Enhancing and Strengthening the Public Healthcare System

June 2021

A competent Public Healthcare System is the key to combat and manage future pandemics and health crises.

IS THE 3^rd WAVE OF COVID IMMINENT?

Considerable speculation has already commenced in the media about the timing and contours of a third wave of COVID. Predictions have been made, by mathematical modelers and some epidemiologists, that we may be rocked by the third wave in November 2021. While the accuracy of such predictions is uncertain, since they are based on several assumptions, we do need to be well prepared to meet such a threat whenever it arises.

Several elements will determine the severity of a third wave:

• nature of variants in circulation
• number of persons who have acquired immunity from vaccination or recent infection
• number of susceptible people who are available for the virus to infect and cause symptomatic illness
• adherence of people to public health advisories on wearing masks and avoiding crowds
• ability of public authorities to prevent super-spreader events
• preparedness of our public healthcare systems to ensure timely case detection, supportive home care or assured hospitalization with competent service provision.

 WHAT NEEDS TO BE DONE?

Sharpening surveillance

• Our surveillance systems must be sharpened, to detect the levels of circulating variants and the emergence of new forms.
• Case detection will need to be based on both testing and clinical features gathered by healthcare teams visiting homes.
• False-negative results from tests can be compensated by adding clinical criteria (syndromic surveillance, as used for other infectious disease outbreaks).
• Genomic analysis of 5-10 % of all positive test samples would be needed, with higher levels of scrutiny for virus samples recovered from international travelers.
• In rural areas, testing would pose more challenges so symptom-based surveillance and contact-based quarantine would have to be followed, along with the use of rapid antigen tests (RAT) for spot diagnosis and mobile laboratories to carry samples for RT-PCR testing to authorized laboratories.

Healthcare resources

Home care would be appropriate and adequate for 85-90 % of all symptomatically infected cases. Primary health care teams must be trained in providing supportive care and monitoring. Symptoms, pulse oximetry readings, temperature should be part of daily monitoring of such home-managed persons. If the person is a diabetic, blood sugar too should be monitored with a glucometer. Telemedicine facilities should be scaled up and standardized, to support home management. Prior planning should be done to ensure the timely transfer of a person under home care to an intermediate or advanced care facility when the need arises.

Sub-district, district and medical college hospitals should be equipped to handle a possible surge of the third wave. It is difficult to predict how severe it would be, as it depends on the behavior of the virus and its different variants, as well as the behavior of people in adhering to public health advisories on masks, ventilation and avoidance of crowding. However, strengthening of the public healthcare infrastructure and health workforce at various levels of care is long overdue. This is an opportunity to reduce the existing disparities of healthcare provisions between states and districts as well as between urban and rural areas.

Vaccination

Vaccination must be speeded up, with accelerated domestic production and international procurement. The number of vaccination centers must be increased. Vaccination in rural areas will require careful planning of logistics, sensitive communication for confidence building and remove hesitancy, support for overcoming technology barriers to registration and availability of close-to-home vaccination centers. The Delta variant poses challenges with high infectivity and capacity for vaccine evasion, at higher levels than the wild virus or the Alpha variant. However, there is reassuring evidence that the variant responds well to two doses of all available vaccines. So, we need to provide both doses of vaccines to vulnerable persons, identified by age and co-morbidities. Children and even pregnant women now need to be regarded as candidates for priority vaccination.

Protecting Children

There is speculation in the media that children will be more affected in a third wave. It is possible that more children will be exposed in an open society than during the first wave when they were mostly sheltered or even during the second wave when they were still partly guarded. The numbers of susceptible adults may also decrease by that time as several of them would have been vaccinated or infected by then. Nevertheless, adults will still be far more likely to have severe infection than children where the vast majority will have asymptomatic or mild infections. Even so, expanding hospital services for children, including intensive care capacity, will still serve a useful purpose by strengthening pediatric care for many serious illnesses.

Collaboration

The period of relative calm will also give us time to build partnerships between and among government services, local bodies, non-governmental organizations, schools and educational institutes, trade unions, industry representatives, community groups and citizen volunteers. Capacity-building for concerted action among these groups will give us the collective strength to respond more effectively to the third wave, and enhance public healthcare. Whether to promote COVID-appropriate behavior or to reduce vaccine hesitancy, local networks in the community are vital. Community-based surveillance systems can also give early alerts of rising cases.

Health Awareness

We should also utilize this opportunity to enhance health and nutrition literacy to increase immunity. Healthy diets and physical activity are vital for both innate and adaptive immunity to fight the virus and also for prevention and control of non-communicable diseases which are the predominant co-morbidities that predict poor outcomes in COVID infection. Promotion of healthy living habits using the COVID platform will help foster future health and well-being.

We need to prepare well for a competent and concerted response that can anticipate, avert or attenuate future public health emergencies. By being forewarned and forearmed, we can restrict the third wave to a ripple rather than a tidal wave.

Dr Naresh Purohit is Consultant, Community Healthcare in Bhopal, and Medical Expert and Advisor National Communicable Disease Control Programme. He is also Advisor to six other National Health Programs and visiting Professor in five Medical Universities of Southern India including Thrissur based  Kerala University of Health Sciences. 

Also read:

The 2nd Wave of COVID: What One Must Know

5 Important Points about COVID Vaccines

COVID Treatment and Medical Care

5 Important points of care for Coronavirus and COVID-19