On the frontline, fighting the coronavirus

The Kasturba Hospital in Mumbai has been designated as the nodal isolation facility for COVID-19 patients in the city. (Below): Patients with COVID-19 symptoms wait for medical examination outside ward 9 at the hospital.Vivek Bendre/ Prashant Nakwe  

At 4.30 a.m. on March 1, a flight from Abu Dhabi landed at the Chhatrapati Shivaji International Airport in Mumbai. Among those disembarking from the aircraft was a group of 40 returning from a six-day Dubai-Abu Dhabi tour.

The travellers said goodbye to one another and headed home. Some of them, who live in Mumbai, went home by road. Others began their journey to Pune, Yavatmal, Ahmednagar, Beed and Nagpur. Three women, all senior citizens, went to Belgaum in Karnataka. It is now believed that the novel coronavirus, which has spread like wildfire and brought the world to a grinding halt, travelled with them to Maharashtra.

On March 9, a 51-year-old manager from Pune (to protect his identity, let’s call him Praful) and his 42-year-old wife, who were both part of the tour, tested positive for COVID-19. “It was our first foreign tour. Who had thought we would come back to become the index patients of some new kind of virus?” says Praful, who had booked the tour for his 25th wedding anniversary. Praful had saved for over a year and liquidated some of his fixed deposits to pay for the trip that cost Rs. 85,000 per person. To feel at ease in a new country, the couple also took their 23-year-old daughter along. She too tested positive for COVID-19 the next day, along with the cab driver who ferried them from Mumbai airport to Pune.

“I had started feeling feverish the day we reached home. I popped a paracetamol and went to a doctor the next day,” says Praful. At the time, he says, his wife and daughter had no symptoms. “The medication worked initially. But the fever returned. That’s when the doctor suggested that I go to the civic hospital to test for COVID-19.” On March 9, when he visited the Naidu Hospital, doctors took his throat swab and sent it for testing. His wife, a close contact, was also tested. The reports from Pune’s National Institute of Virology (NIV) laboratory arrived a few hours later. Both Praful and his wife had tested positive for COVID-19. This triggered a flurry of activity at the hospital. The couple was forbidden to leave the premises. “We thought that would last 4-5 days. But it’s nearing two weeks now,” says Praful, who has been admitted in the isolation ward of Naidu Hospital.

What followed was nothing short of an investigation. The minutest movements of the couple had to be pieced together. Two doctors sat with Praful and his wife separately to probe what they had done over the last eight days. One of them was Anil Todsam, the residential medical officer at Naidu Hospital. “History-taking is a tedious task, especially when you are not simply asking medical questions but general questions about their everyday life,” he says. Todsam prepared a list of people with whom Praful’s wife had interacted. The list was mind-boggling. It included vegetable vendors, the milkman, neighbours, yoga classmates, and a large group of women she had mingled with at a Women’s Day event. Todsam began jotting down as many numbers as possible. The exercise took him more than three hours.

On the other hand, Praful had limited contacts. He had been to work one day. Two of his colleagues who sat close to him were put on the watch list. The couple’s daughter, a 19-year-old son who did not join them on the trip as he had exams, and the cab driver were also summoned. At the end of the day, a list of nearly 50 contacts was drawn up.

Meanwhile, the larger contact-tracing exercise had begun. “We got in touch with the tour operator and fetched the list of all the group members,” says Ramchandra Hankare, the chief medical officer of Pune Municipal Corporation. When Hankare saw the list, he panicked a little. “The group had dispersed to many corners of the State.”

The beginning in Hubei

In December 2019, China first noticed a cluster of patients with pneumonia in Hubei province. On December 31, it informed the World Health Organization about the cases. The cause of the disease was still undetected. The fact that a new virus had surfaced began to be widely discussed and the world closely followed the developments in Hubei. The primary response was to start screening passengers at airports.

On January 18, the international airport in Mumbai, India’s second busiest airport, began screening all passengers arriving from China. Travellers feared to have been exposed to the virus were sent to isolation wards as a precautionary measure and their samples were sent to NIV, Pune. By March 1, when the group of 40 returned to India, the screening had been extended to travellers coming from 11 other countries: Iran, Italy, Vietnam, Nepal, Indonesia, Malaysia, Hong Kong, Thailand, Singapore, Japan, and South Korea. The UAE did not feature on this list.

