Indian Journal of Public Health

BRIEF RESEARCH ARTICLE
Year
: 2022  |  Volume : 66  |  Issue : 1  |  Page : 67--70

Evaluation of point of entry surveillance for COVID-19 at Mumbai international airport, India, July 2020


Khyati Aroskar1, Rajesh Sahu2, Sushma Choudhary3, Achhelal R Pasi4, Pragati Gaikwad5, Tanzin Dikid6,  
1 India Epidemic Intelligence Service Officer, Epidemiology Division, National Centre for Disease Control, New Delhi, India
2 Professor, Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
3 Program Adviser, South Asia Field Epidemiology Network (SAFETYNET), India
4 Joint Director, Airport Health Officer, Airport Health Organization, Mumbai, Maharashtra, India
5 Deputy Airport Health Officer, Airport Health Organization, Mumbai, India
6 Joint Director, Epidemiology Division, National Centre for Disease Control, New Delhi, India

Correspondence Address:
Khyati Aroskar
India Epidemic Intelligence Service Officer, Epidemiology Division, National Centre for Disease Control, 22, Sham Nath Marg, Delhi - 110 054
India

Abstract

India started Point of entry (PoE) surveillance at Mumbai International Airport, screening passengers returning from coronavirus disease (COVID-19)-affected countries using infrared thermometers. We evaluated in July 2020 for March 1–22 with the Centers for Disease Control and Prevention evaluation framework. We conducted key informant interviews, reviewed passenger self-reporting forms (SRFs) (randomly selected) and relevant Airport Health Organization and Integrated Disease Surveillance Programme (IDSP) records. Of screened 165,882 passengers, three suspects were detected and all were reverse transcription-polymerase chain reaction negative. Passengers under-quarantine line-listing not available in paper-based PoE system, eight written complaints: 6/8 SRF filling inconvenience, 3/8 no SRF filling inflight announcements, and standing in long queues for their submission. Outside staff deployed 128/150 (85.3%), and staff: passenger ratio was 1:300. IDSP reported 59 COVID-19 confirmed cases against zero detected at PoE. It was simple, timely, flexible, and useful in providing information to IDSP but missed cases at PoE and had poor stability. We recommended dedicated workforce and data integration with IDSP.



How to cite this article:
Aroskar K, Sahu R, Choudhary S, Pasi AR, Gaikwad P, Dikid T. Evaluation of point of entry surveillance for COVID-19 at Mumbai international airport, India, July 2020.Indian J Public Health 2022;66:67-70


How to cite this URL:
Aroskar K, Sahu R, Choudhary S, Pasi AR, Gaikwad P, Dikid T. Evaluation of point of entry surveillance for COVID-19 at Mumbai international airport, India, July 2020. Indian J Public Health [serial online] 2022 [cited 2022 Jun 30 ];66:67-70
Available from: https://www.ijph.in/text.asp?2022/66/1/67/342592


Full Text



The World Health Organization declared coronavirus disease (COVID-19) as a Public Health Emergency of International Concern on January 30, 2020.[1] India started point of entry (PoE) surveillance at three international airports: Mumbai, Delhi, and Kolkata from January 18, 2020 to March 22, 2020 (international flights prohibited).[2] Airport Health Organization (APHO) was the nodal agency for PoE surveillance. Stakeholders who benefited were the public and private partners of the airport and the Integrated Disease Surveillance Programme (IDSP): Central Surveillance Unit, State Surveillance Unit (SSU), and District Surveillance Units. The SSU regularly disseminated and utilized information generated from the system.[3]

All arriving passengers filled a self-reporting form (SRF). The form included information on flight, seat, and phone number and the presence of COVID-19 symptoms. Initially, only field workers from APHO screened arriving passengers for temperature above 38°C with infrared thermometers as the Ministry of Health and Family Welfare guidelines.[4] IDSP cross-notified APHO if COVID-19-positive travelers were identified in the community. The APHO then extracted details of the copassengers traveling from the concerned airline.

With increasing cases and the need for a multiple stakeholder response, we evaluated the PoE surveillance attributes to assess if it met its objectives (identify cases early and raise awareness) and provide evidence-based recommendations to strengthen the system.

We conducted a cross-sectional evaluation at Mumbai PoE in July 2020. We used the COVID-19 surveillance definitions.[4] We evaluated the surveillance system with attributes of simplicity, stability, acceptability, timeliness, data quality, flexibility, sensitivity, positive predictive value, and usefulness [Table 1].[5] We reviewed passenger SRFs selected by simple random sampling and all relevant records collected during passenger screening from March 1 to 22, 2020 (reference period). The records included the daily report format “A” reported from APHO to IDSP, which had the number of suspect passengers, inventory, APHO registers, and official e-mail records. We reviewed the Maharashtra SSU COVID-19 line list containing demographic details, foreign travel history, and date symptom onset and interviewed cases arrived at PoE from the line list. We referred to guidelines for notified countries and the WHO enlisted countries with COVID-19 local transmission.[4],[6]{Table 1}

We identified key informants: medical officers, airline representatives, airport operators, medical services representatives, immigration, security, and customs officials, APHO officers engaged in screening for the entire reference period, and passengers screened (randomly selected). We interviewed using a semi-structured questionnaire and entered data in Microsoft Excel with analysis for frequencies and proportions using Epi Info.

