key: cord-1006841-bjfz26ja
authors: Sarkar, Amitabha; Liu, Guang-Qi; Jin, Yinzi; Xie, Zheng; Zheng, Zhi-Jie
title: Public Health Preparedness and Responses to the COVID-19 Pandemic in South Asia: A Situation and Policy Analysis
date: 2020-11-12
journal: Glob Health J
DOI: 10.1016/j.glohj.2020.11.003
sha: 47a20fab42e8a7fb57e5236dc0fac7a080f0be84
doc_id: 1006841
cord_uid: bjfz26ja

Like rest of the world, the South Asian region is facing enormous challenges with the Coronavirus Disease 2019 (COVID-19) pandemic. The socio-economic context of the eight South Asian countries is averse to any long-term lockdown program, but the region still observed stringent lockdown close to two months. This paper analyzed major measures in public health preparedness and responses in South Asian countries in the fight against pandemic. The research was based on a situation analysis to discuss appropriate plan for epidemic preparedness, strategies for prevention and control measures, and adequate response management mechanism. Based on the data from March 21 to June 26, 2020, it appeared that lockdown program along with other control measures were not as effective to arrest the exponential growth of fortnightly new COVID-19 cases in Afghanistan, Bangladesh, India, Nepal and Pakistan. However, Bhutan, the Maldives and Sri Lanka have been successfully managing to limit the spread of the disease. The in-depth analysis of prevention and control measures espoused that densely populated context of South Asia needs community-led intervention strategy, such as case containment strategy, in order to reverse the growing trend, and adopt the policy of mitigation instead of suppression to formulate COVID-19 action plan. On the other hand, mechanism for response management encompassed a four-tier approach of governance to weave community-led local bodies with state, national and international governance actors for enhancing the countries’ emergency operation system. It is concluded that resource-crunch countries in South Asia are unable to cope with the disproportionate demand of capital as well as skilled health care workforce at the time of the pandemic. Hence, response management needs an approach of governance maximization instead of resource maximization. The epidemiologic management of population coupled with suitable public health prevention and control measures may be a more appropriate strategy to strike a balance between economy and population health during the time of pandemic.

The Coronavirus Disease 2019 (COVID- 19) pandemic has cornered the world into standstill. The World Health Organization (WHO) first declared the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), virus causing the COVID-19 disease, as Public Health Emergency of International Concern on January 30, 2020, and thereafter raised the alert level to pandemic urgency on March 11, 2020. 1 Post the pandemic announcement and subsequently the exponential growth of infection followed by the contraction of health care service delivery systems in Italy and Spain due to overcrowding of COVID-19 cases, countries across the continents (except Antarctica) had gone into "lockdown" mode to halt the outbreak of SARS-CoV-2. At the time while a third of the global population (till 17 April) was on lockdown 2 , it was of a public health importance to examine the impact of such a pandemic in poor countries that always struggles to balance between economic stabilization and population-level health outcomes. This paper was a situation assessment of South Asian countries at the onset of COVID-19 pandemic and up till current time.

Historically the South Asian (SA) countries are not new to infectious diseases, cholera being the single most example even till date. 3 The region is comprised of eight countries, namely Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and Sri Lanka, and have collectively 25% of total global population at over 1.8 billion, but accounts only for 5% of world"s gross domestic product (GDP). 4 The region has high income inequality and on average, 45% of income or consumption belongs to the richest quintile in all the eight countries. 5 South Asian countries accounted for 33.4% of global low-income population, and India and Bangladesh have 21.2% and 18.5%, respectively, population living below the international poverty line of 1.90 US$. 6 The health system especially at the primary level in the region has inadequate public investment with scarce health care workforce and excessive out of pocket expenditure. 7 Over the past decade, the health system has shifted more towards medical-centric based care on the insurance mode for service provision from private sector. 8 The ignorance to public health is a major cause for high burden of morbidity and mortality, especially due to communicable diseases. Malnutrition continues to be a serious public health problem, for example, South Asia alone hosts nearly world"s half of the wasted children (i.e. low weight for height) (26.9 million children as of 2018). 9 Except Sri Lanka, all the countries lack adequate public health capacity and competence such as disease surveillance system, a major barrier for effective 5 management control intervention for infectious diseases. 10 Stuck between poverty-inequality and fragile health system condition, the pandemic-imposed-lockdown already lowered the region"s GDP growth forecast from 6.3% to 1.8-2.8% for 2020. 11 Amid this bleak macro-economic scenario, the nation-states" aggressive move of lockdown to contain COVID-19 in the region remains doubtful owing to three long-standing factors -availability of water chiefly in summer and access to hand wash, crawling space that denies physical distancing, and the poor state of health system organization and management. 12 Lockdown is a protective short-term measure in the absence of any vaccine and/or well-defined clinical treatment. South Asian countries could not afford to bear the burden of complete lockdown for very long time. The nation-wide lockdown may not be a solution; rather it has been a problem for South Asia. At present, the routine vaccination was under threat in Bangladesh, Nepal, Pakistan and Afghanistan. 13 India had alarmingly reported on low number of tuberculosis (TB) cases during the lockdown weeks, 11367 compared to the average pre-lockdown weekly number of 45875 in 2020. 14 The access to HIV medication, cancer treatment (in India) 15, 16 , maternal care services (in Nepal) were hindered due to mobility restriction. 17 The international experience of managing the pandemic is equally disturbing. Due to lack of public health planning and preparedness, countries across the world had to bear high COVID-19 related mortality at the cost of social and economic disruption. In order to tackle the pandemic, countries urgently need to raise its own COVID-19 epidemic preparedness and response management profile. 6 The epidemic preparedness epitomizes planning, epidemiological projection, and public health driven prevention and control measures (screening, lockdown, testing, contact tracing and risk communication). The result section analytically describes all these three key features of epidemic preparedness in order to discuss an operational plan followed by intervention strategy (including clinical management) for the countries. Furthermore, the response management system is elaborated to prioritize the importance of governance robustness to aid preparedness activities and successfully manage prevention and control operations.

