India’s Containment Plan for Large Outbreaks

Stepwise plan for rolling out the Containment Strategy

The containment strategy’s objective is to stop the chain of transmission, reducing the morbidity and mortality due to COVID-19. The containment plan is a detailed and thorough documentation of the steps to be followed by the government machinery once a geographical area is deemed to suffer from a large outbreak of COVID-19.

This plan is based on the successful containment of COVID-19 cases in Bhilwara (Rajasthan) as devised by the IAS officer Rajendra Bhatt (popularly known as the Bhilwara Model).

A large outbreak is defined as a localized increase in the incidence of COVID-19 cases occurring within a designated geographic area, e.g., in a village, town, or city. This could also imply the progression of a small cluster, earlier noticed for which cluster management action is under implementation, into multiple clusters.

The Cluster Containment Strategy aims to contain the disease within a defined geographic area. The containment is achieved by early detection of cases, breaking the chain of transmission, and thus preventing its spread to new areas. This would include geographic quarantine, social distancing measures, enhanced active surveillance, testing all suspected cases, isolation of cases, quarantine of contacts, and risk communication to create awareness among the public on preventive public health measures. During the 2009 outbreak of H1N1, it was observed that a large number of cases were reported from well-connected cities with substantive population movement, whereas rural areas exhibited few instances. The geographical spread of COVID-19 mimics the pattern of H1N1, which calls for differential strategies across geographies. Mathematical models and containment efforts of China demonstrate that the virus spread can be contained when public health interventions are combined with an effective social distancing strategy. India is on the cusp of entering Stage 3 of COVID-19 transmission, and the administration is confident that the containment strategy will be successful in controlling the spread.

The geographical spread of COVID-19 mimics the pattern of H1N1, which calls for differential strategies across geographies.

Before we get started, let’s set the records straight on a few must-know terms concerning COVID-19.

1. Index Patient- The first case that usually is responsible for the spread of the disease in the community/geographical area. Typically has travel history to infected countries/cities.
2. Cluster- A set of cases in a small geographic area.
3. Cluster transmission- Source of infection is known and can be traced back (Stage 2)
4. Community Transmission- Community transmission as evidenced by the inability to relate confirmed cases through chains of transmission for a large number of cases (Stage 3)
5. Chemoprophylaxis- the use of drugs to prevent disease. E.g., Hydroxychloroquine is used as chemoprophylaxis for COVID-19
6. Severe Acute Respiratory Infections (SARI)- An acute respiratory infection with a history of/ measured fever (≥ 100 F°), cough with onset within the last 10 days, and requires hospitalization.
7. Influenza-Like Illness (ILI)- An acute respiratory infection with measured fever (≥ 100 F°) and cough with onset within the last 10 days

Action Plan:

Legal Framework:

The legal instruments that aid in the execution of the containment plan are

1. Disaster Management Act (2005)
2. Epidemic Act (1897)- Enacted during the outbreak of Spanish Flu
3. State Specific Public Health Act
4. IPC (Sec. 270)- Power to act against people who indulge in spreading of disease
5. Sec. 144 of Code of Criminal Procedure- Prohibits gathering of 5 or more people

Institutional Mechanism:

1. Union Govt. level- Group of ministers (GoM) under the Chairmanship of Union health minister will be the apex body. The GoM will consist of Ministers of External Affairs, Civil Aviation, Shipping, Pharmaceutical, and Home Ministry.
2. State Govt. level- State Crisis Management Committee and Disaster Management Authority
3. Operation level- District Collector/ District Magistrate

Geographic Quarantine:

Geographical quarantine strategy calls for near interruption of people moving to and from the identified geographical area where there is a large outbreak of COVID-19 cases. In simple terms, it is a barrier erected around the infected area. The strategy involves the following steps-

1. Trigger for action-Epidemiological intelligence or an increase in the incidence of COVID-19 cases within a geographic area is the trigger for action.
2. Deployment-The Ministry of health and family welfare will deploy the Central Rapid Response Team (RRT) to support and advise the state. Additionally, the state and district RRT will also be deployed.
3. Define boundary- The boundary for the quarantine will be based on the largest administrative unit containing all clusters (with a minimum of 1 district) and feasibility to implement strict interruption of movement of people. The adjoining districts/blocks of the affected district will be considered as a buffer zone. Entry and exit points are to be clearly defined.

