Bumpy road

Despite posting impressive recovery from a sharp spike in COVID-19 cases, Tamil Nadu is worried about losing a battle as lack of adequate testing kits has hampered aggressive testing during the lockdown.

Customers throng to buy fish without adhering to physical distancing in Chennai on April 19. Such congregations could lead to a spike in the number of COVID-19 infections, undoing the gains made by the State so far.

AS on April 20, Tamil Nadu recorded 1,520 positive COVID-19 cases, which included 33 children below the age of 10. Seventeen deaths were reported until April 20, which works out to a case fatality ratio (CFR) of 1.1 per cent against the national ratio of 3.34 per cent. As many as 457 persons who tested positive have recovered, for a recovery ratio of 30 per cent.

As on April 20, 2,10,538 passengers who came from overseas and other States were under home quarantine, of whom 1,07,103 persons were in 558 confinement zones and the rest at home. Some 47,710 persons had been tested. The highest number of tests in a day was 6,109 on April 20, of whom 43 were positive.

Calling the virus an “imported infection”, Chief Minister Edappadi K. Palaniswami claimed that due to sustained and dedicated efforts of the government, the infection ratio had started falling from its steep jump mainly from a “single source”. “In the past three days, i.e, from April 14 to April 16, we have been seeing less number of positive cases,” he said. He said confidently that in another four or five days the State would achieve “zero positive”.

His heightened optimism seems to have stemmed from an impressive list of details and statistics he was given and which he shared with the media on April 16. The Chief Minister told the media that his government had upped the ante against the virus from the last week of January itself on multiple fronts. It had stocked adequate quantity of medicines and emergency equipment. It had also augmented its health care infrastructure besides adding additional services such as isolation wards.

Surveillance at airports was put in place on January 23 though the first infection was reported on March 7. Subsequently, on March 15, places of public congregations such as malls, cinema halls, places of worship and educational institutions were closed. A prohibitory order under Section 144 of the Criminal Procedure Code was promulgated on March 23, a day ahead of the first nationwide 21-day lockdown announced by the Centre, he said.

The Chief Minister has entrusted the task of dealing with the emergency situation caused by the pandemic with a 12-member Task Force consisting of senior Indian Administrative Service (IAS) officers headed by Chief Secretary K. Shanmugam.

A senior bureaucrat at the State Secretariat said there was no interference with the team’s work. “The Chief Minister listens to them, consults them and makes suggestions, if any, to them,” he said.

Besides, a 19-member medical expert committee has been formed to offer medical and technical suggestions. Multiple sub-squads, headed by bureaucrats and police officials, were formed to monitor other related works in all districts.

More than 500 doctors, 1,000 nurses and 1,500 medical technicians were appointed on a priority basis to bolster the public health system. Special incentives were announced for those working in the front line of the battle against the virus.

The Chief Minister said the State had 3,371 ventilators, of which 2,501 were in government hospitals. It was in possession of 65 lakh three-layered routine masks and three lakh N95 masks and two lakh units of personal protective equipment (PPEs). A total of 1.95 lakh reverse transcription-polymerase chain reaction (RT-PCR) test kits were available, of which 68,000 were disbursed to the districts.

Tamil Nadu received 24,000 rapid test kits on April 18 as the first instalment (from China), and an additional 12,000 kits from the Centre. The test kits were sent to Erode and Coimbatore zones immediately. Testing commenced in Chennai, Coimbatore, Salem and Erode under the first phase.

Health Minister C. Vijayabaskar and Health Secretary Dr Beela Rajesh share the Chief Minister’s optimism. They maintained that Tamil Nadu was still in stage II of the pandemic and had not entered the community spread phase. After the “single source” spike, Tamil Nadu started recording fewer number of positive cases, suggesting that the State is yet to reach its peak load, which can occur only when the community spread starts. Vijayabaskar said, “We are prepared for any eventuality.” The State has 33 laboratories with a combined testing capacity of 6,000 a day. Its hospitals, both government and private, have 29,074 beds.

