India extended lockdown until May 3rd as a measure to further control spread of the COVID-19 pandemic. The lockdown has challenges. The two challenges looming large over India are the socio-economic impact of the lockdown and the under-preparedness to care for patients following a rapid increase in COVID-19 infections. The acute phase of the pandemic cannot be overcome until over 60% of the population is infected naturally or vaccinated.
Herd immunity for the young (below age 60) is being suggested to ease the socio-economic pressure. Gaining ‘herd immunity’ in case of COVID-19 at this point would imply more people be exposed to the virus and develop immunity by suffering the infection. India has a smaller elderly population (» 10%) who are at the greatest risk of dying from the infection and they would continue to be under lockdown. The working age population (» 45%) are at a lower risk of mortality and those below 18 years (» 45%) are at minimal risk of mortality from COVID 19. Herd immunity, it is assumed, could help the current challenges in two ways. First, it would be a minimal burden on the health care system assuming that the younger people, when sick, would not develop serious breathlessness and it would suffice to keep them in isolation or quarantine at subsidiary facilities. In the best-case scenario, they could be isolated at home. They would develop antibodies against the virus with minimal symptoms of fever and cough. They would need symptomatic treatment for fever and cough, which the healthcare system can provide for. Second, though exposure brings immunity at a much higher cost than vaccination, it would still address the socio-economic challenge. It is being viewed as the next best option in the absence of a vaccine. The losses from not letting people work at all, are weighed against the cost of approximately 15 days of work people would miss from being sick and the cost of healthcare provision during that time. Of course, it is not accounted for that over 95% of healthcare spending in India is out-of-pocket. Currently public hospitals are bearing maximum burden of the pandemic, but this will change if lockdown is exited and out of pocket expenses will increase.
Herd immunity has clearly not been implemented given the extremely high risk it poses. It is known that young people are fatally succumbing to the disease and the estimated mortality among the young is 1%. Let’s assume that the urban young will face maximum exposure to the virus as indicated by the current spread of the disease. The working age population of India in urban areas is about 17 crores. Going by conservative estimates even if fifty percent exit lockdown, then a one percent mortality among those who will get the disease would be over 6 lakhs. This still does not account for the fact that the young population of India is at a very high risk of high blood pressure and type 2 diabetes, with over 10% of them already suffering from either or both of the conditions. Respiratory illnesses are also very common and are the leading cause of premature mortality in India. It would not come as a surprise if the mortality among the youth increases in India. The expected mortality itself weighs down on the expected benefits of not overburdening the health care system. India is not prepared for lakhs of people needing intensive care.
Forced herd immunity among the young would make continued isolation and quarantine of the elderly difficult. Indians largely live as joint rather than nuclear families. Thus, working adults would invariably expose elders at home on their return. Isolation and non-exposure are extremely difficult to achieve. Exposures are not happening only at family levels and hence the idea of herd immunity can get out of control.
Herd immunity could happen alongside a phased lockdown exit. For that to happen with minimal damage a comprehensive plan must be rolled. It should include movement and distancing of those exiting the lockdown within workspaces and public spaces, focus on maintaining good health among those exiting homes (vide Blog by Dr. Nagral), keeping other infections in control with enhanced environmental public health practices and most of all, health care provision for all. Simply buying personal protective equipment for medical staff will not suffice. Protocols for functional and effective health care have to be bought in place.
Guidelines will have to be more detailed and enhanced planning will be required to maximize the use of our healthcare, subsidiary facilities, as well as home care. Dedicating hospitals to COVID, shutting down hospitals because staff are testing positive for COVID, refusing patients and shifting positive patients to COVID hospitals are not sustainable methods for handling the pandemic. Deficient testing, poor monitoring of overall mortality and blind prescription of HCQS are further complicating the lack of a protocol for the health and safety of all. Lockdown exit must also plan for the fact that most people who have tested positive for the virus in India have remained asymptomatic and we currently do not have reliable antibody tests, let alone the capacity to conduct them, to know if they have developed immunity. Contact tracing methods will have to remain highest priority as we exit lockdown and core public health teams need to be strengthened.
We are about 45-60 days away from monsoons, which will add a burden of several other acute diseases on our healthcare system. Dengue, malaria and other viral illnesses will surge. We were not prepared for this burden, so we must act quick.
Such a comprehensive plan has to be rolled out in the next ten days if we are going to phase ourselves out of the lockdown before a vaccine is accessible. If not, given the slow rise of cases in the country, every nearing end of a lockdown will continue to look overwhelming and if we give up in desperation, we will be worse prepared.
