How Kerala rose to the occasion to contain coronavirus cases in this high-risk district

On March 11, Pathanamthitta, a migration hotspot in Southeastern Kerala, became the district with the highest number of cases in the state. Among the districts with lowest poverty rates in the state in India, it had nine cases, all linked to foreign travellers and their primary contacts.

Most of those who were infected had travelled widely across the district before they were diagnosed with the infection, it was later found. This, along with the fact that the virus’ reproductive number –the number of secondary infections generated from one infected individual – is 2-2.5 persons, had led to fears that the district was looking at an unmanageable contagion.

But over nearly two weeks to March 23, the district managed to limit the cases to 10. On March 29, it had a total of 12 cases. Kasaragod, in North Kerala, is now the district reporting the maximum cases, mostly Gulf returnees and their contacts.

How did Pathanamthitta manage to minimise the transmission of the virus and ensure adherence to rules of quarantine among its residents? Rigorous and unrelenting surveillance by the district control team was the solution, we found, as we travelled to the district to understand how a team of doctors, medical and field staff, and officials worked through days and nights to track the virus’ journey.

Through contact tracing, the team was able to track nearly 98% of all primary and secondary contacts, who have been advised home- or hospital-isolation, district collector PB Nooh told IndiaSpend.

The first cases

It was 2 am on March 8, the day after the first set of diagnoses, when an extraordinary video conference was held at the collectorate between the collector, the district surveillance officer and the state health secretary. There was a reason for the panic: When swabs had been taken from a family of five for diagnosis, no one had expected every one of them to test positive.

“We were so taken aback that most of the team [was] here by 7 am the next morning. There was no time to lose,” said AL Sheeja, the district medical officer in charge of coordinating the efforts at the district level.

By 7 am on March 8, calls were already going out to doctors, medical staff, drivers and vehicles to gather by 8 am at the collectorate so that 10 teams could trace the travel history of the patients. Every contact of the infected family that had returned from Italy was to be traced from the time it landed in India on February 29, to the time of its isolation.

From then on, how the team worked on surveillance, gathering travel history, contact tracing, and ensuring quarantine by providing essential and psychological support offers an insight into how the district managed to control the spread of the virus. Today, the team spends much of its time following up on primary and secondary contacts of the first few patients, keeping a watch on other travellers and developing software for its data dashboard and ensuring that the essential needs of those in isolation are met. There were more than 4,800 people – foreign travellers, primary and secondary contacts, and healthcare workers – in isolation in the district, according to district data from March 25.

India declared a three-week lockdown on March 24 to contain the spread of SARS-CoV-2 virus which has infected 1,637 and killed 38 in the country, as of April 1.

As of April 1, Kerala had 241 confirmed Covid-19 cases, according to Coronavirus Monitor, a HealthCheck database. Kerala leads the country in testing, having cumulatively tested 4,516 samples, indicating states with higher testing are reporting more cases, IndiaSpend reported on March 25, 2020.

Surveillance war room

The district control cell includes multiple teams – surveillance, call centre, psychological support, training and awareness, community-level volunteers, media monitoring among others.

The din of more than 100 people – doctors, public relations officers, mental health counsellors, and volunteers from engineering colleges – working together in the surveillance war room did not seem to bother Resmi MS, a doctor who specialises in community medicine, and leads the surveillance with a team of 450 people at the district control cell. At the far end of the room, volunteers of an engineering college sit, developing a heat map to visualise the clusters and households under quarantine.

Although surveillance was set up soon after the first case was reported on January 30, it was stepped up after the five cases were confirmed in Pathanamthitta, said Resmi. She has been here every day since, leaving her eight-month-old baby in her parents’ care because her husband, a naval officer, is posted in Mumbai.

On March 8, the teams went to locations visited by the affected family. “We did two things – got their travel history, and got the field teams to visit every location and check as many CCTV footages as possible to ascertain their primary and secondary contacts,” said Resmi.

Although the quarantined family spoke to Nandini CS, the district surveillance officer over the phone about their movements in the days following their return from Italy, it soon became clear that there were many critical gaps in their story. Amjith Rajeevan, also a community medicine expert, then decided to visit them in the isolation ward to protect them.

He walked into the ward, shielded by personal protective equipment, to convince them to share all their contact details. “I told them it was important to contain the spread,” he recalled. Rajeevan then stepped out of the room and got the details down over the phone – inside the ward, pen and paper are not allowed.

The contact tracing team then got to work. They mapped the family’s movements on a flow chart and shared it with the public and found over 1,000 primary and secondary contacts who now needed further monitoring. “We got around 175 calls and established that there were three primary contacts and 42 secondary contacts,” said Resmi.

Calls and follow-up

The activities of the team have been streamlined since the call centre was set up on March 10. Now it routinely calls those in home isolation, including those who returned from abroad and have to be quarantined for 14 to 28 days. Almost all the 76,542 people under surveillance in Kerala are in home quarantine and 532 in isolation facilities, as per March 25, 2020 state government data.

“We started the call centre to monitor and ensure that people were in quarantine,” said Harikrishnan B, 33, a doctor leading the call-centre operations. “If they were not at home, we needed to know why they are not.” He has been in calls and meetings, providing crucial feedback for the daily district report, unable to even visit his pregnant wife, now mother to twins.

