This year, on World Health Day, April 7, a patient asymptomatic for COVID-19 was admitted with chest pain in a hospital in Maharashtra. Diagnosed with coronary artery disease, he was treated surgically. Five days later he developed COVID-19 pneumonia and eventually succumbed. Did he come infected or did he get infected in the hospital? Either way, evidence is clear for community transmission. The hospital was closed for containment of further transmission.
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Similar events have recurred across several parts of the country. At the All India Institute of Medical Sciences, New Delhi, many doctors, nurses and other staff became infected with SARS-CoV-2 and had to be quarantined, depleting a range of health-care professionals. On April 8, a government hospital in Jahangirpuri, Delhi, was closed after 14 doctors and nurses were found positive for the novel coronavirus infection. Recent reports indicate that one in 15 SARS- CoV-2 infected individuals in the national capital is a health-care worker.
What about individual medical practitioners? On April 9, a 62-year-old physician in Indore, Madhya Pradesh, to whom many slum-dwellers came for care, died of COVID-19, despite treatment. The Chief Medical Officer (CMO) told the media that his contact history was unknown — most likely from a patient. Did the doctor lower his guard, as the official version was “no community transmission in India”?
The next day, an Ayurvedic physician, aged 65, died of COVID-19 in Indore. Again, the CMO confessed that contact history was unknown: perhaps from some patient.
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On April 14, a popular 76-year-old “family doctor” died of COVID-19 in Kurnool, Andhra Pradesh. After retiring as Medical Superintendent of Kurnool Medical College, he ran a private hospital. On March 25, he closed the hospital, complying with the lockdown. He died; his wife and children tested positive for the novel coronavirus. The doctor’s contact history could not be traced; most probably from a patient.
A 55-year-old neurosurgeon died in Chennai on April 19, with severe COVID-19. Once again the contact remains unknown — one of his patients is a good guess. Without proclamation of community transmission, respiratory precautions were perhaps deemed unnecessary by these doctors.
In all these situations, a correct understanding of the nature of the epidemic and acknowledging community transmission would have alerted the medical profession and avoided a loss of lives.
Epidemiologically important
What is community transmission? One infected person in the community, unaware that he is infected, infects others in the community. If A was infected by a known contact B, in epidemiology we say B infected A. When contact is unknown we say ‘someone in the community’ infected A; hence the term “community transmission”. When did community transmission begin in India? On March 18, Tamil Nadu reported the second infection in the State, an example of community transmission. A 20-year-old man travelled by train from Delhi and had no contact with any known infected person. In Chennai, he developed symptoms and tested positive on March 18. So community transmission had started in India by, or before, mid-March 2020.
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Every pandemic emerges from a country of origin — the 2009 H1N1 influenza pandemic originated in Mexico and COVID-19, in China. For every other country, the initial infection would be “imported” from another country. Importation means that the traveller got infected in a foreign country but developed symptoms and got diagnosed in the host country. If secondary transmission occurs from the imported infection, it is qualified as contact of imported case. If the importation-contact further infects someone in the host country, such infection by in-country transmission is called “local”, “indigenous” or “autochthonous” infection. This is epidemiologically important information. It indicates the start of in-country epidemic, in other words, when the imported infection becomes indigenous. As the epidemic advances, community transmission is natural and inevitable. If the intention is to intercept chains of transmission, then there should be acknowledgement of indigenous (community) transmission.
Necessary step
A country denies community transmission at its own peril. In times of epidemics, leaders may be tempted to deny the problem: but, prudence is the better part of valour. Once community transmission of COVID-19 came to light on March 18, warning all medical professionals, coupled with strong recommendations for strict implementation of appropriate protective gear by all health professionals in all levels of health care, was the correct public health procedure.
The lives of many health-care professionals need not and should not have been lost on account of semantic mis-interpretation of epidemiology. Admitting community transmission does not lower the honour of mother India in the eyes of foreigners; on the contrary it boosts the sagging morale of health-care professionals, prevents avoidable loss of manpower in the face of the epidemic, and preserves the integrity of the entire health-care system.
Protecting the lives of health-care professionals by acknowledging community transmission and strict implementation of appropriate personal protective equipment will ensure that there is no attrition of the pool of health-care professionals needed to deal with the epidemic. Such a courageous step, taken with openness, only enhances national prestige.
Dr. T. Jacob John is Retired Professor of Virology, Christian Medical College (CMC), Vellore. Dr. M.S. Seshadri is Retired Professor of Medicine, CMC, and now Medical Director, Thirumalai Mission Hospital, Ranipet, Tamil Nadu
