Why India needs to extend the nationwide lockdown.

The ongoing COVID-19 pandemic has afflicted almost the entire world. China and Italy have been some of the worst hit while the first world economic superpowers like United States of America and United Kingdom have had an onerous load on their respective healthcare systems. On January 30, 2020 India became part of this global carnage with the first COVID diagnosis [1]. The numbers have risen steadily since then, albeit at an alarming rate in the final days of March. Aiming to control community transmission, the Indian government took the step of declaring a 21 day nationwide lockdown starting on March 24th [1].

As we approach deeper into the lockdown, a steep rise in the number of confirmed cases has been noted. Despite this, as of now, the Central government has expressed no intention of extending the lockdown.

Epidemics are a numbers game and as far as numbers are concerned, India has its hands full.

India has the second largest population after China but India's population density far exceeds China's (455/km2 vs 148/km2) [2]. This is should be an extremely pertinent factor while designing the epidemic response suited to the country. When we look at the rate which screening is being done, India ranks at the lower end of the spectrum. If the maximum number of people cannot be diagnosed, how can one expect them to quarantined or treated.

Availability and cost of testing kits are valid concerns which perhaps cannot be dealt with at this juncture in a manner of urgency. What can be done is to contain the spread of the infection to as few individuals as possible before this becomes the wildfire that some countries have had the misfortune of being witness to.

The answer lies not in clinical medicine. This battle cannot be won inside the hospital. There are no evidence based treatment options and a vaccine does not seem to be in sight anytime soon. Healthcare systems across the resource rich countries have visibly crumbled under the case loads. The answer lies in the fundamentals of epidemiology.

Recently a predictive model of the way the infection could spread in India was published by Singh and Adhikari [3]. Emphasizing the importance of social distancing as the only effective tool against COVID for now, they have formulated various predictive models based on Bayesian imputational analysis.

Their recommendations are very clear. For the lockdown to be effective, there are only two approaches:

Extend the lockdown to a total of 49 days or

Phased lockdowns of 21, 28 and 18 days with intervening periods of 5 days of suspension.

Both the models seem to suggest effective control of spread of infection [3].

Even if mathematical models are not convincing enough, we need to look at the other side of the available statistics. At the time of writing this article, India has tested 114,015 people out of which 4616 have been reported to be positive [4]. Considering the strength of iceberg phenomena in India, one should not draw any delusive contentment from these statistics.

Seventeen cases and three fatalities [5] out of the largest slum dwelling in India-Dharavi, with a population density of a staggering 870,000/mile2 (335,907/km2) [6], is a data set that should be a cause for serious concern.

India is yet to visualize the true impact of this pandemic. Using the current statistics to formulate epidemic control policy would be equitable to running in the blind. If the government decides to end the lockdown as planned, it could spell doom for the entire country. The mortality numbers in Italy and Spain would seem like specks of dust. As clinicians, we should be building surge capacities for the time when the lockdown is lifted. This lockdown is the dam holding back a flood. Once it breaks, our entire healthcare system, public and private, will drown in the torrent that follows.

The most pragmatic way to deal with this pandemic is what is being done right now-a lockdown. If implemented with integrity, it could prevent this disaster from engulfing a large section of the Indian diaspora.

We live in an extremely connected world. Considering that the Indian lockdown directly concerns approximately 18% of the world's population [7], its impact can go far beyond just the Indian borders.

In the recent years, Indians have taken great pride in the strength that they display in numbers. This population has been the cornerstone of India's phenomenal economic success.

COVID-19 threatens the very foundation of this triumph. A storm is coming. We better take shelter.

Disclosure of funding

No funding was given for this article.

Declaration of competing interest

There is no conflict of interest.