New Delhi: The Government of India has been issuing guidelines and advisories from time to time to the States to assist their efforts in containing the ongoing COVID Pandemic. On 5th January 2021, the Union Health Ministry had advised States to keep a ‘strict vigil’ and take steps so as to curb recent spike in COVID cases. On 21st February 2021, States/UTs witnessing spike in cases were requested to undertake immediate requisite public health interventions. Further, on 27th February 2021, all States were advised not to lower their guard, enforce COVID appropriate behaviour and to follow effective surveillance and tracking strategies in respect of potential super spreading events. On 20th April, 2021, Union Health Ministry had conveyed to all States/UTs projections of COVID-19 cases, with a request to ensure sufficient infrastructure and logistic requirements for the same. These are besides series of video conferences with States at the level of Union Health Minister, Cabinet Secretary and Union Health Secretary with States and Districts to review and highlight the steps to be taken to control spread of infection and manage the surge in cases.
On account of a very high number of daily new COVID cases being reported for the past few days, the Union Government has expressed the urgent need for States to consider strict COVID management and control measures in surge areas to bring the situation under control to contain the spread of infection in areas reporting higher cases and surge. The existing infrastructure may not be able to cope with this kind of surge, it has been stressed.
Prompt and targeted action needs to be focused on specific districts/cities/areas in order to flatten the current curve of the epidemic which may be identified by States as per the parameters:
| S. No. | Parameter | Threshold |
| 1 | Test Positivity | Test Positivity of 10% or more in the last 1 week |
| OR | ||
| 2 | Bed Occupancy | Bed Occupancy of more than 60% on either oxygen supported or ICU beds |
Districts fulfilling any one of the above two criteria are to be considered for taking intensive action and local containment measures. Local containment primarily focused on restricting intermingling of people is to be undertaken for a period of 14 days for breaking the chain of transmission duly following epidemiological principles. Classification of districts requiring intensive action and local containment is also to be undertaken by the State on a weekly basis and may also be made available online, besides being given due publicity in the media.
The areas requiring intensive action and local containment connote specific and well-defined geographical units such as cities/towns/parts of the towns/district headquarters/semi-urban localities/municipal wards/panchayat areas etc.
The local containment will essentially focus on three strategic areas of intervention, which include Containment, Clinical Management and Community Engagement.
Identification of areas for local containment should be a dynamic exercise aiming to break and suppress the chain of transmission of SARS-CoV-2 and save precious lives in areas reporting higher surge in cases and deaths and exhibiting overstretched healthcare systems.
The Centre has also suggested monitoring mechanism in this regard. As the situation is dynamic, a daily review should be taken up at the highest levels in the State. States, after identification of districts/parts of districts/ towns/ parts of towns for intensive and local containment, should appoint senior Officials as Nodal Officers to be stationed in these districts for 14 days for effective monitoring & implementation.
The State Nodal Officer in consultation with the District Collector and Municipal Commissioners concerned should identify the area to be taken up for local containment based on clusters of cases reported in the district. This may include cities, towns, municipal wards or part of town or panchayat primarily identified based on areas where larger spread of infection and high surge in cases are getting reported. The State Nodal Officer should submit details of all such areas identified for local containment to state government for approval.
The District Collector/Municipal Commissioner should undertake a daily status review, including analyzing details of case trajectory, day to day operational planning, implementation of various activities as per the field level feedback.
It has been pointed to the States that a daily status report should be submitted to the State Government by the District and the consolidated report at the state level may also be sent to the Government of India for information.
If required, all States may also consider a further graded response in accordance with local situation, requirements, and resources.
Implementation Framework for community containment/large containment areas entails:
Understanding the virus transmission dynamics:
The virus transmits through the human host. It is imperative to understand that in order to contain the transmission of the virus, the strategies involve not just containing the virus but also the human host.
