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CASE STUDY
Year : 2020  |  Volume : 64  |  Issue : 6  |  Page : 240-242  

Containing the first outbreak of COVID-19 in a healthcare setting in India: The sree chitra experience


1 PhD Scholar, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
2 Scientist F, Department of Biochemistry, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
3 Scientist C, Department of Microbiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
4 Junior Administrative Medical Officer, Directorate of Health Services, Government of Kerala, Thiruvananthapuram, Kerala, India
5 Professor, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Submission04-May-2020
Date of Decision07-May-2020
Date of Acceptance10-May-2020
Date of Web Publication2-Jun-2020

Correspondence Address:
Biju Soman
Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_483_20

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   Abstract 


The response to the first health worker case in India and novel strategies adopted in the context of evolving pandemic of COVID-19 is presented here. On the same day of confirmation, institutional COVID cell was established, and contact tracing was started. A total of 184 contacts were identified and quarantined. Hospital services were scaled down, and responsibilities were reassigned. In-house digital platforms were used for daily meetings, contact tracing, line listing, risk stratification, and research. Reverse transcription polymerase chain reaction-based severe acute respiratory syndrome-CoV2 testing facility was established in the institute. All high-risk contacts were given hydroxychloroquine prophylaxis. No secondary cases were found. Hospital preparedness, participatory decision-making through institutional COVID cell, optimal use of in-house digital platforms, and coordination with the state health department and national bodies, including Indian Council of Medical Research, were the supporting factors. Rapidly evolving guidelines, trepidation about the disease, logistic delays, and lack of support systems for people under quarantine were the challenges in the containment exercise.

Keywords: Contact tracing, containment, COVID-19, healthcare worker, hospital outbreak


How to cite this article:
Singh G, Srinivas G, Jyothi E K, Gayatri L K, Gaitonde R, Soman B. Containing the first outbreak of COVID-19 in a healthcare setting in India: The sree chitra experience. Indian J Public Health 2020;64, Suppl S2:240-2

How to cite this URL:
Singh G, Srinivas G, Jyothi E K, Gayatri L K, Gaitonde R, Soman B. Containing the first outbreak of COVID-19 in a healthcare setting in India: The sree chitra experience. Indian J Public Health [serial online] 2020 [cited 2020 Sep 30];64, Suppl S2:240-2. Available from: http://www.ijph.in/text.asp?2020/64/6/240/285605




   Introduction Top


The first case of COVID-19 in a health worker got diagnosed at Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Kerala, in early March 2020. At this time, the guidelines, policies, and protocols related to COVID-19 were being updated at a rapid pace. Further, the key factors (e.g., incubation period, serial interval, effective reproduction number, secondary attack rate) that define the subsequent stages of an epidemic were evolving.[1] This setting thus posed challenges from the public health investigation and response point of view. The present communication briefly shares the institutional response related to COVID-19 in the country.


   The Situation Top


The index case, a young male doctor, who rejoined the institute after traveling from Spain on the March 2, 2020, was diagnosed with COVID-19 on the 14th day of his return.[2]


   Institutional Response Top


The Public Health Unit of SCTIMST had conducted a sensitization session on severe acute respiratory syndrome (SARS)-CoV-2 on the very next day of the declaration of COVID-19 as a public health emergency of international concern by the World Health Organization on January 30, 2020,[3] which was attended by many clinical staff and students. This and the subsequent awareness activities of the institute's infection control committee had heightened the vigilance on COVID-19 at SCTIMST, well before the first case arrived.

On the same day of diagnosis of the case, an institutional COVID cell with representatives from all the departments and administrative divisions was constituted to coordinate the control strategies and measures within the institute and with the state and central government agencies. Contact tracing included identification of contacts, their line listing with risk stratification, and follow-up. All potential contacts, including the community contacts, were identified and put under surveillance with the help of state health authorities, and the 184 institutional contacts were quarantined by the institute. Computer-generated short message services from the institute's server and mHealth measures such as social media networks and online meeting platforms were established for surveillance, communication, and follow-up of quarantined.

