The relentless spread of COVID-19 has caught major global economies off-guard, including BRICS nations, USA, UK, and others. The disease was first reported in Wuhan province of China in early January although there were reports of unknown pneumonia as early as last December.
Widespread human to human transmission of SARSCOV2, which causes COVID-19, led to a major outbreak in Wuhan and also a potential global spread to major cities connected through global airlines networks. To contain the outbreak, China responded by instituting time-honoured infectious disease containment measures like testing, tracing, isolation and quarantine and scaling up healthcare infrastructure like testing facilities, hospital beds and ICU beds.
In addition, an extreme form of social and physical distancing along with travel restrictions and closure of all non-essential services, which can also be called a full lockdown, was enforced to contain the spread of the virus in the Wuhan. This may be the first major ‘lockdown’ of the modern world to contain an infectious disease.
Over the last few months, the ‘lockdown’ has emerged as one of the key strategies and possibly the most favoured intervention to contain the spread of the disease by several nations, except a few like Sweden, South Korea, Singapore and Japan. Although the strategies adopted by these countries may be termed as a softer form of lockdown. The decision of national governments, in terms of timing and scope of lockdown, are primarily informed by disease-related epidemiological data, health system capacities (both routine and surge), population density and mixing pattern, type of economic activities and other considerations like system of governance including legal backing for such measure that are at odds with personal liberties.
Interestingly, some commentators have argued that the emergence of the SARSCOV2 in China and its success in containing COVID-19 and also reducing its global spread, by putting Wuhan and neighbouring provinces in lockdown, set the precedent. The strategy of ‘lockdown’ was later picked up by other European nations that witnessed the spread of COVID-19 more or less at the same time as seen in China.
One of the early adopters of the lockdown strategy in mainland Europe was Italy, albeit after initial flip-flops, resulting in a leaky lockdown initially. The northern Italian region of Lombardy was one of the worst affected regions in the world and in Italy during the initial spread of COVID-19, which overwhelmed the Italian health care system to such an extent that there were close to 1,000 deaths per day during the peak of the outbreak, forcing health professionals in moral dilemma of triage of patients in non-war situation. However, in terms of success – the lockdown strategy benefitted Italy later in due course of epidemic by reducing stress on healthcare facilities to cope with surge in the demand on services.
Learning from the Italian experience, neighbouring countries like Spain and France did institute a full lockdown or a hard lockdown early in the outbreak with penal provisions for violators using law and order institutions like police services. This could also be seen as an extreme form of social and physical distancing and a complete ban on all services, except essential services through legal provisions, as opposed to the soft lockdown where citizens are expected to maintain social distancing on their own.
It could be argued that with hard lockdown measures, Spain and France managed to prevent health facilities and services being overwhelmed as has been the case in Italy. Although these countries could not prevent the pandemic wave during the peak of which both countries were reporting close to 900 deaths per day.
Interestingly, the response of another neighbour, Germany, has been quite different -- in addition to a full lockdown, it consistently maintained very high testing rates and ensured isolation of cases and quarantine of suspects throughout the pandemic period. Germany was one of the first countries to develop tests to detect COVID-19 in early January when the virus was first reported and it has the highest number of ICU beds per 1,000 population in Europe highlighting robust health care system and surge capacity. Consequently, they have one of the lowest mortality rates for COVID-19 in the world. During the time of writing this piece, the number of deaths is declining and is at the lowest since the outbreak begin in the last week of March in a majority of the European nations.
Another European country extensively reported on - the United Kingdom - has had a change of strategy mid-way between the pandemic wave. It has been reported that initially the UK adopted a strategy of a soft lockdown with focus on protection of vulnerable population and high-risk population like the elderly and those ewith co-morbidities. It was also reported that the outcome of such a strategy was population-level herd immunity. However, a report by London's Imperial College predicted scenarios of numerous deaths and overwhelmed health service in absence of a full lockdown, i.e. the absence of any intervention to contain population mixing and mobility will result in scores of deaths. As a result, the UK instituted a hard lockdown and has possibly benefited in terms of a reduced number of deaths although the numbers are now reducing on a daily basis, but at the peak of the pandemic the UK witnessed close to 900 deaths per day. Although the number of deaths in any country depends on many factors, including population age structure, responsiveness of health care system and others, in Europe timing of the full lockdown had been a critical factor.
Interestingly, the USA's federal structure allows states to take independent decisions and initiatives to respond to COVID-19 not only in terms of scope and scale of lockdown but also on other economic and health matters, which is reflected in their approach. In the US, cities on the west coast were the first to bear the brunt of the SARSCOV2. Consequently, they were the first to implement the lockdown, which has been quite successful, as compared to their east coast counterparts.
Unfortunately, some of the east coast states and New York particularly were late to initiate a full lockdown and have now seen one of the highest number of cases and deaths globally. During the peak of the pandemic, New York hospitals were overwhelmed and reported excess deaths, both COVID and non-COVID ones.
In contrast, another north American country, Canada, introduced several precautionary measures as early as March to contain the spread of the virus. But in the later weeks when some provinces saw an upsurge in cases, the government enforced a full lockdown, which helped in containing the spread of the pandemic in Canadian territories. In addition, surge capacities of healthcare system were strengthened to respond to demand for care. Many provinces are now looking forward to opening up based on risk assessment with several restrictions in place.
South Korea, Hong Kong, Singapore and Japan also had great success adopting similar strategies. Although we know that in these Asian countries, the lockdown has been a softer one and massive testing played a major role. But we also know that some of these countries, especially South Korea and Hong Kong, witnessed other coronaviruses in the recent past, SARS-CoV and MERS-CoV, as a result of which they are better prepared than others. Although lately Singapore and Japan have seen a rise in COVID-19 cases and have now returned towards harsher lockdown measures expected to remain in force for at least a month.
