The seven-month journey has been fraught with challenges and some successes. What is clear is that there can be no let up in the future with regard to prevention, treatment and follow up activities, for what we have seen of the pandemic so far, is merely the tip of the iceberg.
In a span of seven months, Tamil Nadu has gone from 124 to 7,06,136 cases of COVID-19. The journey into the pandemic has been dotted with ups and downs. But healthcare providers and policymakers know that it is nowhere near the end. Even though fresh COVID-19 infections are falling in the State, newer challenges are emerging.
Tamil Nadu’s prevention and control strategies that began in mid-January have drawn nearly as much appreciation as criticism. While the ramping up of its health infrastructure has paid off, the way the State had handled clusters and data drew a lot of flak. As the State moves ahead, the challenges are numerous — overworked healthcare providers/staff, increasing number of persons with suspected COVID-19 symptoms, high fatality rate among the elderly, post-COVID sequelae and poor adherence to masking, physical distancing and crowding in public places.
The State now has the fourth highest number of cases and accounts for 9.05% of the total COVID-19 cases reported in the country. It has the second highest number of deaths with a case fatality rate (CFR) of 1.55%. With a recovery rate of 93.36%, Tamil Nadu is among the majority of States that now have a recovery rate of more than 90%.
Though the number of cases reported daily in the State has come down in the past two weeks, Tamil Nadu is still among the top five to six States that are reporting more than 3,000 cases a day. Similarly, it continues to be among the top five States reporting more than 40 deaths a day.
Tamil Nadu has significantly ramped up its testing capacity since the outbreak began and remains one of the very few States to rely only on RT-PCR (Reverse Transcription-Polymerase Chain Reaction) tests and not on Rapid Antigen tests for diagnosis. More than 10% of the population has been tested so far. Owing to increased testing, the daily test positivity rate that peaked in July and August has now come down below the desired 5% mark.
“We are at a crossroads now,” Health Secretary J. Radhakrishnan said. “If we continue to follow COVID-19 appropriate behaviour and not let down our intensity in the fight against the infection, we will definitely see better times and further gradual reduction.”
But he had a word of caution. “However, since the virus has the tendency to spread rapidly in newer areas, we are advised not to let down our guard and continue aggressive RT-PCR testing, conduct fever camps, apart from workplace interventions. We are in uncharted territory. Certain other countries that have seen a substantial dip in cases are seeing another surge. The challenge for us is to continue to keep a watch through fever surveillance, and simultaneously keep in mind the monsoon and early January-February period as the State is prone to other communicable diseases such as dengue and flu,” he added.
Since the first case of COVID-19 was reported in early March, the State has been constantly equipping government hospitals at different levels. R. Narayana Babu, Director of Medical Education (DME), said, “Nearly 95% of patients were treated in government medical college hospitals, and we have improved all basic facilities from the start. From 232 oxygen-supported beds in March, we now have 36,729 beds in DME institutions. We have increased oxygen capacity from 223 KL to nearly 500 KL. Today, we have a total of 1.4 lakh beds earmarked for COVID-19 patients in the State”.
Another strategy that helped the State was the triaging of patients, according to T.S. Selvavinayagam, Director of Public Health and Preventive Medicine. “Triaging was something that we planned as a strategy. Asymptomatic persons and those with mild symptoms were referred to COVID care centres or to home isolation. This turned out to be a good strategy as there was no unnecessary load on hospitals.”
Testing and good capacity of oxygen beds have in fact been the strengths of the State, helping to cope with COVID-19 better, Prabhdeep Kaur, Scientist-E and Deputy Director, Indian Council of Medical Research-National Institute of Epidemiology, observed.
“Nevertheless, enforcement of masks and physical distancing needs to improve in places such as restaurants and market areas. One of the big challenges now is that people are not following any of the norms of masking and physical distancing. The risk perception is very low,” she added.
