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ORIGINAL ARTICLE
Year : 2020  |  Volume : 64  |  Issue : 6  |  Page : 177-182  

Insights from COVID-19 cluster containment in Bhilwara District, Rajasthan


1 Associate Professor, Department of Paediatrics, RNT Medical College, Udaipur, Rajasthan, India
2 Senior Resident, Department of Community Medicine, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. RML Hospital, New Delhi, India
3 Advisor, National Vector Borne Disease Control Programme, Government of India, Delhi, India
4 Senior Regional Director, Regional Office of Health and Family Welfare, Jaipur, Rajasthan, India
5 Senior Medical Officer, Medical and Health Department, Government of Rajasthan, India
6 Chairperson, Indian Public Health Academy, Former Executive Director, NHSRC, New Delhi, India

Date of Submission11-May-2020
Date of Decision11-May-2020
Date of Acceptance15-May-2020
Date of Web Publication2-Jun-2020

Correspondence Address:
Shyambhavee Behera
Department of Community Medicine, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. RML Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_489_20

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   Abstract 


Background: In March 2020, a healthcare professional from a renowned private hospital, in the textile city of Bhilwara, Rajasthan, reported clustering of cases of pneumonia amongst doctors and paramedical staff suspected to be due to COVID-19. The basis of suspicion was clinico-eco-epidemiologic-radiological findings as, by that time, about 20 COVID19 cases were reported from the state of Rajasthan including a big Italian group of tourists who travelled extensively in Rajasthan, including Udaipur city. Objectives: The current study presents the field experience of the Central and the State Rapid Response Teams (RRTs) in the cluster containment at Bhilwara. Methods: The information regarding the sociodemographic profile of the cases was provided by the Senior Medical Officer In-charge. The containment strategy was modeled under 6 pillars. Google Maps was used for preparing spot map. Results: Immediate public health actions of cluster containment including contact tracing, quarantine, and isolation were initiated using epidemiological approach of mapping the cluster and taking care of reservoir of infection by the District Public Health Team supported by Multidisciplinary Rapid Response Team. This was supplemented by strict enforcement of lock down in the District taking care of daily need of the community by the leadership of administration with very strong intersectoral co-ordination (locally called “ruthless containment”). Conclusion: The forthcoming challenge resides in re-establishment of inter-district and inter-state travel, which can become a risk of re-entry of the new cases, which needs to be taken care of, with the help of stringent administrative measures and screening at all points of entry. The team in Bhilwara needs to remain vigilant to pick up any imported cases early before local transmission establishes.

Keywords: Bhilwara, cluster containment, COVID-19, explosive epidemic, health-care workers


How to cite this article:
Meghwal B, Behera S, Dhariwal AC, Saxena D, Singh R, Kumar S. Insights from COVID-19 cluster containment in Bhilwara District, Rajasthan. Indian J Public Health 2020;64, Suppl S2:177-82

How to cite this URL:
Meghwal B, Behera S, Dhariwal AC, Saxena D, Singh R, Kumar S. Insights from COVID-19 cluster containment in Bhilwara District, Rajasthan. Indian J Public Health [serial online] 2020 [cited 2020 Oct 25];64, Suppl S2:177-82. Available from: https://www.ijph.in/text.asp?2020/64/6/177/285609




   Introduction Top


India witnessed its first case of COVID-19, caused by novel coronavirus of family Coronaviridae on January 30, 2020, from Kerala originating from Wuhan, China.[1] This marked the beginning of the current established outbreak in the country reporting 59,662 cases and 1981 deaths as on May 9, 2020 (08.00 a.m.), in India and 3579 cases and 101 deaths from Rajasthan.[2] The World Health Organization (WHO) declared COVID-19, as a Public Health Emergency of International Concern on January 30, 2020,[3] and subsequently global pandemic on March 11, 2020.[4]

In mid-March 2020, a health-care professional from a renowned private hospital, in the textile city of Bhilwara, Rajasthan, reported clustering of cases of pneumonia among doctors and paramedical staff. The situation got more alarming when a doctor working in the intensive care unit (ICU) at the facility was admitted to the isolation ward in Jaipur, Rajasthan, with similar symptoms and was found positive for COVID-19 on March 18, 2020. The next day, nine more cases tested positive from the cluster. Identifying early warning signs followed by timely investigation and action holds the key for containment of any epidemic. Although the steps adopted for cluster containment were the same as of the Government of India guidelines, its execution suiting to local requirement with dedicated and sincere health and administration team paid the dividend in achieving zero local case.


