India is failing on a crucial Covid-19 front: Keeping mild cases away from hospitals

In the first week of March, when cases of the novel coronavirus first began to rise in India, Kannur Medical College was designated as one of Kerala’s main treatment centres for the pandemic, admitting all Covid-19 patients from within and around the district.

By the next week, as the infectious virus spread further, Kerala was quick to change its strategy. Kannur Medical College and other major hospitals began admitting only severe coronavirus patients. “In the initial days we admitted and isolated mild cases too, but now they are sent to separate health facilities,” said Dr K Sudeep, the hospital superintendent of the medical college and hospital.

By March 28, Kerala’s health department had issued official guidelines for setting up three different kinds of Covid-19 facilities: Covid care centres for quarantining people entering Kerala from outside, Covid hospitals for severe cases, and Covid firstline treatment centres for mild and moderate cases.

This segregation of milder and more severe Covid-19 patients has been recognised in several countries as crucial to the fight against a disease that has infected more than 16 lakh people around the world and killed nearly one lakh.

Grouping both mild and severe cases in the same hospitals carries the risk of aggravating the condition of the less-severe patients. It also further endangers the hospitals’ health workers, who are already struggling with acute shortages of personal protective equiment. More significantly, it increases the burden on hospitals, whose limited resources would be stretched beyond capacity if they had to also handle patients who could recover in simpler isolation facilities or even at home.

Home isolation and creating special centres for mild and moderate cases is a part of the World Health Organisation’s recommendations for managing coronavirus, since the vast majority of Covid-19 cases are mild. Countries like China, South Korea and Germany acknowledged early on that every coronavirus patient does not need to be hospitalised. In South Korea, the strategic separation of milder cases – along with testing and quarantining thousands of suspected carriers – has played a significant role in slowing down the contagion.

In Germany, those with mild Covid-19 symptoms are expected to quarantine at home, and are monitored through “corona taxis” – vehicles in which medical workers in protective gear drive to patients’ homes five or six days after they get the virus to examine them and recommend hospitalisation only to those whose symptoms have worsened.

But most states in India, other than Kerala, are struggling to enforce this distinction. The country has recorded at least 8,356 Covid-19 infections and 273 deaths till April 12 evening. The Ministry of Health and Family Welfare said 70% of the cases have mild and moderate symptoms.

In guidelines issued on April 7, the ministry acknowledged that such mild and moderate cases do not require hospitalisation. But with many Indians living in small, cramped spaces, home isolation for suspected or confirmed coronavirus patients may not always be possible or wise.

This means states need to create separate isolation facilities for mild cases. But how far have they managed to do that?

No facilities even in hotspots

In Mumbai, where over 1,000 people have been infected and over 1,200 samples are tested every day, the head of a major public hospital was upfront about the tight spot the city has been in so far.

“We are testing suspected cases but it is not possible to quarantine everyone who is waiting for their test reports,” said Dr Mohan Joshi, the dean of Sion Hospital, indicating that many who come for Covid-19 testing are sent home before the results are out.

Between getting tested and waiting for test results, the health ministry’s guidelines state that suspected patients must be kept in isolation. The guidelines also ask states to set up three types of dedicated Covid-19 facilities, each with separate areas for suspected and confirmed cases.

The first type is a “Covid care centre” – makeshift facilities in hotels, schools, hostels or stadiums for mild or very mild cases, with each person given an individual room wherever possible. The second is a “dedicated Covid health centre” for moderate cases – either a hospital or a hospital block – while the third is a “dedicated Covid hospital” for the severe or critical cases.

Many state governments are now requisitioning urban hotels, lodges and several large stadiums to quarantine people while they wait for their test reports. Mumbai’s National Sports Complex of India is being converted into a 300-bed quarantine centre, as is Hyderabad’s Gadchibowli Indoor Stadium and Howrah’s Dumurjala Stadium.

While these converted centres will help isolate suspected patients from their families and residential communities, the health of the quarantined people will also depend on the quality and conditions of the infrastructure provided. So far, there have been multiple reports of Indians escaping quarantine facilities because they were forced to use stained bedsheets in dirty rooms and share clogged toilets with dozens of others.

In Delhi, another major Covid-19 hotspot, most suspected cases are sent to quarantine centres while they wait for their test results. But among confirmed cases, attempts to segregate mild, moderate and severe cases have been minimal so far.

“Right now, all positive patients are being admitted in hospitals, even those who are asymptomatic,” said Dr Manoj Beri from Hindu Rao Hospital, a Covid-19 screening centre where suspected cases are assessed and referred for testing to other hospitals. In the Covid-19 wards of different Delhi hospitals, Beri claims patients are a mix of severe and mild cases and beds are typically placed two metres apart from each other. “This will only change when there are too many cases for the hospitals to handle.”

Missing mild cases

To isolate large numbers of mild and moderate Covid-19 cases, those with mild symptoms must first be tested in large numbers – something that India is yet to do.

“Right now the government’s strategy is to pick up mild and moderate cases only through channels of contact tracing, but these cases are not part of their general outreach,” said T Sundararaman, the former executive director of the National Health Systems Resource Centre, an advisory body to the health ministry. In Tamil Nadu, Rajasthan and other states, Sundararaman claims that people with mild or moderate symptoms are often given paracetamol and sent home. “The testing is done only when the symptoms become severe.”

The health ministry’s guidelines recommend setting up “fever clinics” as separate spaces in hospitals or community health centres to identify suspected cases, assess them for severity and refer them for testing to one of the three types of facilities.

While urban screening centres are better equipped to test larger numbers of suspected patients, a doctor at a primary health centre in Maharashtra sheds light on the practical problems that rural health workers face when it comes to screening and isolating mild cases.

“As per government guidelines, we are supposed to set up a fever clinic for a few hours every morning, and have an isolation ward for suspected patients to stay in before they are sent to Pune for testing,” said Dr Rajendra Mohite, the doctor from primary health clinic in Pune district’s Khed block. “But we have only one small building with one entrance and one toilet, so how can we create an isolation ward to separate suspected Covid patients from other regular patients?”

Similarly, the clinic has just one doctor’s chamber for consultations with patients, which doubles up as a “fever clinic” from 8 am to 11 am. “But villagers still come for check-ups whenever they get time during the day, so it does not make a difference,” said Mohite.

Almost half the people who showed up at the Khed clinic exhibited mild Covid-19 symptoms, and almost all of them were sent home with routine medications to manage them. This is because until April 12, India’s official testing strategy did not extend to patients with mild symptoms but without travel and contact history.

So far, Mohite’s team has referred two people to Pune for Covid-19 tests. To transport them, the PHC had to call for ambulances through the government’s 108 helpline service. “With two cases it was fine, but when cases increase, we will not have enough ambulances and no place to isolate people.”

Mohite is certain he will have to send many more suspected cases for testing very soon, and his prediction is based on grim calculations. In the days immediately after the central government announced a nationwide lockdown to contain coronavirus, hundreds of migrant workers from Pune and Mumbai returned to their villages in Khed block. “Even now, despite government claims that migrants are being kept in quarantine shelters, 100-150 people return to the taluka every day,” said Mohite.

As the number of people showing up at the clinic for screening increases, the doctor is also scared for his staff, who are forced to examine patients without any personal protective gear. “We have been provided with some masks, which are not even proper N-95 masks, and we have been instructed not to wear them till the number of cases increases. So what is the point?”