The South Asian countries have already faced several contextual challenges in the fronts of social, economic and political spheres. The arrival of pandemic has made them multifold and posed severe challenge to the current health policy and planning mechanism. The research was aimed to address this complexity by analyzing the region"s epidemic preparedness, guidelines for prevention and control measures, operational plan and intervention strategy and response management mechanism.

This is a health policy research to analyze the situation of South Asia region in the wake of COVID-19 pandemic. Situation analysis is a widely held method in health policy research to understand the present condition of any given context. The WHO recommends it in order to study or develop countries" national health policy, plan and strategy. 18 It is a method evolved from grounded theory to map out context and complexity of various situations. 19 The adoption of situation analysis has helped the research to set the priority actions for health policy and planning in South Asian countries to combat with the pandemic in the long run.

The narrative systemic reviews of literature were conducted to assess journal articles, edited books, monographs and other secondary materials. Since the pandemic is still at the beginning and there is a dearth of scientific research literature, thus reputed newspaper reportage, blogs, website information, magazines were also reviewed to collect the real time information/data for assessing the ground-level situations. The data bases from the World Bank, the WHO Situation Reports and other quantitative sources were also utilized for descriptive statistical analysis to assess the situation and argue for strategic moderation in public health approaches.

Epidemic preparedness is a comprehensive emergency management planning framework that in consultation with epidemiological projection devises prevention and control measures. This management in any epidemic (or per se pandemic on this occasion) is a continuous process to predict, avert, spot as well as respond to mitigate the effect of outbreaks. 20 The epidemic preparedness is often a policy-level action at national and state or provincial levels. South Asian countries need dedicated epidemic management team, monitoring taskforce, decision making body for an inter-departmental coordination. Apart from epidemic management team, all other policy bodies must also have adequate representation of public health professionals.

The epidemic management team is ideally to be comprised of public health, epidemiological, medical care treatment, hospital management, community medicine and urban planning experts. The technical body of epidemic management team is expected to provide insights and suggestions to other politico-administrative constituent bodies for decision making choices. There is a requirement of basic information outflow in regards to the epidemic management decisions for the health workers at all the levels (including medical care providers).

In order to plan for prevention and control measures, the epidemiology of Barring from Bhutan, the least populated country in South Asia, Afghanistan (703), Nepal (27) , Sri Lanka (11) and the Maldives (8) have reported deaths from COVID-19. Though the figure was inconclusive because of under-reporting as well as unavailability of age and sex-wise distribution of cases, India (3%) had so far highest crude case fatality rate followed by Afghanistan (2.29%) and Pakistan (2%), as of June 26, 2020 from the WHO situation report (no. 159) on 27 June 2020. 100 The reporting of COVID-19 cases with socio-economic classifications, such as age, sex, religion, and income, is not readily available for any South Asian countries.

According to the WHO situation report, the male to female sex ratio for infected case among all the age groups is 1.03:1. The infectivity rate is proportionately high (40-45% of total case load) and stable in the age group of 40-59 years, and continuously increasing (roughly from 10% to 25%) for the category of 20-39 years of age in the observation period, while the ages 60 and above had decreased case load from 50% to 25%, with the progression of pandemic, probably because of strict intervention measures started from second half of the March in various part of the world. 22 The natural history of COVID-19 is still not well understood so the period of infectiousness and transmissibility also vary in research findings. 23 A scoping review indicated different estimations for average incubation period (from 4.8 to 5.6 to 7 days) in COVID-19 with a broad range of 2 to 14 days variation. 24 This limitation hampers the process of effective case management, and also to estimate basic reproduction number (R0) of COVID-19 for assessing its transmission potential.

Nevertheless, the most up-to-date research findings suggested that age gradient and condition of comorbidity were definite markers in the probability of hospitalization requirement and risk of death. 25, 26 In the front of epidemic preparedness, South Asian countries in coming months should plan their activities based on the three key analytical tools (epidemiological projection, better clarity about the distribution of COVID-19 in community, and technical know-how about natural history of disease) in order to prevent and control the pandemic.

Epidemiological projection is the single most priority task in epidemic preparedness. The projection gives an early prediction in order to prepare the blue-print for planning and operation. Epidemiological projection is a comparative exercise to explore and analyze different effectiveness of control measures in epidemic management. [27] [28] [29] [30] [31] However, the latest projection exercise has been shifting towards stochastic simulation models instead of traditional analytical models, which are otherwise good to understand the complexity and explain theoretical basis of epidemiological interventions. [32] [33] [34] In this pandemic, the mathematical models have become the most referred forecasting tool for projection exercise. Only on India there have been four mathematical models for epidemiological forecasting developed by the Indian Council of Medical Research/ICMR study, the Michigan study, the Hopkins study and the Cambridge study. 35 These mathematical computational models have data limitation, thus are unable to capture the dynamicity of virus-human interaction in real lives. 36 For example, standard epidemiological forecasting models like Susceptible-Exposed-Infectious-Recovered (SEIR) may not necessarily know the infectivity of sub-clinical cases, effectiveness of contract tracing or even success of quarantine measures, they all are vital in reducing susceptibility and/or exposure rate in the community. 37 The forecasting models could work better only when all the variables remain static, which is why their prediction may work on the occasion of lockdown where dynamic observations are remote. Concomitantly, it is also true that long term lockdown is impractical irrespective of economy size and social composition.

