In a tacit admission that the fight against Covid-19 in urban areas is hobbled by the lack of field health workers, the Centre has issued a guidance document that calls upon municipal authorities to get all hands on deck. This includes not just health and sanitation workers on their payroll but any available manpower in nearby areas whose information can be accessed through the CovidWarriors website.
The government has also asked for religious leaders to be used as community volunteers for better outreach.
There are 30 municipal areas which currently constitute 79 per cent of India’s case load. These are BrihanMumbai, Greater Chennai, Ahmedabad, Thane, all Delhi MCs, Indore, Pune, Kolkata, Jaipur, Nashik, Jodhpur, Agra, Tiruvallur, Aurangabad, Cuddalore, Greater Hyderabad, Surat, Chengalpattu, Ariyalur, Howrah, Kurnool, Bhopal, Amritsar, Villupuram, Vadodara, Udaipur, Palghar, Berhampur, Solapur and Meerut.
According to 2011 Census there are 2,613 towns/cities with such settlements with 6.54 crore population residing in 1.39 crore households, representing 17.4 of all urban population. This would have increased since that time.
In what seemed to be preparation for greater flexibility to states, the Health Ministry brought out two containment plan documents: one for large outbreaks, and one for others. A large outbreak is defined as an area with 15 or more cases.
Both documents left out the size of the perimeter of the containment and buffer zones, and also laid down procedures for travel related and other cases, for the time when travelling would be allowed. Earlier, these zones were clearly defined as a 3-km radius containment zone and a 7-km radius buffer zone.
It laid down: “Geographic quarantine (cordon sanitaire) strategy calls for near absolute interruption of movement of people to and from a relatively large defined geographic area where there is single large outbreak or multiple foci of local transmission of COVID-19. In simple terms, it is a barrier erected around the focus of infection. Geographic quarantine shall be applicable to such areas reporting large outbreak and/or multiple clusters of COVID-19 spread over multiple blocks of one or more districts that are contiguous based on the distribution of cases and contacts.”
All ILI/SARI cases reported in the last 14 days by the Integrated Disease Surveillance Programme (IDSP) in the containment zone will be tracked and reviewed to identify any missed case of Covid-19 in the community. The documents draw on the experiences of 2009 H1N1 Influenza pandemic on geographic quarantine.
In what could be a sign of things to come in Lockdown 4.0, when more relaxations are expected, the containment plan says: “All mass gathering events and meetings in public or private places, in the containment and buffer zones shall be cancelled / banned till such time, the area is declared to be free of COVID-19 or the outbreak has increased to such scales to warrant mitigation measures instead of containment.”
Health secretary Preeti Sudan on Saturday held a meeting with the municipal authorities in these 30 places to discuss the government’s Covid strategy.
On Saturday morning, India overtook China in the number of Covid cases after its total caseload touched 85,940, with 3,970 new cases and 103 deaths in the last 24 hours. So far, 30,152 people have recovered.
The guidance document on preparedness and response to Covid-19 in urban settlements prepared by the Directorate General of Health Services says: “In most cities/towns the disease surveillance system is not as well organised as in rural areas. This is more so pronounced in these urban settlements. Hence the surveillance system shall be strengthened for surveillance and contact tracing mechanism. This would include identification of the health workers in the health posts/dispensaries, ANMs, ASHAs, Anganwadi Workers, municipal health staff, sanitation staff, community health volunteers and other volunteers (NSS/NYK/IRCS/NCC and NGOs) etc. The trained manpower available on http://www.covidwarriors.gov.in will be contacted for their readiness to deployment at short notice.”
Sources said urban hotspots are part of a larger problem in big cities across the country — the lack of dedicated health workers such as ASHAs and ANMs, thanks to the launch failure of the urban health mission and the absence of personnel of the Integrated Disease Surveillance Programme. NUHM was passed by the Cabinet in 2013 but was no longer a priority a year later. IDSP’s structure is designed for access into rural areas, small towns, etc, but not in big cities.
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The document lays down that an incident commander should be identified for a specified geographical area to identify its planning, operation. Logistics for implementation of the preparedness measures. The person would report to the municipal commissioner.
The document also recognises the challenges of practising social distancing in an urban settlement or a slum. It says: “Social distancing will be a major challenge due to many people crammed into very small living spaces. While sleeping the distancing can be achieved to an extent by sleeping in opposite direction in a manner that head end of one person faces the leg of the other. Social distancing should be practiced particularly in community water points, public toilets, PDS distribution points, health centers etc.”
Part of a presentation made to officials from 30 worst-hit municipal corporations were observations made by Central teams deputed to the states, which flagged issues such as delayed testing results, and limited active case searches. One of the primary observations enumerated in the presentation that there was limited active case search through house-to-house surveys due to non-cooperation from community and demotivated health workers.
The solution suggested for this problem stated, “Reorganisation of house to house surveillance teams- 2 members per team- 1 male member and 1 Asha, 1 supervisor/religious leader/political leader, 1 police personnel for every ten teams. 1 team to survey 100 houses daily, provide adequate masks and gloves for the team. Covidwarriors.com can be leveraged.”
Flagging a delay in getting lab results as an observation, the presentation makes the case with labs to be adequately strengthened with logistics and manpower, with an additional provision to “receive samples after 7 pm in view of ongoing Ramzan etc”. While the Central teams also noted the prevalence of social stigma attached to the disease, they suggested these be addressed by intensive communication through autos and rickshaws in localities and interpersonal communication to address apprehension in communities including by religious leaders.
The Central teams have also identified as a problem a delay in sample collection, noting that the solution was an “arrangement for immediate sample collection of ILI cases identified in the routine OPD- at the health facility itself.”
“Testing mobile vans should accompany health teams while on survey,” the presentation reads. On issues of health workers such as a problem in movement, safety and personal security and concerns of infection, the presentation made to the municipal corporations said that adequate protection, cross-border mobility through inter state communication and that “chemoprophylaxis of HCQ may be done — after adequate check up.”
The teams have also flagged issues of waste disposal from Covid-positive houses, for which they have suggested “distribution of bleaching powder for self sanitization of wastes from COVID positive households before disposing it off with general waste. On the key issue of relief camp for migrant workers, the central teams have flagged the need to ensure adequate number of toilets and effective sanitation.”
In a separate meeting with district administrations on Saturday, the Health Ministry also shared an IT tool that would help the district administration assess the future need for Covid care infrastructure, and if there is apprehension of that being insufficient, make alternative arrangements.
In the meeting with the municipal authorities, a presentation was made on the present status of Covid-19 infections in the districts while highlighting the high-risk factors, indices such as confirmation rate, fatality rate, doubling rate, tests per million, etc. They were briefed about the factors to be considered while mapping the containment and buffer zones; the activities mandated in containment zone like perimeter control, active search for cases through house-to-house surveillance, contact-tracing, testing protocol, clinical management of the active cases; surveillance activities in the buffer zone like monitoring of SARI/ILI cases, ensuring social distancing, promoting hand hygiene, etc.