; it is human nature. Much like Ganapati celebrations in Mumbai, public celebrations must be low key with restrictions on gatherings, crowding in marketplaces etc,” he said.

Data from across the world suggests cases have spiked wherever schools have opened. “Children and young children can’t follow social-distancing norms, India doesn’t have the capacity to control large classrooms,” Dr Guleria added.

Crowding must be stopped till there are clear reductions in daily cases, the experts said. “The government must forbid crowding, including in the festive season, till we see the last of the virus. In Europe, the virus appears to have got milder, with cases rising in the second wave but deaths not increasing correspondingly. Its evolutionary biology, but it takes several months. We have to slow infection by changing behaviour by avoiding crowds so we nudge the virus to a milder form, eve as more people recover from infection,” said Dr Reddy.

IMPROVE TESTING
The turnaround time of test results must be reduced to 24 hours or less as the utility of testing lies in results being quick, particularly for RT-PCR tests. “Delhi needs to do more RT-PCR (reverse transcription- polymerase chain reaction) tests, which currently accounts for around 30 of the total tests, ratio of RT-PCR ad antigen testing should be reversed,” said Dr Guleria, adding: “antigen tests have higher positivity in symptomatic cases and does not pick up infection in close contacts, asymptomatic and mild cases. It’s useful for point-of-care testing and containment zones to quickly quarantine and isolate patients, but doing it on a large scale has limitations”.

FIGHT FATIGUE
Experts said the government response needs to focus on leading indicators, like identifying outbreaks early, than lagging indicators like death, which occurs after the epidemic has taken seed. Even the number of known cases is slightly lagging because people develop symptoms, get tested, and have the test reported to government, by when it is likely been a few days.

“The leading indicator is symptoms. The minute you find lots of people reporting symptoms, such as loss of smell, in any part of Delhi even before the tests come positive, you know that something is happening in this area, all the people in that area can be warned,” said Dr Anurag Agrawal, director, Institute of Genomics and Integrative Biology (Council of Scientific and Industrial Research

He agreed that public fatigue was a worrying factor, and that officials should consider a “smart, guided precautions communicated via a tool people trust”. “The closest thing we have to that is Aarogya Setu. But it must be made stronger so it adds value to people’s lives. Simply telling people to wear a mask is weak messaging, you have to value add so people get into the habit of checking their Aarogya Setu every time they step out to identify safe areas and avoid unsafe ones to help maximise mobility and minimizing risk,” said Agrawal.

FOCUS ON RESOURCES
Clinical preparedness must continue to manage cases and save lives, said ILBS’s Dr Sarin. “Our job is to ensure people know they have to go to the hospital first, where they must get treated. We have plasma bank facility and if applied early in first72 hours, then definitely it gives benefits. I have always said that we have another year before we will settle down,” he said.

On a hopeful note, Dr Reddy added behaviour change may not be as tough as it appears. “We have been trained to work from home, now we must learn to socialise and pray from home,” Dr Reddy.