The epidemiological projection should consider the merit of forecasting models, and try to incorporate these approaches in overall projection exercise. National-level forecasting in the context of South Asian countries is not very effective however. The

Indian example shows that all the eight North Eastern states collectively accounted for only 52 cases out of 16,116 cases till 19 April 2020, but had to face the impediments of initial twenty five days lockdown (commenced on the midnight of 25

March 2020) like the rest of the country. 38 Similarly, the low number of cases in geographically smaller countries (Bhutan -05 and Nepal -30 as of 17 April 2020) question the logic behind nation-wide lockdown. 22 On contrary, the Maldives (28 positive cases as of 17 April 2020) tactical deployment of a fourteen-day lockdown on its capital Male is well understood since it is a popular tourist destination and therefore might already be a potential hotspot. 39 In South Asia where urban-rural disparity and intra-country regional or inter-state deprivation are common, these forecasting models are usually good for state-level or provincial management of epidemic preparedness. It would be an advantage to go for context specific local models in order to have fewer assumptions and be mindful of local behaviors.

Considering the challenges clipped with forecasting models, there is an urgent need that projection exercise should be based on the system of epidemiological intelligence and qualitative prediction for data processing and analysis. The epidemiological intelligence is an organization of network that comprises of both public health surveillance and community action. The intelligence network is mandated for ad hoc detection of unverified events and accountable to verify, process and communicate unstructured information gathered from official, community or even internet-based sources. 40 In order to initiate that, secondary (or facility-specific) disease surveillance programs should be converted into field-based surveillance at least in most or severely affected districts or urban municipality areas. Apart from the sentinel surveillance sites, the cluster surveillance practice based on demarcation of hotspot or high-risk zones is also urgently required.

The intelligence network needs a trained workforce, which is a time taking and a resource intensive process. Governments and health system should take the responsibility for developing this network by creating district-level dedicated posts for senior public health experts who could serve as disease detectives. The involvement of community is also required where participatory epidemiologic methods can be followed by investing on key community resources for developing capacity in field-based surveillance, control measures (like, suspected/active case finding) and communication actions. 41 This network should remain active at least for next two years with gradual increase in strength and growth in quality. The epidemiological intelligence and qualitative prediction should aim to seek data on both bio-social and bio-medical conditions of COVID-19 cases as well as for general population in order to assess the situation and predict the future scenario. It thus is a timely call for the countries especially in LMICs to further strengthen information architecture and infuse positive atmosphere for real time data collection and reporting. 42 The analysis of intelligence network"s processed feed should be consulted with context-relevant factors for better qualitative prediction. This prediction along with local-level situation-specific forecasting models should further be discussed, compared and analyzed for a reliable epidemiological projection and to help develop and improve the control measures accordingly.

South Asian countries, known for their resource-crunch health system, are facing enormous challenges in combating the pandemic as currently there is no available antiviral drugs or vaccines for COVID-19. As a novel infectious disease, it is epidemiologically classified as a human to human transmitted disease 43 , and clinically classified as a respiratory disease. 44 However, of late the WHO has acknowledged the chance of airborne transmission in specific circumstances and settings. 104 

Screening is an established preventive tool. Since the SARS-CoV-2 has now reached to all the South Asian countries, hence, the screening measure will not be any more limited to international travellers but also needs to be expanded to intra-country or even at times within the state mobility purposes. The recent research on the effectiveness of symptom and risk screening has estimated that even at best-scenario, airport screening would miss more than half of the infected cases due to undetectable sub-clinical cases, especially in the incubation period, and cases who unaware of their risk exposure. 45 Experience from South Asian countries adduced the same, outbreaks in several places could not be stopped despite all the countries imposed screening for international travellers latest by 29 January, 2020. 46 Thus apart from thermal and symptom monitoring, individual risk assessment of travellers, such as pre and post-travel interviews including assessment of recall bias, local authority certification from the source of travel, and post travel quarantine option, should also be included.

Additionally, rapid testing subject to screening verification of selected (or suspected) travellers as preventive measure could also be a good option for most of the South Asian countries because of high volume of mobility.

Non-pharmaceutical interventions (NPI) include contact tracing, case isolation, quarantine, social distancing, and lockdown. Lockdown has become the single most popular measure during the COVID-19 pandemic that help ensure of physical distancing to stop human to human transmission. The rationality behind lockdown is to reduce the basic reproduction number (R0) of SARS-CoV-2. 47 This control measure generally is aided with other major control measures, chiefly case testing, followed by case isolation, contact tracing and quarantine. But South Asian countries are under severe criticism for low rate of testing and eventually being unsuccessful in active case finding. 48 In policy implications, South Asia may have missed the opportunity given by the lockdown window at the cost of economic impediment.

This technical error occurred because the mathematical models-derived estimated number has been given more priority than epidemiological projection in the planning of imposing lockdown. Hence, from the technical perspective operative function (physical distancing to reduce R0) has become lockdown"s sole objective in order to achieve "flatten the curve" outcome. As a result, the epidemic management has ignored lockdown"s strategic goal, i.e. contain the infection within a geographical area and accordingly make it infection freesuccinctly a disease containment strategy in a given geographical boundary. This needs quick spotting of outbreak sites and rapid action of micro-management operations in hotspots. For instance, a modelling study in Wuhan, China suggests that active surveillance, contact tracing, quarantine, and early measures of stringent social distancing could be effective to stopping or slow down the virus transmission. 49 The graph (and thereafter the table) below from all the South Asian countries reveals that strict lockdown has definitely curbed the growth of infection, but failed to reverse the growth trend.