   Materials and Methods Top


The current study is based on the field experience of the Central and the State Rapid Response Teams (RRTs) in the cluster containment at Bhilwara. The information regarding the sociodemographic profile of the cases was provided by the Senior Medical Officer In-charge, who was dealing with the contagion at the district level. The team was involved in the cluster containment and worked very closely with District Public Health Team, MG Hospital administration, and district administration, and observations are summarized as result and observation. Google Maps was used for preparing spot map.


   Results Top


The study presents an overview of the epidemic and the actions taken in transforming an emerging epicenter into zero locally acquired case in the district in a very short span of time, as this can become a model in the nationwide fight against the epidemic of COVID-19.

Identification and confirmation of the outbreak and defining in terms of time, place, and person

On March 18, 2020, an unusual number of cases of pneumonia came into notice of District Health Authority from a private hospital (Brijesh Banger Memorial Hospital, Bhilwara, Rajasthan). In view of country-wide ongoing epidemic of COVID-19, oropharyngeal and nasopharyngeal swabs were sent for reverse transcription-polymerase chain reaction for novel coronavirus at SMS Medical College, Jaipur. The first laboratory-confirmed case of COVID-19 was reported on March 19, 2020, followed by more positive cases in the subsequent days.[5]

Within a span of the next 2 weeks, a total of 27 COVID-19 cases were reported.[6] All these cases were linked to exposure from Banger Hospital either as health-care workers (HCWs) or patients or their families who took treatment from the hospital. This indicates point source outbreak. Fifteen more cases were reported after April 3, 2020. However, all these cases have a history of coming to Bhilwara from various other cities (Mumbai, Delhi, and Jaipur). [Table 1] shows the distribution of patients in various age groups. Nearly 80% of the cases were under the age of 50 years. The age range of the COVID-positive cases was found to be 17–70 years, with almost 63% of them being males. Multiple cases were reported within a family. Most of the cases (81%) were from Bhilwara township area. A spot map of the cases was made using Google Maps (till May 8, 2020) [Figure 1]. The district reported two fatalities, although the cause of death was later reported to be due to their comorbidities. The district reported no new case for few days and then 1–2 cases after a gap of a week indicating the need of vigilant surveillance system that needs to be continued [Figure 2].
Table 1: Age.gender distribution of the COVID-19 cases and case fatality rate in Bhilwara (n=42)

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Figure 1: Spot map showing geographical distribution of cases in Bhilwara district (as on May 8, 2020).

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Figure 2: Date-wise COVID-19 cases in Bhilwara district and public health interventions taken (n = 42) (as on May 8, 2020).

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The source of infection was initially thought to be the contact of one of the medical staff with a history of foreign travel. Although, it was later informed by the Banger Hospital administration that the likely source of infection could have been a patient who was admitted to the ICU, who was later transferred to another health facility and died.

In view of lack of information regarding the definitive source of infection, the district administration along with the medical authority decided to seal and screen the whole population of the district. The strategy to eliminate the local transmission of COVID-19 outbreak in Bhilwara district was modeled under six pillars (Bhilwara model) [Figure 3] as under:
Figure 3: Bhilwara model for cluster containment of COVID-19 outbreak.

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Pillar 1: Committed and compelling administrative and public health leadership

As soon as the outbreak was confirmed, the overall administrative charge was taken over by the District Collector. Immediate mobilization of the public as well as private resources was commenced for swift action in containment processes. Public health experts from national, state, and medical colleges were deployed in the affected area for designing an effective microplan for the purpose of mapping, surveillance, contact tracing, and institutionalizing quarantine and isolation facilities.

RRT of health experts from the state including specialists from Public Health, Epidemiology, Respiratory Medicine, Pediatrics, General Medicine, Microbiology and Otorhinolaryngology from RNT Medical College, Udaipur; Integrated Disease Surveillance Programme District Epidemiologist; and Surveillance Medical Officer of National Polio Surveillance Programme WHO India were also mobilized for further situational analysis and timely implementation of containment measures.

