COVID-19 quarantine and the way forward. (Special Issue: The epidemiologist and the pandemic.)

Quarantine is a tool that was used anciently and now used as a public health measure in a more strategic manner for containment of a disease. It requires a lot of planning for implementation depending upon the burden of disease, resources to carry out the same in a stringent manner. Benefits and outcomes need to be measured carefully while imposing quarantine especially of a larger scale. We have tried to put up the rationale behind the current quarantine measure carried out in the wake of COVID 19 and factors to keep in mind for the future.

The Challenges of Frontline Health Managers during the COVID-19 Pandemic in India: A Framework Analysis Study (preprint)

Background: Coronavirus was first officially reported in Wuhan city of China in December 2019. As this novel coronavirus spread rapidly throughout the world, health care workers faced many difficulties addressing the pandemic. In the present study, we explored the challenges faced by front-line health managers on human resource management, execution of the central policies, training and in formulating innovative approaches during the covid-19 pandemic in India. Methods: A qualitative study was conducted using framework analysis among front-line health managers concerning covid-19 management at the district level. We conducted 120 in-depth interviews (IDIs) among eight states with the use of an Interview guide. Results: The results are described under five sections: First: 'challenges of front-line managers in policymaking and its execution' 'human resource management' 'gaps in local execution of central policies' 'challenges in training workforce and data management' 'innovative approaches adopted during COVID 19'. Conclusions: We observed that a centre-down approach was not appreciated much. Many participants felt that there was a need to understand the local context and appropriate amendment. The private system is a part of the Indian health system and can never be ignored, thus all guidelines should include the private system.

RNA-extraction-free diagnostic method to detect SARS-CoV-2: an assessment from two States, India (preprint)

With increasing demand for large numbers of testing during COVID-19 pandemic, came alternative protocols with shortened turn-around time. We evaluated the performance of such an approach wherein 1138 consecutive clinic attendees were enrolled; 584 and 554 respectively from two independent study sites in the cities of Pune and Kolkata. Paired nasopharyngeal and oropharyngeal swabs were tested by using both reference and index methods in blinded fashion. Prior to conducting RT-PCR, swabs collected in viral transport medium (VTM) were processed for RNA extraction (reference method) and swabs collected in dry tube without VTM were incubated in Tris-EDTA-Proteinase K buffer for 30 minutes and heat inactivated at 98{degrees}C for 6 minutes (index method). Overall sensitivity and specificity of the index method were 78.9% (95% CI 71% to 86%) and 99 % (95% CI 98% to 99.6%) respectively. Agreement between the index and reference method was 96.8 % (k = 0.83, SE=0.030). The reference method exhibited enhanced detection of viral genes (E, N and RdRP) with lower Ct values compared to the index method. The index method can be used for detecting SARS-CoV-2 infection with appropriately chosen primer-probe set and heat treatment approach in pressing time; low sensitivity constrains its potential wider use.

Association Between Ambient Air Pollutants and Meteorological Factors With SARS-CoV-2 Transmission and Mortality in India: an Exploratory Study (preprint)

Background: The Coronavirus disease 2019 (COVID-19) pandemic poses a serious public health concern worldwide. Certain regions of the globe were severely affected in terms of prevalence and mortality than other. Although the cause for this pattern is not clearly understood, lessons learned from previous epidemics and emerging evidences suggest the major role of ecological factors like ambient air pollutants (AAP) and meteorological parameters in increased COVID-19 incidence. The present study aimed to understand the impact of these factors on SARS-CoV-2 transmission and their associated mortality in major cities of India.Methods: This study used secondary AAP, meteorological and COVID-19 data from official websites for the period January-November 2020, which were divided into Pre-lockdown (January-March 2020), Phase I (April to June 2020) and Phase II (July to November 2020). After comprehensive screening, five major cities that includes 48 CPCB monitoring stations collecting daily data of ambient temperature, particulate matter PM2.5 and 10 were analysed. Spearman and Kendall’s rank correlation test was performed to understand the association between SARS-CoV-2 transmission and AAP and, meteorological variables. Similarly, case fatality rate (CFR) was determined to compute the correlation between AAP and COVID-19 related morality.Results: The level of air pollutants in major cities were significantly reduced during Phase I compared to Pre-lock down and increased upon Phase II in all the cities. During the Phase II in Delhi, the strong significant positive correlation was observed between the AAP and SARS-CoV-2 transmission. However, in Bengaluru, Hyderabad, Kolkata and Mumbai AAP levels were moderate and no correlation was noticed. The relation between AT and SARS-CoV-2 transmission was inconclusive as both positive and negative correlation observed. In addition, Delhi and Kolkata showed a positive association between long-term exposure to the AAP and COVID-19 CFR.  Conclusion: Our findings support the hypothesis that the particulate matter upon exceeding the satisfactory level serves as an important cofactor in increasing the risk of SARS-CoV-2 transmission and related mortality. These findings would help public health experts to understand the SARS-CoV-2 transmission against ecological variables in India and provides supporting evidence to healthcare policymakers and government agencies for formulating strategies to combat the COVID-19.

A Model Based Analysis for COVID-19 Pandemic in India: Implications for Health Systems and Policy for Low- and Middle-Income Countries (preprint)

Background Our analysis aims to model COVID-19 pandemic in India, potential impact of various measures, along with assessment of health system preparedness and cost to manage the epidemic. Methods We developed a susceptible-exposed-infectious-recovered (SEIR) mathematical model to predict the health outcomes under an unmitigated scenario which comprises of air travel restrictions alone, and the current scenario consisting of air travel restrictions along with 8-week lockdown. In addition, we also evaluate the effectiveness of 8-week lockdown along with intensified public health measures at varying level of effectiveness. We assessed the impact of these interventions on COVID-19 related health outcomes in comparison to the unmitigated scenario. Next, we ascertain the need for augmenting infrastructure and the costs of COVID-19 management in India. Findings In the event of a lockdown for 8 weeks, the peak of the epidemic shifts by 34-76 days, and the number of cases at the end of 8-week lockdown reduces by 69% to 97% with varying effectiveness of lockdown. However, the cumulative long-term cases remain the same. Intensification of public health surveillance measures with 60% effectiveness is estimated to reduce the cases at peak and cumulative number of infections by 70% and 26.6% respectively. The requirement of ICU beds and ventilators would reduce by 83% with intensified public health measures. The cost of managing COVID-19 in India is nearly 4.5% of the gross domestic product (GDP) in the absence of any intervention which increases to 6.2% with intensified public health measures for COVID-19 response. Conclusion Lockdown measures delay the onset of peak, and give much needed time to health system to prepare. Strengthening the public health system response in terms of testing, isolation treatment of cases, and contact tracing needs would lead to significant gains in terms of case load, and meeting health system needs.

Determinants of COVID-19 incidence and mortality: A cross-country analysis (preprint)

The authors have withdrawn this manuscript because the source data was last updated at the end of March, and hence the authors believe that the results derived and conclusions drawn in the manuscript may not hold true now. Therefore, the authors do not wish this work to be cited as reference for the project. If you have any questions, please contact the corresponding author.