Primary response to COVID-19 situation by Himachal Pradesh, India, during pandemic year 2019–20: “Exceptional and emphatic”—A commentary

Gopal A Sharma; Vijay K Barwal; Anmol Gupta

doi:10.4103/JIMPH.JIMPH_8_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 1 | Issue : 2 | Page : 42-48

Primary response to COVID-19 situation by Himachal Pradesh, India, during pandemic year 2019–20: “Exceptional and emphatic”—A commentary

Gopal A Sharma, Vijay K Barwal, Anmol Gupta
Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Submission	14-Aug-2022
Date of Decision	30-Oct-2022
Date of Acceptance	31-Oct-2022
Date of Web Publication	20-Feb-2023

Correspondence Address:
Dr. Gopal A Sharma
Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JIMPH.JIMPH_8_22

Abstract

BACKGROUND: India announced its first incidence of corona virus disease-2019 (COVID-19) in the state of Kerala on January 30, 2020. The severe acute respiratory syndrome- coronavirus-2 (SARs-CoV-2) pandemic was also unavoidably pounding on the doors of the state of Himachal Pradesh (HP), with enormous regional discrepancies necessitating remarkable insight. SETTINGS: On February 5, 2020, HP’s health authority took its first reaction step and followed it with a swift, adequate, and innovative response subsequently. Assuming R₀ of 2.28 at the early stages of an epidemic, the outbreak threshold (T₀ = 1/Log R₀) is estimated to be mere 2.7 infections. However, with the emergence of only two positive cases, the state acted conscientiously vigilant to announce a lockdown at an opportune moment. METHODS: Department of Information and Technology developed a “CORONA Mukht (free) App” for keeping a digital record of all home-quarantined persons on the administration vigil list. During the active house-to-house case-finding campaign, an exercise involving 16,000 healthcare workforces, around 10,000 individuals with influenza-like illness (ILI) were screened. The ambulances were modified innovatively as “mobile sample collection kiosks” for sample collections throughout. The state added additional categories in the sampling protocol to keep a vigil for any community transmission. The protocol included samples from Flu clinics, ILI patients from the community, and occupants with ILI from migrant relief camps. DISCUSSION: On April 20, 2020, there were 23 incident cases in the state and declined to 10 on April 27, 2020. On May 3, 2020, out of 40 positive cases reported, there was only one active case under treatment. Subsequently, with effective containment measures, the state succeeded in keeping the test positivity rate below 2% from May to August 2020. Effectively during the specified period, cumulative deaths reported were 33 only in the state, with a case fatality rate of 0.56% at the end of August 2020, lower than the national average of 2.1%. CONCLUSION: It can be concluded that HP’s initial response to SARS-CoV-2 pandemic was exceptional and emphatic.

Keywords: COVID-19, Himachal Pradesh, pandemic response

How to cite this article:
Sharma GA, Barwal VK, Gupta A. Primary response to COVID-19 situation by Himachal Pradesh, India, during pandemic year 2019–20: “Exceptional and emphatic”—A commentary. J Integr Med Public Health 2022;1:42-8

How to cite this URL:
Sharma GA, Barwal VK, Gupta A. Primary response to COVID-19 situation by Himachal Pradesh, India, during pandemic year 2019–20: “Exceptional and emphatic”—A commentary. J Integr Med Public Health [serial online] 2022 [cited 2023 Mar 27];1:42-8. Available from: http://www.jimph.org/text.asp?2022/1/2/42/370078

Introduction

On January 30, World Health Organization (WHO) notified the outbreak of coronavirus disease as a Public Health Emergency of International Concern, and on the same day, India reported its first case of corona virus disease-2019 (COVID-19) in Kerala, at the South-end state of the country.^[1] Subsequently, the state further confirmed the third case of COVID-19 by February 3, 2020. In India, by the first week of March 2020, the confirmed positives swelled to double digit, and soon the numbers were in hundreds by the middle of the month across the country.^[2]

The pandemic of severe acute respiratory syndrome-coronavirus-2 (SARs-CoV-2) with origins from Wuhan had traversed exhaustive terrains and was inevitably knocking at doors of the state of Himachal Pradesh (HP), India, also. HP is a hilly state of India, almost 3000 kms far away from Kerala, inhabited by 6,864,602 residents.^[3] HP had always remained a favorite destination state for tourists and travelers from across the world, with influx of more than 17 million in the year 2018.^[4] The state of HP with wide geographical disparities, extreme terrains, harsh weather conditions ensuing winter, and massive tourist influx had enormous challenge on its hand, warranting extraordinary vision from the state authorities for effective containment and control of the novel pandemic threat of COVID-19.

