Updated: March 16, 2020 2:40:30 pm
My friend, whose daughter is in the US, rang me up for advice. A coronavirus case has been reported from her city. Should he get his daughter to India? Is air travel safe? Everyone is worried about the way the COVID-19 outbreak will play out. In today’s networked world, heightened sensitivities make it more difficult to manage such situations. There is a need for more informed decision-making and better dissemination of information.
The chance of getting infected is not very high and given the low mortality rates (to the general population), the threat perception should be low. The people who should be worried are healthcare workers, the elderly and other vulnerable groups and those who have had contact with the infected. Given the immunity levels of people in different parts of the country, even with low mortality rates, there are likely to be large number of deaths in a short period of time. This is a public health problem, but it should not be a personal problem for most people. Yet, people are overreacting by stocking sanitisers, masks and paracetamol. This is related to how the risk is communicated by governments and other sectors and how it is perceived by people. Our approach must be to have a clear public health focus while assuaging fears at the individual level.
The public health response to such outbreaks comprises three phases: The containment phase, delay phase and mitigation phase. During the containment phase, the aim is to detect and isolate cases and trace people who have been in contact with those infected. From a country point of view, the goal is to “prevent the disease taking hold in the country for as long as is reasonably possible”. However, by the time the COVID-19 outbreak was known to the world outside China, many people had already travelled out of the country.
There are many unknowns when such an outbreak starts. For example, the incubation period (interval between being infected and showing symptoms) may be unknown and hence we do not know how long people should be quarantined. Similarly, we do not always know how many days before and after the onset of symptoms a patient is likely to pass on the infection. Moreover, if persons are infective even before they show signs and symptoms, they are likely to have already infected their close contacts and their isolation after diagnosis would not be very useful.
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If containment does not work and the number of cases rise dramatically (there is no clear definition), we enter the delay stage — which is perhaps where we are in the current crisis. Delay is largely engineered through “social distancing” strategies and personal protection measures. These are the main tools to prevent accelerated transmission when no vaccine or prophylaxis is available. This includes school closures, encouraging more home working and reducing large-scale gatherings. China did these most effectively, but other countries may find it difficult to follow it with the same effectiveness.
However, the evidence is not clear on the efficacy of measures like closing schools and stopping big gatherings. It is not possible to conduct “trials” to test such measures. Most of the evidence is based on modeling the spread of the infection, given the properties of the agent and social mixing in the population (who meets whom and how often). For many respiratory infections, children have been shown to bring the infection into the family from the schools. However, there are many things yet to be learnt with regard to the coronavirus infection.
Another purpose of the delay phase is to push the outbreak away from the winter season. If the peak of the virus can be delayed until the warmer months, it could possibly reduce the risk of transmission as the life of the virus in the environment is expected to be shorter. This phase allows time for strengthening the health system to prepare for the patient load.
In the event of the outbreak worsening, the response will escalate and the focus will be on providing optimal care for people who need hospitalisation and ensuring support for those who become infected but do not require hospital treatment. It also involves plans to minimise the impact of disease on society, public services and the economy.
The WHO was criticised for its handling of communication during the SARS epidemic — it was felt that the agency overreacted. Many lessons have been learnt since then. In the current situation, I am sure the WHO will be criticised for playing safe. In today’s global environment, being balanced is very difficult and hindsight is cruel in its judgement. Travel advisories have serious economic and diplomatic consequences, especially if large and powerful nations are involved.
In such situations, it is not only necessary to give appropriate advice but also explain the process and purpose. The UK’s approach has been praised for its transparency. In India, Kerala has received praise for its handling of the situation. However, we often get it wrong, as one hand of the government does not know what the other hand is doing. For example, on the day the Delhi government closed schools, I heard an advertisement on the radio in which a schoolchild complains that very few children came to play and the father reassures that there is no reason to worry about this in India.
There are some things we must not do — for example, politicise the matter. While there can be criticism of the way the issue was handled, this should not be given a political colour. This erodes trust in the government, which can be very harmful in a sensitive situation.
As the WHO has said, the world is entering unchartered territories. One of the tragedies of public health is that its failures are well known but its successes in preventing calamities are always questioned — as there is nothing to show. Let us hope that we not only mitigate the coronavirus infection but also learn lessons from it.
This article first appreared in the print edition on March 16, 2020 under the title ‘Virus, on balance’. The writer is professor at the Centre for Community Medicine, AIIMS, New Delhi. The views expressed are personal
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