South Asian countries, except the Maldives (where lockdown was circumscribed for capital Male and adjacent peri-urban areas only), went into lockdown mode between 19 March and 1 April 46,54-55 . The lockdown continued with varied degree of movement control in all these countries more or less till the May end. 101 From June first week onwards, South Asian countries (except Nepal) have been slowly unlocking themselves to gradually move out of lockdown condition.

( Figure 1 ) (Table 1) The lockdown was unable to arrest the exponential growth of fortnightly new COVID-19 cases as shown in the above graph especially for Afghanistan, Bangladesh, India and Pakistan wherein the case load is mostly concentrated. The doubling time for new cases was close to a fortnight for all these four countries during the lockdown period from March 21 to May 29, 2020 . For example, in India where the maximum number of cases was, the fortnightly number of new COVID-19 cases has got leapfrogged from fortnight-2 (12,077) to fortnight-3 (22,958) to fortnight-4 (48, 154) to fortnight-5 (88, 273) . On the other side, Bhutan, the Maldives, and Sri Lanka appeared to avert the exponential growth from the beginning only. These three small countries have been limiting the individual case load to a satisfactory level for last three months. In contrary, Nepal being a small country did not succeed in containing the infection. Nepal has been witnessing the spike in COVID-19 cases since fortnight five (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) onwards, when the other countries were in the process to ease their lockdown restrictions in order to restart economy.

The lockdown was initially beneficial for all the eight countries. Afghanistan, Bangladesh, India and Pakistan have managed to seize the initial spike in the number of fortnightly new cases. Thus the spike between fornight-2 (22,958) and fornight-3 (48, 154) was not as high as it was between fornight-1 (2,018) and fornight-2 (12077) for India. The similar pattern was observed for Pakistan. Afghanistan and Bangladesh also had the parallel trajectory, though they have started regulating the spike from fortnight three onwards instead of fortnight two. But overall these four countries were unremittingly adding sizeable number of new cases. This means during the period of lockdown, either within these countries new areas were getting affected from where the new cases were coming up (that essentially means failure of governance), or the same affected areas are reporting more number of weekly cases (that necessarily means failure of operation strategy). At the time of lockdown, the first proposition in general does not hold much merit, except sporadic cases in new places owing to lockdown relaxation, due to mobility constraint. For instance, in India, the number of districts reporting any new COVID-19 case decreased from 356 on April 15, 2020 to 216 on May 8, 2020 , whereas total number of infected cases got increased. 56 The post-lockdown scenario of unlock period from May 30 to June 26, 2020 projects a complex picture. The ease of lockdown has not so far adversely impacted the growth of COVID-19 cases in the four most affected countries (Afghanistan, Bangladesh, India and Pakistan). For these four countries, the number of fortnightly cases did continue to rise in the month of June, but far from the signpost from where the case load can be doubled. In fact, Afghanistan has registered a negative growth in the last fortnight of June (9,659 of fortnight-6 to 6,514 of forthnight-7). The smaller countries, except Nepal, remain efficient in keeping the case load low in the unlock period also. Whether it was an enhanced operation strategy or development of community-level immunity or something else resulting into this slower growth of COVID-19 cases in unlock period; it is not possible to derive any analytical conclusion by observing at only last two fortnights" data in the month of Junemore time is required to understand the trend and see the change, if any, in ground-level operational maneuvering. However, from the trajectory (from the beginning of lockdown to the present unlock period) of Afghanistan, Bangladesh, India, Nepal and Pakistan, it is quite evident that lockdown has not been pursued with its strategic goal (disease containment) in order to rapidly sanitize the containment zone (or hotspots) for making it infection free through various control measures.

Countries need to think carefully before going for another long-term nation-wide lockdown. It is really a contested strategy for a region like South Asia where 36.6% of population resides in urban area (which is more exposed to the virus threat because of travel mobility and high population density). 57 The urban spaces in South Asia lack proper housing and accommodation especially for millions of migrant and vulnerable population. 58 For example, Dharavi in Mumbai, India (Asia"s biggest slum) was a hotspot with 214 positive cases and 13 deaths till April 23, 2020. For this place of one million population with a density of 270,000/square KM, depending fully on public community toilets (225) and communal water supply, physical distancing even inside the tiny room is impossible. [59] [60] The same concern is pertinent for densely populated Bangladesh (1240 people/square KM) and the Maldives (1719 people /square KM). 61 Lockdown alone is not a public health solution for COVID-19 outbreak in any thickly populated area/country. Therefore, it is recommended that based on the outbreak reporting, the localized lockdown for fourteen to twenty one days aided with active public health surveillance, adequate testing, case finding, and strict quarantine of the exposed population in hotspot zone should be the outbreak operation structure of control measures in any South Asian country.

This pandemic driven lockdown is rather based on more administrative forewarning than public health rationale to contain COVID-19 as strategic goal. This strategy has two-fold approaches otherwise; arresting the transmission rate to make any defined community disease free, and plan for health system preparedness actions.

