Tamil Nadu Lockdown Diary: Resilient tracking and testing helped Perambalur contain spread of COVID-19
With just 13 active cases and one death so far, Perambalur district has the most impressive figure in Tamil Nadu, the second-worst affected state in India
Editor's note: This multimedia series documents the mechanics of how 12 districts in Tamil Nadu worked during the COVID-19 lockdown; told through the stories of healthcare workers, sanitary workers, district officials, other essential workers, administrators, locals and patients. The series resulted from three weeks of travel through the state.
“We can no longer attribute cases to the source like foreign returnees, Koyambedu or residents returning back to their home district. Cases are popping up here and there, across the community. I am expecting this to peak sometime in September,” Dr Geetha Rani, the deputy director of health services of Perambalur informed the author as a matter of fact. The evenness in her tone and the no-nonsense attitude seems to stem from how she views the COVID-19 pandemic.
In her 20 years tenure as a public health official, Dr Rani has overseen successful control and prevention of dengue and swine flu outbreaks. She also holds a degree in public health from ICMR and has done in-depth research on diseases. Yet, the SARS-CoV-2 virus and its unpredictability has kept Dr Rani on her toes since it entered Perambalur.
Perambalur is a district in central Tamil Nadu with a population exceeding six lakhs. More than twenty percent of this population travels out of the district, overseas and domestic, for work. Even before the WHO declared COVID-19 a pandemic, close to 1,200 residents had returned to Perambalur from outside the country. After March, the inflow of residents from Chennai and other states has been constant. Since Perambalur and Ariyalur were formerly one single district, carved out of Tiruchirapalli, movement between these three districts is very fluid as well. All these factors have added to the difficulties of the district administration in tackling the spread of COVID-19 .
According to the state's COVID-19 portal, as of Wednesday, with just 13 active cases and one death so far, Perambalur has the most impressive figure in Tamil Nadu, the second-worst affected state in the country. The total confirmed cases in the district stands at 178, whereas Tamil Nadu has reported 1,47,324 confirmed cases so far.
What Dr Rani has been doing, since February, is what they call ‘outbreak investigation’ in epidemiological language.
“Where is the virus?” This is a question Dr Rani poses to herself and her team every time a contact tracing operation is put into motion. Every case, she explains, has to have a beginning and an end.
“If not, the virus will keep making its rounds within whatever is in its reach. We have to eliminate every possible source, or, this virus will persist. It is a very intelligent creature, this virus. In the very first month, I had understood that I can’t take it lightly,” she says.
Tracking and tracing
One of the first experiences that Dr Rani had with COVID 19 was when her team was trying to trace the contacts of a foreign returnee from Tiruchirapalli who had tested positive. His co-passengers were all tested. Dr Geetha pushed for testing their families as well, though this wasn’t mandatory at that time. The results showed negative for all of them except for a four-year-old.
“This child wasn’t a primary contact. If we had only tested those who had been in contact with this positive patient, we would have missed testing the child. This experience right in the beginning gave us enough perspective for every other investigation we intended to crack,” says Dr Rani.
Echoing Dr Rani’s thoughts is V Santha, the District Collector of Perambalur. “The effort is to tie up all the loose ends through a three-step process of continuous sampling, contact tracing and containing,” says Santha.
There have been instances where people resisted the processes and the district collector had to get herself involved. The virus doesn’t stop for tantrums.
But how complicated can typing up ‘loose ends’ be?
Extremely, especially in a district with minimal facilities, says Dr Rani. “I am not complaining, we’ve managed with what we have. The point is efficiency,” she adds.
While this reporter tailed Dr Rani and her team, they opened up about some of the cases which had the entire administration up and about for weeks. Out of them, the case of a college student, which has all qualities to qualify as a mystery novel.
The mysterious college student case
Venkatakrishnan (name changed) was tested for COVID-19 after he showed influenza like illness (ILI) symptoms. Dr Rani’s team tried to understand how he might have come in contact with the virus.
"This was a time where all COVID-19 cases could be attributed to a source,” says Dr Rani.
When it seemed like Venkatakrishnan's source couldn’t be established, the administration brought the town to a halt.
“We had to shut everything down as the threat of community spread was something we couldn’t take lightly,” says Santha.
Venkatakrishnan had five siblings, and his father was a watchman at a milk parlour. All his family members and everybody at the parlour were tested. A four-member team was appointed comprising Shiva, a tehsildar from the revenue department, BDO Manivasagam, special branch Inspector Vanita and medical officer Dr Kalaimani, to quickly gather information about how Venkatakrishnan might have come in contact with the virus.
"He wasn’t forthcoming of where he had been or places he had frequented, in spite of multiple requests from our side. All he said is that he had been home, hadn’t met anybody from outside and hadn’t traveled anywhere,” says Shiva.