Hospital infection prevention and control measures included disinfection of all the common places, modification of biometric attendance mechanism, social distancing across the institute including canteens and hostels, procurement and use of appropriate personal protective equipment (PPE), re-scheduling of elective procedures, adoption of a rotational working policy, and establishment of the Indian Council of Medical Research (ICMR)-approved COVID-19 testing center. All high-risk contacts were given hydroxychloroquine and were screened with reverse transcription polymerase chain reaction on completion of 14-day quarantine period. No secondary case was detected among institutional contacts. Ethics clearance was obtained from the institutional ethics committee for the use of the data collected during this outbreak for research (SCT/IEC/1531/APRIL/2020 dated April 9, 2020).


   Discussion Top


The overall response by the institute took place in the backdrop of an atmosphere filled with panic, anxiety, and heightened emotions in the community. The steps taken by the institute were later reflected on the guidelines for non-COVID healthcare facilities published by the Ministry of Health and Family Welfare, Government of India, dated April 20, 2020.[4] Universal screening and mandatory quarantine guidelines of travelers from foreign countries were evolving when the index case had returned to India. Furthermore, there were uncertainties on issues such as changing infectious period and duration of quarantine in the initial phase of the pandemic.

Healthcare workers are known to be at the highest risk of COVID-19.[5] Several factors could have led to the success of the control strategies at SCTIMST. The WHO-China Joint Mission Report suggests that human-to-human transmission occurs primarily in close familial clusters.[6] The wearing of a triple-layered surgical mask by the index case, prior sensitization sessions, heightened awareness regarding the preventive measures, use of appropriate PPE by a majority of healthcare workers, isolation of the index case, overcautious way of putting all potential contacts under quarantine, and implementation of hospital infection control measures can be contributed as key identifiable measures. Further, as per narratives from the contacts, the index case was asymptomatic in the initial days after return to India. Route map [Figure 1] showed that the index case remained at home on 6th, 8th, and 9th March 2020. In addition, on March 7, 2020, the index case was not involved in patient care, and he was put under home isolation on March 12, a couple of days before he got diagnosed with COVID-19. The transmission dynamics of SARS-CoV-2 suggests the possibility of transmission of infection from 2 days before the onset of symptoms.[7] The initial asymptomatic period, the presence of many holidays, and duty-off in the department are further crucial factors that might have prevented the spread of infection.
Figure 1: Route map of index case for institutional contacts. Source: Department of Health Services, Kerala.[2]

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Adoption of broader definition for the identification of contacts in the present case scenario is debatable. We could achieve a break in the chain of transmission, but it led to issues in the functioning of the institute. There is a need for modified case definitions for healthcare establishments in pandemics, which could be done through disease modeling approaches. In addition, the availability of updated employee records, along with functional contact details, plays a crucial role in communication and surveillance in such outbreaks. During the present study, challenges were faced in communicating with a few of contacts because of the same first name, changed mobile numbers, and inadequate updating of contact details of employees in the institute records. It is recommended that the healthcare institutes should update the contact details of all their employees at frequent intervals.

Use of information technology (IT) plays a vital role in all phases of prevention and control of SARS-CoV-2 in the institute. Digital means of communication were used for planning of containment measures. Even though many employees holding crucial administrative posts were put under quarantine, the optimal use of web-based platforms ensured smooth functioning of the institute, although in a scaled-down fashion. Important decisions, including change in workflows and finalization of protocols, were made in a time-bound manner. Footages of surveillance cameras were used to fine-tune the route map of the index case that helped in tracing further contacts. As social distancing remains a crucial measure in the containment of COVID-19, judicious use of digital platforms across the departments of a healthcare facility must be encouraged and incorporated in its routine functioning. Technologies such as image processing-based artificial intelligence for the identification of all the institutional employees have a potential for enhancing surveillance. In Taiwan, big data analytics based on national insurance and travel details have played a significant role in the identification of cases.[8]

Research in outbreak situations plays a vital role for evidence-informed decision-making. On the occurrence of SARS-CoV-2 pandemic, the institutional ethics committee formulated mechanisms for the expedited review process for the studies related to SARS-CoV-2. The ICMR 2017 guidelines on Ethics, Section 12 provides guidelines for ethics committees on expedited ethics review processes.[9] The conducive environment, thus provided for researchers, enables innovation and solutions. The same should be adopted by various ethics committees to provide boosting support researchers and innovators for evidence synthesis within the ambit of ethical norms and guidelines in outbreak situations. The bio-medical technology wing of the institute has been instrumental in innovating multiple products till date, which includes the development of sample collection booth, disinfection gateway, cheaper rapid diagnostic kit, swabs for easing out sample collection procedures, and improvised viral transport medium among others.[10]