A senior public health official said: “We are ready for the emergency situation if the case load peaks. Buildings have been identified to have an additional capacity of one lakh beds.”

But the top-level bureaucrats who are coordinating with health officials on the ground maintain that it is too early to lower the guard. One of reasons for their caution is that around 30 cases, though a negligent number in the overall total, did not have any known travel or contact history.

On April 8, the local media reported the death of a 45-year-old man, who had no contact or travel history, at the CMC Hospital, Vellore. The report from the Health Secretary was silent on this. Another report said that those who worked in a mall in Chennai tested positive. The first COVID-19 positive patient, a sales girl in the mall, had a contact history with a Kerala source who had travelled to Sri Lanka and back. Thus, his contacts could not be traced. The girl’s colleagues, too, tested positive subsequently. The government put out a request to those who visited the mall during that time in March. Some 3,000-odd people turned up for tests. None tested positive.

“But we did not have the exact numbers of people who visited the mall during that period. We tested those who turned up,” the public health official said. “Though these cases with no records are few and far between, we are still worried,” he said. Heath officials said the State did not fudge statistics as alleged by some people but they had no answers to the crucial question of ramping up testing.

The single source scare

There was a spike in the number of coronavirus infection cases in Tamil Nadu after some of those who returned from the Tablighi Jamaat event in Delhi tested positive. Subsequently, their primary and secondary contacts also tested positive. The government prefers to call it “single source” infection.

As per statistics provided by the Health Department, other than the “single source” infections, almost all the other positive cases shared in the public domain had travel or contact history.

“When the ‘single source’ infection jacked up the total, we were first worried. From the last week of March to April 12, the graph showed a steep upward trend. But after contact tracing and testing we realised that they were not super spreaders, as feared. The participants at the conference, after some initial apprehensions, came forward and submitted themselves for screening and testing,” a senior IAS officer, who is a core member of the Task Force, said. A total of 1,302 had tested positive as on April 16.

In fact, the exercise of testing, surveillance, contact tracing and quarantining of those from the “single source” was relatively easy, since they happened to live in specific pockets in cities and towns. This particular source of infection was found to be largely confined to primary and secondary contacts.

Beela Rajesh said during one of her media briefings that the task of identifying each and every person of the source and bringing them to hospitals for mass testing and monitoring was being done at an exponential rate. “Combined teams of police, revenue, health and local bodies in each district were involved in the exercise of door-to-door verification and to identify and trace out the last contact in the link,” she said.

What she, however, failed to mention was that the job could not have been accomplished but for the cooperation of the minority community, which was pilloried by majoritarian fanatics as “super spreaders”. Elders and youths of the community volunteered to accompany the officials in their endeavour to trace and test the primary and secondary contacts. These “volunteers” spoke to frightened women and children in houses and convinced them that it was essential to undergo screening and testing for the “health of their families and society overall”. In Coimbatore, they accompanied health workers and paramedical staff, who were also Muslim women, to complete the task of contact tracing, screening and testing.

“We were thus able to trace almost all primary and secondary contacts of the single source now. The result is that we could see a significant drop in the total number of cases,” the health official said.

A study of the reported positive cases since April 1 shows the trend. On April 1, a total of 110 positive cases were recorded of which a major portion was traced to the single source.

Similarly, the figure was 102 on April 3, 86 on April 5, 96 on April 9 and 106 on April 12—a majority of the cases were attributed to the single source. When almost all the primary and secondary contacts were brought under the surveillance radar, tested and quarantined, the total number of cases stabilised and started showing a downtrend. On April 14, there were 31 cases, on April 15 it was 38, and on April 16 it was 25.

Shortage of kits

One virologist said: “We are confining ourselves to those who have travel history and contact history besides the single source infection, which was an unexpected one. We have to come out of the comfort zone. To understand the harsh reality, we need to go for mass testing at the community level. And to identify and ascertain the source of infection one needs to broaden the testing for which adequate testing kits are needed.”