“The airport was chaotic when we landed. We must have spent nearly three hours there as many flights had landed around the same time. But we were not screened,” recalls Praful. Two days after the couple from Pune became the index patients in Maharashtra, a senior citizen couple from Mumbai, who had travelled in the same group, tested positive for COVID-19 too. By then, the State had activated its Integrated Disease Surveillance Programme cell and informed the civic bodies and district-level officers. “Within a day, the entire Dubai tour group was tracked and brought to hospitals and their contacts were traced. The Karnataka government was also alerted as three people from the group were from there,” says Anup Yadav, who heads the Directorate of Health Services, Maharashtra. At first, doctors at the airport screened people but as more countries got added to the list, over 100 doctors from the civic body as well as the State had to be posted there in rotational shifts, he says.

‘Like soldiers posted on borders’

Vishal Rakh, a 29-year-old speciality medical officer from the civic-run Nair Hospital in Mumbai, was among the first lot of doctors who were posted at the airport for screening. Armed with a thermal gun, an N95 mask, gloves and surgical caps, Rakh’s primary role was to detect high temperatures and probe the history of travellers. “For the first few days, travellers were extremely impatient. Many would argue with us because the screening caused them delays. But as news about COVID-19 continued to spread, they began to cooperate,” he says. “Most of the travellers are asymptomatic. But they could be in the incubation period and infectious,” says Rakh, who has referred two senior citizens to the Kasturba Hospital’s isolation facility in the past one week. “Both had a fever, co-morbid conditions, and a travel history to COVID-19-affected countries,” he says.

The travellers are divided into three categories. People coming from COVID-19-affected countries and showing symptoms like fever, cough and cold fall in Category A. Those with no symptoms but having co-morbid conditions or who are senior citizens fall under Category B. And those with a travel history but no symptoms fall under Category C. “We had the highest workload during night shifts as most international flights land at that time,” says Rakh. He adds that on an average, they screen 80-90 travellers each during one shift.

At the Kasturba Hospital, Mumbai’s nodal isolation facility, 35-year-old resident doctor Avkash Sinha is among those posted on ‘COVID-19 duty’. He is the first point of contact at ward 9 where a dedicated COVID-19 outpatient department (OPD) has been opened. He has also been on rounds in wards 27, 28 and 29, which are the quarantine wards for those awaiting results. “Ward 30, which is the isolation facility, is the most restricted ward. Only treating doctors go in and out of that ward. That’s where all the patients with COVID-19 are kept,” says Sinha, who studied medicine at the Armed Forces Medical College in Pune and has completed Short Service Commission. “We are like soldiers posted on borders. The enemy here is the virus and our efforts are meant to protect the general population,” says Sinha, who was posted in Jammu and Kashmir for three and half years. While serving in the Army cantonments, he dealt with infectious diseases like chickenpox. “As doctors, we are constantly at risk. But we have responsibilities as well,” he says. All the doctors have made a pact that they will eat food on time, follow good hygiene and infection-control practices, and be well-rested so that they can serve better, he says. “My parents back home in Jharkhand are concerned. I have assured them that I will be cautious,” he says.

In the laboratory

When fear of the virus crept into India, Pune’s NIV was the only laboratory in the country to test samples. By February, the laboratory at Kasturba Hospital was prepared share the load. Trained healthcare staff collect samples from the back of a suspected patient’s throat on tiny nylon or dacron swab sticks and dip them in test tube bottles containing a liquid meant to keep the virus viable for testing. These bottles are carried in a thermos-like vaccine carrier to the Polymerase Chain Reaction (PCR) laboratory on the ground floor of the isolation facility at Kasturba Hospital. As the samples arrive, the scientific officers spring into action.

The samples are first put into a lysis buffer solution that helps in breaking the cells and rendering the virus non-viable. Next, the process to extract the RNA of the virus begins, followed by PCR amplification and detection using the real-time PCR system which is connected to a computer running graphs. It is the movement on these graphs that tells us conclusively about the presence of the virus in a sample.

“In a positive test, it takes anywhere between three to five hours to get a screening result and another two hours for the confirmatory result,” says microbiologist Jayanthi Shastri, who is at the helm of the Mumbai lab. The lab is working four shifts to test samples 24X7. At present, the facility tests 100-150 samples daily.

“Sample collection is the most critical step in the entire process,” she says. “The healthcare staff has to rub the swab stick in such a way that enough cells are collected. If that’s not done properly, we cannot interpret the results and the test has to be repeated.”

When more and more cases were reported in Hubei, the scientists were not surprised that the virus moved closer home. “We were not in a slumber. The question in our mind was, will this new virus really hit us? Because, for some reason the SARS outbreak in 2002 never did,” says Shastri. She adds that preparedness of testing facilities began from January 28 when the Indian Council of Medical Research held its very first zoom meeting. “It helped that China released the genetic sequence of the virus on January 11. We got some time to prepare,” she says.