The evaluation was an urgent public health response and was exempt from scientific and ethical review by the National Centre for Disease Control. All ethical guidelines were adhered to and evaluation aimed at achieving public good (beneficence) and collective welfare (solidarity), no harm was done to any individual (nonmaleficence), fair, honest, and transparent (accountability and transparency), and data was deidentified before analysis (confidentiality). The evaluation was conducted after obtaining necessary permissions from institutional authorities with the involvement of stakeholders.

We extracted 400 passenger SRFs and 22 days of records (daily reports, inventory, attendance, and official e-mail records). The PoE surveillance screened 165,882 passengers arriving from notified countries using infrared thermometers from March 1 to 22, 2020.

From March 1 to 14, 2020, PoE surveillance screened 111,394 passengers, of which one passenger was identified as a COVID-19 suspect; from March 15 to 22, of screened 54,488 passengers, isolated suspects were two.

The medical officers (2/2) were aware of complete case definitions; reported screening was easy to perform. They conveyed that some airlines provided “passenger manifests” on the arrival of flight. This document had the passenger's line listed and their seat numbers in flight. This made it simpler to cross-verify any missed paper-based SRFs.

The ratio of staff: passenger per day was 1:300. There were 22 staff from APHO for screening and 128 staff deputed from central, state, and local government health services. Thus, 128/150 (85.3%) staff were from outside agencies. APHO stored passenger SRFs papers bundled by flight number and date. There was no record of screening disruption in the reference period.

Of the four arriving passengers interviewed, all (4/4) had filled the SRFs by themselves (4/4). They conveyed that their copassengers had difficulty filling SRFs, as airline staff did not inform passengers that SRFs were mandatory. In addition, the forms were only provided in English and no additional support was given to them for translation.

The proportion of completely filled passenger SRFs were 392/400 (98%). Passengers submitted eight e-mail complaints including a presentation noting the inconvenience of filling the SRF (6/8) and standing in long queues (3/8). The presentation submitted highlighted that no inflight announcements were made; no information about quarantine given before landing.

The daily screening format “A” report was sent timely, daily until noon (22/22). There were COVID-19-positive travelers identified by IDSP twice, and APHO gave their flight details as feedback. APHO extracted details of the copassengers traveling from the concerned airline and gave to IDSP within a day.

The system was manual and paper based. The daily paper-based screening format “A” was completely filled on all days (22/22).

Of the 400 selected passenger SRFs, 49 had newly added variables. These variables were nationality, age, and comorbidities. SRFs with newly added variables filled were 100% (49/49).

The proportion of suspected cases identified at PoE screening among COVID-19-positive travelers later detected by Maharashtra SSU was zero (0/59). Of the 59 detected by SSU, 20 laboratory-confirmed cases answered our call. Of the 20, five reported being home quarantined and tested COVID-19-positive. Only one of the five got tested on symptom onset (1/5), rest four self-reported for fear of disease onset. Of the 59 cases, 47% (28/59) had travel history to the Middle East, of which 25 had traveled to the United Arab Emirates [Figure 1]. The PoE/SSU had no line listing of the categorized passengers though numbers were available.{Figure 1}

The three passengers sent for isolation and testing at the hospital were negative by reverse transcription-polymerase chain reaction. The proportion of isolated detected positive from PoE was zero.

The system contributed to control of COVID-19 by sharing suspect SRFs with IDSP for passenger follow-up regarding the development of COVID-19 symptoms. In addition, provided IEC to the passenger for COVID-19 and contacting concerned health authority.

However, APHO did not get line listing with inbuilt feedback absent for the positive patients diagnosed later through IDSP. The evaluation of the surveillance system revealed that as a response to the ongoing COVID-19 pandemic, the system screened passengers arriving from notified countries. In the beginning, system only detected suspects, but later on with the introduction of categorization, it detected high-, medium-, or low-risk suspects. The PoE surveillance system provided useful passenger's SRFs to the IDSP network for follow-up regarding the development of COVID-19 symptoms. However, the PoE system did not detect any COVID-19 cases.

The system was simple but could have been improved if the SRFs were not paper based and airlines would have submitted the passenger's inflight document before the arrival of flight. The stability of the system was questionable as maximum workforce available was from agencies outside of APHO. As there was no line listing feedback of the positive confirmed cases to APHO, the system depended on feedback taken independently. We recommend complete automation of data with line listing both ways from IDSP and APHO can help in the early identification of cases.