Regarding the first approach, the administrative readiness has ensured to reduce the transmission rate but the sheer ignorance to public health has impacted undesirably on the effectiveness of control measures to contain the disease. The second approach is being actively pursued in order to buy time to prepare the health system by deferring the peak (when the need for medical support will be highest due to abysmal growth of infection rate) away by few weeks. This is especially relevant for the three most populated countries of South Asia (Bangladesh, India and Pakistan). The primary observation indicates while both disease containment strategy and health system preparedness actions are clearly public health responsibilities, the resource allocation remains at the disposal of governance decisions. So South Asian countries (in fact many other countries in different parts of the world), on one side, has deployed bargained resources (testing, contact tracing, and quarantine centers for isolation) to contain the disease. On the other side, they are struggling to speed up health system preparedness arrangements (hospital beds, ICU facilities including ventilators, quarantine facilities, searching for stop-gap standard treatment protocol etcetera) likewise to delay surge in health care system.

Lockdown is a few of the rarest conditional situation where both disease containment and planning for disease mitigation could go hand-in-hand. It is obvious that resource crunch condition pushes most of the South Asian countries to be stuck in between the choices of prioritizing disease containment or mitigation action. Testing as control measures could contain as well as mitigate the disease since it is primarily a case finding mechanism. Testing is extremely low in most of the South Asian countries, except Bhutan, Nepal and the Maldives. 48, 62 The cost of testing, and its operation mostly through public provisioning are the main reasons behind the governments" restricted testing practice. 63 In addition, COVID-19 confirmatory testing (reverse transcription polymerase chain reaction/RT-PCR) needs skilled human resource, technologically advanced laboratory set-up and accessible collection-cum-testing center, which is altogether definitely a challenging combination for most of the South Asian countries.

South Asian experience indeed reveals the exercise of test rationing in COVID-19

control. The stringent testing guidelines imposed by many governments are restricting access to testing for risk exposed population. For example, the Indian Council of Medical Research (ICMR), India"s apex health research institute, until 9 April 2020 limited testing only to individuals with symptoms coming from abroad, symptomatic medical care worker, facility reported Severe Acute Respiratory Infection (SARI) patients and close contacts of COVID-19 laboratory confirmed cases. 64 This strategy in effect discounts all the suspected Influenza-like Illness (ILI) persons without any foreign travel or positive COVID-19 contact history from testing. Hence, institutionally testing is strategized as an exclusive control measure.

At the same point of time, it is also required to recognize that calling for mass testing, may not be justifiable in the current public health situation. At the stage of local transmission and spread, testing coverage should be based on the principle of population risk assessment that builds on the strategy of access to geographical mobility of any defined population. In that order, in general urban population compared to peri-urban or peri-urban compared to rural population is more at risk because of the greater chance of mobility with the already exposed population.

Similarly, the highly dense population in urban slum in comparison to the gated community in high-rise building is more vulnerable. Hence, the epidemic preparedness should identify the high risk zones of possible outbreak in advance along with the list of existing hotspots in order to test all the clinically and the socially suspect cases.

There is a need also to develop a national testing policy instead of testing guidelines so that all the states/provinces should prepare their own epidemic preparedness profile to geographically assess the population risk and strictly comply with the rational testing practice with all laboratory reported and/or referred cases. Furthermore, the South Asia region needs to explore and prioritise the option of using rapid kit testing as high as possible. This is a much negotiated resource compared to the RT-PCR, and could be a primary mode of diagnosis alternative for asymptomatic or moderately symptomatic individuals. This effort could also lower the transmission and the death risks in the community. The tactical use of rapid testing may help in community surveillance on both the occasions of suspect case detection (through Immunoglobulin M, IgM) and reviewing immunity coverage (through Immunoglobulin G, IgG).

Contact tracing is another mandated control measure. Across the world, the COVID-19 laboratory confirmed positive cases are mandatorily followed up with contact tracing and accordingly testing (as per the symptoms, if needed), case isolation and/or quarantine. Unless tested positive, the traced contacts should be in quarantine for a fortnight. 65 For South Asian countries, the challenge is tracing the contacts given the high mobility and density of the population. It is also not known what is the standard R0 (basic reproduction number of a laboratory confirmed cases) in South Asian countries. In China (from Wuhan to various parts of Hubei province and China), the estimated R0 for the COVID-19 outbreak was 2 -2.5/2.5. 66 A computer simulation exercise estimated that 70% of contacts need to be traced for an R0 of 2.5, similarly 90% of contacts to be traced in case of R0 of 3.5 to avoid any major outbreak. 67 At any circumstances, even close to these percentages are near impossible to achieve for Bangladesh, India or Pakistan like countries. Hence, contact tracing (in the conventional practice, using human as tracer) should be a tactical resource in the context of South Asia. It should be used heavily at the time of sporadic transmission in any geographical area. Likewise, it is not very much advisable to use the resource for contact tracing in the situation of random transmission in major outbreak sites.

