COVID 19 in Rural India: Assessment and Mitigation after Peaking
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India has been subject to some of the harshest public visuals of its independent history over last year. The shortcomings of our public systems nurtured over decades has been exposed by the COVID-19 pandemic. As we grapple and overcome the second wave, we risk losing sight of our underserved regions, where the virus is still under transmission and vaccine shots are yet to be administered to the masses. Unlike the first wave, the lockdowns in the second wave have been localized with significant variations and flexibility in rules. The unlocking shouldn’t be any different. It should be kept localized and staggered.
However, as we unlock, the popular media attention which has been instrumental in highlighting the rural and migrant crisis would inevitably shift towards the activities in the urban centers. The unlocking may engage the better part of scientific and administrative capacities in the urban context as well. Though the governments, however subdued, have addressed the realities of COVID 19 in vulnerable rural areas, especially during the second wave, losing the limited track we have had of the rural spread may add to projected fatalities and dilute our rural response.
Living through the descending stretch of the curve of second wave, in the context of reasonable and gradual unlocking, while primarily understanding the rural spread, the article attempts to briefly address the following rural questions going forward.
· How should we ensure transparent tracking of rural COVID-19 spread and response?
· How should we assess the impact of second wave in rural areas? How much of the rural population has developed antibodies?
· How should we detect rural outbreaks as early as possible?
Beginning of the Localized Staggered Unlocking
Chhattisgarh and Delhi would have a vastly different population composition as of July 1, 2021 as per the latest report of the Technical Group on Population Projections[i]. Though they peaked on subsequent days, the progression of second wave was different in these state/UTs. Chhattisgarh had a relatively slower rise and fall of cases compared to Delhi, largely due to different arrangements of living spaces. Delhi is almost completely urban with people living in close proximity, while Chhattisgarh is nearly three-fourth rural with a distributed population (Figure 1). They present an important contrast of different types of settlements undergoing a staggered unlocking.
After the long and heart wrenching days over last two months, many states have managed to reduce their positivity rate and case load significantly. The positivity rate in Delhi at 36.24% on April 22, 2021 has been reduced to below 2%[ii], similarly it has been reduced from 30.63% in mid-April to 3.8% by May 30, 2021 in Chhattisgarh[iii]. But irrespective of the different nature of rise and decline in positivity rates, and urban-rural composition, these states are and by extension India would go through localized, staggered and versatile unlocking.
Delhi and Chhattisgarh along with Maharashtra were among the worst hit regions during the initial rise of the second wave. Having reduced the positivity rate both have initiated unlocking, but much like their lockdowns and testing strategies, their unlocking plans are unique and rooted in the local disease dynamics and economics.
Delhi extended the lockdown for week a till June 7, 2021 while allowing construction and manufacturing activities in the interest of workers with limited income from May 31, 2021 onwards[iv]. On June 6, 2021, they further allowed metro services with 50% capacity, and shops and malls to open from 10AM to 8 PM based on odd-even scheme. This may trigger an influx of migrant workers — who had left Delhi overnight in April — many of whom may get exposed during the journey in cramped vehicles. A large section of incoming workers may seek vaccine shots in Delhi, which is already facing a supply crunch.
Chhattisgarh deployed a district level unlocking approach similar to the localized lockdowns in the state. On May 24, 2021 they allowed markets — shops and showrooms — to function till 6 PM in select districts based on their positivity rates[v]. Figure 2 depicts the districts of Delhi and Chhattisgarh in three categories of positivity rate as recorded from May 21, 2021 to May 27, 2021.
Other than the lockdowns and unlocking measures, they had different testing strategies as well. Delhi relied on RTPCR to detect cases while Chhattisgarh used RAT before testing with RTPCR for negative results only. These two initiations of localized and staggered unlocking indicates a larger possibility of complicated regional unlocking in the upcoming weeks. If that happens, it would certainly consume a major part of popular media attention diverting it from rural areas.
