Tamil Nadu reported its first case of COVID19 on March 9th. An individual who had travelled to Kanchipuram from Oman showed symptoms and tested positive. He was admitted to the Rajiv Gandhi Government General Hospital in Chennai. Seven others who had been in close contact with the infected individual were also placed under observation for symptoms and tested negative for COVID19.

On March 11th, Tamil Nadu’s Health Minister Vijayabaskar announced that the first person found to have been infected with COVID19 in the state has tested negative after treatment and subsequent tests. With this, the number of infected persons in the state currently stands at zero. 

So is COVID19 under control in the state and can we relax for now? 

The answer to this question lies in analysing the protocols followed for testing and examining the state’s rationale for the decisions that have been made so  far in combating COVID19.

Who can get tested?

The current testing guidelines that are in place for COVID19 being followed by all states has been dubbed as an evolving strategy from the Ministry of Health and Family Welfare (MoHFW). Testing is being carried out by 65 designated labs across the country.

Under the existing protocol, tests are being administered only to

• Those individuals categorised as high risk, who have a recent travel history to COVID19 affected countries and are symptomatic within a period of 14 days of quarantine

                                                          and 

• Those who have come into direct contact with an individual confirmed to have COVID19 and are symptomatic within a period of 14 days of quarantine 

Asymptomatic individuals with relevant travel history have not been brought under the umbrella despite evidence that they could still transmit the disease.

Testing protocol followed by the MoHFW.

Tamil Nadu’s approach

According to a release by the Ministry of Health, Government of Tamil Nadu, the state has carried out 98 tests for COVID19 as of March 16. 

Screening at airports has resulted in a total of 2221 individuals, with travel history to high-risk countries, being placed under home quarantine for 28 days to prevent the potential spread of COVID19. The state doubled the quarantine period (from 14 to 28 days) to restrict the spread of the virus by asymptomatic individuals who could atill be carriers.

Dr S Raju, Deputy Director, State Public Health Laboratory, elaborated on the protocol followed in Tamil Nadu at present.  “There is a very clear Government of India guideline on who should be tested. This is being followed. If people travelling from high-risk places show symptoms they can reach us 24*7 on the helpline number (see box below) put out by us. If they contact us on the number we advise them on the next course of action. If they are really unwell, we will send our ambulance and take them immediately to our isolation wards and take samples for testing. Depending on the results they will be put under home quarantine or continue treatment in the hospital.”

As for the state’s capacity to test for COVID19, Dr Raju states that Tamil Nadu is well-equipped to handle the situation, even without the involvement of private testing facilities at this stage, and prevent potential price gouging. 

Four labs have been designated for testing for COVID19 in the state:  King’s Institute of Preventive Medicine and Research, Chennai, and the Viral Diagnostic Laboratories in Theni, Thiruvarur and Thirunelveli. Official sources claim that the four labs have a total capacity to carry out close to 500 tests in a day at present, with King’s Institute possessing the bulk of the capacity at 300 tests. 

In addition, there are 20 other labs with varying testing capacities that can be called upon to conduct further tests if the need arises. 

Government rationale for low number of tests

The current strategy limits the pool of individuals who can get tested and leaves little option for testing for those who display symptoms of COVID19 but do not fall under either of the above-mentioned categories. The existing testing protocol operates on the assumption that there is no threat of community transmission of COVID19 at present. 

Authorities state that opening up testing to a broader category of persons is unnecessary at the moment and would lead to mass panic. “We have been closely monitoring every individual returning from high-risk countries through the control room. A dedicated team is in touch with them on a daily basis to know if any of them are displaying COVID19 symptoms. The message to the public on hand hygiene has reached every section. The people already know that there is no vaccine as yet, but hand washing can prevent the spread,” says Dr Raju.

On limited testing, he added that since they have been able to prevent local transmission through contact tracing, the chances of a community spread are unlikely. For the one infected individual who tested positive, more than 30 persons he had come into contact with, including cab drivers who took him from the airport, were tracked and monitored. All the related tests were negative.

Turned away without tests

Questions have been raised about the limited testing protocol of the MoHFW as accounts of individuals with symptoms similar to those seen in cases of COVID19 were turned away for tests at the Rajiv Gandhi Government General Hospital in the city as they did not have relevant travel history.

The telephonic message that plays across the state urges people to follow hand hygiene and visit the nearest health center. Calls to local Primary Health Centers confirmed that they have been instructed to send patients, who come in with similar symptoms, to the General Hospital. But under the current testing standards, most such patients would hit a dead end in their quest to confirm if they have indeed been infected with COVID19.

An account of what happens to an individual looking to get tested was shared by activist Gayatri Khandhadai. She had a travel history spanning Myanmar, Nepal and Switzerland and transit through Dubai in recent weeks. On her return, she began to develop cough, fever and shortness of breath. Due to her travel to countries with COVID19 outbreak and interactions with citizens from affected nations, she sought to get tested.

