India is facing one of the greatest crises in its history and maybe the worst of any country during this horrific pandemic. Hospitals are running out of beds, staff and oxygen. Patients are dying in such large numbers that the bodies of the deceased are being cremated in mass funerals. The country is recording more than 300,000 new detected infections and over 3,000 deaths a day — both of which, experts say, are massive undercounts because of severely limited testing and don't account for the terrible burden of diarrheal diseases, heart attacks and other conditions going untreated.
While some initiatives are forming to provide materials to scale vaccine production, these efforts will take weeks or months to have any effect — India will not be able to vaccinate its way out of this surge quickly, no matter what. Even if the United States were to donate all of its vaccine doses to India now, it would still take months to immunize enough people to control the outbreak. Lockdowns, as some states and cities are reinstituting, can quickly stunt transmission of the virus, but in a country with high rates of poverty, informal work and unreliable social safety nets, restrictions need to be implemented with adequate social and economic support for the vulnerable. India has a number of such programs in policy and on paper, but their actual implementation is fraught even in non-crisis times; none of that was enough to offset the fallout from the first set of lockdowns. Any new lockdowns may inadvertently drive people doing informal work in cities back to their villages, where they may carry the coronavirus and further spread the pandemic.
But two other interventions could be implemented almost immediately to counter the tsunami of infection: more masks and rapid home-based antigen tests. The White House is sending millions of such masks and tests to India as part of the U.S. emergency assistance, which is a good start. But with more than 1.3 billion people in India, much more will be needed.
The coronavirus is transmitted by respiratory particles, including smaller aerosols that can get through or around many cloth masks. "Hi-fi" masks that have both high-grade filtration and a tight fit around the mouth and nose can more reliably block these particles. A number of such masks exist, including N95s and reusable elastomeric masks from the United States, KN95s from China, KF94s from South Korea and FFP2s from Europe. India needs to urgently assess the availability of these masks and begin a campaign to procure and distribute them in huge numbers. One U.S. manufacturer, for example, has openly offered to donate hundreds of millions of such masks. India should also make efforts to accelerate domestic production. Another option would be to mass-produce and distribute "mask-fitters" that enhance the seal formed by surgical masks, which are ubiquitously available throughout India and have sufficient filtration to block most particles that transmit the virus. The fitters have simple designs made from common materials, allowing for immediate scale-up of their production. One makeshift approach that can be used until other options are available would be double-masking, with a cloth mask used over a surgical mask to improve its fit.
If worn widely when indoors and among crowds, these options could rapidly impede transmission. They can be mass-distributed through existing channels such as the national food supplementation system, which has a designated person in each village to distribute food rations. In addition, public uptake of such masks will require politicians and celebrities — some of whom have, in recent months, not been wearing masks in public — to promote them now.
The second intervention that can have an immediate effect is the large-scale deployment of rapid antigen tests that can provide results in minutes and be administered by community health workers (who are already in place nationally in India) or even possibly by people themselves. Currently, India relies on PCR, or polymerase chain reaction, testing. But given the sheer volume and pace of virus transmission, PCR cannot be scaled widely enough nor deliver results fast enough to identify those infected before they transmit to others or become sick. Some experts have argued against using such rapid tests because they can sometimes result in false negatives or false positives. Studies, however, have shown that rapid tests tend to be accurate when people are most infectious and could be used every few days so that an infection missed on one day is likely to be detected by the next test. False-positive results can also be offset by using PCR or another rapid test that targets a different antigen to confirm the diagnosis.
Another challenge is whether people who screen positive will have the space and resources to isolate safely. This is tough to solve in a crisis, but communities could perhaps designate buildings or spaces in cities and villages for people to isolate with food and other essential needs supplied to them.
Even if implemented imperfectly, widespread rapid testing would still be better than the alternative of people not getting tested. If done at scale, this approach could help cut off enough chains of transmission to help reduce the surge. As with masks, India needs to urgently assess the global supply chain for rapid tests so available supplies can be imported and deployed as soon as possible.
If pursued nationally with global support, hi-fi masks and rapid tests could be scaled up within a matter of weeks alongside efforts to engage communities on why these measures are important and how to employ them. These measures could damp the exploding rates of infection while longer-term interventions to boost care capacity and vaccination take root. Masks and rapid antigen tests should be used urgently to start pushing back the tide. Without these urgent interventions to slow transmission, the crisis is likely to get much worse before it gets better — and thousands more lives will be lost.
Adrish Bhadra is a physician and director of Optimize Health/Gramin Swasthya Utprerak Sansthan, a nonprofit working on primary healthcare in rural India.
Abraar Karan, a physician at Brigham and Women's Hospital and Harvard Medical School, worked on the Massachusetts state COVID-19 response as well as for the Independent Panel on Pandemic Preparedness and Response. He has worked in global health throughout Sub-Saharan Africa, Asia and Latin America.
Devabhaktuni Srikrishna is the founder of www.patientknowhow.com, which curates patient educational content on YouTube, including information on N95 masks and high-quality alternatives.
Ranu S. Dhillon is an instructor and global health physician at Harvard Medical School and Brigham and Women's Hospital in Boston. He previously worked as an advisor to India's National Rural Health Mission and is a cofounder of Optimize Health, a nonprofit working on primary healthcare in rural India.
This piece was written for The Washington Post.
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