In the first week of April 2020, the government’s top scientists laid out conditions for lifting the Covid-19 lockdown. The government ignored that advice and evolved its own criteria, still unclear to states. The result is a surge in cases and ever-changing criteria
MRIDULA CHARI & NITIN SETHI
An ICMR advisory to states on efficient testing, admits that cases are rising exponentially, and no longer only through contact with those testing positive for Covid-19.
Mumbai: Carry out house-to-house surveillance in each district to actively identify people showing symptoms of Covid-19. Quarantine those detected with symptoms as quickly as possible without awaiting test results. If after 14 days of establishing such quarantine and active surveillance in a district, Covid-19 cases decline by at least 40% and medical infrastructure is ready to deal with future cases, only then relax the lockdown.
The lockdown in every district could be lifted only when these conditions were met, the Indian Council of Medical Research (ICMR) advised the government. Article14 reviewed a presentation ICMR made to the government in the first week of April. It laid down criteria for easing the world’s most-stringent lockdown.
The scientists warned these were the “only effective intervention (sic) known” and “cases would rise again if no intervention was in place.” They also said that “without local monitoring and data, relaxing lockdown may not be considered”.
ICMR’s presentation included a flowchart to help administrators decide how the lockdown could be lifted.
Despite six weeks of lockdown and two extensions later over 49 days, the government has neither put in place the nationwide house-to-house surveillance mechanism nor is it following a “decision-making tree” suggested by the ICMR to lift the lockdown. It has, instead, decided upon a set of opaque parameters—the details of which it has not revealed to state governments—to assess the lockdown’s effectiveness and decide relaxations across 700 districts nationwide.
The result of ignoring expert advice has been a surge in cases despite the lockdown, in contrast to downward trends in some countries.
When the lockdown began on 24 March, the government had detected 618 active Covid-19 cases. By 11 May, there were 67,000, a rise of 10,741%, with 4,213 cases added that day, the largest single-day increase, coming 48 days after the lockdown began.
On 7 May, 15 major cities, including Delhi, Mumbai, Chennai and Ahmedabad, accounted for 60% of cases. These cities have stayed locked down. Yet, the cases flow in. Mumbai began the lockdown with 67 cases; by 11 May, it had more than 13,000, up 19,303%; Delhi had 35 active cases, by 11 May 7,233, up 20,565%; Ahmedabad 14 on 25 March; by 11 May, 5,818, up 41457%.
Meanwhile, officers in Maharashtra have finally admitted that community transmission is taking place in parts of the state. Odisha’s Covid-19 cases have doubled in a week. The Union government’s prediction on 24 April that India would record no new Covid-19 case by 16 May has been proven wrong.
According to a Ministry of Health and Family Welfare order issued on 30 April, the Centre decided to ease restrictions by classifying districts as red, orange or green zones on four parameters: active Covid-19 cases, days it takes for cases to double in the district, “the extent of testing” and “surveillance feedback”. A red zone would see the strictest lockdown restrictions and a green zone the minimum.
Article 14 sought comment from India’s Health Minister Harsh Vardhan, Health Secretary Preeti Sudan, ICMR Director General Balram Bhargava and ICMR chief of Epidemiology and Communicable Diseases Raman Gangakhedkar about the parameters the ministry uses for the zoning policy and why they did not follow the ICMR advice.
The secretary forwarded this email to others in the ministry and ICMR and copied us. Bhargava replied to the email thread saying, “The matter regarding mail from Ms. Mridula Chari is related to MOHFW and not to ICMR.” Bhargava did not reply to a separate email with questions pertaining directly to the ICMR. The story will be updated if and when a response is received.
In the 30 April order, the government did not reveal to states how these four parameters would be used in combination to lift restrictions. The health ministry’s order only said: “It is further highlighted that based on field feedback and additional analysis at state level, states may designate additional red or orange zones as appropriate. However, states may not relax the zonal classification of districts classified as red/orange as communicated by the Ministry.”
