[Analytics] Unmasking India and Indonesia’s Covid-19 challenges

COVID-19’s unprecedented health, economic, social and geopolitical impacts are still unfolding. It is often compared to the 1918 Spanish flu because both pandemics have similar fatality rates, but the world has become much more dependent on global supply chains, travel and trade. Raina MacIntyre specially for the East Asia Forum.

Tackling a highly infectious disease requires global disease control. Governments cannot neatly segregate populations and selectively apply epidemic control measures. Singapore learned this lesson with a resurgence of cases in migrant worker dormitories. Poor control of infection in any part of a society will affect all of society and poor control in any country will have global impacts. This is why Asia’s response to COVID-19 matters for the rest of the world.

The novel coronavirus is far more difficult to control than SARS. First, the disease is most infectious just before symptoms develop. It is also transmissible in people who never develop symptoms. In contrast, SARS was only infectious when infected people displayed symptoms. Second, there is growing evidence that the virus can be transmitted through fine, respiratory aerosols.

Without a vaccine, societies must rely on five measures to contain the spread: testing, contact tracing and quarantine, travel bans, social distancing and the use of face masks.

Low-income countries’ capacities for testing may be limited and of low quality, so their official case numbers are the tip of the iceberg. Indonesia became a focus of interest in February because it had not yet reported any cases of COVID-19. Yet modelling predicted that by 4 February, Indonesia should have had at least five cases.

Identifying cases of infectious diseases depends on public health infrastructure, routine disease surveillance systems, diagnostic testing capacity and reporting. Many low-income countries in Asia and the Pacific cannot comply with the WHO’s regulations of surveillance and reporting because they have weak health systems and poor diagnostic tools. Others fail to report cases because of fears that this may impact tourism, trade and the economy. This may be creating a silent epidemic in Southeast Asia.

The rate of testing per head is low in India and even lower in Indonesia. Indian data shows a steady rise in detected cases, suggesting poor compliance with social distancing despite being in lockdown.

Indonesia took a softer approach, with localised lockdowns in Jakarta but other centres remaining open. The epidemic curve shows a more constant rates of new cases, reflecting the limits of testing capacity, if only a fixed number of tests are administered each day.

Test kit availability is reportedly low and their price high in Indonesia. There are also concerns that Indonesia has used unreliable antibody tests, so the true scale of infection is unknown. Despite this, there are plans to reopen Bali to tourists by July.

Urban slums are another concern for amplified transmission and explosive outbreaks. India’s slums have been locked down, leaving people unable to work and living in conditions which make social distancing impossible. In these conditions, universal face mask use may be useful to mitigate spread.

Extensive testing and the ability to move sick people into isolation are also important to reduce transmission. The crowded, unsanitary conditions in urban slums are a public health concern as a source of epidemic spread — the virus is shed in faeces. The Dharavi slum in Mumbai has over 1800 confirmed cases and Mumbai is a hot spot for COVID-19 in India. This and the total current reported case numbers for India — over 200,000 — are likely to be a significant underestimate of the true burden.

In Indonesia, COVID-19 is spreading in kampungs (urban slums) but testing is limited and relies on antibody screening, which cannot identify active infections. A lack of assistance for people who are unable to work may further worsen epidemic control as people breach disease control mandates to work. If people are required to remain in lockdown in crowded slums, provisions for food, water and sanitation — as well as extensive testing and isolation facilities — are essential.

The strength of health systems is crucial to epidemic control. This includes physical resources, human resources and essential medical supplies. One state in India that stands out as having an excellent public health response is Kerala, which has the experience of Nipah virus. States and countries with low ratios of doctors and nurses per capita will not fare as well.

Countries with highly privatised health systems such as India will require public-private partnerships for epidemic control. The Australian example of ‘nationalising’ private hospitals in preparation for the pandemic may be a useful model.

Some have argued for allowing the widespread transmission of COVID-19 in India with the aim of acquiring ‘herd immunity’. They argue the death toll will be low due to India’s young population. But an Indian study estimated that an unmitigated epidemic would result in over 364 million cases of COVID-19 and 1.56 million deaths by mid-July in India. The hope of acquiring herd immunity through infection is a myth. It has never been achieved. Indeed, India was the last stronghold of smallpox in the world and it did not magically eradicate itself by unmitigated spread. Nor will COVID-19. Others, including the WHO, have argued for human challenge studies — where volunteers are vaccinated and then deliberately infected. These studies raise ethical questions, are most likely to be done in low-income countries such as India, and have the potential to exploit vulnerable people and cause harm, especially as no rescue proven therapy is available.

While we wait for a vaccine, it is likely that we will live with intermittent epidemic periods of COVID-19 for two to five years. This may require applying and releasing the brakes of epidemic control, with continued travel restrictions. A COVID-19 vaccine stamp may become a requirement for travel, much like that for Yellow Fever.

It is possible that in the medium term, countries with similar levels of epidemic control could open their borders to each other. This could be an incentive for countries to commit to common disease control approaches — including expanded testing capacity and reliably reported health data.

Dr Raina MacIntyre is National Health and Medical Research Council Principal Research Fellow and Professor of Global Biosecurity at the University of New South Wales, Sydney.