Year : 2020 | Volume
: 6 | Issue : 2 | Page : 88--92
Determinants of COVID-19 transmission in India: Issues and challenges
Ganesh Kumar Saya, Palanivel Chinnakali, KC Premarajan
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medicine and Research, Puducherry, India
Dr. Ganesh Kumar Saya
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medicine and Research, Puducherry
The recent increase in trend of COVID-19 cases in India is an important public health issue. Cases reported vary in calendar time in different states and regions. Case presentations, its determinants and mediators such as behavioral and social factors may be different across and within countries. Although agent, host and environmental factors play a major role, there are other influencing factors for transmission of infection. Appropriate cost-effective prevention strategies such as social distancing, use of face mask and its implementation in the Indian context is a big challenge. Recent data available on the public domain was reviewed on various issues and challenges related to determinants of COVID-19 and its transmission in the Indian context. This review emphasizes to further strengthen prevention of infection transmission strategies at regional and state level by a combination of multiple strategies and robust surveillance system.
|How to cite this article:|
Saya GK, Chinnakali P, Premarajan K C. Determinants of COVID-19 transmission in India: Issues and challenges.Indian J Community Fam Med 2020;6:88-92
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Saya GK, Chinnakali P, Premarajan K C. Determinants of COVID-19 transmission in India: Issues and challenges. Indian J Community Fam Med [serial online] 2020 [cited 2021 Feb 27 ];6:88-92
Available from: https://www.ijcfm.org/text.asp?2020/6/2/88/304796
Recent data on COVID-19 cases in India show that there is an increase in the trend, but it differs across states and regional level. There is also a difference in the number of cases reported across countries. Although international and interstate travel was the main reason for its transmission at the initial stage, there will be other important determinants which influence morbidity and mortality at the state or regional level of each country. Recent articles highlighted the limits of Public Health Science related to COVID-19. It cautioned the usefulness of mathematical models of infectious disease transmission in various countries. The four factors namely rate of tests performed in the population, calendar time of occurrence of events, use of linier scale, and population of each country affected may not be addressed in these models. Although initially, Kerala reported more cases, afterward more cases reported from Maharashtra, Delhi, Gujarat and Tamil Nadu and other states. About 80%–90% of all cases report it as mild or asymptomatic, and severe cases in 10%–20% cases. Overall and age-specific case fatality rate differs across counties and it could be over 15%. There is also variation in case of fatality rate across states in India with Kerala reporting <1%. There are variations in the epidemiology of COVID-19 morbidity and mortality across countries. Therefore, situational analysis of its determinants in Indian context across state and regional level is an important health issue to be discussed so that appropriate intervention measures may be adopted to control the spread of infection. With this background, this review critically discusses various possible determinants of COVID-19 in the Indian context and its public health issues and challenges.
Recent data were collected from Medline and other sources. Information gathered was summarized for the Indian context and analyzed for discrepancies. Information was presented under categories of various determinants and challenges to address the problem in the country.
As the country proceeds from the local transmission to wider spread, there are various factors influencing this through contact between infected and uninfected people. Basic Reproduction Number (R0) which determines the communicability of disease varies widely, which again depends on many factors like infectivity of virus, its structural variation and environmental factors. Social distancing is an effective method of prevention of droplet transmission. Countrywide lockdown since March 25, 2020 contributed in substantial reduction in cases in the initial phase without going to the stage of community transmission. However, there are instances where its guidelines were not followed. In many states, vegetable and fruit market is one of the important areas where people gather without maintaining social distance and thus spreading the infection. Some religious events like held in Delhi just before the lockdown period with international delegates may be another reason in India favoring the spread of COVID-19 in the initial period. Social customs, including marriage and social gathering held in many parts of India without following rules which is another reason of worry for its rapid spread.
There may be differences in factors influencing disease transmission in urban, rural, and tribal areas which needs to be addressed. It is the lack of awareness in the community about its mode of transmission where people may not consider the seriousness of this disease. For example, in Mumbai, thousands of people especially those in the slums rushed to pick up their food package without maintaining social distancing. Poverty, unemployment and migration affects the transmission. Food or ration may be served to the houses of this vulnerable population by proper planning and distribution system. In these slum areas, it is difficult to follow social distancing measures. All concerned stakeholders and people should be trained through awareness generation about this effective social vaccine method for prevention of transmission of COVID 19 disease.