The Rural Crisis So Far
At the onset of COVID 19 pandemic in India, in late March 2020, Dr Ramanan Laxminarayan, an economist and an epidemiologist, Director of Centre for Disease Dynamics, Economics and Policy, predicted a tsunami of COVID 19 cases in India. Dr Laxminarayan estimated 300 million cases with 2–2.5 million fatalities[vi]. The prediction, as frightening as it was, found a place in Indian media widely. However, as it fell short by far in the first wave, it was mocked equally widely.
The model couldn’t have accounted for the mitigation response that followed — world’s strictest lockdown, phased unlock and fastest vaccine development programs in human history etc. However, as the largely unanticipated and more lethal second wave, after causing mayhem and leaving the urban health care facilities in disarray, has advanced towards rural India, more devastation could be anticipated. Though the estimations may never come true in reported numbers due to limited testing capacity and under reporting, India may inch towards the estimations as cases which go unreported rise in rural areas. In fact, the third national sero survey conducted by ICMR, a door-to-door survey method used to estimate prevalence of infections by checking for antibodies among communities, had reported that 21.5% of Indians developed antibodies against COVID 19[vii]. The study was conducted between December 17, 2020 and January 8, 2021 with a sample size of 28,589, including 19.1% rural samples, collected from 70 districts distributed across 700 wards and Panchayats[viii].
The accurate prevalence of COVID 19 in rural India is difficult to demarcate from the regular state health bulletins. Other than occasionally shared rural infection numbers by government officials, media reports have been the primary source indicating the spread and fatalities over last few weeks. Mysterious and sudden deaths, mass burial sites and floating dead bodies in rivers have been reported[ix].
The State Bank of India (hereafter SBI), while reporting on economic indicators, shared details on contribution of rural districts in new cases. Figure 3, based on SBI report, presents the monthly share of rural district in new cases. A rise of 7.6% in April 2021 from March 2021 indicates a disconcerting trend. In May, the share of rural district in new cases at 45.5% may approach the previous peak of 53.7% from August 2020 during the first wave[x].
Data Source: Research Department, State Bank of India
There are 272 districts covered under the Backward Region Grant Funds issued by the Government of India. These are largely rural districts. The available data for 243 of these districts shows 36,523 deaths by May 5, 2021 since the beginning of the pandemic on January 30, 2020. At the peak, during the first wave on September 16, 2020, these districts had recorded 9,555 deaths. The death toll has increased by a factor of four. The contribution of these districts in total recorded cases in India is approximately the same as the first wave at 18.6% but the share of deaths in the national death toll has increased from 11.5% on the peak of first wave to 16% as of May 5, 2021[xi].
In response, on May 16, 2021 the Government of India issued detailed standard operating procedure, including the list of equipment and community preparedness checklist, to mitigate the spread of COVID 19 in peri-urban, rural and tribal areas[xii]. Some of the guidelines are:
· A three tier model — COVID Care Centre (CCC) to manage mild and asymptomatic cases, Dedicated COVID Health Centre (DCHC) to manage moderate cases and Dedicated COVID Hospital (DCH) for severe cases.
· Every CCC has to be mapped with DCHCs and at least one DCH. These CCCs should have basic life support ambulance facility with sufficient oxygen supply.
· Peri-urban and rural areas are recommended to prepare a 30 bed COVID care center.
· Rapid Antigen Test kits shall be made available to every sub-center and primary health center.
· Chief Health Officer and ANMs are to be trained to conduct RAT while a selected group of volunteers must be trained in using PPE kits, recording respiratory rates, using pulse Oximeter.
· Pulse-Oximeter and thermometer to be distributed on loan to families with positive case through ASHA workers.
· Makeshift COVID care center are to be set up in nearest school, community halls, panchayat buildings. These makeshift facilities are to be mapped with nearest dedicated COVID care center.
Hospitalization Facilities and Vaccines
Indian rural healthcare system is based on a three-tier model comprising of sub-center, primary health center and community health center. Rural Health Statistics 2018–19, a report by the Government of India observes a shortfall of health care facilities in rural area — 18% at sub-center, 22% at primary health center and 30% at community health center[xiii]. A KPMG — OPPI report on rural health care found 80% of doctors working for 28% of urban population[xiv].