Surveillance:

In the containment zone, contact listing, tracking, and follow up shall be carried out. It involves-

1. Precise mapping of the outbreak
2. Passive surveillance for containment zone and adjoining districts for ILI and SARI cases
3. All hospitalized cases for ILI and SARI to be tested for COVID-19
4. Field surveillance (door-to-door) for ILI and SARI cases
5. Thermal Screening at entry and exit points

The perimeter control involves the suspension of vehicular movement across the boundary, enforced by the police force. Individuals moving across the boundary for essential/emergency purposes to be tracked. The incoming public would be administered Hydroxychloroquine. All outgoing vehicles would be decontaminated using Sodium Hypochlorite solution (1%).

Patient Care:

Testing Criteria:

1. All symptomatic individuals with international travel history (last 14 days)
2. All symptomatic contacts of laboratory-confirmed cases
3. All symptomatic health care workers
4. All hospitalized patients with SARI and ILI
5. Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact.

Hospital Care:

A three-tier approach would be adopted to ease the burden on the block COVID hospitals

1. Mild cases to be kept in makeshift hospitals (stadiums, hotels near COVID hospital)
2. Dedicated COVID hospitals/ blocks in large hospitals would be identified and operationalized. Moderate to severe cases to be admitted to COVID hospitals.
3. Critically severe cases to be shifted to the nearest tertiary care hospitals.

Every hospital needs to set up fever clinics to limit the contamination of other patients. Based on the severity of the outbreak, private hospitals can be roped in, and sites earmarked for temporary hospitals operationalized to augment the surge capacity.

Discharge Policy:

For patients who tested positive for COVID-19, their discharge from hospital will be based on two samples consecutively testing negative and the patient being free from symptoms.

Pharmaceutical Interventions:

As of now, no vaccine or approved specific drug exists for the cure and prevention of COVID-19. However, Hydroxychloroquine has been recommended as a chemoprophylaxis drug for use by asymptomatic healthcare workers and asymptomatic contacts of confirmed COVID-19 cases. A combination of Hydroxychloroquine and Azithromycin has been advocated for use in severe cases of COVID-19 (under medical supervision).

Non-Pharmaceutical Interventions:

1. Quarantine: Refers to the separation of people who have the potential of falling sick. Those above 60, or with co-morbidities would be shifted to a designated quarantine facility.
2. Isolation: Refers to the separation of people who are ill and are suspected/confirmed cases of COVID-19. Dedicated makeshift hospitals/COVID blocks in hospitals would be used for isolation purposes. A minimum distance of 1 meter to be maintained between beds.
3. Psychological Support: The National Institute of Mental Health and Neurosciences (NIMHANS) will be the nodal agency to plan and execute psycho-social support. NIHMANS will prepare a Psycho-Social Support plan and implement the same in the COVID affected areas.
4. Social Distancing Measures:

i. Closure of schools, colleges, and workplaces

ii. Ban on mass gatherings

iii. Cancellation of public transport

iv. Home delivery of essentials through a dedicated helpline

Communication Channels:

1. Dedicated helpline numbers to be set up
2. Media interaction agents limited to Secretary, Principal Secretary, and District Magistrate
3. Leverage social media to address any misinformation
4. Regular press conferences and briefings

Scaling down of Operations:

The operations will be scaled down if no secondary laboratory-confirmed COVID-19 case is reported from the geographic quarantine zone for at least four weeks after the last confirmed test has been isolated, and all his contacts have been followed up for 28 days. The containment operation shall be deemed to be over 28 days from the discharge of the last confirmed case (following negative tests as per discharge policy) from the designated health facility, i.e., when the follow up of hospital contacts will be complete.

Risks:

Several variables determine the success of the containment operations through geographic quarantine. These are:

1. Number and size of the cluster/s
2. Effectiveness of geographic quarantine
3. How efficiently the virus is transmitting in the Indian population, taking into account environmental factors, especially temperature and humidity.
4. Public health response in terms of active case finding, testing of a large number of cases, immediate isolation of suspect and confirmed cases and quarantine of contacts
5. Geographical characteristics of the area (e.g., accessibility, natural boundaries)
6. Population density and their movement (including migrant population)
7. Ability to ensure necessary infrastructure and essential services

However, if the containment plan is not able to contain the outbreak and large numbers of cases start appearing, then a decision will need to be taken by the State administration to abandon the containment plan and begin on mitigation activities.

For more details, refer to the Ministry of Health and Family Welfare document-

Disclaimer: The views expressed are those of the author.