Prepare or perish - Readiness is the key to reopen for routine eye care

“In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing.”

- Theodore Roosevelt

India seems to have taken the right leadership posture and public health measures at quite the right time to significantly slow down the spread of COVID-19 pandemic and has very quickly learned from the errors in judgment of other countries. The phased approach incorporates several perfectly timed vital steps - 1. Slowing the pandemic, 2. Cautious reopening, and 3. Ensuring long-term protection. We are currently in the phase of slowing the pandemic and are perhaps inching slowly towards the phase of reopening.[1]

Slowing the Pandemic

Slowing the pandemic involved complete country-wide lockdown for 4 weeks to ensure optimal physical distancing, inculcation of personal hygiene practices and the use of face masks, while we built a robust data collection and reporting infrastructure and augmented our diagnostic capacity.[2] Parallelly, health care systems were reinforced with the creation of critical care facilities to specifically treat COVID-19 patients and the procurement of personal protection equipment (PPE).[2] Targeted testing and data analysis ensured the identification of hot spots and an understanding of the local disease transmission pattern and enabled massive contact tracing and quarantine as appropriate.[2] That, coupled with robust surveillance and creation of containment and buffer zones for a deep lockdown, seems to have helped in slowing the doubling time of the disease from about 3 days to about 6 days now.[2] The first phase was not without problems - limited testing capacity, unexpected major hot spots, socioeconomic implications of the lockdown triggering unrest and reverse migration and suboptimal availability of PPE were the major challenges, which have been overcome to the extent possible. The blunted curve seems to have emboldened the Government to allow for a cautious reopening of a few critical sectors, while the general lockdown has been extended until May 3.

Cautious Reopening

A sustained reduction in cases for at least 14 days, hospitals being in the state of readiness to treat all patients requiring hospitalization, capacity to test all the people with COVID-19 symptoms, and contact-tracing and isolation are the trigger factors to slowly pass on to the second phase of calibrated and cautious reopening.[1] Such a transition would need a smart and balanced approach. While physical distancing is maintained, barrier and hygiene measures (maintaining hand hygiene and respiratory etiquette, wearing a face mask in public, regularly disinfecting high-touch surfaces, etc) are sustained, high-contact settings (such as educational institutions, theaters, and shopping malls) remain closed, vulnerable population (>60 years, immunocompromised, etc) are kept home-bound, mass public transportation systems remain restricted, and teleworking continues where feasible, critical sectors and businesses (which are in a state of readiness to open) are allowed to slowly start functioning with limited capacity in Phase 2.[1] As we open up, we have to continue to aggressively control the disease transmission to minimize the risk of lapsing to Phase 1 and look at possible new treatment measures that might give critically ill patients a better chance of survival or prevent many with an early disease from needing hospitalization.[1] Either would be an important win.[1] A vital step at this stage may be to identify those who are immune and therefore no longer vulnerable to infection using widely available, accurate, rapid and low-cost tests. 1 As we better understand the immune response in COVID-19, those who have adequate antibody titers could be issued an Immunity Card and can be drafted to serve in high-risk front lines of the health care and epidemiological surveillance systems.[1]

Recalibrate – Reinforce – Reopen

“Everyone wants to know when this will end. That's not the right question. The right question is: How do we continue?”

- Devi Sridhar

COVID-19 seems to be here to stay. Beyond the pandemic, it is likely to haunt us as an endemic with exacerbations in certain foci and at best be seasonal world-wide. Universal rapid low-cost testing is 6-9 months away, vaccines are at least 12-18 months away, and universal vaccination seems to be an extremely difficult, expensive and distant reality. It is imperative that we make a cautious and calculated timely beginning to reopen and meet the new normal head-on or opt to perish. Indian Journal of Ophthalmology (IJO) has been providing timely guidelines to ophthalmologists to deal with COVID-19.[3] This issue of IJO carries preferred practice guidelines issued by the All India Ophthalmological Society- IJO Expert Committee for the triage of patients, identification of emergencies with a potential threat to vision, eye, and life and the precautions to be taken in handling such patients during the phase of lockdown and beyond[4] and several other useful articles on the treatment of COVID-19, conjunctivitis in the era of COVID-19 and economic implications of COVID-19.[5,6,7,8,9] While only a few eye hospitals continue to triage and care for ophthalmic emergencies, most seem to have completely shut down for the last few weeks. Although the Government of India has permitted all health care facilities to reopen from April 20, personal readiness is the vital key to restart seeing and treating elective patients.

Point-of-entry, waiting room, out-patient clinic, procedure room and operation theater guidelines for the lockdown phase should all be followed meticulously as we reopen.[3,4] Each ophthalmologist should go through these measures and self- assess the readiness. Poor preparedness, suboptimal screening at the point-of-entry and lack of adequate PPE come with a heavy price of having to shut down the hospital for 4 weeks and quarantine each exposed staff (and their contacts) if they were to come into unprotected inadvertent contact with an active COVID-19 patient. In this context, it is suggested that each ophthalmologist studies the Preferred Practice guidelines in detail, has an honest discussion with professional colleagues, hospital staff and administration and makes a personal checklist to self-assess readiness.[4] Our suggested checklist is shown in [Supplementary Table 1] [SUPPORTING:1].[10] Besides, practical local considerations include the ability of the staff to commute, provision of a travel pass to the staff and patients, availability of support services for facility upkeep and maintenance, biomedical waste disposal, medical gas supplies, consumables, and costing exercise to account for the increased expenditure and relatively reduced volume, etc.

Ensure Long-term Protection

Once the systems are in place and are tested and optimized to prevent COVID-19 infection, identify and treat those infected, provide prophylaxis for those exposed, and build population- level immunity, it may be time to lift all physical distancing measures. This process is estimated to take 18-24 months. The COVID-19 pandemic has exposed serious, seemingly ludicrous, and wide gaps in the pandemic preparedness across the countries. We must invest in scientific, public health, medical infrastructure, epidemiological intelligence, and a powerful infectious disease forecast mechanism and rebuild our readiness for the next pandemic.[1]

Endgame

Even an epidemiologically perfect response is unlikely to end this pandemic soon. Ed Yong predicts that there are three possible endgames: one that is very unlikely, one that is extremely dangerous, and one that is very long.[11] The first possibility of worldwide synchronous control of the infection by concerted efforts seems too optimistic.[11] The second possibility is that of herd immunity, which may be relatively quick, but will also come at a terrible cost - extremely high mortality and devastated economies and health care systems.[11] The third scenario involves tacking the outbreaks until a vaccine can be developed and administered worldwide.[11] This seems to be the best option, but also the longest and most expensive. Control of COVID-19 pandemic, therefore, seems to be evolving into a protracted struggle. It is in our interest that we quickly adapt to the new normal. and try to get on with our professional work to the extent possible, safely and effectively.

“We′re in the endgame now. This is the fight of our lives. Whatever it takes.”

from Avengers: Endgame 12