Containment zones: What is India’s plan to handle coronavirus after the national lockdown ends?

On April 14, India will complete three weeks of a national lockdown announced by Prime Minister Narendra Modi to halt the spread of the new coronavirus. Even if the lockdown ends up being extended, as reports say the government is considering, it will have to end at some point. What will a post-lockdown India look like?

Countries around the world are beginning to discuss what life looks like after a lockdown. For many, such as Italy or the United States, the lockdown is expected to be eased only after hitting a peak in Covid-19 cases.

India’s strategy will have to be different from most. When Modi announced the lockdown, India was only beginning to see its infection numbers go up. The country had less than 500 cases at the time. As of April 7, it has 4,400, with cases doubling about every four days.

In a conversation with chief ministers of India’s states last week, Modi emphasised the need to “formulate a common exit strategy to ensure staggered re-emergence of the population once lockdown ends”.

The Centre’s approach for the areas that are hardest hit seems to focus on what is being called the “Bhilwara model”, named after a town in Rajasthan that had a high number of cases but moved aggressively to prevent further spread. This involves identifying clusters of the virus around the country and putting in place restrictions, even harsher than the lockdown, that would stop the virus from going beyond those areas.

Meanwhile, states and analysts have discussed other approaches, including alternating periods of lockdown and relaxation, an approach focused on isolating just the elderly and a phase-based plan that would dictate when people can return to the streets.

On Tuesday, reports began emerging that the Centre is considering a combination of some of these measures.

Cluster containment

A document of the Ministry of Health and Family Welfare from last week, coupled with the actions of a number of states, gives us a glimpse of what post-lockdown restrictions may look like for the worst-hit districts.

“The Cluster Containment Strategy would be to contain the disease within a defined geographic area by early detection of cases, breaking the change of transmission and thus preventing its spread to new areas,” the document says.

The strategy builds on the experience from the 2009 H1N1 influenza pandemic, with that virus affecting bigger cities and well-connected towns much more than rural areas.

“This suggests that while the spread of Covid-19 in our population could be high, it’s unlikely that it will be uniformly affecting all parts of the country,” the document says. “This calls for a differential approach to different regions of the country, while mounting a strong containment effort in hotspots.”

According to Dr Gautam Menon, a professor at Ashoka University, Sonepat and the Institute of Mathematical Sciences, Chennai, this approach mimics other responses to infectious disease in the past and would find an echo in what was used in the worst hit parts of China.

“I think what the government is contemplating, i.e. a strategy of local geographical quarantine followed by cluster containment makes sense,” he said. “It would be the standard advice for dealing with an outbreak: wait for the number of cases in any well-defined geographical region to exceed a certain amount, then isolate that region, identify those infected belonging to a cluster or clusters of infections through intensive testing, quarantine them and then once case numbers have decreased sufficiently, relax these measures.”

How it works

Once authorities identify a cluster – based on the number of confirmed cases in that region – it will set up a containment zone and a buffer zone.

The former will have restrictions that are even harsher than during the lockdown. The document recommends prohibition of all movement of vehicles or personnel, and a ban on anyone entering or exiting the zone unless they are providing essential services.

“Intensive risk communication campaign will be followed to encourage all persons to stay indoors for an initial period of 28 days, to be extended based on the risk assessment,” the document says. “The perimeter control and movement of vehicles within the containment zone will be prohibited except for those (identified through special passes) earmarked for providing essential services... Those found defaulting of government orders will be prosecuted.”

The document allows for states to define the exact size and spread of the zones based on local conditions, with the aim being to prevent all movement in and out of the containment zone, and a minimum of movement within the buffer.

“All vehicular movement, movement of public transport and personnel movement will be stopped. All roads including rural roads connecting the containment zone will be guarded by police,” it says.

Once the area is locked down, authorities will depend on health workers to go door-to-door informing people about the strategy and asking them if they have been unwell, coupled with an aggressive testing strategy.

Anyone entering the containment zone, for essential services “shall be given a chemo-prophylactic dose of hydroxy-chloroquine,” the controversial malaria drug that the government is recommending for healthcare workers.

And the containment zones will be shut down only if no new cases have been identified for a period of four weeks.

“The operations will be scaled down if no secondary laboratory confirmed Covid-19 case is reported from the geographic quarantine zone for at least four weeks after the last confirmed test has been isolated and all his contacts have been followed up for 28 days,” it says. “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.”

Already in place

Even before the end of the lockdown, some states have already begun implementing the containment-and-buffer zone approach.

Municipal authorities in Mumbai, the capital of the state with the highest number of cases so far, Maharashtra, made public a map that detailed more than 200 containment zones across the city, before later making it available only to government staff. In some cases these zones only cover a building or two, with the buffer being the buildings around it. In others, it includes slightly larger urban areas.

The Indian Express reported on how one containment zone is actually working in Worli Koliwada, a fisherman colony in the city:

“For the last five days, [Santosh] Hinde has been shuttling between his office, where he currently stays, and the barricaded entrance of the Koliwada to ferry essentials for his family that isn’t permitted to leave the containment zone.