   Conclusion Top


The investigation, prevention, and control measures initiated in a non-COVID hospital, following the identification of COVID-19 case, with the support from central and state authorities, are the learning experience for similar settings in India. Preparedness through sensitization that heightened vigilance, the establishment of a participatory institutional COVID cell in the institute, timely and thorough contact tracing in multiple phases till route map and case definitions are formulated, use of IT and innovations in identifying and connecting with the potential contacts, catering to support services during quarantine, and scaling up of in-house testing capabilities were the crucial lessons learned during this outbreak.

Acknowledgment

We would like to acknowledge Dr. Madhusoodanan UK, Dr. Ravi Prasad Varma P, Dr. Indu PS, Dr. Tony Lawrence, Dr. Cibin TR, Mr. Bevin Vijayan, and the members of the SCTIMST COVID Team. We would also like to acknowledge the contribution and support from all the faculty members, students, and staff of SCTIMST, the scientists from the National Institute of Epidemiology (NIE), the officials of the Directorate of Health Services, Kerala. We would like to acknowledge the ICMR for their support in establishing testing center in the institute.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020;395:931-4. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673620305675. [Last accessed on 2020 Apr 26].  Back to cited text no. 1
    
2.
Directorate of Health Services, Kerala. Route Map. Directorate of Health Services, Government of Kerala. Available from: https://dhs.kerala.gov.in/route-map/. [Last accessed on 2020 Apr 25].  Back to cited text no. 2
    
3.
World Health Organization. Statement on the Second Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus (2019-nCoV). World Health Organization. Available from: https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regard ing-the-outbreak-of-novel-coron avirus-(2019-ncov). [Last accessed on 2020 Apr 30].  Back to cited text no. 3
    
4.
Ministry of Health and Family Welfare, India. Guidelines to be followed on Detection of Suspect/Confirmed COVID-19 Case in a Non- COVID Health Facility. Directorate General of Health Services, EMR Division, Ministry of Health and Family Welfare. Available from: https://www.mohfw.gov.in/pdf/Guidelinestobe followedondetectionofsuspectorcon firmedCOVID19 case.pdf. [Last accessed on 2020 Apr 25].  Back to cited text no. 4
    
5.
Ng K, Poon BH, Puar TH, Quah JL, Loh WJ, Wong YJ, et al. COVID-19 and the risk to health care workers: A case report. Ann Intern Med 2020; L20-0175. Available from: https://annals.org/aim/fullarticle/2763329/Covid-19-risk-health-care-workers -case-report. [Last accessed on 2020 Apr 25]  Back to cited text no. 5
    
6.
World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). World Health Organization. Available from: https://www.who.int/docs/default-source/corona viruse/who-china-joint-mission-on-Cov id-19-final-report.pdf. [Last accessed on 2020 Apr 26].  Back to cited text no. 6
    
7.
Coronavirus COVID-19 (SARS-CoV-2). Johns Hopkins ABX Guide. Available from: https://www.hopkinsguides.com/hop kins/.//view/Johns_Hopkins_A BX_Guide/540747/all/Coronavirus _CO VID_19__SARS_CoV_2_?refer=true. [Last accessed on 2020 Apr 25].  Back to cited text no. 7
    
8.
Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big data analytics, new technology, and proactive testing. JAMA 2020;323:1341.  Back to cited text no. 8
    
9.
Indian Council of Medical Research. National Ethical Guidelines for Biomedical and Health Research Involving Human Participants. Indian Council of Medical Research. Available from: https://www.icmr.nic.in/sites/default/files/guidelines/ICMR_Ethical_Guide lines_2017.pdf. [Last accessed on 2020 Apr 26].  Back to cited text no. 9
    
10.
Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum (SCTIMST). Available from: https://sctimst.ac.in/About%20SCTIM ST/Organisation/. [Last accessed on 2020 Apr 25].  Back to cited text no. 10
    


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