The team gathered his call records and began inquiries. One of the neighbours informed the team that Venkatakrishnan would regularly frequent a nearby medical shop and an adjacent ATM. The team gathered all the possible CCTV footages and looked for possible contact with secondary sources. One such contact was a fire service official, who frequented the same medical shop as Venkatakrishnan. He too tested positive and that meant the entire fire station had to be tested. Yet, there was no breakthrough on the source of the virus for close to a week. It had become evident by then that Venkatakrishnan’s non-cooperation could cost the Perambalur administration deeply.
In the course of further enquiry, a source informed the team that a foreign returnee naed Syed Haneefa had stayed in the same vicinity as Venkatakrishnan in the third week of March. The team assumed that Haneefa must have stayed close by and kept looking for more solid primary sources.
Through further perusal of Venkatakrishnan's call records, the team zeroed in on David. The team discovered that Venkatakrishnan was a recently converted Pentecostal christian, and he and David were spiritual buddies. Both of them had travelled together to Chennai on a scooter for the funeral of a pastor, just weeks before Venkatakrishnan tested positive. Could this have been the source of the virus? Not really.
Upon further investigation, the team found that Haneefa was related to Venkatakrishnan. In fact, Haneefa is Venkatakrishnan’s uncle. He had converted to Islam just like Venkatakrishnan had to Christianity. More surprisingly, Haneefa had stayed not at an adjacent house, but in Venkatakrishnan’s house, for a full three days. Nobody could have guesssed this. But the team, on its part, had covered all other bases, without the patient himself uttering a single word. Venkatakrishnan eventually tested negative and quarantined himself at his home for a long time after.
“So, there it was. We would have never known about this little bike escapade of David and Venkatakrishnan if we hadn’t pulled out call records,” says Shiva.
The mystery however, didn't end there, as according to Shiva both David and Haneefa tested negative for the virus, even though these were the only two sources that could’ve infected Venkatakrishnan.
There is no explanation as to why David or Haneefa didn’t test positive for the virus. There are two possibilities: one is that they aren’t the carriers, two, that they are immune to it or have overcome the virus or were yet to show symptoms.
Dr Rani says that 'avirulence' is something that nobody has yet solved. But to plan better for COVID 19, this needs to be looked at, she insists.
She informs that the serology tests, which look for antibodies in one’s body to viruses are crucial in helping districts understand immunity within the community. States across the country ordered COVID-19 rapid serology tests in April but there was a confusion regarding its efficiency.
“People failed to understand what the test is meant for,” she says.
The point of these tests, Dr Geetha explains, isn’t primarily to tell if a person is positive or negative to the virus. “It is for us to understand what stage of the virus spread we are at,” she says.
ICMR carried out a sample sero-survey in May, the results of which are yet to be announced. It was also announced earlier this week that ICMR would attempt a national survey soon as well.
But such testing for Perambalur is not going to happen anytime soon. So, avirulence aside, the problem which continues to affect Perambalur is, like in Venkatakrishnan’s case, unchecked movement.
“The biggest roadblock which we face in keeping the virus out (of the district) is that there is only so much monitoring we can do. Even when our borders are sealed, if residents travel in and out, there is little we can do,” says Shiva.
Movement between districts
Though movement of people has been faced by all districts in the state, for Perambalur, the pain point is largely the inability to check movement of people between adjoining districts of Ariyalur and Tiruchirapalli, says Dr Rani.
Just the other week, a patient from Perambalur tested positive but got themselves admitted in Tiruchy. Authorities at Perambalur were informed two days after this was reflected as part of the Tiruchy database at the Chennai headquarters.
"We can’t afford to be late with our investigation. It needs to be immediate," explains Dr Rani. This was also experiential learning for Perambalur, brought about by what happened in May and June.
In the aftermath of the Koyambedu market breakout in Chennai, the panic was high as people rushed back to their home districts fearing the virus. Many sneaked back into their districts by jumping checkpoints and tried to shut themselves in their homes. Others weren’t forthcoming about symptoms. Some more hid themselves in the forest-like regions during the day, only to venture home in the night to meet their families.
The panic buttons turned red in the middle of May, when close to 20 pregnant women tested positive for COVID-19 . This emerged only because all antenatal mothers were being tested for COVID-19 on a priority.
Among the pregnant women who tested positive, K from Kumarabalayam Kudikkadu tested positive nine days before her due date. This reporter met with her family on the day of her discharge. K’s mother explained that not only their family but many in the district had been on the edge all of May. Though K had been asymptomatic, the cause of concern was the nature of COVID 19.
“None of us knew what this was. We couldn’t see it or feel it, but we knew we had it. It was a strange kind of panic,” says K.
She has delivered a healthy baby and both tested negative before they were discharged.
Perambalur continues to test patients after 10 days, before they can be processed for discharge. Dr Rani has seen to it that this process remains unaltered, irrespective of the numerous changes in the national guidelines for testing.
After the news about pregnant women testing positive spread across Tamil Nadu, there was a turn around in the community. Susheela, an expecting mother, turned her husband in by herself. She called the helpline and informed them that her husband had returned from Chennai and was at home. He was soon transferred to a quarantine facility.
“Arresting the spread of COVID-19 is a two-way process. We’ll continue to try our best but people should help us too,” says Santha.
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