The lockdown might have cost the country billions of dollars, but it is estimated to have saved thousands of lives. The epidemic curve has been flattened. By reducing the number of people getting infected during a given time interval, lockdown has prevented the uncontrolled flow of patients to hospitals. At this point, it appears that the virus has largely been confined to individual households, except for a few crowded regions in the country where the virus is spreading.
As lockdown is about to be lifted, this article is being written to look at two potential threats that could take away most of the advantage gained by the largest social distancing exercise in the history of the world. As has already happened in Pakistan and Singapore, the arrival of NRI’s will import fresh supplies of virus from other countries. If schools are reopened too soon, the virus will be able to travel from one household to the other--using schoolchildren as a medium.
What is the problem with school reopening? How does it cause viral spread?
Children belonging to assorted social backgrounds converge into the same classroom. A few of these children will be carrying the virus, but without symptoms. When they pass on the infection to their classmates, the classroom effectively becomes a convenient hub for the virus to penetrate deep into the community. From the individual homes of students, it will then spread to offices, markets and other homes as the adults go to work.
At this time, the virus has been contained by social distancing measures that cut off the links between individual households. Opening schools now will be like turning on the main switch after a short break in power supply. Just as the flick of the switch allows electricity to flow through every appliance plugged into the circuit, the process of opening schools will result in all homes becoming instantly connected with each other, essentially creating a convenient circuit for the virus to spread. The lifting of lockdown planned for later this month, and the arrival of NRI’s will serve as boosters for this process.
In countries like India with wide economic disparity, schools serve as social equalisers. Some children come from crowded residential communities, loosely referred to as ‘colonies’ or slums. It is harder to practise social distancing in such settings where several individuals share tiny living spaces. If the virus was already present in those communities, the child might bring it to the classroom, where it can freely disseminate. With the school playing the role of a central hub by erasing social inequality, the virus finds its way to even the most protected and secluded mansion--where the richest child in class might be coming from.
Likewise, a visitor from abroad might import the virus into a wealthy household, from where it would travel to the homes of the less privileged—utilizing the same hub.
Children are emotionally close to their grandparents, and multigenerational households are common in Indian culture. Consequently, when the child gets home from school, the elderly population will get exposed easily to the virus. Reverse quarantine has been discussed earlier, and will be impossible in such a setting. Reverse quarantine refers to taking extra measures to protect the elderly and other vulnerable people from coming into contact with the virus.
In a classroom, children sit together over a period of several hours. The virus spreads between them through tiny droplets generated during conversation. Not all those who have the infection would feel ill. In other words, the children who spread the virus might not even know that they are infected.
R-0 is the average number of people whom one infected person will infect, and is used as a measure of contagiousness of a virus. Higher R-0 indicates greater ability to spread between people. While different viruses have different R-0 values, the R-0 of a virus is not necessarily a fixed number. Under favourable conditions, a virus could develop an R-0 which is higher than previously documented. According to WHO, R-0 of the SARS-Cov 2 virus is 3, but these estimates are from developed nations that tend to be less crowded. Recent studies have estimated higher R-0 of 5.7.
R-0 of the SAS-Cov-2 virus could be higher in a classroom.
Among other factors, R-0 of a virus also depends on the behaviour of the community it is infecting. It drops during lockdown due to social distancing, and will go up when people start mingling with each other. In other words, as a community, we have the power to decide the R-0 of a virus. In a crowded classroom, the R-0 of the SARS-Cov2 virus can be naturally expected to be higher.
Can we end the pandemic? What are our options?
If R-0 can be brought below 1 with relentless social distancing strategies, we can kill the pandemic. The disease continues to spread as long as it remains above 1.
In a popular twitter video, Angela Merkel, Chancellor of Germany and a scientist herself, can be seen explaining this concept in under two minutes. Under the leadership of Prime Minister Jacinda Ardern, New Zealand is attempting to completely eliminate the virus from that country.
Without widespread testing however, it is impossible to chase the virus out of any country--unless it chooses to disappear on its own, as was the case in the SARS pandemic of 2003.
‘Herd immunity’ is a commonly discussed concept in the context of Covid-19. The idea is that if adequate number of people in a community develop immunity after suffering the infection, the virus will eventually run out of people to infect.
However, herd immunity is a controversial topic, and is not guaranteed to work against this virus. We do not know yet how many will become immune, and if they do, how good that immunity might be. The preliminary estimates of community antibody levels are discouragingly low in the range of 0.8-2.8%, nowhere near the 60-80% levels that are recommended by its proponents.
Vaccination is yet another topic that is often heard during discussions on Covid-19. The reality however, is that vaccination for the SARS-Cov-2 virus is a ‘bird that is still in the bush’, as opposed to a ‘bird in hand’. In other words, we will know that it works only if it can be successfully made, and then gets effectively tested over a stipulated period of time before the official launch. This multi-step process could take several years, and these steps cannot be compromised for reasons of safety. It must be emphasised here that the safety that we enjoy today of present-day vaccines is the result of elaborate safety checks and trials that each one of them had been put through.
