Preparedness, response and assessment of first phase lockdown impact amid COVID-19 pandemic – India Scenario

The Corona Virus Disease (COVID-19) pandemic has been created due to the infection by novel coronavirus. Globally, countries have taken measures to reduce social contact to slow down the spread of the virus. Social (physical) distancing via lockdown and awareness on personal hygiene are mitigating measures to prevent transmission of disease. Indian government has implemented the first phase of national lockdown for 21 days (March 24 to April 14, 2020) to reduce the transmission of COVID-19. This study is performed in two stages. First, review of Indian scenario till the end of the first phase of national lockdown and second the impact assessment of the first phase of social lockdown on doubling rate of COVID-19 cases in different Indian states and overall India. The timeline of activities, health care facilities, schemes and services by government and private organizations in combating COVID-19 in India are presented. Analysis is performed using the 3-day moving average daily growth statistical technique. The states are categorized based on the improved doubling rate during third week (Category 1) and second week (Category 2). The overall Indian scenario is analysed to assess the consequences of social lockdown on the transmission rate of the virus. Kerala and Orissa handled the pandemic effectively by drawing lessons from earlier epidemics and disasters. Telangana, Andhra Pradesh, Uttara Pradesh, West Bengal and Maharashtra has improved doubling rate during second week of lockdown. The average doubling rate of coronavirus cases in India improved after lockdown, account for 7.5 days compared to 3.4 days before lockdown. Lockdown played a key role in reduction of increasing rate of confirmed cases. The stringent lockdown combined with rapid testing led the nation in yielding positive outcomes. The discussions presented in this article will equip the council’s authorities and regulatory bodies globally in designing the mechanisms for handling present and future epidemics or pandemics.


Introduction
Pneumonia of unknown cause detected in the city of Wuhan is reported to the World Health Organization (WHO), in China on 31 st December 2019. Investigations on the cluster of pneumonia cases in Wuhan are initiated on 4 th January 2020 by WHO, and first guidance on novel coronavirus is issued on 10 th January 2020. The first case of novel coronavirus outside China is reported on 13 th January 2020 in Thailand. Novel coronavirus is renamed as Corona Virus Disease (COVID-19) on 11 th February, 2020. Assessing the situation globally, COVID-19 is characterised as pandemic on 11 th March, 2020 by WHO. Although the cause of pneumonia is quickly identified as a new coronavirus named SARS-CoV-2, the scientific knowledge of this novel virus remains very limited [1].

COVID-19 resembles SARS in terms of viral replication in the lower respiratory tract.
It generates secondary viremia, followed by an extensive attack against target organs that express angiotensin-converting enzyme 2 (ACE2), such as heart, kidney, gastrointestinal tract and vast distal vasculature. The main transmission route is through direct or indirect respiratory tract exposure [2]. WHO does not recommend any specific vaccine for the treatment of COVID-19. However, hydroxychloroquine, lopinavir, ritonavir and other identified drugs are being applied contextually in treatment. The investigations and clinical trials are still underway to identify specific vaccine due to mutation in strain [3].
Social (physical) distancing via lockdown and awareness on personal hygiene are mitigating measures to ensure personal safety and prevent transmission of disease to others [4]. Globally, countries have taken measures to reduce social contact to slow down the spread of the virus, such as closing workplaces, food services, public transport and events [5]. The complete lockdown has implemented by China, India, France, and Britain while Spain, Italy, and Germany imposed partial lockdown; Turkey and Iran implemented conditional lockdown and US confines to social distancing measures [6].
India is a low-income country with 1.38 billion population and a population density of 464 per square kilometre [7]. Cumulative data specify that 10363 individuals are infected out of which 339 deceased as on 14 th April 2020 in India [8]. With 0.7 hospital beds per 100 people (recommended 5) and doctor to population ratio of 1: 1800 (recommended 1:1000), combating global health catastrophe such as this pandemic is a challenge in the Indian scenario. Given the lack of facilities, for India, it is better to prevent rather than cure. Indian government, therefore, implemented nation-wide lockdown from 24 th March 2020, for 3 weeks to prevent the spread of COVID-19. Essential and emergency services such as health, security, sanitation, and food supply are made available during that period. Social lockdown is aimed to reduce stress on health care facilities through containing the rate of transmission in affected areas and secure the non-affected areas [9]. The present study is aimed to assess the impact of social lockdown on the doubling rate of transmission in Indian states. The outcomes of this study will assist authorities in decision-making and regulatory bodies in development of policy directives on social lockdown during present and future pandemics or epidemics, especially in the developing nations.