The initial impact of COVID 19 was observed in urban centers resulting in disproportionate allocation of medical facilities. For instance, Madhya Pradesh, as of May 1, 2021 had only 69 COVID 19 treatment center located in rural areas from a total of 819[xv]. Similarly, of the total 21,637 isolation beds, 22,145 oxygen beds and 9,271 ICU beds, only 3,039, 338 and 51 were in rural locations respectively. In cases of severe infection or late detection rushing to distant urban center is the last resort.
The viruses of the coronavirus family impact the lungs of an infected individual which causes short breath. Before COVID-19, SARS in 2002 and MERS in 2011 of the same family had similar impact. Therefore, the treatment process may require consistent supply of medical oxygen. The Government of India issued a tender for 150 Pressure Swing Adsorption oxygen plants — 12 such plants latter facilitating 154 Metric Tonnes of oxygen. As of April 15, 2021 only 33 of these plants were installed while the rest of the plants was supposed to be operational by end of May 2021[xvi]. However, all these plants are mapped to district hospitals within allocated states[xvii].
Data Source: National Family Health Survey; Round 75
The rural population suffered in the process of vaccination as well. The initial vaccine registration process was an online affair, it still is in many states. Though a major chunk of rural population owns a mobile phone, it is not always a smartphone and internet access is skewed. The walk in vaccine registration for the 18–44 years age group was allowed only on May 24, 2021[xviii].
Figure 4 presents the status of internet access in 17 states surveyed during NFHS 5. Here, we take cognizance of differential access of the internet by same gender within rural and urban areas. The state wise ratio of percentage of men who reported having used the internet at least once in rural areas to that of urban areas is depicted on the horizontal axis, while the vertical axis depicts similar indicators for women. Thus, an inclination towards 1 on both the axis represent more equitable access by a specific gender in different areas. The plot area is divided into four quadrants numbered in anti-clockwise direction. By considering values on both the axes together we can understand the intensity of differential access between genders, where the third quadrant is the best and first is the worst to fall into.
To Track and Mitigate
· Transparent Health Bulletins:
Since the beginning of the pandemic, state governments have been apprehensive of sharing COVID 19 data/information as it is. Allegations of data manipulation and deliberate under reporting are common. However, even after the distrust, government health bulletins are important source of actionable information, but it doesn’t explicitly declare the rural data. Though major cities have had their own health bulletins, even a few records of rows and columns on rural areas would ensure transparency and guided accountability. As the media attentions diverts towards unlocking, we will still have some public evidence to attract attention when required and demand a better mitigation response. These records citing rural data are easy to add for governments.
· Fourth National Sero Survey
Dr Balram Bhargava, Director, ICMR pointed at the reduced scientific relevance of Sero surveys due to ongoing vaccination program[xix]. The logic is, a Sero survey may not be able to differentiate between antibodies of asymptomatic-untested individuals from those acquired post vaccination as such distinction between antibodies for infectious diseases are rare. Thus, an accurate study of transmission with existing design of surveys is difficult. However, a Sero survey, in parallel with vaccination program may still hold relevant information about waning antibodies, overall prevalence of antibodies and trends of immunity in urban and rural areas. The information on these parameters could guide our response, at least administrative response. The fourth national Sero survey with a representative sample of the population is essential in case of a third wave.
· Augment Genome Sequencing Capacity
Most countries started genome sequencing early after the outbreak. Genome sequencing help in surveillance and monitoring of novel variants. On October 17, 2021 the PMO shared details of two pan India study conducted by ICMR and Division of Bio Technology[xx]. The studies found the virus to be genetically stable, which delayed the genomic sequencing in India. Having found new variants of concern in November, 2020, India started late on December 30, 2020 by setting up Indian SARS-COV-2 Genomic Consortium (INSACOG) — a coming together of ten affiliated research laboratories, two in Delhi, Pune, Hyderabad, Bengaluru each, and one in Kalyani near Kolkata and Bhubaneswar each[xxi]. The country was divided into six zones with each zone being attached to certain laboratories. A nodal unit comprising of members from Division of Bio Technology, Epidemiology and Central Surveillance Unit was commissioned to coordinate between State Surveillance Units and smooth transportation of samples for sequencing.
