COVID-19 Situation in Telangana Needs a Top-Gear Response Now

COVID-control strategies in Telangana have to adopt a twin track approach: health systems and community engagement.

As of the 21 July 2020, India reported 870 cases per million population and 21 deaths per million population. Compared to 25 April 2020, the increase in cases per million on 21 July 2020 is 50 times. The increase in deaths per million population is 35 times.

Eight States have reported higher cases per million population compared to the national mean cases per million – Delhi, Maharashtra, Tamilnadu, Telangana, Jammu & Kashmir, Karnataka, Haryana and Andhra Pradesh. In terms of deaths, compared to the national mean of 21 deaths per million population, only four States have reported rates higher than the national mean – Delhi, Maharashtra, Gujarat and Tamil Nadu. The death rate per million population in Andhra Pradesh, Haryana, West Bengal and Telangana seems to be following similar trajectories. Deaths generally tend to be more accurately reported compared to cases.

How Bad is the COVID Situation in Telangana?

Telangana is in the fourth spot in terms of the confirmed cases per million and the ninth spot in terms of the confirmed deaths per million. The confirmed case load per million population has increased by 45 times between April 25 and July 21 in Telangana, while the death rate per million in the same period has increased 15 times. Both are lower trajectories than the national mean, especially the deaths per million.

In discerning trends, it is good to look at weekly new cases and deaths reported factoring in the incubation period and the likely transmission to contacts occurring at similar time intervals.

This is because evidence shows that substantial transmission occurs at the household level rather than among casual incidental contacts.

Telangana reported its first positive case on 5 March and almost all the initial cases were linked to international travellers and their close contacts. Later, in April, internal migration of home-bound workforce fuelled a rapid increase.

• Till the week ending 31 March, the new cases per week were in double digits.
• In the week ending 8th April, it increased to triple digits. In fact new cases per week increased 8.5 times in this one week!
• Till the week ending 20 May the pattern plateaued with a few weeks in between reporting double digits.
• Then, the week ending 27th May showed a 1.5 times increase in new cases compared to the previous week.
• Then, onwards weekly new cases kept increasing steadily at a rate of 1.5 – 2 times per week reaching a peak of 12,179 new cases in the week ending 8th July.
• The two subsequent weeks have recorded a 20% decrease till 22nd July.

Deaths and Distribution of COVID Cases in Telangana

In terms of deaths, till the week of 26 May, 5-6 new deaths were reported per week and this increased nearly 4 times in the week ending 27 May. The peak in new deaths per week seems to have reached 62 on 15 July and has shown a16% drop in the week ending 22 July. All these computations are based on reported data and looking at these trends, it appears that COVID-19 may have peaked in Telangana. Of course, we will have to study trends over the next 2-3 weeks to see whether the trend is sustained.

Interestingly, the Greater Hyderabad Municipal Corporation limits were reporting 75% to 90% of all the reported cases in Telangana. This dropped to below 60% for the first time on the 10 July and this proportion has been steadily decreasing and on 22 July was less than a third of the reported cases in the State. This shows that the pandemic is now spreading to other districts in the State, including rural areas.

Telangana Needs Top-Gear COVID Response

As new cases are showing a reducing trend in the Hyderabad city limits but increasing in the other districts of Telangana, the response has to switch into the top gear now.

To be successful COVID-control strategies have to adopt a twin track approach:

• Health System level
• Community engagement level

The health system’s prime responsibility will be to prevent COVID related deaths. An added responsibility would be to enact policies and implement guidelines that will provide an enabling framework to reduce transmission.

The community’s prime responsibility is to act cohesively to reduce risk of transmission by adoption of positive behaviours. The organised formal leadership at the village level through the panchayati raj system is more robust compared to the mostly informal leadership at the urban level. Therefore, it may be more challenging to enforce guidelines through concerted community action in urban areas.

Augment the Ecosystem for Tracing, Tracking, Testing and Treating

• Hyderabad being the IT hub for the country, efforts should be made to engage the IT and ITES industry to leverage technology for tracing and tracking to support the health workers in the field. This will also provide real time data for immediate action. Contact tracing and early identification have to be emphasized without fail.
• The State should designate an expert committee which will quickly develop treatment protocols and monitor adherence of hospitals to the standard protocols.
• To get an accurate reflection of case load it is important to test all those likely to have the disease without any delay. This includes all those who have symptoms suggestive of COVID-19 like severe acute respiratory illness or influenza like illness and those who are immediate contacts of the positive cases. Testing such targeted people yields a much higher result of suspected COVID-19 cases compared to testing indiscriminately and is therefore more cost-effective. The need of the hour is to identify all the COVID-19 cases and suspect COVID-19 cases through active surveillance.

Optimise and Promote Home Isolation

• Home isolation should be promoted for mild COVID positives. If this is not possible due to space constraints or lack of acceptance by family members, Level I facilities (designated isolation centres for patients without respiratory problems) where these people can be housed should be utilized. Local community volunteers could be called on to support and monitor this level of facility. All patients in home isolation should be followed up on alternate days by a mobile medical van team and on other days by a dedicated tele-consultation portal.
• Health personnel at all levels of public health care should be trained using virtual platforms. Retraining needs to be done every 10 days as medical practices related to COVID are evolving rapidly.
• A dedicated helpline which also provides real time information of the availability of beds as well as provides counselling support should be available 24x7.
• 5-6 mobile sample collection units in Hyderabad and at least one for each of the other districts should be commissioned.

Build Hospital Capacity on a War Footing

• All medical college hospitals (28), district hospitals and some of the bigger Area Hospitals should be augmented with adequate isolation and respiratory support including oxygenation facilities such that these facilities are available at a distance of 50-100 kilometres (Level II facilities). Some bigger private hospitals can also be designated as Level II facilities if they have ICU facilities.

• Increase Level III facilities (those with ventilation support and multispecialty services) by incorporating private hospitals with requisite infrastructure. These should not be limited to Hyderabad but be geographically spread across the State.
• A COVID treatment package should be included in the State’s Aroygasri Insurance Scheme and to ensure participation of the private hospitals, some corpus could be given to each hospital as advance payment for treatment when a case is admitted.

Community Engagement Measures

Apart from this, community engagement is critical for success of COVID-19 control efforts in the state. Appropriate information should be provided to local community leadership using inter-personal channels led by community health workers like ASHAs and ANMs and RWA representatives.

The importance of early detection and its role in preventing deaths has to be stressed. People have to be convinced that the risk from surface contamination is miniscule compared to risk of parties at home with large gatherings. COVID transmission is mostly indoors and is spread rapidly when an infected person is in close contact with those uninfected for more than 15 minutes.

A large proportion of deaths in Hyderabad have been in middle and higher socio economic strata after attending closed door parties.

The risk of this has to be highlighted citing instances where it happened. This behaviour change is in people’s hands and if they indulge in indiscriminate behaviour they should be held liable for their actions.

Finally, the importance of S (Sanitizing), M (Mask Use) and P (Physical distancing) has to be enforced only by people themselves and with their full understanding and participation. Housing societies should insist on regular use of masks for all their members. Offices and shops should enforce this.

(Dr GVS Murthy is Vice President (South), Public Health Foundation of India; Director, Indian Institute of Public Health, Hyderabad; and Professor, London School of Hygiene & Tropical Medicine. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for them.)