Pillar 2: Containing the infection at the point of origin

The apparent source or the epicenter of the disease transmission, i.e., the Brijesh Banger Memorial Hospital, was sealed immediately. All admitted patients at the health facility were transferred to other nearby hospitals, and standard disinfection procedures were performed.[7] The District Health Authority along with the help of the administrative body of the district immediately started the process of delineating the containment and the buffer zone, as per guidelines of the Ministry of Health and Family Welfare, Government of India.[8]

Search for the cases

The Chief Medical and Health Officer (CM&HO) of the city, a public health expert, along with his team started the process of line listing of all the high-risk contacts. A line list of 613 inpatients, 96 ICU patients, nearly 5600 outpatients, and 350 staff working in the hospital premises was prepared for screening for COVID-19.[9] All the high-risk contacts were screened on the priority basis and quarantined at the identified centers. Listing, tracking and isolation of other 36 patients who relocated themselves in 4 other states and 498 in 15 other districts of Rajasthan in the last 28 days, was also done in order to contain the disease transmission. The authorities in these states and districts were informed to track and isolate these patients.

Contact tracing and follow-up of cases of Bhilwara revealed that a total of 27 cases have been observed to be connected to Banger Hospital. This might have happened due to inadequate infection control practices in the hospital exposing to HCWs, patients, and their attendants.

Pillar 3: Protecting the uninfected

Door-to-door active surveillance

In view of the prevailing threat of local transmission of the disease owing to the high-risk exposure at the health facility, more than 1100 Mobile Health Teams were trained by the specialists and deployed for door-to-door screening for any influenza-like illness (ILI) of all the residents as well as migrants of the district. Within a span of the next 7 days, the whole district population of nearly 30 lakh was screened.[10] This aggressive first cycle of screening was followed by another round of screening in the subsequent week of all contacts of the patients who reported ILI.[11] Patients having symptoms related to COVID-19 were sampled and isolated, while the asymptomatic were home quarantined.

Implementation of the curfew

The city and the district borders were immediately sealed with twenty checkposts at all points of entry/exit. Curfew was also enforced under section 144 in the city.[12] All the public transports including the train and bus services were stopped with immediate effect. Strict sealing measures of the city were taken with the help of city-wide police checkposts, with strict administrative actions, in case of any break in the curfew. All the checkposts were further empowered with doctors and HCWs for screening of the population crossing the checkposts.

Other novel measures taken by the district administration

  • Rajasthan Social Media Platform application, available on both Android and iOS devices, was designed and used for Global Positioning System tagging and localization of all the suspects who were advised home quarantine measures.
  • Rotational duties of medical staff providing health care including 1-week work in the health-care facility followed by 2 weeks of quarantine were done in order to minimize the infection among them.
  • Home delivery of all the essential supplies including food grains, fruits, vegetables, and milk to the whole population was ensured in order to restrict the movement and eliminate community exposure.
  • Regular disinfection of all the hotspots, including containment and the buffer zone, offices dealing with the epidemic containment, areas near the residents of positive cases, ambulances, police vehicles, and all the health facilities catering to the suspects and the positive cases, was practiced with the 1% sodium hypochlorite solution.


Pillar 4: Rapid establishment of all levels of COVID-dedicated health-care infrastructure

Rapid measures to identify the facilities for patient management were started. Quarantine centers were established including 27 hotels (with nearly 1500 single isolation rooms), institutions, and hostels with dormitories with around 13,000 beds for admission of suspects and mild symptomatic cases. The district hospital of Bhilwara with a capacity of 200 beds which could be expanded to nearly 400 (if required), along with 4 other private hospitals, was converted to dedicated COVID hospital for management of moderate-to-severe cases.

Pillar 5: Capacity building of the workforce in implementation of containment guidelines

Training of all the medical, paramedical, administrative staff as well as the police workforce working at the grass-roots level was conducted by the State and District RRTs. Monitoring and empowerment of the staff including the ground-level corona fighters[13] was done by the Subdivisional Magistrate, Block Development Officers, CM&HO with the help of video conferencing and sharing of all the containment guidelines with detailed individual roles and responsibility as per the state guidelines.[7] The staffs were also trained for appropriate use of personal protective equipment including facemasks and effective hand hygiene practices. A 24 × 7 helpline was established at various offices including Collectorate, CM&HO Office for round the clock support.