Next comes surveillance. “As we open up more and more, it becomes increasingly difficult to monitor. We need to expand surveillance to cover more places where clusters may emerge. The third big challenge is private sector regulations. CT scans are being misused as a diagnostic tool for COVID-19. It should be used for only patients with confirmed RT-PCR testing. Another matter of concern is the overuse of antibiotics. Even those in home isolation are prescribed steroids,” she said.
She stressed on the need for a long-term strategy balancing regular services and continuing COVID-19-related health interventions of testing, tracing and treatment.
But Tamil Nadu, with excellent basic healthcare facilities, could have done better if the lockdown was planned better, DMK MLA and president of the party’s medical wing, Poongothai Aladi Aruna, said.
“The government’s planning was poor. We have lost over 10,500 lives. The government keeps saying that the numbers are low but we need to understand that at least 35% of them were in the productive age group of 20 to 60 years. We have lost a significant young population to COVID-19. Still, deaths due to complications post-COVID are not counted as COVID-19 deaths, and this way of calculating is wrong,” she pointed out.
T. Jacob John, retired professor of virology, Christian Medical College, Vellore, felt that the interventions were imposed before time. “Tamil Nadu’s caseload was zero in mid-Jan and miniscule in March. Interventions were imposed before time and when the time of need came, people were getting tired of restrictions. People have become very complacent and relaxed. They should be given regular pep talks about mask wearing, not to crowd, physical distancing and hand hygiene,” he said.
“On March 24, there was no epidemiological reason for lockdown. Such preventive lockdowns do not produce results. The State needed lockdown only in July-August, by which time the economy was in shambles. Under these circumstances, I must say Tamil Nadu has done reasonably well. The volume of case numbers are proportional to population size, which cannot be altered. What could be altered is the speed of spread and mortality. The State’s epidemic curve and testing volume parallel very much, indicating that testing kept up with demand or need for testing,” he further added.
Case fatality has been consistently about 1.6%, equal to that of Karnataka and marginally lower than the national average of 1.8-1.9%, Prof. John observed. “Tamil Nadu’s epidemic curve peaked 10-12 days after the national peak and that also indicates that the State did not lag behind for interventions. From early October, numbers are steadily declining in the State.”
In his view, the State can establish District Task Forces to manage the unlocking process under local conditions. “Every activity — manufacture, industry, wholesale marketing, festivals, temples, mosques, churches and schools — must have decentralised district plans of action until after the epidemic is over and/or the vaccine becomes available. Even vaccination can be decided by task forces, once a national policy is announced,” he said.
For healthcare providers in government hospitals, the challenges are different. A government doctor on COVID-19 duty, on condition of anonymity, said, “Now that we are 10 months into the pandemic, we are anticipating a spike in post-COVID sequelae. More patients are being diagnosed with new-onset diabetes, hypertension and lung sequelae after recovering from COVID-19. Most of them are in the younger age group, and this seems to be a new challenge ahead. Reinfection is also turning out to be common among healthcare workers. More than five staff nurses have had the infection for the second time recently”.
This was not all. There are more cases of swab negative with CT findings suggestive of COVID-19. In fact, of late, 40 to 50% of patients presented this way, and the situation in rural and semi-urban areas could be worse, he added.
Another area of concern remains the fatality among elders. Though the State has maintained the overall CFR fairly low at 1.55%, the CFR among the elderly (more than 60 years) population is high at 7.36%. While the overall CFR is beginning to show a marginal decline, the CFR among the elderly continues to increase. This is despite the overall number of elderly persons testing positive for COVID-19 coming down in the past three weeks.
Above all, a worrying trend is the sense of complacency among the public. “In Chennai, surveys have shown that 30% have immunity. So, 70% of the population is still susceptible, and this could flare-up any time. The virus is there, the host is there and we have less control now. So, we cannot be complacent and need to be prepared as many countries around the world are now facing a worse second peak than the first one,” Dr. Kaur added.