Cases with no travel, contact history a worry

Patients in Pune and Chennai spark concerns that the disease may have reached its most dangerous stage; govt says no evidence of community spread

INDIA IS CURRENTLY IN STAGE 2 OF THE COVID-19 OUTBREAK, ACCORDING TO THE HEALTH MINISTRY

NEWDELHI: A 41-year-old woman in Pune tested positive for the coronavirus disease or Covid-19 on Saturday, becoming the second patient in India with no history of foreign travel or documented contact with previous cases and fuelling fears that the country had slipped into the deadly third phase of the infection when the contagion spreads rapidly.

At this stage of the outbreak , known as the community transmission phase, the origin of any individual patient’s infection cannot be pinpointed to travel to a global hotspot of the disease, or documented contact with a previously infected person. This means that the virus is freely circulating in the community, making it tough for authorities to control its spread or enforce containment measures.

In countries worst-hit by the coronavirus disease, or Covid-19, such as China, Italy, Iran or South Korea, the number of infections and fatalities rose sharply once the country moved into the community transmission phase.

Late evening, authorities in West Bengal reported that a 57-year-old man, who had not travelled abroad and had no documented contact with a previous patient, had tested positive for Covid-19 – indicating that more cases of people with no obvious origin of infection were showing up across the country. The case was confirmed by two state government laboratories but not by the NIV, the national nodal authority, at the time of going to print.

GOVT DISMISSES

The government dismissed claims of community transmission, and said the two cases simply represented a failure of contact tracing, a process by which authorities identify everyone a coronavirus patient has come in contact with. This is crucial in figuring out how many people a particular patient might have potentially infected.

“Right now we are focussing our efforts on tracing the contacts of all the positive cases. Contact tracing is not a simple exercise –we are currently monitoring over 7,000 people who have come in contact with those who tested positive. So far, there is no evidence of community transmission,” said Lav Agarwal, joint secretary, Union health ministry.

But experts point out that having no obvious source of an infection, or not being able to immediately trace an infection to either foreign travel or direct contact was a clear indication of community transmission. Moreover, because of a paucity in testing — India has tested just 16,911 samples so far ,one of the lowest testing rates in the world — experts had no clear idea if community transmission was occurring among patients.

IN DENIAL?

“We need to expand testing to identify the infected early and treat them effectively and delay their getting into a critical stage...just the same strategy as we followed for HIV AIDS .... Yes, it (the possibility of community transmission) has been worrying me for over a week,” said Sujatha Rao, former health secretary, ministry of health and family welfare, and former director general, National AIDS Control Organisation, India’s apex body for preventing HIV in India.

“We have wasted time being in denial, exactly the way we were with HIV AIDS. We haven’t learnt lessons.”

A senior health ministry official said that community transmission could only be confirmed when national surveillance network picks up a high number of positive cases. “Or we start reporting 200 or 300 cases and don’t know the source of a high number – 50 to 60 of these cases,” he added, suggesting that two or three cases that can’t be explained do not confirm community transmission.

There are four stages of an outbreak. Stage I is when cases are imported by travellers from other countries, Stage II is when these travellers then pass on the infection locally to people living or working around them, Stage III is when community transmission happens and the health care workers are unable to trace the source of infections, and the last Stage IV is when the disease is widespread in a population.

India is currently in the Stage II of the outbreak, according to the health ministry.

“Yes, there are cases where we haven’t been able to pinpoint the source of the infection. However, I will consider this to be the failure of our contact tracing efforts rather than community transmission,” said the Union health ministry official. Knowing whether there is community transmission is important as people with undetected infection could lead to an explosion in cases like in Italy, where Covid-19 cases and related fatalities shot up suddenly when community transmission began. “I think it is just a matter of time that India sees an explosive rise in the number of cases,” said Lalit Kant, former head of epidemiology and communicable diseases at ICMR. The Pune woman was brought to the governmentrun Bharati hospital on March 16 with complaints of fever and breathlessness.

“As per the information from her family, she started developing initial symptoms on March 3. After that, she took public transport to travel to an anganwadi and also attended a wedding in Navi Mumbai,” said Sanjay Lalwani, medical director of the hospital.

Divisional commissioner Deepak Mhaisekar said four of her family members were isolated at their homes while the driver of taxi she had hired was quarantined.

“We have already traced over 100 people who came in contact with the patient and also contact tracing those who came in contact with the four family members. This number may run in hundreds. A central government team has visited the hospital to decide on whether the case is of local transmission or community transmission,” he added.

The case came a day after the government said it was yet to trace the origin of infection of the 20-year-old Delhi man who travelled by train from Delhi to Chennai on March 17.

In the Bengal case, the man, a resident of Dum Dum on the fringes of Kolkata, was admitted in a private hospital on March 16 after being ill with fever, accompanied by a dry cough, since March 13, a top state health department official said. His condition deteriorated on March 19 with the onset of acute respiratory distress syndrome and he was put on ventilator, the official said on condition of anonymity

TRACING DIFFICULTIES

Authorities argue that contact tracing becomes incredibly difficult, especially when people travel in public transport like in the case of a 46-year-old Delhi man who took the Metro for days testing positive. Delhi authorities said they were able to trace his contacts in the neighbourhood where he lived and at his workplace, but there was no way of tracing the people on the metro.

The same was true of one of the three initial cases in India.

“If you remember the first three cases of Covid-19 in India, one of them had taken multiple flights, trains and other public transport. Do you think we were able to trace all of the people on those vehicles? No. And, someone else might very well contract the infection in transit and we will not know the source. But, does it suggest community transnorthern mission? No,” the health ministry official said.

To detect community transmission, the Indian Council of Medical Research (ICMR), the country’s apex health research body, has been conducting surveillance testing by lifting random samples of patients suffering from severe acute respiratory infections (SARI), including severe pneumonia.

These samples are taken from people with no travel history or contact with a positive patient. All 826 samples collected during the second round of community testing in March returned negative for Covid-19, according to ICMR. With the ICMR expandbefore ing its testing criteria to include all patients hospitalised with SARI Friday onwards, early detection of community transmission is likely.

“The ICMR says that there is no community transmission as of now, but my feeling is we just haven’t been able to pick up. Initially, we were just testing symptomatic people who had travelled abroad and those who came in contact with them, how would we then be able to detect if anyone among the 1.3 billion people have it? The revised criteria that allows for testing all patients with SARI will help in picking up community transmission,” said Dr Kant.