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Containment plan Coronavirus 2019 and STRATEGIC APPROACH

Novel Coronavirus Disease 2019 (COVID 19) Version 2 (updated 07.07.2020)

The Ministry of Health, Government of India has given some precautions to take for Covid-19. Coronaviruses are huge gatherings of infections that cause disease in people and creatures. Once in a while, creature coronaviruses can advance and taint individuals and afterward spread between individuals, for example, has been seen with MERS and SARS.

WHO (under International Health Regulations) has proclaimed this episode as a "General Health Crisis of International Concern" (PHEIC) on 30th January 2020. WHO along these lines proclaimed COVID-19 a pandemic on eleventh March, 2020.

1. INTRODUCTION

Base of Coronavirus 
Coronaviruses are a large group of viruses that cause illness in humans and animals. Rarely, animal coronaviruses can evolve and infect people and then spread between people such as has been seen with MERS and SARS. Although most human coronavirus infections are mild, the epidemics of the severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), have caused more than 10,000 cumulative cases in the past two decades, with mortality rates of 10% for SARS-CoV and 37% for MERS-CoV. The outbreak of Novel coronavirus disease (COVID-19) was initially noticed in a seafood market in Wuhan city in Hubei Province of China in mid-December, 2019, has now spread to 214 countries/territories/areas worldwide.

WHO (under International Health Regulations)  says about coronavirus
WHO under International Health Regulations has declared this outbreak as a “Public Health Emergency of International Concern” (PHEIC) on 30thJanuary 2020. WHO subsequently declared COVID-19 a pandemic on 11th March, 2020. Most people infected with COVID-19 virus have mild disease and recover. Approximately 80% of laboratory confirmed patients have had mild disease, 15% require hospitalization and 5% casesare critical requiring ventilator management. The overall case fatality ratio (CFR) is 6.9% globally, which is considerably lower than that was reported during SARS (15%) and MERS-CoV outbreaks (37%). The CFR varies by location and intensity of transmission. The mortality is high among elderlies, particularly those with comorbid conditions like coronary artery disease, diabetes, hypertension, chronic respiratory diseases etc.

Universal  Ratio
As on 7th July, 2020, COVID-19 confirmed cases are being reported from 213 countries and territories around the world. A total of 11,790,944 laboratory confirmed cases and 6,776,519 Recovered, 5,41,895 deaths have been reported globally. Focus of the outbreak that was initially China, has now shifted to European region and the United States of America. Maximum number of cases is currently being reported from the USA, Russia, Spain, UK, Italy, Germany, Brazil, Turkey and France. 

covid-19 universal report

COVID-19

 

Indian Ratio
As on 7th July, 2020, a coronavirus cases: 723,195 active, 441,733 recovered / discharged and 20,201 deaths have been reported so far.

India COVID-19 Cases

 

Symptoms of epidemiology
Coronaviruses belong to a large family of viruses, some causing illness in people and others that circulate among animals, including camels, cats, bats etc. Rarely, animal corona viruses may evolve and infect people and then spread between people as witnessed during the outbreak of Severe Acute Respiratory Syndrome (SARS, 2003) and Middle East Respiratory Syndrome (MERS, 2014). The etiologic agent responsible for the current outbreak of SARS-CoV-2 is a novel coronavirus closely related to SARS-Coronavirus. In humans, the transmission of SARS-CoV-2 can occur via respiratory secretions (directly through droplets from coughing or sneezing, or indirectly through contaminated objects or surfaces as well as close contacts). Current estimates of the incubation period of COVID range from 2-14 days. Common symptoms include fever, fatigue, dry cough and breathing difficulty. Upper respiratory tract symptoms like sore throat, rhinorrhoea, and gastrointestinal symptoms like diarrhea and nausea/ vomiting are also reported. As per analysis of the biggest cohort reported by Chinese CDC, about 81% of the cases are mild, 14% require hospitalization and 5% require ventilator and critical care management. The deaths reported are mainly among elderly population particularly those with comorbidities. At the time of writing this document, many of the crucial epidemiological information, particularly the source of infection, mode of transmission, period of infectivity, etc. are still under investigation.

