1. Support evidence-based medicine:

A key problem during the second wave of COVID-19 infection was medication misuse. Numerous drugs, none proven effective against COVID-19, were prescribed extensively, even prophylactically, in some states. This inappropriate and ineffective use heightened concerns regarding antimicrobial resistance, a major problem in India.

Corticosteroids (especially dexamethasone)—the one drug class known to have a positive impact on clinical outcomes if properly timed—were prescribed during the viremic phase, which exacerbated mild infections and sent patients from home to hospitals. The Ministry of Health has since removed most inappropriate drugs from treatment protocols; however, vigilance is needed to prevent administration of unproven drugs. Treatment protocols for COVID-19 must be simple to understand and apply.

As evidence for clinical management evolves, training and skills of health-care workers must be continually upgraded, especially in peri urban and rural areas. Medical associations and hospital groups should disseminate simple guidelines to warn against inappropriate self-medication and discourage demands for maximal interventions when routine care is sufficient.

Treatment protocols for COVID-19 must be simple to understand and apply.

2. Conduct serological surveys:

Serological surveys across different geographies and populations provide invaluable information about viral transmission, identify vulnerable groups, and guide control measures. The first serological survey conducted in Mumbai in 2020 showed that antibodies were present in 57 percent of slum populations versus 16 percent of high-rise populations, suggesting greater susceptibility in high rises. Data from the Mumbai Municipal Corporation indicates that 90 percent of infections in the second wave occurred in high-rises.

Serological surveys should be conducted in multiple settings (rural/urban areas, slums/societies) and populations (adults/children) to identify at-risk populations. Use of new tools such as point-of-care quantitative antibody testing can scale up surveys.

3. Develop data-driven vaccine allocation plans:

Vaccine doses should be prioritized to at-risk populations according to demographics, geographic locations, and risk factors. Allocation strategies should be regularly updated to include emerging evidence from serological surveys and ongoing infection. This would ensure that doses with limited availability are best used to maximize the impact of vaccination on lives and livelihoods. Vaccine hesitancy and access issues should be addressed to ensure that the vaccination campaign reaches priority populations. 

4. Ramp up genomic surveillance:

The circulation of variants of concern (VOCs) has a major impact on the dynamics of transmission and the effectiveness of vaccination. The recent increase in VOC circulation requires a ramp-up of genomic surveillance to monitor the prevalence of identified VOCs and detect the appearance of new strains. Ramp-up can include enabling existing labs to conduct genomic sequencing and establishing a platform to standardize reporting. Studies should be conducted to evaluate the transmissibility and virulence of new strains as well as their impact on vaccine efficacy.

5. Adopt localized stepwise reopening strategy:

 To avoid a spike in cases post-lockdown, easing restrictions requires a careful strategy based on three conditions:

•  Stage-wise: To allow full impact assessment of the ongoing stage, a window of three weeks should be allowed before implementation of a new set of authorizations/restrictions. Restrictions associated with each level of reopening should be clearly communicated to industries and the general public.

• Data-driven: The decision to move one level up or down in restrictions should be based on the following indicators (monitored daily):

  • effective reproductive rate (i.e., spread of cases in the population),

  • daily new COVID-19 cases and test-positivity rate,

  • vaccination rate, and

  • availability of hospital beds and oxygen.

• Localized: The opening of service, retail, and manufacturing sectors should be tailored to the economic environment in order to minimize economic disruption.

6. Scale-up non-pharmaceutical interventions (NPIs):

 Non-pharmaceutical interventions, especially mask-wearing and improved indoor ventilation, are essential to limit virus transmission. Implementation of NPIs currently depends on individuals following COVID-19–appropriate behaviors—which may be hindered by pandemic fatigue and lack of information. Governments can support better implementation of NPIs through:

• mask distribution campaigns and behavioral science-based interventions to encourage uptake and

• recommendations to improve ventilation in public buildings and support to organize essential activities outdoors. 

In the medium term, building ventilation systems should be improved. This is essential post-pandemic as well to decrease transmission of other airborne pathogens. Excellent air quality should become as much of a right as clean water.

7. Guide industries:

 Provide understandable, easy-to-implement guidelines for sectors on best practices for safe reopening and limiting virus transmission within their premises. Guidance should include risk assessment, recommendations for vaccinated and unvaccinated employees, maximum number of employees on-site, mask mandates, hand hygiene, improving indoor ventilation, and testing strategy.

8. Set up early-warning systems:

Such systems help identify early clusters, predict surges, and pinpoint locations for targeted testing. A twofold approach can be based on wastewater and sentinel surveillance. Wastewater surveillance, an effective, affordable way to detect transmission, can be complemented by sentinel surveillance in high-risk groups.