Broadly, the strategies are:
- Individual actions such as wearing of masks, maintaining a distance of 6 feet from others, sanitizing one’s hands frequently and not attending any mass gathering; and
- Public Health measures to contain the virus by:
Quarantining and testing individuals suspected to be positive including contacts of SARS-CoV-2 positive persons, SARI cases, persons with flu like symptoms etc. and ensuring that they are not mobile and thus able to spread the infection isolating all those who are positive, tracing their contacts, quarantining and testing them. Where there are clusters of cases, simply quarantining individuals or families will not help. In that case, containment zones with clear boundaries and stringent controls will be required to ensure that the infection does not spread outside. This is in line with the containment strategy followed worldwide and also already enumerated in SOPs of the Ministry of Health. This would mean a large geographical area like a city or district or well defined parts thereof, where cases are high and spiraling up, gets contained physically, However, regulated movement of public transport would be permitted.
- Evidence Based Decision: The decision on where and when to go for large Containment Zone (CZ) has to be evidence based and done at the State/UT level after proper analysis of the situation, such as; the population affected, the geographical spread, the hospital infrastructure, manpower, the ease of enforcing boundaries etc.
- However, in order to facilitate objective, transparent, and epidemiologically sound decision making, the following broad-based framework is provided to aid States UTs in selection of districts/areas:
| S. No. | Parameter | Threshold |
| 1 | Test Positivity | Test Positivity of 10% or more in the last 1 week |
| OR | ||
| 2 | Bed Occupancy | Bed Occupancy of more than 60% on either oxygen supported or ICU beds |
- The areas requiring Intensive action and local containment connotes specific and well defined geographical units such as cities/town/part of the towns/district headquarters/semi-urban localities/municipal wards/panchayat areas etc.
- The areas so identified for intensive action and local containment will primarily focus on the following strategic areas of intervention:
- Containment
- Focus will be on containment as a major approach to flatten the current curve of the epidemic.
- Night curfew: Movement of individuals shall be strictly prohibited during night hours, except for essential activities. Local administration shall decide the duration of the night curfew hours and issue orders, in the entire area of their jurisdiction, under appropriate provisions of law, such as under Section 144 of CrPC, and ensure strict compliance.
iii. The spread of the infection has to be controlled through restricting the intermingling amongst people, the only known host for the COVID-19 virus.
- Social/ political / sports / entertainment / academic / cultural / religious / festival related and other gathering and congregations shall be prohibited.
- Marriages (attended by up to 50 persons) and funerals/ last rites (attended by up to 20 persons) may be allowed.
- All shopping complexes, cinema halls, restaurants & bars, sports complexes, gym, spas, swimming pool and religious places should remain closed.
vii. Essential services and activities such as healthcare services, police, fire, banks, electricity, water and sanitation, regulated movement of public transport including all incidental services and activities needed for a smooth functioning of these activities shall continue. Such services shall continue in both public and private sector.
viii. Public transport (railways, metros, buses, cabs) to operate at a maximum capacity of 50%. There shall be no restrictions on inter-state and intra-state movement including transportation of essential goods.
- All offices, both government and private, to function with a maximum staff strength of 50%. All industrial and scientific establishments, both government and private may be allowed subject to the workforce following physical distancing norms. They shall also be tested through RAT (in case of individuals identified with flu like symptoms) from time to time.
xii. The SOPs already issued by MOHFW, including training manuals for surveillance teams and supervisors are available on the website & must be followed
xiii. However, these are indicative activities, and States/ UTs should make a careful analysis of the local situation, areas to be covered, and probability of transmission and then take a decision.
xiv. The restrictions as above shall continue for a period of 14 days.
- Before declaring a containment area, make a public announcement, outlining the rationale for the same and the kind of restrictions that will be in place (a leaflet in local language may be distributed highlighting the gravity of the situation and restrictions to be followed)
xvi. Community volunteers, civil society organizations, ex- servicemen, and members of the local NYK/NSS centers etc. should be involved for sustainable management of containment activities, translating the aforementioned leaflets and for encouraging people in the community for sustained behavior change as well as vaccination.
- Testing and Surveillance
Districts will continue with the strategy of ‘Test-Track-Treat-Vaccinate and implementation of Covid Appropriate Behavior across the district as the ongoing strategy for the management of COVID-19.