Like any new medication, a newly developed vaccine could occasionally cause unexpected complications. The SARS vaccine induced lung disease during animal trials, and a new vaccine against RSV virus caused the death of children who received it. Neither of these were subsequently approved for general use.
If it takes several years to develop the SARS-Cov-2 vaccine, we do not know if the virus will even be around at such a time in the future. Besides, not all viral illnesses are vaccine-preventable, and no vaccine has ever been tried out in humans against any of the corona viruses.
Vaccine trials are ongoing in several nations. Unfortunately, over-optimistic announcements are common from biotech firms and regional institutes who are in the race. Such statements prompt more than a few people to believe that a Covid-19 vaccine is something like a made-to-order pizza with a fixed time-frame of delivery.
School outbreak: a recipe for Manpower Madness
While planning the academic year, it is important to estimate the manpower required to track down and quarantine the contacts if there were an outbreak in a school. Several thousand people will need to be tracked down. The same machinery that is being used to track the NRI’s and their contacts will have to be used, which will cause considerable strain on the system.
While taking care of the 500 Covid19 cases in Kerala to date, health officials and volunteers have had to quarantine 2,22,848 people, and initiate 6,31,127 tele-counselling calls. The logistics and man-hours involved for such a feat is imaginable. In addition, test kits are already in short supply, and will likely get exhausted if such an event occurred.
But don’t they say there is no community spread in India?
Although we would like to believe there is no community spread, all indications are that it is already there. India’s testing rates are low when compared to other nations. We do not know the extent of asymptomatic infection in our society.
All over the world, the role of ‘undocumented infections’ is being discussed now; numbers in excess of 80% are quoted in the latest published papers.
How much are we testing now?
For its population of 1.3 billion, India has done 1276781 tests so far, that is 0.94 people per 1000 population. Corresponding numbers for other countries include Australia 26, Canada 25, US 22, UK 15, Cuba 5, Ghana 4, Pakistan 1.01, Senegal 0.97 and Kenya 0.48. By testing 33,800 samples for a population of 34 million, Kerala has tested 1 out of 1000 so far.
India’s daily testing rate is 1 per 16,000. Kerala’s daily testing rate is 1 per 24,000 (1402 daily average for the past week)
When is the tentative date of school reopening?
As of today, no official date for school reopening has been announced for India, but several factors will need to be carefully considered in that decision. Teachers are already working, and distance-learning is being ramped up.
Is distance-learning feasible in India?
Having a phone and internet connection are no longer considered a luxury in India. Children as a group are smarter than adults with mobile technology. Those without internet access can meet in small groups at a classmate’s home for distance learning. NGO’s and CSR initiatives can help. The school curriculum can be rearranged to fit this platform until regular classes resume.
NRI return and School opening: Double threat
NRI is a term that expands as Non-Resident Indians, broadly referring to people of Indian origin, who are living in other countries. There is a widespread fear that people returning from multiple nations with high prevalence of Covid19 would bring infection into the country. Those NRI’s who were living in crowded conditions pose a greater risk of bringing the virus with them when they return. For instance, out of 209 people brought home from UAE to Pakistan on 28 April, 105 have been found positive for Covid-19.
Opening of school and college amplifies this threat. This is because children who belong to homes where the incoming NRI’s reside or visit could potentially bring the virus to school.
As has already happened in Singapore, the influx of NRI’s in large numbers can be expected to cause a spike in cases, which will be difficult to control. With limited testing kits available, there is no way to determine how many people in this group are asymptomatic carriers. Even when available, testing is not fool-proof, turning false negative due to a number of reasons.
Violation of quarantine has previously occurred in Kerala even with smaller NRI numbers- and history could repeat. Unfortunately, with this virus, the irresponsible actions of one or two individuals could endanger a whole region.
The Singapore story: “From Hero to Zero”
Singapore is suffering from a massive recent surge in cases, after they also got a good start like Kerala with early stringent measures. There are lessons to be learned from their success and failure.
According to BBC, thousands of Singapore citizens recently came back from other countries, some of whom were not stringent with measures. Along with this, the virus ripped through labour camps where people from several countries are housed in cramped conditions. Singapore has the highest number of Covid-19 cases now in east Asia: 19,410, more than Indonesia (12,071). As a result, Singapore has gone from Hero to Zero, for no fault of theirs.
What can we learn from all this?
In a pandemic, we need to consistently stay two steps ahead. A single mistake in our strategy could be all that it takes to erase everything that has been built up so far. For instance, if the opening of schools leads to widespread virus outbreaks, all the benefits of lockdown could be irreversibly erased in a matter of days.
Fighting a pandemic is like playing a game of chess. It involves calculating what the opponent’s next move is. Chess is about finding the balance between attacking and defending--using strategy. Once we make a wrong move, there is no backtracking. Sometimes we reluctantly but willingly sacrifice a rook (‘chariot’) or bishop (‘elephant’) to save our Queen and King.