Source: MoHFW Guidance Document on Genome Sequencing; NCDC
The initial sequencing strategy was chalked out to assess 100% samples of International Travelers, cases of reinfection and cases of infection post vaccination, while a representative sample of 5% of all new cases were to be assessed. As of March 18, 2021 India reported three variants of concern, having not utilized the existing capacity to full (Table 1), India sequenced less than 1% of all cases from January 1, 2021 to March 18, 2021[xxii]. Much of the problem leading to limited sequencing reported from logistical difficulties and absence of meta data of the sampled cases.
It is essential to augment sequencing capacity, on May 17, 2021 Health Minister Dr Harsh Vardhan had shared the plans to add seventeen more labs to INSACOG[xxiii], but it is important for these labs to be geographically well distributed. Resolving the logistical issues and consistent sharing of meta data of samples may lead to optimum sequencing.
· Dignity in death
A large faction of rural income depends on remittance. Series of lockdowns have resulted in loss of income and work. People admitted to dropping dead bodies of possible COVID 19 cases into rivers due to lack of money for crematorium charges[xxiv]. Infected bodies floating in river for long is a threat. Also, it is established by now that crematorium are better points to record deaths. Both, as containment measure and on humanitarian grounds, the government must augment no-cost on-call pickup cremation and burial capacities.
A network of crematorium and compilation of daily records could be an instrument of real time impact assessment. Building such capacities are easier compared to ensuring oxygen supplies, land or wood is not a scarce resources for the government.
· Priority Vaccination of ASHA
ASHA workers are the lifeline of rural healthcare system. They have been assigned with important responsibilities under the latest guidelines for peri-urban, rural and tribal areas, which leaves them exposed to infectious circumstances. Having taken the first shot, as of May 26, 2021, 68 Lakh 42 thousand frontline workers are expecting the second shot[xxv]. The state governments must inoculate ASHA workers at the earliest. ASHA taking vaccines might dilute hesitancy issues in villages.
· Basic Income, Foodgrains and Bank Mitra
The loss of income and work over last year would make it difficult to follow COVID precaution for daily wage earning villagers. A basic income for all poor families in addition to already existing systematic distribution of foodgrains is important. However, the transferred amount may not reach every family in need or be withdrawn as easily, a bank mitra would be essential to deliver cash to individual villagers. Under the same consideration as ASHA workers, bank mitra must be administered vaccines on priority.
· Pre-fabricated VPSA Oxygen Plants
The PSA oxygen plants are attached with District hospitals creating dependencies in sub-center, primary health center and community health center. In order to reduce such dependencies to an extent, the pre-fabricated Vacuum Pressure Swing Adsorption oxygen plants, a smaller version of large PSA plants could be commissioned. It can be planted within 2–4 days and costs minimum manpower.
· Bhilwara Model of Testing and Tracing
The centralized case tracking and bed allocation system without a major call center and trained workforce (medical) would be difficult to handle. However, the Bhilwara model of door-to-door testing and tracing could be replicated in rural areas, it was widely discussed during the first wave.
Feasibility and Stakeholders
Conclusion and Limitation
The article is based on extensive secondary research, but only secondary research. Data points shared are crossed checked from multiple sources.
A localized-staggered-versatile unlocking of states with complications and contradictions between rules is on the cards. It is important to identify and undertake necessary measures in order to continue mitigating the rural spread of COVID 19 as we unlock. A major part of migrant and oxygen crisis was attributed to administrative failures, they are considered avoidable to an extent. As the second wave descends, we don’t have the room for any administrative shortcoming in case of a third wave. Only intense preparation in advance may reduce the devastation in rural India.
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