- Ensure adequate testing and door to door case search in the area through adequate number of teams formed for such purpose.
- Plan for testing of all clinically resembling cases of Influenza like illness (ILI) & SARI through RAT. All symptomatic individuals turning out to be negative for SARS-CoV-2 infection with RAT need to be retested through RT PCR.
iii. Ensuring compliance of COVID Appropriate Behaviour aggressively both through creation of awareness through involvement of the communitybased organizations and through stringent regulatory framework.
- Clinical Management
- Analysis to be undertaken with respect to requirement of health infrastructure so as to manage the present and projected cases (next one month) and necessary action initiated to ensure sufficient oxygen-supported beds, ICU beds, ventilators, ambulances including creation of makeshift hospitals, as needed. Sufficient quarantine facilities shall also be re-activated.
- Leverage government, private health facilities including hospital facilities available with central ministries, railway coaches, temporary field hospitals etc.
iii. Ensure that people satisfying protocol for home isolation only are allowed under home isolation. Create a mechanism for their regular monitoring through Call Centres along with regular visit of surveillance teams to such houses.
- Provision of a customized kit for all patients under home isolation, including detailed dos and don’ts to be followed by them.
- Specific monitoring shall be done for highrisk cases and their timely shifting to the health facility. Similarly, elderly and co-morbid contacts of positive cases shall be shifted to quarantine centres and monitored.
- Appoint senior district officials as In-charge for all Covid dedicated hospitals and create a mechanism for seamless shifting of patients (including home isolation cases) as per their symptom to the relevant facilities.
vii. Ensure availability of sufficient ambulances for such purpose.
viii. Coordinate availability of oxygen, other related logistics, drugs etc. in collaboration with state officials and ensure their rational use.
- Oxygen therapy for the admitted cases shall follow the guidelines issued by Ministry of Health on the rational use of oxygen.
- Use of investigative drugs (Remdesivir / Tocilizumab etc.) shall also strictly follow the clinical management protocol/advisories issued by Ministry of Health.
- Facility wise cases and deaths shall be analyzed on daily basis by the Incident Commander/District Collector/Municipal Commissioner. Death audit shall be undertaken for all deaths in the hospitals and in the community to provide supportive supervision to field staff/hospitals.
- Vaccination
100% vaccination for the eligible age-groups shall be undertaken duly creating additional vaccination centres and optimal capacity utilization of existing Centres.
- Community Engagement
- Ensure adequate advance information to community, also highlighting the need for stringent containment actions so as to win their involvement and support.
- Provide enough time for people movement for essential requirements etc. before announcing the large-scale containment.
iii. Take necessary actions to avoid misinformation & panic in the community.
- Involve local level NGOs/CBOs/CSOs, Opinion Makers and subject experts to create a positive environment and for sustained dialogue with the community.
- Create wide publicity on early warning signals and self-reporting so as to identify cases early and to prevent avoidable deaths among home isolation patients.
- Give wide publicity on the mechanism whereby people can get themselves tested, details of available health facilities, requisitioning an ambulance etc (community based organizations should be encouraged to create WhatsApp groups for quick dissemination of information so that the individuals in need of prevention and/or care services do not suffer delay).
vii. Ensure that details of hospital beds and their vacancy status is made available on-line and also released to media on a daily basis.
viii. Details on availability of oxygen, drugs, vaccine and vaccination centres, including the guidelines related with use of Remdesivir/Tocilizumab etc. be also widely publicized so as to create confidence in the community.
- Community should be oriented about the feasibility of managing mild COVID-19 cases at home with appropriate monitoring of vital parameters such as temperature and oxygen saturation with the help of pulse oxymeter.
- Need for COVID Appropriate Behaviour including regulatory framework for enforcement should be widely publicized.
- Build confidence in community duly highlighting the nature of disease, the fact that early identification helps in early recovery and more than 98% people recover to remove fear as well as stigma related with Covid-19. Involvement of civil society organizations to hold such orientations go a long way in this regard.
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