The air was tense as anxious people kept streaming into the COVID-19 outpatient department and waited for their turn to get screened. Nursing superintendent (grade II) A. Sheela, a nurse for over 25 years, had her job cut out, but the uncertainty brought in by a new virus did unsettle her.
Armed with a N95 mask, gloves and cap, she might have lost count of the number of persons who crossed her path each day. But she remembers the fear on their faces. That was in early 2020, when SARS-CoV-2 started surging in Tamil Nadu and the mildest of coughs and fever sent shivers down the spine of people. Three years later, in the midst of yet another gradual rise in fresh infections, precaution and better know-how have replaced fear and uncertainty as Ms. Sheela walks around the State’s largest government health facility — Rajiv Gandhi Government General Hospital (RGGGH) — reminding people of the need to wear masks and keep their hands clean.
“When it all started, we knew very little and had no idea of what would happen next. Over the years and through the three waves, we have learned a lot and have clear-cut protocols in place. Now, my focus is on prevention, starting with sanitation on my own campus,” said the 56-year-old nurse, who now takes care of the hospital’s outer sanitation.
Ms. Sheela’s confidence stems from the State’s present outlook. Tamil Nadu, where the COVID-19 cases dropped to the lowest on February 3 this year, is once again tightening surveillance and preventive measures, while ramping up infrastructure, in the wake of a slow, yet gradual, rise in fresh infections since the beginning of March. To start with, the State made masking mandatory at all healthcare facilities from April 1.
Here is a glance at where the State stands: there has been a multifold increase in the daily cases — from 44 on March 15 to 502 on April 15. In a month, the active caseload has soared from 269 to 3,048. Chennai, Coimbatore, Chengalpattu, Kanniyakumari, Tiruvallur and Salem districts top the list. The latest Whole Genome Sequencing data identified the Omicron sub-variant XBB in over 90% of the samples sequenced.
After weeks of no fatalities, five persons — all aged above 60 and having co-morbidities — have died since April 10. However, hospital occupancy remains low — nearly 5% of the active cases are hospitalised.
T.S. Selvavinayagam, Director of Public Health and Preventive Medicine, points out that there will be a gradual rise in infections in the coming weeks, but it will not be exponential. The main concern is that senior citizens, pregnant women and those with co-morbidities are at an increased risk.
“We are at the accelerating stage, and infections will continue to rise for the next 10 to 15 days before dropping. But the current number is only the tip of the iceberg as many with symptoms are not getting tested. Fortunately, a majority of them are having only mild infections,” says Suresh Kumar, consultant, Infectious Diseases, Apollo Hospitals.
There has been no increase in outpatients and inpatients at hospitals, especially government facilities. At RGGGH, about 20 persons with symptoms report at the outpatient department a day, while there are seven inpatients. After the second wave, there has not been any increase in the number of inpatients, says Dean E. Theranirajan. “Yes, there is a rise in the positivity rate but we do not think it may lead to an increase in admissions,” he adds.
The situation is similar at Government Stanley Medical College Hospital. Its Dean P. Balaji says fewer than 10 patients with fever report a day.
“We must watch the daily number of cases and deaths,” explains virologist T. Jacob John. “The present rise in the cases is not a surprise because this was preceded by a period of very low daily number — I say unnaturally low number — from November 2022 through early March 2023, with the number consistently below 1,000, dipping to 100s and a few days even below 100,” he adds.
Dr. John reasons, “India entered the ‘endemic phase’ about a year ago. From November 2022 through early March 2023, we had a low number, which resulted in accumulation of uninfected susceptible people. The present rise is slow and steady, starting from about March 1.”
“There was a very similar rise and fall from June to September 2022, with the peak of just over 20,000 a day. That led to the lull during November 2022 through February-end 2023 that I pointed out earlier. These rises and falls are a natural phenomenon for any endemic disease, rather like influenza. Tamil Nadu is participating in this all-India phenomenon, but Delhi, Kerala, Maharashtra, Haryana and Punjab are more severely affected than Tamil Nadu,” he says.
Dr. Suresh Kumar has two observations. “First, in the last 10 days, we have seen around 100 patients. Most of them have received two doses of COVID-19 vaccine but hardly anyone has taken the booster dose. Second, the classic symptom of loss of taste and loss of smell is back after the first wave.”
Elaborating on the former, he notes that there is an impression that the Omicron variant had swept through the population, but it did not. “Most of the patients say they had no prior COVID-19 infection. This brings us to another point. We are relying on vaccine-induced immunity, which is slowly going down.”
The challenges of poor booster uptake and long COVID-19 remain. “Long COVID-19 is yet to be prioritised. Even after a year of testing positive for COVID-19, patients have complaints of brain fog, inability to think clearly or recollect and fatigue. Some have difficulty in breathing while climbing stairs. These are not only patients who were hospitalised but also those who were in home isolation,” he said.