Greater Chennai Corporation’s Commissioner G. Prakash told the media on April 14 that about 37.11 lakh households were surveyed in Chennai since April 5. But the exercise that continues to date is confined to jotting down a few bare details, such as names and age of the inmates, whether anyone in the surveyed household is a diabetic and has symptoms of flu and fever. With no test kits available, the Corporation could identify 695 cases of influenza like illness with symptoms of flu and fever, of whom 404 were referred for further screening and monitoring.

Before the door-door survey was undertaken, the civic body had placed an independent order for 50,000 rapid test kits with a Chinese firm in the first week of April. The hard fact is that in the absence of testing kits, the Corporation lost the opportunity offered by the lockdown to carry out aggressive testing. “How could we do testing when we don’t have kits to study the prevalence of the virus in the community?” the virologist asked.

However, Beelah Rajesh, downplayed concerns about inadequate stocks of test kits, saying the State has enough stock of RT-PCR kits. She said rapid test kits were meant only for preliminary screening in the community and could not confirm the prevalence of the infection. “It is not finality. We have adequate RT-PCRs, which are more than enough as of now,” she said.

The Centre’s interference

The Centre did not allow the States to decide on their needs and requirements independently. It mooted the idea of centralised purchase and distribution. The Union Ministry of Health and Family Welfare in its notification issued on April 2 told Health Secretaries of all States and Union Territories that “State governments and Union Territories may not go for procurement of crucial medical equipment and these should be procured centrally by the Ministry of Health and Family Welfare and distributed to the States.” The notification further said that the Ministry had to “revisit the actual requirement of crucial medical devices for COVID-19 management such as PPEs, N93 masks and ventilators and to aggregate the States’ demand and come up with a special figure on a rational basis”. By appropriating such vital powers of the States, despite health being in the State List, the Central government stalled any independent purchase by the States. When a journalist asked Shanmugam on the non-arrival of rapid test kits on April 11, he said the kits were “diverted to United States of America from China.” “You know better,” he said sarcastically. In his videoconference with the Prime Minister on April 10, the Chief Minister told him that the State urgently needed Rs.9,000 crore for the management of the pandemic and that funds meant for the State had not been disbursed so far. He sounded exasperated when he told the press that, “We [States] are in a position to receive and they [Centre] are in a position to give.” That the State remains underfunded is a serious concern in the fight against the virus.

“We have received just Rs.510 crore from the Centre. It is a tough job for the State government to manage a pandemic with no concrete support from the Union government,” a spokesperson of the ruling All India Anna Dravida Munnetra Kazhagam said. However, party spokespersons have been instructed not to criticise the Centre openly on media platforms. S. Venkatesan, Member of Parliament from Madurai and a Communist Party of India (Marxist) functionary, helped Madurai Rajaji Government Medical College Hospital to procure equipment such as PPEs and masks from local manufacturers under his Member of Parliament Local Area Development Fund. “The exercise was completed swiftly before the Centre could suspend the scheme. They have usurped Rs.750 crore allotted to the Tamil Nadu MPs’ local development funds,” Venkatesan said in his statement.

The presence of a few cases with no traces of contact is worrying since the pace of transmission in a highly urbanised State such as Tamil Nadu could not be predicted. A senior doctor says that cases of acute respiratory syndrome, dengue and even malaria are getting reported now.

“It is a bureaucratic myopia. We need an open and straightforward dialogue with opposition parties,” said K.G. Gopikumar, State secretary of the Centre of Indian Trade Unions (CITU). He urged the government to show the PPE and masks stored in its Medical Corporation godowns to the media to counter the claim of opposition parties that the stock of PPEs and masks were insufficient and were of substandard quality. “We cannot ignore the fact that 13 doctors have tested positive, so far,” he claimed.

The uncertainty and unpredictability has forced the Chief Minister to not relax the lock-down regulations in Tamil Nadu. “How long can we continue like this? Like dengue and malaria, this virus is going to be there with us. We have to learn to live with it. Hence we need to plan accordingly,” an IAS officer said. Transparency about what is happening will go a long way in building confidence in the minds of the people about their safety.