Sweden has also been an outlier with regards to strategy to combat this pandemic. Since the beginning of the pandemic, Sweden had pursued a strategy of soft lockdown with specific focus on protection of vulnerable population. In terms of health sector response, extensive testing, isolation, contact tracing and quarantine was adopted. In addition, ICU bed capacities were increased threefold.
However, as the number of cases surged, contact tracing and quarantine was stopped. Consequent to their strategy, though the health system has not overwhelmed, the number of deaths in Sweden was higher as compared to their Scandinavian neighbours but not as high as other western European nations. There are arguments, both for and against, the strategy of Sweden. Supporters have argued that eventually lockdowns have to be lifted, which would result in the spread of the virus in the population, so it’s better to allow that to happen in a controlled way while at the same time protecting the vulnerable population. In addition, health infrastructure for testing and care should be ramped up quickly to provide care to those who suffer. The critical question posed by Swedish model supporters is – what is the exit strategy from these lockdowns? Or how will countries get out of the lockdown?
In India, we are in lockdown phase 3 that will last for another two weeks till May 17. India had initially announced the full lockdown from March 25 for three weeks, which was later extended for another three weeks. Epidemiological evidence suggests that India has been able to time its lockdown better than European and American counterparts. This has resulted in slowing the spread of the pandemic across various states and districts. As per reports, nationally the doubling time – a measure of epidemic spread – has increased from four days before the lockdown to around 10 days after the fifth week of the lockdown.
In addition, extensive testing in hotspot zones followed by contact tracing and quarantine has also helped in containing the spread of SARSCOV2 within the country although there are still some districts with hotspots. A majority of these hotspots are in big metropolitan cities like Mumbai, Delhi and others, which have extensive global air connectivity and were the first to receive the virus from overseas travellers. They are also major business hubs with high population density resulting in more opportunities of contact between infectious individuals and susceptible population and higher probability of SARSCOV2 transmission. Given the vastness of Indian states and the realisation that spread of SARSCOV2 in states and districts are independent of each other, the infectious disease containment and control measures are being adapted and implemented locally which has shown good results as we can see in state specific performances.
In addition to full lockdown, India adopted a multipronged strategy involving not only fundamental approaches of infectious disease control by laboratory-based testing of suspected cases by RT-PCR based technique, their isolation, contact tracing and quarantine, but also scaling up the health infrastructure in terms of developing dedicated COVID-19 hospitals, stockpiling testing kits, medicines, PPEs and other health commodities. Furthermore, major financial and material resource allocation has been made to the states to respond to socio-economic demands and as well as investments to scale up health and hospital services for ensuring robust response toward containing COVID-19.
The strategy of centralized guidance and decentralized implementation do have its fair share of successes and failures to which India is no exception. Critics have pointed out about migrant crisis, scarcity of PPE and constraints with regards to testing - low per capita testing rates as compared to global figures and others. Overall, as predicted by infectious disease modelling studies, in addition to direct disease control measures like testing, tracing, isolation and quarantine, lockdowns do play an important role in reducing the spread of disease by directly reducing force of infection, which is evident in the trajectory of pandemic in India also. However, unintended consequences of economic stagnation are also an outcome. To answer the question of getting out of lockdown, India has prepared a detailed plan to stimulate economic activity while at the same time containing the spread of pandemic. GoI has devised a graded response strategy for opening up economy at the district level on the basis of risk of transmission and other epidemiological parameters.
Experience from some Asian countries especially Japan and Singapore who has not resorted to hard lockdown in the earlier phase and kept the business activity ongoing had seen surge of COVID-19 cases in recent weeks, forcing them into lockdown. Hence, we have to follow a cautious path and cannot let the guard down. Experience from Germany and South Korea suggest that this is very much possible as along as we have massive lab-based testing and surveillance system in place along with dedicated isolation, quarantine and care facilities available with sufficient surge capacity to handle any unwanted outbreak.
In addition to kick starting economy by sector wise opening of economy and through stimulus package, we must ensure that hard won success of COVID-19 containment must not be lost. One of the fundamental strategies to ensure this is to keep eye over trend of COVID-19 related cases and deaths, through a robust surveillance system which is both sensitive and specific. Hence, it is important to test suspected COVID-19 cases and their contacts, but equally important to test ILI patients, and patients with breathing difficulty, in both hot spots as well as non-hot spot zones. The later ones are critical to success of surveillance strategy because they will be able to pick up unknown transmission and detection of new hotspots.
Equally important is to keep an eye over both COVID-19 and non COVID-19 deaths, as they reflect performance of health and hospital services and may also reflect communities’ health seeking behavior. In addition, those who test positive needs to be isolated and contacts to be put under quarantine, which demands scaling up of isolation and quarantine facilities. Also, for those with mild, moderate and severe disease are required to be provided care and treatment requiring scale up of inpatient and intensive care beds with oxygen and mechanical ventilation support. In summary, massive upgradation of health infrastructure especially laboratory-based testing and treatment center at district level and state level is paramount to beat this virus because eventually everyone is at risk of the disease once the lockdowns are relaxed to maintain business continuity. The next two-week period under lockdown should be considered as continued opportunity for preparedness purposes at district level specially to ramp up health infrastructure and stockpiling of commodities like masks, PPEs, ventilators.
(The authors are with the Indian Institute of Public Health, Delhi, PHFI. Views are personal.)
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