In Germany, the case fatality rate was lower with 1.2% as on April 2, 2020. People when voluntarily adhere to guidelines of strictly following social distancing norms like done in Germany may help to contain the spread of disease. Taking appropriate early actions to prevent social or public gathering in business or market areas and schools is another important step required. Since health is a state subject, they may take early actions unilaterally whichever is required to contain the spread of disease similar to actions taken by Germany's 16 states. Mandating isolation of people who had COVID-19 positive and quarantine of contacts is also an important step required. It requires improving the testing capacity and robust health care system to find out the eligible group for testing by field surveillance for influenza-like illness or by aggressive contact tracing as done in Germany. There is a need for monitoring of social distancing norms to understand on to what extent these guidelines were adhered in various regions in India.
Kerala model worked well at the initial stage in the drastic reduction of reporting of new cases because of strict adherence to these guidelines with community involvement. “Break the chain” campaign with focusing on social distancing, hand washing, and sanitizing was a success story. There may be other factors also like less dense population in cities which reduce the spread of disease. In slum areas of major cities where following social distance is difficult, it requires to adopt multiple other approaches by concerned health stakeholders to contain the spread of disease. Behavioral change on prevention measures of COVID-19 requires awareness generation and motivation of people with community participation.
Hand and Personal Hygiene
Water scarcity is one of the important issues in urban and rural areas of India. For example, in the village of Kaithi, in the Bundelkhand region in north-central India, there is one shared tap for every five households. This may lead to crowd around the tap for washing their hands. In slum and rural areas where access to piped water supply and soap availability is not there, it may become one of the important reason for transmission of COVID-19 infection if not taken care of. Alcohol-based hand rub is an alternative to the use of soap. In the absence of licit liquor, there are incidents in Karnataka that people have reportedly resorted to consuming alcohol-based hand sanitizers. There have been some reports in the UK and USA of patients drinking alcohol-based hand rubs. However, in the Indian context where water is available, it is better to wash hands with soap and water frequently which is cost-effective and sustainable, while in water deficit area hand sanitizers may be advised temporarily taking necessary precautions. We need to address the risks involved in the use of hand sanitizers.
Hand washing practice with or without soap varies in different circumstances. In urban slums, the availability of adequate water is a problem. In Dharavi, Mumbai slums where more 168 cases have been reported as on April 20, 2020, along with social distancing, hand hygiene also will play a big role in the transmission of disease. A study in India highlighted that extent of desirable practices regarding hand washing is lacking and needs to be emphasized in the urban and rural community But to what extent in the current scenario according to COVID 19 guidelines people use hand and personal hygiene practices may be understood by further research in different regions of the country.
Use of Mask and Personal Protective Equipment
Although there is controversy when to use mask for community people, it is a welcome step that India has made the wearing of face masks mandatory when people leave their homes. Ministry of Health and Family Welfare (MoHFW) guidelines mention the use of homemade protective cover for face and mouth for people who are not suffering from medical conditions or having breathing difficulties. They may use handmade reusable face cover, particularly when they step out of their house. This will help in protecting the community people by preventing the transmission from asymptomatic people at large. This face cover is not recommended for either health workers or those working with or in contact with COVID 19 patients or are patients themselves as these categories of people are required to wear specified protective gear.
Public health professionals, health-care managers, health care, and community health workers have to wear different types of mask depending on exposure risk. Availability of personal protective equipments (PPEs) for the health care workers was an issue during the pandemic as all government rushed stocking PPEs. Also, to reduce common breaches in biosafety during donning and doffing of PPE, proper training is an important aspect to be considered. Recent spread of COVID-19 to health staffs are a major cause of concern whether PPE was used properly according to guidelines or not. About 89 personnel of the Madhya Pradesh health department, including four IAS officers and a few doctors, who have been playing a vital role in the fight against COVID-19, have tested coronavirus positive in the state. Health care personnel in the private sector involved in managing noncovid conditions also been infected and deaths have been reported. There is no data on the availability of PPEs and their usage in the private sector. Facilitating the availability and use of masks or PPE in both government and private sector will help in continuing health care services for routine outpatient and inpatient health care services and emergencies. In this regard, we need to address these aspects to prevent the transmission of COVID-19 to health personnel.