2.STRATEGIC APPROACH

India would be following a scenario based approach for the following possible scenarios:

  • Travel related case reported in India
  • Local transmission of COVID-19
  • Community Transmission of COVID-19 disease
  • India becomes endemic for COVID-19

2.1. Key Approach for when "just travel related cases detailed from India" 
(I) Inter-clerical coordination (Group of Ministers, Committee of Secretaries) and CentreState Co-appointment been set up. 
(ii) Early Detection through Points of Entry (PoE)screening of travelers originating from influenced nations through 30 assigned air terminals, 12 significant ports, 65 minor ports and 8 land intersections. 
(iii) Surveillance and contact following through Integrated Disease Surveillance Program (IDSP) for following voyagers in the network who have gone from influenced nations what's more, to identify bunching, assuming any, of intense respiratory disease. 
(iv) Early finding through a system lab of ICMR which are trying examples of suspect cases. 
(v) Buffer supply of individual defensive hardware kept up. 
(vi) Risk correspondence for making mindfulness among open to follow preventive open wellbeing measures.
You can find out more about India travel and Indian Visa restrictions.

2.2. Neighborhood transmission of COVID-2019 ailment 
The system will continue as before as clarified in para 2.1 as above. What's more, group control system will be started with: 

  • Active reconnaissance in control zone with contact following inside and outside the control zone.
  • Expanding research center limit with respect to testing every single presume test, close contacts, ILI and SARI
  • Establishing flood capacities with respect to detaching all suspect/affirmed cases for clinical the board. 
  • Implementing social removing measures. 
  • Intensive hazard correspondence.

3. Extent OF THIS DOCUMENT 
In arrangement with key methodology, this archive gives activity that should be taken for containing a group. The activities for control of enormous episodes will be managed independently. 

4. Goals 
The goal of bunch control is to break pattern of transmission and reduction the bleakness what's more, mortality due to COVID-19. 

5. Bunch CONTAINMENT 

5.1. Meaning of Cluster 
A bunch is characterized as 'an irregular conglomeration of wellbeing occasions that are gathered in time what's more, space and that are accounted for to a wellbeing office' (Source CDC). Groups of human cases are shaped when there is nearby transmission. The nearby transmission is characterized as a research facility affirmed instance of COVID-19: 
(I) Who has not gone from a zone detailing affirmed instances of COVID-19 or 
(ii) Who had no introduction to an individual going from COVID-19affected zone 
(iii) The cases are epidemiologically connected 
As a working definition, under 15 cases in a zone can be treated as a bunch. 
There could be single or numerous foci of neighborhood transmission. 

5.2. Group Containment Strategy 
The group control system is contain the ailment with in a characterized geographic territory by early identification, breaking the chain of transmission and subsequently forestalling its spread to new territories. This would incorporate geographic isolate, social removing measures, upgraded dynamic observation, testing every presumed case, seclusion of cases, home isolate of contacts, social activation to follow preventive general wellbeing measures. 

5.3. Proof base for group regulation 
Huge scope measures to contain COVID-19 have been attempted in China, Republic of Korea, Germany, France, Singapore and Italy. Since there is effective human to human transmission, accomplishment of regulation tasks can't be ensured. Mediations to restrain dreariness, mortality and social disturbance related with SARS in 2003 exhibited that it was conceivable at that point to activate complex general wellbeing activity to contain SARS flare-up. Scientific displaying contemplates recommend regulation may be conceivable. 

5.4. Variables influencing group regulation 
Various factors decide the achievement of the regulation activities. These are: 
(I) Size of the group. 
(ii) How effectively the infection is transmitting in Indian populace. 
(iii) Time since first case/group of cases started. Recognition, research facility affirmation and detailing of initial hardly any cases must happen rapidly. 
(iv) Active case finding and research center analysis. 
(v) Isolation of cases and isolate of contacts. 
(vi) Geographical qualities of the zone (for example openness, characteristic limits) 
(vii) Population thickness and their development (counting transient populace). 
(viii) Resources that can be prepared quickly by the State Government/Central Government. 
(ix) Ability to guarantee fundamental framework and basic administrations. 

5.5. Suppositions 
(I) The infection isn't flowing in Indian Population. 
(ii) Even if there is a worldwide pandemic, there is huge piece of the nation which remains unaffected and enormous populace which stays vulnerable.