Methodology
The present study is done in two stages. First, review of Indian scenario till the end of first phase of national lockdown and second the impact of the first phase of social lockdown on doubling rate of COVID-19 cases in different Indian states and for the country as a whole.
The primary data associated with confirmed cases, recovered cases and mortalities is retrieved from the Ministry of Health and Family Welfare (MoHFW), Government of India.
The data associated with series activities amid COVID-19 in India, health care facilities, role of self-help groups and non-government organisations and other facilities is collected from online news websites and twitter handles of various organisations.
Analysis of the COVID-19 data is performed using 3-day moving average daily growth statistical technique. This technique helps to smoothen out the high-frequency fluctuations of the COVID-19 infection data. Daily registered COVID-19 cases in Indian states and cumulative cases were collected during the first phase of lockdown from MoHFW website. From the moving average values, daily percentage growth was calculated for each major state across India with comparing overall country' moving average. Based on the moving average daily percentage growth for each state, the states were categorised in two categories to assess the impact of lockdown. The first category includes the states with improved doubling rate during the third week of the first phase lockdown. The second category includes the states with improved doubling rate during the second week and small uplift during last week of lockdown. Finally, the overall Indian scenario was analysed to assess the consequences of social lockdown on the doubling rate of COVID-19.

Registered cases
According to MoHFW, Government of India, confirmed cases of COVID-19 were 10363, recovered cases were 2230 and mortalities were 339 as on 14 th April, 2020. The active cases and deaths per every one million population were 12 and 0.4 as reported by MoHFW as on 14th April, 2020. State-wise confirmed corona cases in the country is shown in Figure   2(a). The confirmed cases in Maharashtra, Delhi, Tamil Nadu, Madhya Pradesh, Rajasthan and Gujarat constitute up to 70% with the maximum percentage of cases in Maharashtra (23%) followed by Delhi (11%). Uttar Pradesh, Telangana, Andhra Pradesh, Karnataka and Kerala constitute up to 20% of cases and with rest of the states contributing to 10% of the cases. The lowest number of cases in north-eastern states compared to other states can be attributed to transport connectivity. State-wise recovered corona cases in the country is shown in Figure 2

Testing kits
The rapid transmission of the novel coronavirus in the country urged the need for huge importation of testing kits. Research activities to manufacture the kits were in progress to meet the demand of the nation on the side. The testing kits produced by Mylab discovery solutions, located in the city of Pune, Maharashtra state, became the first one to be approved by the Government of India. Influenced by South Korea's "Phone Booth" testing system, India adapted the same to test the COVID-19 suspected persons. This was started during the last week of 21-day lockdown and was adapted by Kerala and Jharkhand states immediately.
This method of testing is cost-effective and easily portable to remote locations. The first booth was installed at a Government hospital in Ghaziabad, Uttar Pradesh. As of April 13 th , the testing capacity per million was found to be 105.

Other facilities (include government schemes):
The carrier of COVID-19, the novel coronavirus is expected to be transmitted