Apart from the conventional form of contact tracing, the technology induced app-based surveillance is another tool to trace contacts as well as avoid large scale lockdown as followed in South Korea and Singapore. 68 But the average percent of population using internet is 32% in South Asia, and the figure is about 22% for the three top populated countries (as per 2017 data). 69 Thus it seems to be a doubtful experiment post the lockdown in South Asia where access to smart phone, internet availability, and internet literacy are appallingly low. Similarly, the tool of contact tracing in this region does not rise above the doubt of purported breach in individual privacy given the behavior of current political dispensations in the region at large. 70 However, it should not be discarded either because the 22% internet access population is otherwise assumed to be the most mobile population especially in urban context, and thus likely to be fallen under the broader risk category. Hence, this can be an additional tracing tool provided there are parliament enacted legal safeguard for data protection as well as information security guarantee and fully government run operational framework for data decentralization of mobile-app traced information (against the centralization of data in one server) at the micro-level in COVID-19 surveillance. 71 Irrespective of human or intelligence dependent tracing, the method for contact tracing should not be based on risk exposure assessment of the contacts alone. The categorization as well as demarcation of high risk (primary) and low risk (secondary) contacts does not worth much significance in South Asia because of contextual dynamics. Hence, it is advisable to use contact tracing as a method of overall risk minimization tactic for the contact"s own community in order to crossover to risk communication measure. It is of no use if contact tracing construes only as an act of tracing contacts for the purpose of quarantine or testing. In a densely populated area, the contact tracing should be a combination of follow-up with the contacts and deploy effective communication and social mobilization techniques to stop spreading panic, false information, and pervasive stigma attached to the disease. This particular method was successfully used in Ebola response in Nigeria. 72 

The South Asian countries need to develop context specific risk communication module for social mobilization of community involvement to not only isolate the contacts but also sensitize the immediate community of the contacts in any defined geography or space (per say, work place). This approach of contact tracing shall help not only to sensitize the concerned community about its perceived risk due to the prior exposure to contact/s but also encourage the community members to self-assess their risk and report voluntarily, if need be.

The risk communication independently is also prevention and control measure in the pandemic as it helps the community to willingly participate in the outbreak management. The foremost requirement is to develop communication strategies based on the models of perception behavior attuned to the need of individual community.

Communication strategies should not only educate the public about the available preventive measures, but also direct the public to the reliable information sources. For example, drinking of cow urine as a preventive measure was initially promoted by some politico-religious groups in India. 103 Thus effective and context specific communication strategies could bring positive outcomes for adhering to public health etiquettes and hygiene practices, and prevent the spread of misbelieves among the public.

The other part is management of information. Both misinformation (deduce wrong conclusion from lack of information) and disinformation (intentionally constructed fib to push an agenda) are dangerous at the time of emergency. It is found from the analysis of Wuhan outbreak management that openness and access to information should be the guiding light to device strategy and content involving the network of government-expert-public collaboration with shared accountability that communicates risk. 73 The countries need to urgently adopt the policy of COVID-19 information campaign embodying in the principles of transparency, reliability, trust and collaboration for timely and effective risk communication continuum.

From the onset of COVID-19 pandemic, the South Asian countries like the rest of the world have been heavily depending on NPIs. In policy terms, NPIs can be used either for suppression (strict prohibition on population movement indefinitely to halt the infection transmission fully and keep the case load extremely low) or mitigation (restricted movement of population to slow infection transmission and evade health care surge while protecting the most vulnerable from the disease) of disease. 47 The organization of NPIs in South Asia, by and large, has been adopted the policy of suppression by spear-heading stern lockdown to combat the COVID-19. Under this policy, the method of cordon sanitaire is applied to geographically quarantine the population and contain the disease. 74 But then again, this method is unwarrantedly applied to the entire geographical nation-state territory, and without giving much importance to public health planning and ensure optimal use of control resources. in this strategy. The national case containment strategy is necessary in this regard to develop a country-wide public awareness campaign. This would include a procedural guideline for the containment of case, individual"s role in preventing the transmission, and the structure of incentivizing the community in order to mobilize the entire country. However, it also to be kept in mind that country or state with less population density (Bhutan or Arunachal Pradesh in India) may not need the case containment strategy. [78] [79] The existing disease containment strategy with the adoption of mitigation policy might be more prudent to maintain the low case load in such context.

Followed by the case (or the context-specific disease) containment strategy, the control intervention instantaneously steps in from epidemiological to clinical aspect of disease. COVID-19 as a respiratory disease can be managed in three different set-ups as per the clinical status (mild/moderate, severe and acute) of the cases.

According to the WHO, the case load is more in mild/moderate pneumonia-like uncomplicated illnesses (81%), whereas admission to hospital (along with oxygen support) and intensive care unit are required only for about 14% severe pneumonia and 5% acute respiratory disease syndrome (5%) cases, respectively. 80 Hence, the countries need to emphasize on early detection of cases for early quarantine either at home or government facilitated center to save hospital reserve as a tactic. Similarly, aged and individuals with the history of comorbidity might be given mandatory hospital coverage to protect the most vulnerable, in principle.

In the process of case management measure, the preparedness of health system or in specific the capacity of health care system is ideally to be tested as a part of response management mechanism in the overall epidemic preparedness. The upgradation of health care system is a resource (capital intensive) demanding process.

Thus, South Asian countries should give more emphasis on the epidemiological management of population instead of the clinical management of cases by strategically putting more thrust on prevention and control measures.

Response management is a part of overall epidemic control. In outbreaks the observed number of cases is far greater than expected at any particular point of time.

In the course of pandemic, outbreaks may occur at any time and at any place. The 1918 Influenza pandemic had occurred in three distinct waves over a period of about twelve months. 81 The outbreak control during the pandemic needs a rapid response once it is detected and confirmed by the epidemic intelligence unit. Thus, the development of response management mechanism at the onset of this pandemic is a necessity to mobilize, reserve, manage and coordinate the resources when in need.

The status of selective health system indicators in the table below in regards to COVID-19 epidemic preparedness shows that region is in special need of response management mechanism at the earliest.