So far, about 97% of the eligible population aged above 18 have received the first dose of the vaccine in Tamil Nadu. The second dose coverage remains at 92.47%. The booster dose uptake is abysmal: only 13.82% of the 18-59 age group and 25.01% of those above 60 have taken it so far.
Health officials point out that the State has no sufficient stock of vaccine doses right now but it can be arranged, if needed. “The purpose of vaccination is to get protection. There is no second thought about the need for vaccination. However, the decision on introducing new, additional doses and boosters depends on immunogenicity, immune evasion, severity of the disease and the logistics challenges, including the cost. It is purely a scientific decision,” Dr. Selvavinayagam notes.
Dr. John recommends that all adults take full vaccination — two doses and the booster. “Those at extra-risk like chronic non-communicable diseases, organ transplants, cancer/cancer treatment, aged above 70, ought to take a second booster,” he says. Dr. Suresh Kumar wants the government to make available the vaccines. “What has happened to the nasal spray? People are finding it difficult to access vaccines,” he says.
In the past few weeks, the Health Department has stepped up precautionary measures. It is readying infrastructure to meet any surge in cases. Health Minister Ma. Subramanian ,during media interactions, has elaborated on the infrastructure readied.
The State has 64,281 beds for COVID-19 patients. The number could be ramped up to over one lakh, if needed. The oxygen capacity stands increased from 230 metric tonnes in May 2021 to 2,067 metric tonnes now.
At RGGGH, Dr. Theranirajan says the hospital has already convened a preliminary meeting with the heads of the departments. “We have 150 beds earmarked for COVID-19 patients, and have decided to increase the beds to 300 if we reach 30% occupancy.” The hospital has a liquid oxygen tank of 40-KL capacity, and four pressure swing adsorption (PSA) plants of varying capacities.
The Mahatma Gandhi Memorial Government Hospital, Tiruchi, has 110 beds, in addition to 25 in the ICU, to handle COVID-19 patients. There is a separate section for paediatric and pregnant women. The hospital is equipped to conduct 3,500 RT-PCR tests per day, with a sufficient number of kits in reserve. The testing of samples will also go up. “We have an ample supply of medications and testing kits, and we are prepared to deal with the situation if there is a surge in fresh cases,” says Dean D. Nehru.
In Tiruvarur, the Government Medical College Hospital has opened a special COVID-19 ward with 75 beds. “Around 10 doctors and nurses are working in three shifts,” says Dean G. Joseph Raj. In Salem, COVID-19 patients can be treated at Government Mohan Kumaramangalam Medical College Hospital, 13 government hospitals — including those at Attur, Edappadi, and Mettur — and 64 private hospitals. These hospitals have oxygen beds. The COVID-19 Care Centre (CCC) on the Salem Steel Plant premises is also ready.
GMKMCH Dean R. Mani says 100 beds are ready. If cases surge, 100 more can be added to the CCC on the hospital premises, with oxygen facilities.
During his visit to Coimbatore on April 7, Mr. Subramanian said 1,000 beds were ready at the Government Medical College and ESI Hospital, Coimbatore, besides over 100 beds at the Coimbatore Medical College Hospital. A total of 16 oxygen plants had been set up at the ESI Hospital to meet the medical oxygen requirement.
Joint Director of Health Services E. Chandra said around 20 private hospitals in the district, which offered dedicated treatment during the first and second waves of the pandemic, together kept 1,300 beds ready. Other government hospitals set aside 155 beds for COVID-19 patients, she added.
R. Prabhakaran, COVID-19 Nodal Officer for Government Rajaji Hospital, Madurai, says a 40-bed unit is ready. “Further, a 350-bed isolation ward , comprising 250 beds for adults and 100 for children, is ready. Moreover, if at all cases rise, the hospital is equipped to expand the number of beds at the isolation ward to 1,400.” He notes that not more than 15 patients were treated for COVID-19 in the past three months at the hospital.
Private hospitals have also stepped up preparedness.
Apollo Hospitals, Tiruchi, has a team of 14 doctors — including three pulmonologists, four general physicians, three emergency medicine doctors, and four critical specialists — to handle the patients. It has readied a 30-bed ward for COVID-19 patients. About 50 non-invasive ventilators are kept ready. On an average, around 15 samples are being tested a day. Over 10 persons are getting vaccinated a day, says Stephan Prakash Aruldoss, who heads the Emergency Care Department.
MGM Healthcare, Chennai, maintains an isolation wing for COVID-19 and a small respiratory isolation intensive care unit. These facilities can be ramped up, if needed, says Ananth Mohan Pai, director, Medical Services.
(With inputs from Ancy Donal Madonna in Tiruchi; M. Sabari in Salem; S.P. Saravanan in Erode; Wilson Thomas in Coimbatore; and R. Jayashree in Madurai.)