With multiple complaints, efforts to automate data such as the implementation of electronic SRFs should help improve the acceptability, stability, and usefulness. Furthermore, prior inflight information of all standard operating procedures in detail needs to be ensured. Timeliness and data quality was good. Even the newly added variables changed in the passenger SRF were incorporated well. The SRF should have included demographic details from the beginning. However, as PoE surveillance was paper based, all records were stored bundled. All studies emphasized that since the disease surveillance network reported cases, health care strengthening (both community and hospital based) is required alongside.[7],[8]

Our review indicated that cases could have been detected if the notified list for quarantine also had the Middle East included in March 2020.[9] The United Arab Emirates had local transmission from March 1, 2020, as per the WHO situation report no. 41 onward but were not included as the notified countries at PoE for quarantine till March 18, though universal screening started. Our data shows that 47% of early cases were from this region in Maharashtra. Systematic review reported several positive effects, including discouraging travel of ill, raising awareness of the traveler, and maintaining the operation of flights.[10]

We shared the results of our assessment through appropriate channel of the IHR with all of the stakeholders. A public health action was the introduction of online government airport portal for passenger SRFs as nonscheduled commercial flights started.

During our study, the system was evolving and had many revisions introduced. Hence, some of the findings may not be relevant in the current scenario; however, form an important lesson for future preparedness. Findings of the study cannot be generalized as only one airport PoE evaluated.

Acknowledgment

We acknowledge the following institutions and persons who contributed to this activity: India Epidemic Intelligence Services − Cohort six and seven officers, Dr. Binoy S. Babu, Dr. Chandrakant Moghe, Dr.Valan Siromany, Dr. Kanica Kaushal; National Centre for Disease Control–Dr. Himanshu Chauhan, Dr. Sanket Kulkarni, Dr. S.N. Sharma; Government of Maharashtra State Surveillance − Dr. Pradeep Awate and unit; Central Government Health Services − Medical Officers we interviewed; Chhatrapati Shivaji Maharaj International Airport − Bureau of Immigration, Customs, Central Industrial Security Force, Operator and Medical Services, Airline Representatives; all passengers we interviewed; and the Airport Health Organization staff, Mumbai, India. We thank Dorothy L. Southern for providing scientific writing advice and for critically reviewing the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1World Health Organization Statement, 31 January 2020. Available from: https://www.who.int/news/item/27-04-2020-who-timeline---covid-19. [Last accessed on 2021 Sep 26].
2Ministry of Information and Broadcasting. India's Response to COVID-19. Available from: https://pib.gov.in/PressReleasePage.aspx?PRID=1608727. [Last acessed on 2021 Sep 26].
3Maharashtra, Public Health Emergency Contingency Plan. Available from: https://rfd.maharashtra.gov.in/sites/default/files/DM%20Plan%20final_State.pdf [Last accessed on 2021 Sep 26].
4Ministry of Health and Family Welfare File no. L-21021/01/2020-PH (H) Part dated March 15, 2020. SOP for Categorization of Passengers for COVID-19; 2020. Available from: https://www.mohfw.gov.in/pdf/SOPforqurantine.pdf. [Last accessed on 2021 Sep 26].
5German RR, Lee LM, Horan JM, Milstein RL, Pertowski CA, Waller MN, et al. Updated guidelines for evaluating public health surveillance systems: Recommendations from the guidelines working group. MMWR Recomm Rep 2001;50:1-35; quiz CE1-7.
6World Health Organization Situation Report 41 Dated 2020, March 1. Available from: https://www.who.int/docs/defaultsource/coronaviruse/situateion-reports/20200301-sitrep-41-covid-19.pdf?sfvrsn=6768306d_2. [Last accessed on 2021 Sep 26].
7Pasi AR, Gaikwad PB, Aroskar K, Kumar T, Teddy R, Kundu M, et al. Early detection of suspected cases of COVID-19: Role of thermal screening at international airports in India. Int J Community Med Public Health 2020;7:4817-22.
8Mouchtouri VA, Bogogiannidou Z, Dirksen-Fischer M, Tsiodras S, Hadjichristodoulou C. Detection of imported COVID − 19 cases worldwide: Early assessment of airport entry screening, 24 January until 17 February 2020. Trop Med Health 2020;48:79.
9Gunthe SS, Patra SS. Impact of international travel dynamics on domestic spread of 2019-nCoV in India: Origin-based risk assessment in importation of infected travelers. Global Health 2020;16:45.
10Mouchtouri VA, Christoforidou EP, der Heiden MA, Lemos CM, Fanos M, Rexroth U, et al. Exit and entry screening practices for infectious diseases among travelers at points of entry: Looking for evidence on public health impact. Int J Environ Res Public Health 2019;16:4638.