On Saturday, he and a colleague from his office arrived in a two-wheeler loaded with essentials. The police posted at the barricades supervised as he handed it over to another family member on the other side of the barricade, ensuring that precautionary measures for COVID-19 were adhered to.”

Delhi has so far taken a slightly different approach.

Rather than turn every building or area with more than three cases into such a zone, as Mumbai has done, the national capital has instead declared two hotspots – in Dilshad Garden and Nizammudin – and only very limited containment zones beyond these areas. It is also not providing public information on where cases have been identified.

According to a report in the Hindustan Times, one government officer said “it would be unnecessary to create multiple containment zones. The strategy should be efficiently deployed.”

The report described how the first containment zone outside of the two hotspots, in the slum neighbourhood of South Moti Bagh, is operating:

“All shops, including those selling essentials, were closed, sanitisation workers were seen spraying disinfectants at regular intervals and door-to-door drives were conducted twice a day by government officials to check if any of the residents of the slum had developed any flu-like symptoms, said a senior officer in Delhi government’s revenue department.

“The residents have been asked to stay inside their homes and call the beat staff, local police station, or hunger helpline over the phone if they need food, ration or other essential items. The other option is to call their community leader (Pradhan), who can further send the message across. Arrangements have been made to get the essentials delivered at the slum so the residents do not have to venture out,” said deputy commissioner of police (southwest) Devender Arya.”

‘Bhilwara model’

This approach is being referred to by some, including Cabinet Secretary Rajiv Gauba in his interactions with state bureaucrats, as the “Bhilwara model”. This is a reference to the town of Bhilwara in Rajasthan, which saw a spike in cases in late March.

The local administration then took all the measures that appear in the cluster containment document: a complete curfew, aggressive follow-up with all in the neighbourhood, large-scale testing, and prevention of travel.

According to the Economic Times, despite the early numbers, Bhilwara has reported only one positive case since March 30.

“Government has been adopting a strategy for cluster containment and for outbreaks that are amenable to management,” said Lav Agarwal, the joint secretary of the Union Health Ministry, on Tuesday. “This strategy is producing positive results, especially in Agra, Gautam Buddh Nagar, Pathanamthitta, Bhilwara and East Delhi.”

Reports are now streaming in of state governments identifying containment zones around the country, from Gujarat to Odisha to a hospital in Mumbai where healthcare personnel ended up getting infected.

Post-lockdown plans

The clusters containment strategy is not the only option on the table for the government.

A Cambridge-Institute of Mathematical Sciences study modeling the spread of the disease, for example, recommended “protocols of sustained lockdown with periodic relaxation”, to limit the number of people being infected all at once.

“The idea of staggered lockdown with interspersed periods of relaxation has been raised by others as well,” said Dr Gautam Menon, a professor at Ashoka University, Sonepat and the Institute of Mathematical Sciences, Chennai. “I would prefer a more local strategy, such as the one that the cluster containment document contains, which has also been called a “light-switch” strategy.”

“The idea of the paper from Cambridge/IMSc suggests repeated lockdowns as a pan-India strategy but something on that scale is hard to sustain repeatedly and will have serious economic consequences as well,” Menon said. “So geographical quarantine followed by cluster containment is the better way to go. It is also more flexible.”

An expert committee set up by Kerala has, meanwhile, recommended a pattern to follow for the easing of lockdown restrictions if number of cases begins to come down.

According to this plan, phase 1 would apply to districts that have not had more than one case since April 7. Face masks would be mandatory, the old would have to stay at home, only 25% of workforce would be allowed into offices and authorities could consider schemes like odd-even – where cars are allowed to go out based on whether their licence plates end with an odd or even number.

Phases 2 and 3 would then kick in after, with more relaxations in tandem with more time since the last new case was identified.

“Apart from reducing the spread of the disease and increasing the testing to rule out community spread,” the Newsminute said, this plan “aims to minimise loss of healthcare professionals, reduce the stress on the existing healthcare system and continue public healthcare services such as vaccinations and food/nutrition of children and pregnant/feeding mothers.”

Jayaprakash Muliyil, one of India’s foremost epidemiologists who has argued against attempting to suppress the virus through lockdowns, said the focus after the lockdown should ideally be on isolating the elderly while minimising economic pain.

“Containment of the virus is an early maneuver, I am anxious that we are late. You can keep isolating people, and then supposing the virus keeps growing, you will have to isolate even more people,” he said. “Ideally, the lockdown has to be opened and we have to make adjustments for the differential exposure to the elderly. Everyone else should go around normally – of course with distancing, avoiding crowds – but industry has to come up, agriculture has to go on, immunisation for other diseases needs to happen.”

Muliyil argues that the best thing that can be done is to portect the elderly in our homes.

“The thing that defeats us is a sudden explosion in the admission rate,” he said. “Locking down keeps us susceptible, and there is no end to this. If you remain susceptible, then you are always a target, at least until a vaccine... The best reward we can have is if many of us gain immunity.”