COVID-19: Number of infected on the rise, but are their contacts being traced?

A critical step in containing coronavirus is contact tracing -- identifying anyone who came in contact with an infected person, quarantining and monitoring them. But across Indian states, there seem to be significant discrepancies in the way this is being done.

The whole country is in lockdown in the hope of containing coronavirus. But as WHO has warned, lockdowns alone aren’t enough to tackle the pandemic. A critical step in containing coronavirus is contact tracing — identifying anyone who came in contact with an infected person, quarantining and monitoring them. But in many of our cities, particularly in north India, contact tracing has been poor or even non-existent. Besides, there’s been large scale and blatant violations of the Central guidelines on mandatory quarantine of those who have returned from abroad.

The worst offender is perhaps Bhopal, which doesn’t seem to have any strict measures for quarantining even the primary contacts of the infected person. Primary contacts are those who had been in direct contact with the infected person, whereas secondary contacts are those who came in contact with the primary contact. But forget advanced measures like contact tracing, many cities didn’t even track international and domestic travellers, and didn’t enforce quarantine strictly.

Bhopal does not enforce quarantine even for known contacts

Take the case of a young woman in Bhopal who tested positive on March 25th. She had returned from London a few days ago, but had not been placed under quarantine. On reaching Bhopal, she stayed with her father, a journalist, who then attended a press conference addressed by ex-Chief Minister Kamal Nath. He came in close contact with about a 100 other journalists at the conference.

After the woman tested positive, the administration asked her father – the primary contact – and others at the conference – secondary contacts – to be in self-quarantine. But none of them, including the ex-CM, have been in quarantine or have got tested. As of March 25th, Madhya Pradesh had 25 coronavirus cases. Given the recent political churning in the state, citizens have been simply asked to voluntarily quarantine themselves, and to report if they show symptoms.

Tracking of foreign travellers delayed in Himachal and Punjab

International travellers to Himachal Pradesh and Punjab usually come via the Indira Gandhi International Airport, Delhi. This means, officials in these states are not directly involved with screening or collecting the details of passengers. And though both states announced that international travellers had to report themselves, this hardly happened.

Passengers at Delhi airport are screened and advised quarantine, which the states have to enforce. But the Centre’s list of travellers reached the states much later. Local officials in Punjab say that the data was delayed by at least a week. For example, information on the arrival of priest Baldev Singh – who died due to Corona infection and had passed on the infection to several others – reached the administration on March 13th, a week after he arrived at his village.

Punjab Chief Minister Captain Amarinder Singh has acknowledged that 94,000 individuals had come from abroad in the last one month. But as of Wednesday, the state has placed only 48,000 of them in home quarantine, and was aggressively trying to track down others. ASHA, ANM or anganwadi workers had been entrusted with tracking these individuals earlier, but they were ill-equipped for this.

“Even if some people are left out, they will themselves come to the hospitals sooner or later as they develop the symptoms,” said Punjab Health Minister Balbir Singh Sidhu. But given that over half of coronavirus-infected people tend to be asymptomatic in the early days, they could transmit the disease to several other people before they are diagnosed.

A health official in Punjab says, on condition of anonymity, that contact tracing is done by collecting information from the patient and his relatives, by checking his phone history, and through CCTV footage if required. In the case of Baldev Singh, around 100 primary contacts, and 500 secondary contacts, have been identified, says Sidhu. This is considered quite a low number, considering Singh had organised two congregations, travelled across three districts, and attended the Hola Mohalla festival where 15-20 lakh people were present.

Himachal Pradesh has had only three cases overall, of whom one person Tenzin died. State health authorities and police are now tracking the persons that Tenzin may have come in contact with during his travel from Delhi to Dharamshala in a Volvo bus, plus his family members and the staff at the private hospital that initially treated him.

As with Punjab, Himachal did not have the list of international travellers initially. Many of them had violated quarantine too. Examples include an IPS officer who attended an official event in Shimla and 17 doctors who attended OPDs at the Indira Gandhi Medical College hospital in the city. “The guidelines issued by the central and state governments clearly prescribe scanning and medical examination of those who returned and also others who had been in contact with them,“ admits Additional Chief Secretary (Health) R D Dhiman.

Now, using data from the Centre as well as local officials, the state has tracked all 1895 travellers who arrived after March 15th and have put them under quarantine. “We have now generated complete data of all persons who had travel history from coronavirus-affected countries,” says Deputy Commissioner Kangra, Rakesh Prajapati. 

Lucknow didn’t keep track of domestic travellers

Through the first couple of weeks of March, UP was not keeping any track of those who came from abroad. Though these travellers had been advised quarantine, the authorities were caught unawares when it was found that most were roaming about the city freely. A high profile case was that of Bollywood singer Kanika Kapoor who returned from London and then went to multiple events, mostly attended by top politicians and businessmen. Kapoor later tested positive.

M C Garg, Chief Medical Officer, Moradabad, says it was then decided that notices would be pasted outside the homes of those in quarantine and the public asked to call a control room in case any of them left home. It was only after the Prime Minister’s speech on March 24th that reports from the people and penalties levied by officials, made it difficult for people to violate quarantine.

Worse, UP did not keep track of the huge number of domestic travellers who entered the state, as work-from-home option started becoming available across the country. Besides, starting March 20th, thousands of migrant workers from states like Maharashtra and Gujarat packed themselves into trains to UP, defying advice on social distancing. Subsequently, UP Chief Minister Yogi Adityanath appealed to the travellers to observe home isolation.