A recent study in China showed that older age, male and presence of hypertension were independently associated with severe disease at admission, irrespective of adjustment of time to admission. Case fatality rate also different across counties may be due to different factors like diverse age distribution, different definition of COVID-19– related deaths, country-specific strategy in testing and proportion of asymptomatic cases. The morbidities vary among COVID-19 hospitalized cases., In India, we need to assess the independent effect of host factors by comparing among COVID-19 and non-COVID-19 patients on morbidity severity and mortality by further follow-up studies. Serological surveys using antibody tests will assess the herd immunity status, which is also one of the important determinants of transmission of disease.
Temperature and Humidity
A study from China showed that meteorological factors may play an independent role in the COVID-19 transmission after controlling population migration. Local weather condition with low temperature, mild diurnal temperature range, and low humidity likely favor the transmission. Another study found that no association of COVID-19 transmission with temperature or UV radiation in Chinese cities. Indonesia study found only temperature average (°C) was significantly correlated with COVID-19 pandemic. However, COVID-19 cases increased in summer season in contrast to Severe Acute Respiratory Syndrome (SARS). We do not know whether temperature and humidity act in interaction with host factors and at what level of exposure to these factors. Earlier China study found that SARS outbreaks were significantly associated with the temperature and its variations, but there may be fallacy and the uncontrolled confounding effects which might have biased the findings and the possibility of other meteorological factors having an affect on the SARS outbreaks. Similarly, in the case of COVID-19 also, we need to address confounding factors for showing an increase in trend even in the summer season. In the present context, there may be other influencing factors like virus characteristics, host factors along with control strategies adopted which may strongly favor the transmission of COVID-19. We need to address these issues while interpreting the effect of temperature and humidity on COVID-19 transmission in India.
Screening and Contact Tracing
Testing in India currently not detecting all infected people. Since the community spread is in initial phase, not detecting this group may be one of the important determining factors for transmission of COVID-19 infection. Although the positivity rate in the testing population is important factor for it, there may be other influencing factors which need to be addressed. Contact tracing and testing strategy should be strengthened along with other control strategies. Epidemiological investigation and surveillance of cases is important to understand the transmission dynamics and monitoring of disease.
Arogya Setu App development and use is a welcome step in this regard. It can help people stay safe and adopt necessary precaution in some areas where there are cases and accordingly prevent community transmission by identifying “hotspots.” It also educates on handwashing practices, sanitize surfaces diligently and avoids stepping out of the house, unless important, importance of the use of mask, taking care of high-risk groups like elderlies, children and those with the underlying medical conditions.
Availability of chemopropylaxis is a proven determinant in cutting down the transmission. However, there is no chemoprophylaxis for COVID-19 though Indian Council of Medical Research (ICMR) recommends chloroquine for health care workers. Results of the trials focusing on prevention of transmission, which includes hyrdoxycholoroquine and BCG vaccine will guide us on this aspect.
Understanding the situational analysis of the implementation of various determinants related to COVID 19 transmission by concerned stakeholders and appropriate, timely interventional measuresCommunity participation in following the guidelines. Economically disadvantaged people may violate lockdown. Poverty, reduction of job opportunity in unorganized sector and industries affected the livelihood of the peopleStrengthening multisectoral coordination on matters related to determinants is also another important area to be considered. In addition to the health sector, services and cooperation of other sectors such as home affairs, education, revenue, civil supplies, transport, water supply and sanitation, labor, agriculture, social welfare, information technology, etc., should be strengthenedAdvocacy for improving the system and servicesResource allocation and workforce availability for planning and implementation of above-mentioned measures. There are substantial regional disparities in health-care resource availability and accessibility in ChinaProvision of social assistance package to the vulnerable groupsMental health issues due to financial burden and lockdownHealth-care workers fatigue and burnout due to long working hoursShortage of trained epidemiologists at the state level to guide state governmentsPopulation Bed ratio in IndiaCosts of testing and treatment in the private sector and regulation requiredResearch is essential at the regional and state level to understand the contribution of determining factors for COVID-19 transmission.
The robust surveillance system, timely appropriate corrective actions, planning and implementation of all challenges related to determinants at various levels of administration is important in this regard.
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Conflicts of interest
There are no conflicts of interest.
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