6. Activity PLAN FOR CLUSTER CONTAINMENT

6.1. Institutional instruments and Inter-Sectoral Co-appointment
At the National Level, the National Crisis Management Committee (NCMC)/Committee of Secretaries (CoS) will be initiated. The co-appointment with wellbeing and non-wellbeing parts will be overseen by NCMC/Cos, on issues, hailed by Ministry of Health. Service of Health and Family Government assistance will initiate its Crisis Management Plan.
The Concerned State will actuate State Crisis Management Committee or the State Disaster The executives Authority, as the case might be to deal with the groups of COVID-19. There will be customary co-appointment gatherings between the middle and the influenced States through video gathering.

The State should audit the current lawful instruments to execute the regulation arrangement. A few of the Acts/Rules for thought could be
(I) Disaster Management Act (2005)
(ii) Epidemic Act (1897)
(iii) Cr.PC and
(iv) State Specific Public Health Acts.

6.2. Trigger for Action
The trigger could be IDSP recognizing a group of Influenza like Illness (ILI) or Severe Acute Respiratory condition (SARI), which might possibly have epidemiological linkage to a movement related case. It could likewise be through other casual announcing components (media/common society/medical clinics both government and private area) and so forth. The State will guarantee early finding through the ICMR/VRDL (Virus Research and Diagnostic Laboratory) Network. A positive case will trigger a arrangement of activities for regulation of the group.

6.3. Arrangement of Rapid Response Teams (RRT)

State will send its state RRT and area RRT groups to embrace planning of cases and contacts in order to portray the regulation and support zones. Crisis Medical Relief (EMR) division, Service of Health and Family Welfare may send the Central Rapid Response Team (RRT) to backing and guidance the State.

6.4. Distinguish topographically characterized Containment zone and Buffer zone

6.4.1. Control zone
The control zone will be characterized dependent on: Containment Zones are portrayed dependent on:
I. Planning of cases and contacts
ii. Topographical scattering of cases and contacts
iii. Zone having very much differentiated border
iv. Enforceability of border control, the RRT will do posting of cases, contacts and their planning. This region ought to consequently be suitably characterized by the region organization/neighborhood urban bodies with specialized contributions at neighborhood level. For viable control, it is fitting to decide in favor of alert.

Exercises to be embraced in the Containment zone incorporates:
I. Dynamic quest for cases through physical house to house reconnaissance by Special Teams shaped for the reason
ii. Testing of all cases according to inspecting rules
iii. Contact following
iv. Recognizable proof of neighborhood network volunteers to help in reconnaissance, contact following and hazard correspondence
v. Broad between close to home and network based correspondence
vi. Exacting implementation of social removing
vii. Backing close by cleanliness, respiratory cleanliness, natural sanitation and wearing of veils/face-covers
viii. Clinical administration of every single affirmed case

6.4.2. Border
When the Containment Zone is depicted the border will be characterized and there would be severe border control with:
I. Foundation of clear section and leave focuses,
ii. No development to be permitted with the exception of health related crises and fundamental merchandise what's more, administrations,
iii. No unchecked deluge of populace to be permitted and
iv. Individuals traveling to be recorded and finished IDSP.

6.4.2. Support zone
A Buffer Zone must be outlined around every regulation zone. It will be suitably characterized by the area organization/neighborhood urban bodies with specialized contributions at nearby level. Support zone will be essentially the zone wherein extra and centered consideration is required in order to guarantee that disease doesn't spread to bordering territories. For compelling regulation, it is of vital significance that the cushion zone should be an enormous region. The exercises under the Buffer Zone include:
I. Upgraded detached reconnaissance for ILI and SARI cases in the support zone through the existing Integrated Disease Surveillance Program.
ii. Make people group mindfulness on preventive estimates, for example, individual cleanliness, hand cleanliness and respiratory decorums.
iii. Utilization of face spread, social removing through upgraded IEC exercises.
iv. To guarantee social removing by:

  • Dropping all mass social affair occasions, gatherings in broad daylight or private spots.
  • Maintaining a strategic distance from open spots
  •  Conclusion of schools, universities and work places

7. SURVEILLANCE

7.1. Surveillance in containment zone

7.1.1. Contact listing
The RRTs will list the contacts of the suspect /laboratory confirmed case of COVID-19. The District Surveillance Officer (in whose jurisdiction, the laboratory confirmed case/ suspect case falls) along with the RRT will map the contacts to determine the potential spread of the disease. If the residential address of the contact is beyond that district, the district IDSP will inform the concerned District IDSP/State IDSP.

7.1.2. Mapping of the containment and buffer zones
The containment and buffer zones will be mapped to identify the health facilities (both government and private) and health workforce available (primary healthcare workers, Anganwadi workers and doctors in PHCs/CHCs/District hospitals).