A day later on 1 May, the home ministry, extending the lockdown, reiterated its decision: “States and UTs may not lower the classification of any district, that is included in the list of Red Zone (Hotspots) and Orange Zone by MoHFW (ministry of health and family welfare)” It did not reveal how these decisions would be taken.
A Series Of Missed Chances
An earlier investigation by Article 14 on 23 April revealed how the ICMR had warned the government in the first week of April that large-scale “generalised transmission” of the virus was inevitable in India and the “best use of lock down” was to buy time to prepare the country’s health infrastructure to deal with the crisis.
The ICMR suggested several scientific measures, such as establishing house-to-house surveillance and community-based monitoring to quarantine every one out of two suspected covid-19 positive persons. Without these measures, the scientists had warned the benefits of the lockdown would be “temporary.”
These recommendations from ICMR scientists came after the government had already ignored their warnings against imposing a coercive lockdown in the country, as we reported on 24 April. The scientists had warned as early as February against a China-like lockdown on India. Such a lockdown, they said, could have adverse long-term social, economic and psychological effects. Instead, they suggested that the government prepare medical infrastructure and “community-based” surveillance and quarantine facilities well in advance to fight the pandemic.
Ignoring these warnings, a scientifically unprepared government, imposed on 24 March —with a four-hour notice—a country-wide lockdown, which sparked a livelihood and food crisis among the poor and migrants.
Once the lockdown became a fait accompli, the ICMR scientists again recommended several scientific measures to the government, this time factoring in the lockdown.
The scientists said the measures were required to make the “best use of the lockdown” to prepare the country for large-scale transmission of the virus—which some experts argued is already underway (here and here)—and suggested a “decision-making tree” to eventually exit the lockdown. The government has not implemented these measures.
Now multiple government orders and guidelines over the past month show how, after having failed to put in place the ICMR scientific mechanisms, the government has settled on a reactive strategy.
“Even if no specific treatment is available, if you are keen on discovering and isolating cases, it is important to have a diagnosis,” said K Srinath Reddy, president of the Public Health Foundation of India and member of the National Task Force on Covid-19. “That is why it is better to keep surveillance on in the entire zone.”
Deviating From Scientific Advice
While communicating the ICMR’s decision-making tree to the government in the first week of April, Niti Aayog member Vinod K Paul had said it would take another week for the government to prepare for the measures—the nationwide house-to-house surveillance and quarantine strategy—suggested by the scientists.
All this while, the government maintained in public that the pandemic was in control, but internally the government admitted the worst was yet to come.
On 14 April, a note from ICMR Director General Bhargava to state governments said: “The number of Covid-19 cases in India is rising exponentially” (see lead image).
On the same day, the Centre, for the first time, classified districts into red, orange and green zones, using only one of four criteria it would later apply to identify red zones, districts where confirmed cases were doubling in less than four days.
A government presentation shared with states in the middle of April explains the concept of hotspots and red zones.
Areas that had not recorded any new case for 28 days would be designated as green zones and the rest as orange zones.
If a red zone district did not register new cases for 14 days it could be reclassified as an orange zone. If no case was detected for another 14 days, then the orange zone could be redesignated a green zone.
“At this time many districts were claiming they had no cases. Of course they did not. They were not testing enough or surveilling to detect the cases,” said a member of the government’s task force of public health experts on Covid19, requesting anonymity. “That did not mean the district did not have Covid-19 infected people.”
For instance, Tripura’s Chief Minister Biplab Dev declared the state corona-free on 23 April after the second of its two Covid-19 patients tested negative. Over the next two weeks, positive cases rose to 62, after the state began to test Border Security Force troopers. By 10 May, there were 100 positive cases.
During the first extension of the lockdown, between 15 April and 1 May, the government did not put into place the country-wide, or even city-wide door-to-door surveillance and quarantining of those detected with Covid-19 symptoms, as the ICMR advised in February and then again in the first week of April. Instead it restricted it to areas with clusters of cases, after 17 April.