Shastri and her team had an added advantage. In 2009, when the H1N1 pandemic hit the world, the Kasturba Hospital’s PCR laboratory was upgraded to test respiratory samples for the first time. “Till then we were testing blood samples. But to test respiratory samples, a special set up was needed for the safety of the scientists and technicians who are handling the virus,” she says.

Viruses like H1N1 and SARS-CoV-19 latch on to the nasal epithelium. So, the team has to ensure that there is no possibility of aerosolisation (the process of converting some physical substance into the form of particles small and light enough to be carried in the air) in the room where the samples are being handled. Shastri’s team of eight, including scientific officers and technicians, wear protective gear like goggles, gloves and medical gowns and work within special biosafety cabinets with HEPA filters that ensure that the harmful pathogens don’t come in contact with them.

But they cannot completely ignore the risks associated with their job. “Doctors in wards and OPDs deal with patients. We deal with the virus directly. The risk is equal,” says a doctor from the lab, adding that the key is to practice caution instead of being paranoid.

Basic requirements missing

By Friday, 14 people from the Dubai group tested positive for COVID-19 and five of their close contacts were also infected. In Maharashtra, the number of cases jumped to 53, the highest in India. The death of a senior citizen in Mumbai triggered a debate on the State’s preparedness to contain and treat complications. He was on non-invasive ventilator support. Kasturba Hospital, which has admitted all the positive patients from the Mumbai Metropolitan Region, does not have a full-fledged ICU. Medical experts say that negative pressure with changing air conditioning cycles, HEPA filters, ultraviolet lights and anterooms are essential for any isolation facility admitting infectious patients.

“The State’s isolation facilities are simple rooms where patients are kept in isolation. The basic requirements of a good isolation facility are missing,” says a doctor. Given that we are dealing with a virus that attacks the respiratory system, ventilators and other supportive devices are crucial. “How many of our district hospitals even have intensive care units and ventilators,” asks public health activist Abhay Shukla. “The capacity of our public hospitals has to be upgraded before the epidemic accelerates,” he says. Dr. Shukla, who is the co-convener of Jan Swasthya Abhiyan, says the health system in Maharashtra is highly privatised. “In public health emergencies like these, the State has to in-source private facilities and take control of them,” he says.

Experts say that the epidemic is urban so far, but Maharashtra is a globalised State like Kerala, which puts people at high risk. “The population density varies, but we are 50% urbanised. Social distancing and avoiding crowds are steps in the right direction. But we cannot predict how it will turn out.”

Such epidemics can throw up surprises. For instance, when three people who were a part of the Dubai tour tested positive in the drought-stricken Yavatmal district, nearly 700 km away from Mumbai, the authorities were taken aback. “We have been reading about it in the news but never thought that the virus would reach us,” says Milind Kamble, dean of the government medical college in Yavatmal where the positive patients have been isolated.

Mumbai-based infectious disease specialist Om Shrivastava agrees. The numbers are not overwhelming as of now, he says. “We are in stage two of the epidemic where transmission is still local. Our efforts should be to stop entering stage three, which is community transmission,” says Shrivastava. He says the Maharashtra government’s response has been commendable so far. “We have implemented lockdowns, restricted movement. But we are dealing with a brand new, sly, mysterious virus and it’s hard to predict how it will all pan out,” he says. Many experts, including Shrivastava, say that Maharashtra needs to scale up testing. “We should not be complacent. We have to be watchful,” he says.

At the Naidu Hospital, the index patients and their daughter have now been shifted to the same room. There is considerable distance between their cots. The couple’s son, who did not test positive, has been quarantined on another floor. The trio spend their time watching movies and listening to bhajans on their phones. They are in touch with all the members of the tour group on WhatsApp. Often, the couple skims through pictures from their trip to the Burj Khalifa, Ferrari World, miracle garden, and the mosques. “Everything was so clean and beautiful. I wonder where we got the virus from. It could be from the crowded malls we visited,” says Praful. “Initially, people made us feel like culprits. Our names and photos were circulated. It was disturbing,” he says. “This is a flu. Why does one have to stigmatise so much?”

We have implemented lockdowns, restricted movement. But we are dealing with a brand new, sly, mysterious virus and it’s hard to predict how it will pan out.

Om Shrivastava

Infectious disease specialist

Sample collection is the most critical step. The healthcare staff has to rub the swab stick in such a way that enough cells are collected. If that’s not done properly, we cannot interpret the results and the test has to be repeated.

Jayanthi Shastri