Assessment of the impact of first phase lockdown on Indian states
The daily growth percentage of COVID-19 cases in different states with improved doubling rate during the third week of the first phase of lockdown is shown in Figure 3.
Kerala made the biggest gain in combating COVID-19 and registered a slow rate of new infections during the lockdown. The daily growth rate (three day moving average) is 59.52% on the first day of lockdown. At the end of first week it is 6.77%, second week -3.33% which reduced to -15.38% at the end of first phase lockdown. It has drawn its experience with Nipah virus epidemic in 2018 for extensive testing, contact tracing and community mobilisation to contain the virus and maintain a very low mortality and new infection rate. Integration of rapid testing with the regional medical practices added to reduction in transmission from 59.52% prior to lockdown to an overall daily growth rate of -4.71% after the lockdown. The when the active cases raised to 100, resulting in optimal testing. Nearly 1.7 lakh people are isolated at the peak of the outbreak and when the active cases increased remarkably. They have achieved effective isolation by isolating more than 500 suspected people for one active case. These smart testing, effective isolation and contact tracing helped in reducing the burden on hospitals [11].
In Orissa, the daily growth rate prior to lockdown and during first week is nil. During the second week the growth rate was -85.71%, which reached to 0% at the end of first phase lockdown. The registered cases are below 5 during in maximum number of days. The past experience on handling cyclones helped authorities in prior preparation to combat COVID- 19. In fact, it is the first state to implement 70% lockdown including its capital. Quarantining the people with foreign travel history after March 4 th 2020, incentives for self declation, contact tracing and home quarantine systems equipped in controlling transmission of COVID-19. Application of social media platforms helped in awareness creation, dissemination of updates and appeals on COVID-19. This helped authorities to eliminate the unnecessary spread of false news reducing panic among people [12].
Rajasthan, Tamil Nadu, Delhi, Karnataka and Jammu & Kashmir reported good improvement in reducing the transmission rates. In Rajasthan, the daily growth rate is 125% on the first day of lockdown. At the end of first week it is -11.47%, second week -14.59% which reduced to -34.09% at the end of first phase lockdown. In Tamil Nadu, the daily growth rate is 17.64% on the first day of lockdown. At the end of first week it is 31.52%, second week -18.53% which reduced to -45.10% at the end of first phase lockdown. In Delhi, the daily growth rate is 66.67% on the first day of lockdown. At the end of first week it is 145%, second week 26.71% which reduced to -17.27% at the end of first phase lockdown. In Karnataka, the daily growth rate is 4.54% on the first day of lockdown. At the end of first week it is 33.33%, second week -3.22% which reduced to -37.77% at the end of first phase lockdown. Bihar and Gujarat reported zero cases in the week previous to lockdown, but the number of cases increased during the lockdown period. The average daily growth rate of registered cases of 31.70% and 17.3% is observed during the first phase lockdown [13]. The impact of lockdown in the reduction of new cases is observed in the last week of lockdown.