This is in stark contrast to say, Kerala, which set up teams of medical and police personnel at its interstate border checkposts since March 15th. The medical teams collected details of travellers, checked them for symptoms and isolated those with symptoms. Help desks were set up and checks were done at certain railway stations too. The state subsequently also mandated a 14-day quarantine for those who were coming from other states. Several other states like Karnataka and Tamil Nadu had also restricted movement across their borders late last week, as the number of cases started increasing.

But in UP, it’s only since March 25th, several days after domestic travellers entered the state, that the administration started taking any action. From 25th, the administration has made over 10,000 calls to village pradhans across the state, to collect details of those who had come from other states. Local officials would then check those identified. At the district level, the Local Intelligence Units (LIUs) of the police too are identifying travellers.

Contact tracing in UP has largely been based on inputs given by the infected person. This means that the identified contacts would largely be those close to the patient, whom he can immediately identify.

Kochi and Bengaluru: Cities that did it better

Cities like Kochi and Bengaluru seem to have taken far better measures at contact tracing and ensuring quarantine. In both cities, the state health officials were involved with the screening and data collection at airports directly. Quarantine was mandatory for anyone who came from abroad.

Dr Meenakshi V, State Surveillance Officer, Kerala, says: “We have done more than what was mentioned in the Centre’s guidelines. During airport screening, our staff take symptomatic people to an isolation facility and take their sample for testing. Those with serious symptoms are admitted while home-isolation is allowed for those with mild symptoms. In some cases, the persons advised home-isolation had taken public transport. After this, the state decided that all such persons from Kochi airport would be dropped home by ambulance, even if their homes were in a faraway district”.

The state also has better strategies for contact tracing. “If a person who came by flight becomes ill, we consider everyone in the flight as a contact and follow up with them (though Centre’s guidelines require us to track only those sitting in the three rows in front and three rows behind the person). We also talk to patients and collect details of their contacts, and also verify the information ourselves,” says Dr Meenakshi.

A meticulous route map of each patient (without identifying the person) is made widely available, so that the public can contact authorities if they had been at the same place and time as the patient was. And this has helped authorities trace even primary contacts they had missed.

Route map of a patient from Kozhikode district, Kerala. (click on picture to see larger image)

In Kochi, several members among a group of British tourists had tested positive. District Surveillance Officer, Dr Sreedevi S, is confident that everyone they had come in contact with, have been traced. “The group had used a tour package, so we had the list of all locations they visited. We used CCTV footage from the airport and across the city to track all their contacts. We then sent five medical teams to check the contacts. Though the group did visit some tourist spots, this was in the non-peak hours, and hence they didn’t come in contact with anyone there.” She says her team has been developing more technology for contact tracing.

But the state has had challenges with a few international travellers who violated quarantine, travelled widely and were later found to be infected. Tracing their route maps have been difficult. Hence, in districts like Kasargod, where one such instance occurred recently, treatment of incoming cases is prioritised now rather than contact tracing, says Dr Meenakshi.

“Earlier we only used to call and check upon traced contacts. Now we have asked health workers to visit their homes at least once,” she says With a high count of 164 corona patients, the state now has over 1.1 lakh people in surveillance, including international travellers and contacts of infected persons. Over 5600 people have been tested for the virus.

In Karnataka, a ‘quarantine’ stamp was put on the hands of international travellers, which allowed the public to identify those who violated quarantine. Dr B K Vijendra, Chief Health Officer (Public Health) at the BBMP (Greater Bengaluru Corporation), says they are also now stamping both primary and secondary contacts of infected persons, based on a state government order of March 24. “Public will inform us if they see them going out. We then take them to our quarantine facility, with police help if required,” says Dr Vijendra.

Information for contact tracing largely comes from the patient. “If the patient took a train or bus, we don’t consider every passenger as a contact – only persons sitting two rows ahead and behind, and those in the adjacent row. If the person had travelled with reservation, we can track the primary contacts, not otherwise,” says Dr Vijendra. Like Kerala, Karnataka too has put out route maps of infected persons, so that the public can volunteer information. For 14 infected persons in Bengaluru, authorities had traced 119 primary contacts and 239 secondary contacts.

One case in the city had become particularly complicated, as the patient had travelled widely, including to a club and movie theatre. “We can’t trace primary contacts in the theatre as there are no names in the ticket. We are trying as much as possible, but a few people will get left out of tracing,” admits Dr Vijendra.

Route maps unfeasible, says Maharashtra

In Maharashtra, one of the worst-affected states, Dr Anup Kumar Yadav, Commissioner (Health Services), says contacts are traced by talking to the patient, quarantined/isolated, and followed up for 14 days. The state doesn’t publish route maps though.

“If the person has travelled by train, for example, there’d be too many people on the train. If he alights at CST station in Mumbai, there’d be some 50,000 people there alone. We can’t ask all of them to contact us; we don’t know the level of risk they have. Also we don’t want to publish any details of the patient since there’s a stigma associated with the illness,” says Dr Anup. He adds that anyone who’s left out of contact tracing will be found when they approach authorities with symptoms.

In sum, there are huge discrepancies in how different states are trying to tackle the corona epidemic, revealing the lack of a unified strategy and coordination. If authorities don’t use the lockdown period for aggressive contact tracing and testing, we may well see a steep hike in cases once the restrictions are lifted.

With inputs from Shuriah Niazi in Bhopal, Raj Machhan from Punjab, Ashwani Sharma from Shimla, and Ajit Chak from Lucknow

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