February 5 was precisely the date when the health administration of HP swung into their first responsive action. The State Level Rapid Response team constituted with experts from medicine, pediatrics, microbiology, community medicine, and others invoked a meeting to address the issue with utmost urgency.^[5] The administration response was not only swift and adequate, but it was innovative and backed up by technological advancement delivered at the grass-root level. The following are the few effectual steps undertaken by health administration to contain the contagion spread. The various steps initiated primarily during the early period from March 20, 2020, to May 3, 2020, of the pandemic are discussed below, which led to the containment of the cases to single case only. These initiatives contributed in state’s preparation to health system strengthening and pandemic preparedness, as inevitable community transmission was delayed further.

Methods

Surveillance

On March 20, 2020, HP reported its first two cases of SARS-CoV-2. Prior to that, the health department had kept continuous diligent vigil on all international travelers, including tourists on their return were monitored for the development of any COVID-19 like symptoms as per instructions of the central government. On March 14, 2020, the government further notified and categorized the susceptible travelers into three categories (A, B, C) and were put on strict active surveillance protocol as per guidelines issued by the state nodal agency, National Health Mission (NHM)-HP.^[6] The mandatory surveillance period of 14 days cycle of home quarantine was extended further with the inclusion of subsequent 14 days of the “observatory period” for any reported illness. Hence, each COVID-19 suspect was on health administration vigilance radar digitally, for a full 28-day cycle under the umbrella of the Integrated Disease Surveillance Program. [Figure 1] shows that cumulatively 14,167 persons were put up on extended surveillance, out of those, 7,614 were on active surveillance and 6,553 individuals had already completed the full extended observatory cycle of 28 days.

Figure 1: Surveillance of Himachal Pradesh

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Prompt and Effective Lockdown

On March 23, 2020, HP had confirmed only two positive cases of SARS-CoV-2. The median value of R₀ for SARS-CoV-2 in a finite population of the ship, as reported by Zhang et al., is 2.28.^[7] Assuming the similar R₀ at the early stages of an epidemic in the state of HP, the outbreak threshold (T₀ = 1/Log R₀) is estimated to be mere 2.7 infections.^[8] But, with the emergence of only two positive cases, the state government acted conscientiously vigilant to announce lockdown at an opportune moment for the entire population and followed this by curfew implementation for enforcing social distancing. The effectiveness of lockdown implementation is depicted in [Figure 2], with a decrease in a number of total roadside accidents in HP (proxy indicator) reported during the corresponding period of the pandemic year 2020, when compared with the previous year.^[9],[10] The cardinal feature of the state lockdown was strict implementation through community participation and enforcement of the legal process in case of any violation by offenders. Essential commodities disbursement was ensured by the state government through fair price shop by following strict norms of social distancing. Just few days after the enforcement of the lockdown, the state was declared equipped with adequate supplies of wheat flour, rice, salt, sugar, and pulses.^[11] During the period, social distancing was the most efficient nonpharmacological interventional tool to limit the spread of COVID-19.^[12] Another component was strict enforcement for tourists also, as HP is a favorite destination for many travelers. The influx of tourists, both domestic and foreigner, was halted well in advance before the announcement of lockdown.^[13]

Figure 2: Road traffic accidents in Himachal Pradesh (2019 and 2020)—lockdown effectiveness

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Innovations

For any emergent epidemic, household quarantine is potentially the most effective social distance measure, but only if compliance with the policy is adequate.^[14] In HP, the ever-tested public health tool of quarantine from the ages of Black Death was aptly and swiftly backed up by technological advancements at the implementation level. Department of Information and Technology developed a “CORONA Mukht (free) App” for keeping a digital record of all home-quarantined persons on the state health administration list.^[15] The peculiar feature of the “CORONA Mukht App” was the generation of an instantaneous alert to authorities in case of any breach/violation of quarantine by an individual based on geocoordinates of location. The innovative, deterrent itself was an excellent contrivance to address compliance and keep continuous vigil over erring individuals.