Figure 3. Daily growth percentage of COVID-19 cases in different states with improved doubling rate during the third week
The second category includes the states with improved doubling rate in the second week but small uplift during third week of lockdown, which is a worrying factor. The daily growth percentage in these states during the lockdown phase is shown in Figure 4.
In Maharashtra, the daily growth rate (three day moving average) is 75% on the first day of lockdown. At the end of first week it is 53.78%, second week 1.31% which decreased to -24.04% at the end of first phase lockdown. The average number of daily registered cases during first 10 days is 35.45 while during the last ten days is 199.36. The majority of the cases are registered in Mumbai. Implementation of physical distancing and lock down measures was a challenging task due to high density areas and shanty settlements in the city.
The council authorities enforced social distancing in slums confining residents to their airless and congested dwellings. Reports by civic authorities revealed that in some of the most infected slum clusters in Mumbai, up to 25% of samples tested have come positive [14].
In Telangana, the daily growth rate is 100% on the first day of lockdown. At the end of first week it is 35.08%, second week -9.84% which increased to 34.28% at the end of first phase lockdown. In Andhra Pradesh, the daily growth rate (three day moving average) is 25% on the first day of lockdown. At the end of first week it is 40%, second week -24.59% which increased to 36.20% at the end of first phase lockdown. In Uttara Pradesh, the daily growth rate (three day moving average) is 40% on the first day of lockdown. At the end of first week it is -28.88%, second week -15.30% which increased to 66.4% at the end of first phase lockdown. The highest case load in these states during the second week is attributed to the Markaz event in Delhi [15]. Although, these states witnessed upsurge in confirmed cases in the third week of lockdown, overall, they are partially benefitted with lockdown measures.
The number of new cases increased steeply to as high as 118%, 260% and 90% daily growth rate in Uttar Pradesh, Andhra Pradesh and Telangana respectively. The impact of lockdown in lowering the confirmed cases during second week and up to mid of third week in all the second category states can be observed. The rapid testing and identification of infected people in the third week of lockdown contributed to the increase in the number of new cases from negative daily growth rate to as high as 22% average daily growth rate in these states.
Madhya Pradesh and West Bengal has zero cases in the week before the lockdown but the number of cases increased during three weeks of lockdown [13]. They have registered cases at an average daily growth rate of 17% and 26% respectively during the first phase lockdown.
Reports from central govt. revealed that Mumbai and Pune in Maharashtra, Indore in Madhya Pradesh, Kolkata in West Bengal, Hyderabad in Telangana are marked as emerging hotspots and constituted Inter-ministerial central teams (IMCTs) to assess the serious COVID-19 situations. Incidents ranging from violence on frontline healthcare professionals, attacks on police personnel, violations of social distancing norms in market places and opposition to setting up of quarantine centres are reported as reasons for lockdown violations in these areas [16].
The daily growth rate during the period of lockdown in India is shown in Figure 5.
The lowering in the growth rate of new cases is observed at the end of lockdown in India.
During the first ten days of lockdown, confirmed cases increased, but daily percentage  Mumbai (Maharashtra) and Ahmedabad (Gujarat) registered more than 65% of the state's total cases. Indore and Bhopal (Madhya Pradesh) registered more than 77% of its state's total cases. Jaipur and Jodhpur (Rajasthan), Hyderabad (Telangana), Ranchi (Jharkhand), Korba (Chhattisgarh) and Khurda (Odisha) accounted for more than 50% of the state's total cases. The transmission rate can be well studied by the doubling rate of a number of new cases.
Doubling rate means the time taken for the number of cases to double. A low doubling rate denotes a fast spread of infection and vice versa. The doubling rate of different states in India is shown in Figure 6. The average doubling rate of coronavirus cases in India improved after lockdown, account for 7.5 days compared to 3.4 days before lockdown. In comparison with India, the doubling rate in US 2 days, Germany and Spain 3 days, UK, France and Italy (4 days) and Canada (6 days) as on 14th April 2020. The doubling rate in 18 states of India is better than the national average [13]. The Lancet [17], reported that in India's favour are its young population (65% aged < 35 years), will help in lowering the severity of pandemic than it is feared. Implementation of lockdown will have the desired effect on flattening the epidemic curve. Many public health professionals and doctors say India's grinding lockdown, which has lasted more than a month, could have kept infection and deaths in check. Others believe that India's predominantly young population is helping to keep fatalities low, while older people have an elevated risk of death from the infection. Nevertheless, others talk about the possibilities of the presence of a less virulent strain of the virus in India, along with the possibility that its hot weather is diminishing the contagion. Both these claims are not backed by any evidence. Doctors treating critical COVID-19 patients have said to BBC that the contagion is as virulent here as has been reported elsewhere in the world.
Social distancing via lockdown is observed to be the best way to minimize the transmission rates with no vaccine or specific medicines in place. Importing testing kits, development of indigenous testing kits and implementation of rapid testing systems from global cities improved the rate of testing in India. Severe lockdown estimates combined with an expansion in the quantity of testing led the nation in yielding positive outcomes. India should likewise give a lot more noteworthy consideration to the health sector and perceive the significance of having strong public sector capacity, particularly in primary care at the region level. Across the country, medical infrastructure and healthcare systems need to be strengthened to handle the current and future epidemics [17] In lieu of the concurrent events, the human kind is at its testing times and bearing repercussions of its unpreparedness. The GDP on healthcare is nowhere in the rise of foresight. The doctor to patient ratio is 10 times more in India, than the WHO predictions [18]. As India is crawling towards universal health coverage in the name of Pradhan Mantri Jan Arogya Yojana, it is still in infant stage. Though India is equipped with manpower, many of them are unskilled and absorbed by unorganized sectors. Most of them emigrate to nearby metros in search of livelihood, this resulted in huge migrant labour stranding. As the JAM (Jandhan-Aadhar-Mobile) is still ongoing, many of the unorganized workers need awareness to reap fruits of DBT (Direct Benefit transfer) schemes [19]. Skilled manpower is prerequisite now, though 'National skill India mission' [20] is doing good, but more efforts are required to curb the rural emigrates totally. India's economic survey highlights 'Thanlinomics' [21], is stating that the affordability of a thali (plate of food) increased by 29%, and we have a huge population under BPL statistics. So, India is in need to revamp its schemes integrating evidence-based studies, local systems, economic conditions and visions in order to save lives and to sustain globally.

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