“I called the 104 helpline which I was able to reach after multiple attempts. They directed me to the Rajiv Gandhi hospital. I went along with a friend who also shared my travel history and similar symptoms. But both of us were turned away. The physician suggested I take a paracetamol and report if my symptoms get serious. I have been self-isolating since I felt the symptoms emerge, but the physician did not ask me about my movements or interaction with others, nor did he suggest that I quarantine myself.”

Shocked at the TN government response to Corona. I went to the GH to get tested given my recent travels to Southeast Asia and Europe. They told me to come back when my symptoms were more serious. I offered to pay for the test and they said they won't take blood samples. 1/1

— Gayatri Khandhadai (@gayatrikl) March 14, 2020

Gayatri points out that despite her having returned from high-risk countries and filling out the self-declaration form at the airport, she has not received any follow-up calls. While her contact details were noted down at the hospital, that of her friend who showed similar symptoms was not.

These cases prompt fears that there may be many such patients who have been unable to get tested and that a community spread may already be underway in the state. The announcement by the Chief Minister on March 16th that anyone who has symptoms of COVID19 could approach the government hospital for treatment is not a broad sign of relaxed testing criteria. This was confirmed by Dr K Kolandhasamy, Director of Public Health, who said, “The testing criteria still remains the same. But those who are showing any COVID19 symptoms can approach the government hospitals, where doctors will assess their health and enquire about their history and decide on the next course of action. We have made this move to instill confidence among the people that no one is being denied care.”

Do we need more exhaustive testing?

Across the country, 5900 individuals have been administered 6500 tests so far. In areas where there has been proven community transmission such as Kerala, a high number of tests have been carried out. As of March 13th, Kerala had carried out 1179 tests. The labs across the county, including in Tamil Nadu, have been operating below capacity since the initial testing began. 

Speaking about the testing criteria being followed, Dr Vijayaprasad Gopichandran, public health expert, says, “From the perspective of public health, there is a need to understand how fast the disease is spreading and if there is community transmission in fact; for that, we definitely need data from tests. I have no qualms in recommending that we do some expanded testing and offer the test to a more flexible group of population.”

However, Dr Vijay opines that from a clinical perspective, since there is no vaccine available, knowing that they have COVID19 will not change the way the patients are being treated for their illness. The recommendations of isolation and the treatment of the underlying symptoms should be the suggested remedy, as in the case of other similar diseases such as tuberculosis.

Dr Sudharshini Subramaniam, public health expert, feels that the state can revise guidelines to include a wider pool of individuals for testing such as those displaying symptoms of respiratory illnesses. “There is a need to spruce up the Integrated Disease Surveillance Programme (IDSP), especially in the underserved and rural areas. The government can adopt wider testing through a prudential mix of government bodies and not-for-profit private entities with proven track record. Sentinel surveillance spots can be established across the state to carry this out, without creating a panic situation.”

Is it possible to flatten the curve?

So what are the options the state and the public have in trying to limit the spread of COVID19 and ensure that the health systems are not overburdened? The prescription being offered across the world with regard to this is social distancing.

Countries have tried to limit the spread of COVID19 in the community by shutting down schools, colleges, malls and non-essential services across the world. In India, the response across states has not been uniform. While Kerala, Maharashtra, Telangana and Karnataka have acted aggressively in trying to limit interaction among the public, Tamil Nadu is still lagging behind.

The Chief Minister declared on March 16th that all educational institutions and non-essential services such as bars, cinema halls, malls and resorts will be shut until the end of March. Surveillance has also been stepped up on transport vehicles coming in from other states. The Chief Minister has also advised people to avoid non-essential travel and large gatherings for the next 15 days.

Will these moves achieve the aims of social distancing?

Shutting down non-essential services in a uniform manner and offering the option to work from home for those who can do so will certainly lessen the chances of those people who access the spaces contracting COVID19 or acting as spreaders of the illness as a result of their presence in large numbers at these spots. 

However, complete social distancing cannot be achieved just through spreading awareness and government directives unless cities are under total lockdown as in the case of China or Italy.

“The whole idea of social distancing is very difficult to achieve especially in a country like India. The tips for social distancing such as working from home, avoiding public transport and large gatherings are framed in an urban-centric manner, for a small section of the people. The people who will be affected by such outbreaks, such as the marginalized and poor cannot possibly follow social distancing effectively,” says Dr Sudharshini.

It’s everyone’s problem!

While on one hand, citizens attempting to report symptoms are being turned away in a decision by the state, there have also been instances of irresponsible actions on the part of the general public. Not heeding warnings about the ways the virus can spread could cost us dearly if the situation were to escalate.

To that end, acting with care and caution in the face of COVID19 also forms a key element in combating the spread. Limiting social interaction to the extent possible, educating oneself and the community about risk mitigation and following hand hygiene and other preventive measures is vital. Even as we read reports of suspected COVID19 patients fleeing quarantine, there are other exemplary citizens showing the way.

“Lino Abel of Kerala, who turned himself in for quarantine on showing COVID19 symptoms despite his father’s ill health and death is an example of responsible behavior. This is a measure to prevent the community spread of the disease and what people should be looking to do to for the greater good”, says Vicky Ramalingam, a marketing professional in the city.