( Table 2) The overall resource allocation for national governments on health is below 1% of GDP for three most populated countries (Bangladesh, India and Pakistan). The availability of bed per thousand populations is not even exceeding ten, except for Bhutan, which exhibits the challenge in access to inpatient services. The out-of-pocket share dominates the burden of health care expenditure at the cost of more non-public dependent service and the misery of poor people to afford health care need. The situation of Bhutan and the Maldives are much better than others, but so that they are not comparable anyway because of population size and other contextual differences. Considering the exhausted status of South Asia"s key health system indicators, it is implicit that health system preparedness in terms of expanding health care infrastructure (hospital bed, ventilator etcetera) and resource surplus status of emergency aids (skilled human resource, Personal Protective Equipment/PPE, masks, testing kits and others) is a difficult task.

In these circumstances, the mechanism for response management needs an approach of governance maximization instead of focusing only at resource maximization. For instance, South Asian countries have extremely low representation of above 65 age group in the overall population pyramid, which is a comparative advantage for the region to keep the mortality low as aged persons are the most COVID-19 vulnerable. Hence, policy actions and their proper implementation to protect the aged population (and also persons with comorbidity) in the course of pandemic will be more beneficial instead of leaving them socially unprotected and thereafter striving for more ventilators to cater to their medical need. This framework of response management needs governance coordination (between local, state and national governments), collaboration (between national and international levels) and cooperation (within international/regional organizations and international actors with the countries).

The figure below depicts the framework of response management where community is fundamental to the entire scheme. The governance of local body needs to engage with the community in order to operate the model of participatory governance management in COVID-19 response. Similarly, the layered response from the state and the national governments is also needed to implement and plan, respectively, the governances" response. The outer-most circle is exhibiting the collaborative obligation of international actors with the countries to help in the designing of response strategy in terms of planning and resource organization.

( Figure 2) 

The local body, urban and rural governance system, is the operative arm of response management. The Kerala state of India is a good example in this case. The state"s response to mitigate the effect of COVID-19 has been so far a great success. 84 The community has been the frontrunner in Kerala to complement government"s various social security and grass-root surveillance initiatives. 85 The participatory governance should be the principle for promoting or helping in the control measures.

The containment strategy has already deliberated the importance of the community involvement in case finding and risk communication. The CCDs should be the "agent of change" in this entire response mechanism. The local governance must align with civic bodies, self-help groups and social institutions for information campaign and local-area management (such as, social gathering in market place/event, usage of community toilet etcetera). Similarly, the resource sharing of vector monitoring/control (of Malaria/Dengue control program) team in surveillance and risk communication measures is also essential.

At this level of governance, it is the implementation point for response management. The entire macro-management of COVID-19 response is at the realm of state-level governance. The effort of health care system preparedness is also mostly occurring at this level. In this regard, not only the medical facility expansion or demarcation but also arrangement of large-scale quarantine centers is desirable. The role of private care facilities is decisive in this trying time because of its strength and capacity in service provisions. However, in the case of India the private sector is found to be driven by more business interest than lending the support to the government for fighting the common cause. 86 The state governments in consultation with the union government need to set a special policy guideline to utilize the private sector in service provision. Private sector cannot be left alone to decide its own role in care and support treatment during a time of national emergency. Similarly, the state governments also need to develop district-wise profile of epidemic planning that includes the estimated capacity of health care system at the time of peak.

The governance needs to perform in two-fold scheme; emergency response management and regular administrative management should go hand-in-hand. As a result, the inter-departmental coordination both at ministerial heights and administrative ranks needs to be in place. The decentralized orientation of governance at least in response management is required to follow in principle, otherwise the community led participatory governance shall remain a policy component. The state governments shall be playing the most important role in overall governance coordination to work with local as well as national governments. State shall not be limited to only implement the decisions taken by the national government, rather must take the lead in formulating and modifying the national response management plan by analyzing the experiences encountered by local governance.

The national response management should be the mechanism for policy, planning and technical coordination. Over the course of pandemic, any hindrance either in medical or economic need is debilitating for an already depleted populations" health.

The denial of health care services for non-COVID-19 patients or the plight of migrant laborers (economically one of the most vulnerable category) to avail welfare benefits are not anyway less demanding than controlling COVID-19 in South Asia. [87] [88] Thus the response management should be mechanized with an aim to remould the governance to address both technical as well as humanitarian challenges posed by the pandemic. The technical amendment of operative framework of national health programs in order to develop a minimum convergence approach in the program implementation of COVID-19 intervention is a priority to aspire for zero interruption in regular health service operation. Correspondingly, a carefully crafted pro-poor relief package to address the need of financial, nutrition and other social security needs should be a constant deliverable from the national governments.

The role of the national governments needs to assist, and not guide, the state governments in implementing response management. The coordination with state units to draft policy proposals, assess epidemiological projection, amend technical guidelines, analyze financial cost imperatives for resource generation are few of the steps in this direction. It is unlikely that state or divisional units would be in a long-term position to allocate or generate adequate additional resource for the expansion of health care system or safeguarding the interest of humanitarian causes.

The time is ripe to go beyond fiscal space management conditionality and instead create space to source fund for resource investment (from testing kits to medical care infrastructure) and relief measures. The collaboration with international actors is another task for the national governments to pull in financial (or material) resources and develop technical expertise. One such collaborative example could be to create positive environment for science and invention. India and Bangladesh have already shown good progress in mapping genetic evaluation and understanding rates of substitution (mutation of virus) of the SARS-CoV-2 virus. [89] [90] This would not only help the respective countries but also add value to the work going on all over the world for drug and vaccine research.

