Covid-19: As cases surge in India, most states abandon contact tracing

In the last week of June, a mental health professional and her husband tested positive for Covid-19 in South Delhi. The state’s health department responded promptly. Health workers called within hours to check how they were doing and set up telephonic consultations with doctors almost instantly – the couple had a mild infection and were quarantining themselves at home. Municipality workers also arrived the next day to sanitise the building they lived in.

In the subsequent days, there were more pre-recorded follow-up calls to enquire about their progress and if they needed medical attention.

But in all those calls, full of queries, neither the psychologist nor her husband was once asked whom they may have come in contact with in the previous few days. The woman had conducted mental health workshops for healthcare workers around a week earlier – not too long before she started showing symptoms.

“There were no attempts to do contact tracing,” she recalled. “They didn’t ask us where we had gone, whom we may have met, none of that. In fact, I called my neighbours on my own to tell them that they should get tested as we may have come in contact on the lift or in any of the common areas in the building.”

‘Backbone of containment and surveillance’

India’s Covid-19 containment protocol requires states “to identify contacts as early as possible for preventing spread of further transmission”. The idea is to isolate such people as they could be infected too and possible carriers of the disease.

The protocol laid down by the National Centre of Disease Control states: “ Attempt should be made to identify all household members, social contacts, contacts at work place and contacts in health care settings who have had contact with a confirmed case anytime between two days prior to onset of symptoms and the date of isolation.”

Nutan Mundeja, Delhi’s director general of health services, called contact tracing the “backbone of containment and surveillance”.

“The disease cannot be stopped if you don’t do contact tracing,” she said.

Different cities, same story

Yet, first-hand accounts suggest that rigorous contact tracing seems to have been nearly abandoned in many parts of India as cases surge. Indeed, anecdotal reports indicate that the situation in the national capital is not unique – many states seem to have largely stopped tracing contacts beyond the immediate household members of the patient.

In Mumbai, the worst-affected city in India, the municipal corporation’s spokesperson Daksha Shah said “high-risk direct contacts are being quarantined and tested”.

“It is very clear-cut in the guidelines,” she said.

In reality, though, the National Centre of Disease Control guidelines, state that “equal emphasis must be given for low risk contacts as they are potential source for transmitting the disease”.

“Low Risk Contacts do not mean NO RISK contact,” the guidelines note.In Guwahati too, which has seen a sharp rise in cases in the last couple of weeks, the local administration seems to have restricted contact tracing to immediate high-risk contacts.

Last week, when an Assam government employee tested positive in an antigen test on June 6, his wife and daughter were tested for the virus, but there have been no attempts so far to trace any more people he may have come in touch with the person. “No one has asked us anything,” said the person’s wife. He had been regularly going to work, his wife said.

Similarly, in Hyderabad, when an employee of a leading health non-profit tested positive, all that followed was the sanitisation of the office premises. “She had been coming to the office every day and all of us shared a compact air-conditioned sitting space,” said one of her colleagues. “If there was any contact tracing program, we should have all been tested ideally, but we were just asked to report back to office after a day.”

Similar accounts have been reported in city after city across India – from Mumbai to Kolkata to Chennai – even as the number of tests and confirmed cases continues to steadily rise in the country, courtesy relaxations in the testing criteria.

Concerned government and experts

Experts say this is a dangerous trend. “This needs to be looked into seriously because unless you are tracing contacts of cases and quarantining them, you are not actually breaking the chain of infection,” said DCS Reddy, who heads the research group on epidemiology and surveillance constituted by the Indian government’s National Task Force for Covid-19.

The government also seems to have taken note. On June 7, the Union Ministry of Health and Family Welfare wrote to states and Union Territories asking them to ensure that thecontacts of at least 80% of new cases are traced and quarantined within 72 hours of confirmation of infection.

‘Not possible to trace every contact’

States, for their part, say they are doing as much as they can. “There are very strict orders from us to do it,” said Mundeja. “And our ground workers are keeping good records.”

Mundeja, however, conceded that it was “not possible to trace every contact” as the patient may not be in a state to provide information or may be unwilling to. “But when you know that someone you have met is positive, it is your moral responsibility to quarantine yourself for 14 days,” said the official. “We can only beat the disease with community participation.”

T Jacob John, one of India’s leading virologists and emeritus professor at Vellore’s Christian Medical College, tended to agree about public participation. “The government may not admit it, but we are in the middle of community transmission,” he said. “There are just too many cases to trace all of their contacts.”

State officials admit as much in private. “When there was one patient with 50 contacts, you could do rigorous contact tracing,” said a senior health official from Assam. “When there are 100 patients with 50 contacts, it is not possible as number of contacts are too many. ”

Assam tried engaging medical students in Guwahati to do trace contacts, but the arrangement turned out to be short-lived. “As cases rose, we had to divert them to Covid Care Centres as a lot of positive patients have been discovered in a short period of time and their management has become more important now,” said the official. “We understand that contact tracing is very important but we don’t have innumerable resources.”

In such circumstances, large-scale community outreach programmes that would teach people what to do when were the states’ best bet, said John. “By this time people should have already been taught that if there’s a case in your neighbourhood they should stay home and call the local authorities asking to be tested if they show symptoms,” he said. “It is all about making people understand that they are the ones who can slow down the virus.”

Mass testing as a substitute to contact tracing?

Several states seem to be attempting to offset the absence of contact tracing with mass testing, taking advantage of the rapid antigen tests that produce results in less than 30 minutes. “We have opened up testing now – everyone can go and get tested in their nearby dispensary from 9 am to 12 noon now,” said Mundeja.

Assam too seems to be employing a similar strategy. Almost anyone can get themselves tested in Guwahati. Besides, the state is also conducting door-to-door antigen testing in areas of high prevalence. “Contact tracing and mass testing are two sides of the same coin,” said Lakshmanan S, who heads the state’s national health mission. “When there are less number of cases, contact tracing is an efficient method, but when there are more number of cases, mass testing is a better way.”

Reddy, however, said mass testing was no substitute to rigorous contact tracing. “States are doing mass testing to present themselves as better performing, but testing without attending to the other requirements is not going to solve the problem,” said Reddy. “Increasing in testing is essential but testing should be done following a particular structure and method. It should be associated with contact tracing.”

Kerala, which achieved great success with its elaborate contact tracing strategy in the early stages of the pandemic, still swears by its benefits. “We are still going after all contacts, primary, secondary, high risk and low risk,” said Amar Fettle, the state’s nodal officer for Covid-19. “We believe it is important to spend time on contact tracing.”

Its detractors have pointed out that the state’s testing numbers are not as high as it used to and several states had a better testing rate. But state officials say such criticism did not perturb them. “Just going on testing people randomly is a waste of time and resources,” said Fettle. “Instead, we would contact-trace and isolate people to break the chain. Breaking the chain is almost like a vaccine.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.