7.1.3. Active Surveillance
The residential areas will be divided into sectors for the ASHAs/Anganwadi workers/ANMs each covering 100 households (50 households in difficult areas). Additional workforce would be mobilized from neighboring districts (except buffer zone) to cover all the households in the containment zone. Additional workforce if required will be listed from the covidwarriors.gov.in. This website provides access to list of volunteers trained for surveillance (ASHAs, Anganwadi workers, NSS, NCC, IRCS, NYKV). This workforce will have supervisory officers (PHC/CHC/Ayush doctors) in the ratio of 1:5.

The field workers will be performing active house to house surveillance daily in the containment zone from 8:00 AM to 2:00 PM. They will line list the family members and those having symptoms. The field worker will provide a mask to the suspect case and to the care giver identified by the family. The patient will be isolated at home till such time he/she is examined by the supervisory officer. They will also follow up contacts identified by the RRTs within the sector allocated to them.

All ILI/SARI cases reported in the last 14 days by the IDSP in the containment zone will be tracked and reviewed to identify any missed case of COVID-19 in the community.

Any case falling within the case definition will be conveyed to the supervisory officer who in turn will visit the house of the concerned, confirm that diagnosis as per case definition and will make arrangements to shift the suspect case to the designated treatment facility. The supervisory officer will collect data from the health workers under him/ her, collate and provide the daily and cumulative data to the control room by 4.00 P.M. daily.

7.1.4 Passive Surveillance
All health facilities in the containment zone will be listed as a part of mapping exercise. All such facilities both in Government and private sector (including clinics) shall report clinically suspect cases of COVID-19 on real time basis (including ‘Nil’ reports) to the control room at the district level. The health facilities in the buffer

7.1.5. Contact Tracing
The contacts of the laboratory confirmed case/ suspect case of COVID-19 will be line-listed and tracked and kept under surveillance at home for 28 days (by the designated field worker). The Supervisory officer in whose jurisdiction, the laboratory confirmed case/ suspect case falls shall inform the Control Room about all the contacts and their residential addresses. The control room will in turn inform the supervisory officers of concerned sectors for surveillance of the contacts. If the residential address of the contact is beyond the allotted sector, the district IDSP will inform the concerned Supervisory officer/concerned District IDSP/State IDSP.

7.2. Surveillance in Buffer zone
The surveillance activities to be followed in the buffer zone are as follows:

  • Review of ILI/SARI cases reported in the last 14 days by the District Health Officials to identify any missed case of COVID-19 in the community.
  • Enhanced passive surveillance for ILI and SARI cases in the buffer zone through the existing Integrated Disease Surveillance Programme.
  • In case of any identified case of ILI/SARI, sample should be collected and sent to the designated laboratories for testing COVID-19.

All health facilities in the buffer zone will be listed as a part of mapping exercise. All such facilities both in Government and private sector (including clinics) shall report clinically suspect cases of COVID-19 on real time basis (including ‘nil’ reports) to the control room at the district level. Measures such as personal hygiene, hand hygiene, social distancing to be enhanced through IEC activities in the buffer zone.

7.3. Perimeter Control
The perimeter control will ensure that there is no unchecked outward movement of population from the containment zone except for maintaining essential services (including medical emergencies) and government business continuity. It will also limit unchecked influx of population into the containment zone. The authorities at these entry points will be required to inform the incoming travelers about precautions to be taken and will also provide such travelers with an information pamphlet and mask.

All vehicular movement, movement of public transport and personnel movement will be restricted. All roads including rural roads connecting the containment zone will be guarded by police.

The District administration will post signs and create awareness informing public about the perimeter control. Health workers posted at the exit point will perform screening (e.g. interview travelers, measure temperature, record the place and duration of intended visit and keep complete record of intended place of stay).

Details of all persons moving out of perimeter zone for essential/ emergency services will be recorded and they will be followed up through IDSP. All vehicles moving out of the perimeter control will be decontaminated with sodium hypochlorite (1%) solution.

8. LABORATORY SUPPORT

8.1 Designated laboratories
The identified VRDL network laboratory, nearest to the affected area, will be further strengthened to test samples. The other available govt. laboratories and private laboratories (BSL 2 following BSL 3 precautions) if required, shall also be engaged to test samples, after ensuring quality assurance by ICMR/VRDL network. If the number of samples exceeds its surge capacity, samples will be shipped to other nearby laboratories or to NCDC, Delhi or NIV, Pune or to other ICMR lab networks depending upon geographic proximity.