The governance at the international level for supporting the cause of South Asia shall be a testing period for global health. It depends on the cooperation of international actors within themselves and between South Asian countries. While the one side of governance needs to address the technical capacity building areas to control the outbreaks, the other side must deal with the economic impediments looming around the region. The technical form of governance cooperation from the WHO or other bilateral or multilateral partners may not be a cumbrous challenge.

These need the assistance for countries on knowledge support (such as, in doing epidemiological projection), intervention design, research operation, training management etcetera.

The slowdown in the global economy due to pandemic and oil price fluctuation shall be more onerous challenge for the region"s trade and economy, and also in remittance inflow. 91 The international governance should support the South Asian countries from these forthcoming distresses by creating space for debt relief, interest free loan or loan without conditions measures. In terms of political stability, the pandemic threat is likely to worsen the situation of stateless Rohingya refugee crisis in Bangladesh. 92 The similar concern is for the war-tone Afghanistan also on how to manage COVID-19 especially with other existing health service operation shortcomings. 93 Both the economic challenges and the political tensions shall amplify the humanitarian emergency condition in the region. The international governance must address this complexity while dealing with the pandemic in South Asia.

Similarly, the international governance also needs to function in a unified approach to uphold the spirit of global solidarity. The suspension of funding to the WHO announced on the 15 April 2020 by the United States of America is a dithering move to derail the global fight against the pandemic. 94 Global solidarity campaigns like the People"s Health Movement reminds that the leadership of the WHO at present is most needed not only to steer the global health community but also to help the countries, especially from low-income category, to impart technical guidance and supply emergency medical aids. 95 The member states should resolve the crisis at the earliest in order to strengthen the WHO for more effective international governance and to promote multilateralism in COVID-19 combat.

Economically backward region like South Asia must exercise the channel of diplomacy to rally support behind multilateralism. This would also be more prudent for developing a global access agreement on vaccine based on the spirit of equality. Thus the regional level consolidation to fight the pandemic is very much important.

The South Asian Association for Regional Cooperation (SAARC) has already taken a commendable step on this path by establishing an emergency fund of $18.8 million for the association's eight member countries to fight against the COVID-19. 96 

Based on situation analysis, this study assessed and raised population-level public health measures to combat COVID-19 under the special socio-economic context of South Asian region. Due to inadequate public investment in health system, South Asian region has relatively scarce health care resources. Poverty-inequality and fragile health system condition aggravated medical pressure brought by COVID-19.

Since vaccine was unavailable for now and long-term lockdown program was unaffordable, the socio-economic situation of South Asian region demanded health sectors to find cost-effective plan to combat COVID-19 pandemic with limited budget.

Under the densely populated resource-crunch context of South Asia, COVID-19 action plan should emphasize epidemiological projection, mitigation policy, case containment strategy and four-tier response management. Based on the periodic data collection on both bio-social and bio-medical conditions of COVID-19 cases, context-specific epidemiological projection can be constructed to assess the situation and predict the future scenario. Mitigation policy guidance, case containment strategy and need-based clinical management should be in correspondence with prevention and control measures including screening, lockdown, adequate testing for risk exposed population, contact tracing in sporadic transmission areas, and context-specific risk communication for social mobilization. Response management needs an approach of governance maximization to cope with scarce overall resource allocation, featured by in-depth governance coordination, collaboration and cooperation.

One major limitation of this study is lacking data resource. In South Asia where urban-rural disparity and intra-country regional or inter-state deprivation were common, the forecasting models are usually good for state-level or provincial management of epidemic preparedness. It would be an advantage to go for context specific local models in order to have fewer assumptions and be mindful of local behaviors. However, this study had little access to timely updated population-level data in each country so that WHO data on country level was adopted.

The pandemic may be new for the world in last hundred years, but certainly not for the South Asian countries. The region has a long history of cohabitation with a number of infectious diseases. Many of them have become endemic over the years. SARS-CoV-2 is a noble virus and thus its infectivity and initial fatality are comparatively higher. The prevention and control measures need to strike a chord between health of the population and economy of the nation. At present, neither one is safe until a miraculous medical intervention appears. Conversely, population achieving herd immunity on its own is still scientifically and practically a doubtful time and risk consuming project. 97 The South Asian region should epitomize the model of governance that is always prepared, planned and ready to suppress any outbreak. This alertness needs active participation of community in the process of governance response to avert any risk at the earliest. The epidemiological management of the population with the adoption of mitigation policy to ensure highest safety of individual and assurance of minimal disruption in economy at the cost of lowest possible risk is the way out to combat the pandemic in South Asia.

This paper was supported by the National Natural Science Foundation of China (No.

AS, XZ and GL participated in conception of the research ideas, study design, interpretation of the findings. AS wrote the first draft of the manuscript. YJ and ZZ made critical revisions on the manuscript and provided implications of the study findings. All the authors gave final approval of the version to be published.

The co-authors wish to dedicate this paper in memory of Prof. Zheng Xie, who passed away on June 4, 2020. Professor Xie conceived the idea and helped develop the manuscript. Her passion and dedications to global health will solely be missed by her colleagues and friends. Amitabha Sarkar is a China-India Visiting Scholar for the year of 2020-2021 in the Department of Global Health, Peking University School of Public Health.

The paper had consulted all the secondary resources till 15 May 2020, except the data related to total number of COVID-19 cases and deaths in South Asia for which the time-frame of 27 June 2020 has been considered. This excess time has been considered to see the post-lockdown trend also in the analysis while reviewing the paper based on editors' comments. 

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