The team calls all those in isolation to check on their existing medical conditions, and their medical and non-medical needs. “We realised that people were not following quarantine because they had to step out to get provisions, medicines, livestock fodder, among other essentials,” said Harikrishnan. The surveillance cell began separating medical and non-medical needs and redirected the requirements to the respective primary health centres and panchayats. These essentials were then delivered to the homes of those in isolation.

During these calls, Harikrishnan also filled in an isolation adherence form based on a tool developed at the Government Medical College at Thiruvananthapuram to determine how closely patients and families were following quarantine rules. The call-centre team provides three inputs to the data collated: medical, non-medical, and symptomatics.

Initially, it was observed that very few followed isolation rules strictly. Family members, for example, were sharing utensils, towels and bathrooms, not allowed under home quarantine guidelines. Based on their adherence score, the families were counselled. Within two days, nearly 30% of those in isolation improved their scores and the proportion of those faring badly in the scrutiny fell to fewer than 30%, as per Harikrishnan.

The team calls 40-60 people a day, mostly to counsel those distressed. “We explain why they need to be in isolation,” said Laya Chacko, a district coordinator for accredited social health activists or ASHAs, who works with the call centre team. “Most respond well although a few get upset.”

Multiple teams call them to ask about their well-being, from the call centre and the field ASHAs or health staff.

Priority is given to providing essentials to the elderly, those with comorbidities i.e. other diseases, or households in isolation where members needed palliative care. Among those affected most were families that had to deal with the devastating 2018 floods in the state. There were elements of trial and error in their strategy, admitted Harikrishnan, but the team learned along the way.

The district administration had instructed traders and local delivery services to streamline deliveries. “All these efforts converge,” said Abey Sushan, district programme manager with the National Health Mission.

Ground support

The district has mobilised a 1,000-strong field team of ASHAs, junior public health inspectors and nurses to ensure widespread awareness about the disease and provide ground support. This is in addition to the 450 led by Resmi. The field staff go from home to home, seeking travel details. These home surveillance squads make more than 2,300 home visits in a day, as per data from March 25.

Pathanamthitta district has 920 panchayat and municipality wards with at least one ASHA worker each. Their familiarity with local households makes surveillance easier.

Sini K, an ASHA worker since 11 years in ward 25 of Pathanamthitta municipality, gets tipped off by the district hospital and residents about the need to monitor certain neighbourhoods. As many as 10 persons in her ward have been under surveillance, and one – a Qatar returnee – tested positive.

“We do wear masks and use sanitisers, although both are in short supply, but do not enter their homes, maintaining social distancing,” said Sini. She calls each person in quarantine everyday to enquire about their well-being and reports to the health staff at the general hospital in Pathanamthitta.

Ward sanitation committees, chaired by ward members and convened by a junior health inspector with ASHAs, anganwadi and Kudumbashree workers, have been asked to step up vigil. “Their role is to meet all home-quarantined people at least once in three days,” said Nooh, the district collector. If required, police are called in to enforce isolation compliance.

The emergence of more positive cases has convinced local authorities and health workers of the need to step up the campaign, said Geetha Kumari T, 53, a public health nurse at the district hospital. “We have set up help desks at bus stands and at the hospital,” she said.

The district has also released two exclusive phone numbers which will help people inform the authorities if they find a quarantined individual outdoors.

Mental healthcare

The state government has a district mental health programme in each district across the state. After the 2018 floods, it had offered mental health support through its Pariraksha initiative. These teams are now helping counsel those in quarantine.

There are 22 counsellors from the district mental health programme, 26 from the Integrated Child Development Services counsellors, three psychiatrists, a psychologist, and a psychiatric social worker offering assistance to those affected currently. The team has made thousands of calls to people in quarantine, both at home and in hospitals. On March 25 alone, it made 856 calls and 204 follow-up calls for psychological support, as per the district data accessed by IndiaSpend.

“When we call people in quarantine, we introduce ourselves as mental health professionals, and check if they need support in connection with mental health,” Rashmi A P, 38, district project officer for Pariraksha. “We share our personal numbers and [Direct Intervention System For Health Awareness] is a toll-free number in case of any [urgent] need.”

Rashmi’s day starts with calls to people in hospital isolation. The counsellors escalate to her acute cases of anxiety or stress, which she then forwards to psychiatrists based on her assessment. “There are more stigma-related issues around Covid-19 than anxiety,” she said.

People complain mostly about insomnia, the boredom of isolation and guilt around the infection they may have spread among family and friends, said Sukesh G, a psychiatrist at the Kozhencherry district hospital.

Technology and streamlining

Aswin Mohan, 21, a fourth-year computer science student, is developing a “corona relationship management” software to streamline data collated on a daily basis. This will help the entire surveillance team access one dashboard and not sift through entire worksheets. “Sometimes there is more than one phone number assigned to a household with multiple members in quarantine,” he said, “This will allow us to avoid repeat calls to the family, help us list details together, and ensure that follow up is streamlined.”

He was able to develop the software and carry out a trial run at the call-centre, all within three days to March 18. The software is yet to be opened up to the larger district control team.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.