All test results should be available within 24 hours of sampling. ICMR along with the State Government will ensure that there are designated agencies for sample transportation to identified laboratories. The contact number of such courier agencies shall be a part of the microplan.

The guidelines for sample collection, packaging and transportation is available at

https://www.mohfw.gov.in/pdf/5Sample%20collection_packaging%20%202019-nCoV.pdf

The designated laboratory will provide daily update (daily and cumulative) to District, State and Central Control Rooms on:

  • No. of samples received
  • No. of samples tested
  • No. of samples under testing
  • No. of positive samples

8.2 Testing criteria
The ICMR strategy for testing is given below:

  • All symptomatic individuals who have undertaken international travel in the last 14 days
  • All symptomatic contacts of laboratory confirmed cases
  • All symptomatic health care workers
  • All patients with Severe Acute Respiratory Illness (fever AND cough and/or shortness of breath)
  • Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact Details are available The testing at the field level shall be taken up as per the criteria proposed by ICMR from time to time. 

9. HOSPITAL CARE
All suspect cases detected in the containment/buffer zones (till a diagnosis is made) and those tested positive will be hospitalized and kept in isolation in separate areas in designated facilities. Three tier facility has been developed for isolation of suspect/ confirmed COVID-19 cases.

These are Covid Care Centres (CCC) to keep pre-symptomatic/ very mild/ mild cases, Dedicated Covid Health Centres (DCHC) for those requiring Oxygen therapy and Dedicated Covid Hospitals for those requiring intensive Health care or ventilator management. 

Some patients may progress to multi organ failure and hence critical care facility/ dialysis facility/ and Salvage therapy [Extra Corporeal Membrane Oxygenator(ECMO)] facility for managing the respiratory/renal complications/ multi-organ failure shall be required. If such facilities are not available in the containment zone, nearest tertiary care facility in Government / private sector needs to be identified, that becomes a part of the micro-plan.

Pre-symptomatic and very mild cases have an option of being in home isolation subject to fulfillment of availability of earmarked space for isolation at home.

9.1 Surge capacity
Based on the risk assessment, if the situation so warrants (data suggested an exponential rise in the number of cases), the surge capacity of the identified hospitals shall be enhanced, private hospitals will be roped in and sites for temporary hospitals identified and their logistic requirements shall be worked out.

Related guidelines are available at:

https://www.mohfw.gov.in/pdf/AdvisoryforHospitalsandMedicalInstitutions.pdf

9.2 Pre-hospital care (ambulance facility)
Ambulances need to be in place for transportation of suspect/confirmed cases. Such ambulances shall be manned by personnel adequately trained in infection prevention control, use of PPE and protocol that needs to be followed for disinfection of ambulances (by 1% sodium hypochlorite solution using knap sack sprayers).

10. FINANCING OF CONTAINMENT OPERATIONS
The fund requirement would be estimated taking into account the inputs in the micro-plan and funds will be made available to the district collector from NHM flexi-fund.

10.1 Scaling down of operations
The operations will be scaled down if no secondary laboratory confirmed COVID-19 case is reported from the containment and buffer zones for at-least 4 weeks after the last confirmed test has been isolated and all his contacts have been followed up for 28 days. The containment operation shall be deemed to be over 28 days from the discharge of last confirmed case (following negative tests as per discharge policy) from the designated health facility i.e. when the follow up of hospital contacts will be complete.

The closing of the surveillance for the clusters could be independent of one another provided there is no geographic continuity between clusters. However, the surveillance will continue for ILI/SARI.

However, if the containment plan is not able to contain the outbreak and large numbers of cases start appearing, then a decision will need to be taken by State administration to abandon the containment plan and start on mitigation activities.

11. IMPLEMENTATION OF THE MICRO-PLAN
Based on the above activities, the State/ District will prepare an event specific micro-plan and implement the containment operations.

19. FOLLOWING UP OF ADDITIONAL GUIDELINES ISSUED FROM TIME TO TIME
As the situation is still evolving, based on additional evidence, and the spread of cases, additional guidelines are issued by the government from time to time. Those applicable in terms of management efforts in the identified clusters shall be taken into account and implemented accordingly. The additional instructions, if any, are made available on MoHFW website from time to time.

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