Active Case Finding Campaign

HP was a pioneer state in launching an active case finding (ACF) campaign for COVID-19 suspects, targeting seven million inhabitants of the land. The ACF was conducted for the period from April 1 to April 7, 2020.^[16] The primary aim of the campaign was active house-to-house search of any SARS-CoV-2 cases along with dissemination of awareness about COVID-19 to masses at the household level.^[17] The campaign conducted was by the teams comprising of Accredited Social Health Activists and Aangan Wadi Worker, the pioneers of the successful campaign of pulse polio eradication and ACF campaign for tuberculosis elimination program in the past. The novelty about the house-to-house survey was an entry of data generated through “Google form” for every individual visited and screened at home. After the mammoth exercise involving 16,000 healthcare workforces, around 10,000 individuals with “ILI” were reported and treated after the survey. SARS-CoV-2 testing was conducted for 1,500 of them subsequently, who did not show improvement.^[18]

Mobile Kiosk Vans for Sampling

The mobile sample collection kiosks for collecting a sample of COVID-19 suspects as per the testing policy of the state was another landmark innovative moment in HP’s fight to the pandemic. Displaying exceptional innovation “mobile sample collection kiosks” were modified, equipped state ambulances for smooth mobility in communities of even far-flung inaccessible areas [Figure 3].^[19] Improvisation itself was contemporary in enhancing samples for testing of SARS-CoV-2 from communities with diverse characteristics and dwelling, amidst geographical challenges.

Figure 3: Mobile kiosk of Himachal Pradesh for sampling

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Extensive Sampling as a Surveillance Tool

In the middle of April 2020, India had reported approximately 14,000 COVID-19 positives, and Indian Council of Medical Research (ICMR) was recommending testing for SARS-CoV-2 primarily for five categories, including close contacts by real time reverse transcriptione-polymerase chain reaction (RT-PCR) test. Apart from ICMR recommended categories, HP further added additional categories of samples to rule out and keep a vigil on any community transmission. Samples from Flu clinics, influenza-like illness (ILI) patients from the community through mobile kiosks, occupants having ILI symptoms from migrant relief camps, were included in sampling protocol by State Government.^[20] On May 3, 2020, the state had ramped up the testing facility from 0 to 5 laboratories and had tested 7432 individuals. The testing rate of HP was 1091 per million, much higher than the other states and national average of 758 per million during the period.

Social Security Inclusions

HP had strived hard in achieving Universal Health Coverage through the implementation of the HIMCARE scheme for all sections of the society.^[21] Enrolment and renewal window for the same was extended to beneficiaries promptly till May 15, 2020, so that none of the beneficiary is devoid of health benefits. On similar lines, the testing for COVID-19 was also included under “HIMCARE” insurance scheme by state nodal insurance agency and thereby alleviated economic hardship concerns of any susceptible.^[22]

Discussion

Keeping in mind a state with limited resources and adverse geographic disparities, the state had responded exceptionally to the COVID-19 pandemic during the initial 6 months. Although, it is a plausible explanation that naturalistic geographic variations due to spatial heterogeneity had contributed to the containment of SARS-CoV-2 in this state. But from the global perspective, many European countries with similar topography had been impacted very hard on all counts, unfortunately with COVID-19 during the same period. HP response was potent, emphatic, and valid one. After initial spike in incident cases to 23 on April 20, 2020, subsequently, there were no new case for the past 10 days, which further declined to 10 on April 27, 2020, and out of total 40 positive cases and migration of four cases out of the state, there was only one active case under treatment at the state health institutions on May 3, 2020 [Figure 4]. Because of the effective implementation of the various measures, there was imminent decline in new and active cases, although the cumulative tests to identify incident cases increased 2.5 times all over the state. At one stage of the prevalent pandemic, during the first year, on May 3, 2020, there was only single active case (2.5%) in the state, and the test positivity rate of the state had also further declined to 0.5% only. Moreover, according to the prevalent zone categorization by the government of India being followed during that period, six districts of the state were in the green and orange zones, respectively. None of the districts of the state was in the red zone during postlockdown measures. Later on, as various restriction imposed were gradually lifted systematically, there was a gradual increase in confirmed cases in the state over the period of time.