Pillar 6: Strong intersectoral coordination of both administrative and medical arm pledging toward transforming a state epicenter of COVID-19 epidemic to zero case zone in a short span

The textile city of Bhilwara started as an epicenter of COVID-19 in the state of Rajasthan was able to curtail the epidemic with zero locally acquired case in the whole district since April 9, 2020. One of the strongest keys behind the interruption of the disease transmission chain was the strong intersectoral coordination, starting from the ground-level field workers to the highest administrative authority and their commitment to adhere to the designed action plan, as suggested by the Central Government.


   Discussion Top


Even in the presence of well-established containment guidelines by the center, many regions of the country experienced cluster outbreak but could not hold the spread of epidemic, as achieved by Bhilwara district.[14],[15] Thus, stringent implementation of the cluster containment plan became the backbone in Bhilwara's success story. The active surveillance activity was broadened even beyond the containment zones covering the whole population of Bhilwara district. This extended surveillance activity also acted as a booster in early identification of even a single case.

One of the other major reasons behind the hospital outbreak could have been the breach in the infection control practices. Thus, diligent execution of infection control protocol without fail becomes very important to protect the HCWs in the health facilities.[14] The same was done in the identified COVID-19 hospital, i.e. MG Hospital, Bhilwara, and not a single case was reported. The district reported 15 more cases after April 3, who were either epidemiologically linked to other positive cases or had a history of interstate travel. All the later cases were found outside Bhilwara city, in other parts of the district. Thus, in the presence of well-implemented cluster containment strategy limiting the number to cases to mere 42 cases, the antecedent threat of community transmission in the district was efficiently interrupted.[16]

Although the “ruthless containment” strategy was effective in containing the spread and breaking the chain of disease transmission, the application of this model in other clusters, especially the large one, remains debatable, owing to the scarcity of trained human resource.[17] Thus, further remodeling of the strategy can be done to fit the local needs of the affected cluster. The paucity of trained public health professionals, especially in epidemiology in the country at all levels to tackle such disease outbreaks, has been observed. Thus, strengthening of the public health workforce becomes the need of the hour.[18]

In view of trade and travel across the country, the COVID-19 epidemic spread to many districts of the country including in Rajasthan in a very short span of time. Although Bhilwara district was successful to reach zero locally acquired COVID case, the future challenge lies, once the lockdown is relaxed and inter-district/state travel begins. Thus, again posing a risk of re-entry of the new cases. It needs to be taken care of, with the help of both stringent administrative measures and screening at all points of entry. In view of paucity of literature in the field of cluster containment for COVID-19, the present study might help the other regions to devise their own strategy.


   Conclusion Top


Bhilwara had reported the outbreak of COVID-19. The exemplary leadership shown by the district administration and public health and medical team with guidance of central- and state-level experts leads to meticulous planning and its execution with community support. This is summarized in six pillars and has resulted in bringing down the cases to zero by effectively eliminating the local transmission in the district and has become a model for the rest of the country. The challenge lies in retaining these gains when the restrictions on movements are eased in the future. The team in Bhilwara needs to stay vigilant to pick up any imported cases early before local transmission starts.

Acknowledgment

The cooperation received from the state and district administration is greatly acknowledged. We would like to mention the name of Shri Rajendra Bhatt IAS, District Collector, Bhilwara; Dr. Mustaq Khan Kayamkhani MD, CM&HO, Bhilwara; Regional RRT in particular Dr. Gautam Bunkar, Physician, RNT Medical College, Udaipur; Shri Harendra Singh, IPS, Superintendent of Police; Shri Rahul Joshi, RPS, Dy SP; Shri Rohit Kumar Singh IAS, Additional Chief Secretary (Health) to Government of Rajasthan; and Dr. K. K. Sharma, Director Public Health without whom it would not have been possible to accomplish the task in record time. The confidence shown on us by senior officers of the Ministry of the Health and Family Welfare, Government of India, is also gratefully acknowledged. Last but not the least, the cooperation of community members, all the staff of Bhilwara district, and dedication of many unsung heroes is appreciated in this endeavor of national importance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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