“In Andhra Pradesh and Kerala, there are ward and village volunteers going weekly to houses and asking about symptoms, even during the lockdown,” said Reddy. “It doesn’t require doctors to do this. Volunteers and ASHA workers could also do this.”
Meanwhile, testing rates across the country increased, revealing that the government’s approach had failed.
Over the next 15 days, as the second phase of the lockdown neared its end, the pandemic was still spreading at a rate higher than before. There were 12,000 active cases on 14 April, 33,000 on 30 April and 60,000 by 9 May. The economic pain from an extended lockdown continued to take a toll.
The government changed its approach, once again.
The New Criteria
On 1 May, the Union home ministry issued a 12-page order about classification of zones, changing the designation parameters from one to four.
“Districts shall be defined as Red Zones or Hotspot districts, by the Health and Family Welfare, Government of India, taking into account total number of active cases, doubling rate of confirmed cases, extent of testing and surveillance feedback,” said the order.
The government, either in its order or in subsequent instructions to states, did not explain why it was using these metrics, how they would be considered to ease or end lockdowns and in what combination.
“The lockdown is to ensure that the number of people needing hospitalisation and quarantine remain below the available capacity at the peak of the infection. Without taking into account the medical and quarantine capacity in a district these parameters do not make sense,” explained an officer, requesting anonymity, from a state that has formally requested the Union government to review its zoning policy. He asked that the state not be identified.
“A total of 500 positive cases in a district at a given time can be way too many if I have only 50 beds,” said the officer, requesting anonymity because of the sensitivity of the issue. “The number is manageable if we have 1,000 beds available in the district, and we know the daily trend is ebbing. In that situation one could consider lifting the restrictions. But the Centre’s diktat gives us no clarity on how it is using these parameters.”
Surveillance As A Parameter
Reading the 30 April government order, it is easy, said experts, to confuse “surveillance feedback” with what the ICMR recommended: house-to-house surveillance. If the government order mentions “surveillance feedback” as a criteria, was it adhering to the ICMR recommendations, at least in part?
No, as experts within and outside the government explained to Article 14.
ICMR recommended a biweekly door-to-door survey to detect people showing Covid-19 symptoms across India’s 700 districts. It also recommended “sentinel surveillance”, where the government would test samples of potential Covid-19 patients at hospitals, clinics and fever camps to gauge the broader infection rate in an area.
In areas with no confirmed cases, sentinel surveillance would include testing people visiting hospitals to check for a general spike in coronavirus antibodies, an indication that there might be an increase in Covid-19 cases.
The Union government has made door-to-door surveys compulsory only in “containment zones”, areas with at least one positive case, not entire districts, according to a 17 April advisory, which said an “active case search” would be undertaken only in such zones after sealing them from the outside world.
The Centre advised against a search for cases in adjoining “buffer zones” and defined containment zones in areas with large outbreaks as potentially including a city. On 30 April, the Centre changed the containment-zone definition to smaller units of buildings, neighbourhoods, streets or police station jurisdictions.
“I think it is too late to now adhere to ICMR’s advice,” said the ICMR task force member previously quoted. “The lockdown is causing immense economic challenges and the government has taken a different approach to dealing with the pandemic. It is hard to imagine how we can wait for door-to-door surveillance to be completed and quarantine and other medical facilities to be ramped up the way ICMR had suggested before the lockdown is lifted. Call it a hybrid approach, I guess.”
Some states, such as Andhra Pradesh, Kerala and Maharashtra, have undertaken door-to-door surveys, but none are complete. In Delhi a door-to-door survey is underway, a source in the state government confirmed. Against ICMR advice, which said all symptomatic cases should be quarantined, symptomatic cases in Delhi are being tested at home. Only those with serious symptoms or have tested positive are quarantined.