Figure 4: COVID-19 situation of Himachal Pradesh (March 28, 2020 to May 3, 2020)

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HP Pandemic Response: May to August 2020 Phase

Post May 3, 2020 for the next 3 months, the state efforts in containing the pandemic were equivocally emphatic. On expectant lines, with subsequent ease in restrictions and sequential increase in the economic activity, there was inevitable increase of infectivity among the citizens. However, with persistent effective contact tracing, quarantine protocols, and containment measures, the state succeeded in keeping the test positivity rate below 2% for the period from May to August.^[23] This was noteworthy as, the tests conducted in the state were 20,736 per million on dated July 31, 2020. This was 20-times higher as compared to the tests conducted on May 3, 2020 (1,093 tests per million). WHO had recommended 140 tests per day per million population in its Guidance Note on “Public Health Criteria to Adjust Public Health and Social Measures in the Context of COVID-19.”^[24] On July 15, 2020, the tests per million across India were hovering around 8,994/million, and in the state of HP, the tests per million had reached the milestone of 17,000/million on July 22, 2020.^[25] Additionally, the test positivity rate was within 2% of recommended levels, and the tests being conducted were significantly higher than average at India level. WHO recommended in May 2020 that if the percent positive remains below 5% for at least 2 weeks, then coronavirus transmission can said to be under control.^[26] On July 2, 2022, WHO published, “Learnings from Kerala-Responding to COVID-19,” with 4,189 cases of COVID-19 as on 30 June 2020 and 23 deaths with an impressive recovery rate of 51.7%.^[27] In its feature stories, WHO recognized focused strategy of test, track and treat with extensive screening and quarantine of all the incoming travelers by the state of Kerala for pandemic control. HP also traversed the similar path of pandemic control with identical strategies, but these went unrecognized. HP on July 30, 2020, with comparison to the state of Kerala, the state had better indices of COVID-19 control (no of cases, comparable tests per million, and case fatalities) as depicted in [Figure 5]. HP as a state succeeded in keeping test positivity rate below a level of 2% for more than 12–16 weeks. Effectively during the specified period, cumulative deaths reported were also 33 only in the state, with the case fatality rate of 0.56% at the end of August 2020, 5 months after the onset of the pandemic.^[15],[28]

Figure 5: COVID-19 status of Himachal Pradesh as on July 31, 2020

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Lessons Learnt

Collective implementation of surveillance tools, for example, contact tracing and digital surveillance backed up by enhanced sampling can emphatically impact the spread of epidemic across the region, along with reduced disease burden in healthcare system. This window of opportunity can be further utilized to prepare health systems to handle the future brunt of epidemic both in lower terms of mortality and morbidity.

Conclusion

To summarize, we can aptly conclude that HP’s initial response to SARS-CoV-2 COVID-19 pandemic was exceptional and emphatic during the first 6 months of pandemic.

Acknowledgments

Special acknowledgement to Dr. Nipun Jindal (IAS), currently Deputy Commissioner, District Kangra at Dharamshala, then as Special Secretary (Health) to the Government of Himachal Pradesh, and as Mission Director–NHM, HP (Nodal Agency for the pandemic control in HP) for the significant COVID-19 containment efforts in the state in the form of administrative support along with technical inputs.

Authors’ contributions

GAS: concept, design, definition of intellectual content, literature search, data analysis, and statistical analysis; VKB: data acquisition, statistical analysis, and article preparation; AG: article editing and article review. The article has been read and approved by all the authors, the requirements for authorship as stated earlier in this document have been met, and each author believes that the article represents honest work.

Ethical statement

Not applicable.

Financial support and sponsorship

Nil.

Conflicts of interest

The first author remained attached with the Special Secretary (Health), Dr. Nipun Jindal (IAS) to the Government of HP for COVID-19 containment in the period from March 2020 to July 2020. The second author was the member of Rapid Response team for Shimla & Kinnaur district. The third author was the member of State Level Rapid Response team for COVID-19.

Data availability statement

Not applicable.

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