Last week, the Government of India issued a blanket ban on all international air carriers landing in the country beginning March 22 until March 29. The drastic measure was taken to contain the spread of the novel coronavirus, which causes COVID-19, the disease.
The focus of India’s attention was initially passengers coming from China, where the outbreak began. But by March, as Italy witnessed a massive jump in cases and deaths, the government turned its focus on the European Union, the United Kingdom and the European Free Trade Association which includes Switzerland, Norway etc. Travel bans were imposed against these 27 countries from March 18.
However, by the course of last week, India came to a shocking realisation. A significant number of COVID-19 cases were appearing from Gulf countries, particularly Saudi Arabia, Qatar and the United Arab Emirates, posing a problem that the government had not exactly foreseen. Sixty three out of a total of 95 positive cases in Kerala till Monday are those who returned from Gulf countries, mainly UAE, Qatar and Saudi Arabia. Kerala has discovered this after testing many of its Gulf returnees, however in many other states, the focus is firmly on those who have come back from Italy, Korea and Spain to name a few countries.
The first two cases of COVID-19 among Gulf returnees were confirmed in Kerala on March 12, when a Kannur and Thrissur native landed in the state from Dubai. Within 11 days, this number quickly rose to 28 positive cases in a single day on March 23. Twenty five of them had returned from Dubai.
Given India’s large expat population in the Middle East, the question is could restrictions have been imposed on travelers coming in from these countries earlier? Could India have acted earlier?
Did Middle East countries underreport cases?
Significantly, however, on March 13 - when Kerala had reported its first cases from the Gulf - the UAE already reported 85 positive cases of the virus and had confirmed local transmission while Qatar had 262 positive cases of the virus with local transmission reported. Saudi Arabia, meanwhile reported 21 positive cases, all of them being imported.
By March 17, when the Government of India turned its focus on the Middle East, UAE had reported 98 positive cases, Saudi Arabia 133 and Qatar 439 and Kuwait 130. All the countries had also reported Stage 2 or local transmission of the virus. Presently, the UAE has 198 cases, Saudi has 562 confirmed cases, and Qatar has 501.
"It is as yet unclear whether these Middle Eastern countries correctly reported the cases of the virus and those infected. There is a possibility that local and community transmission had already begun in these countries before they began reporting them. For countries like Saudi Arabia, they had not declared local transmission for days. India went by the list on WHO, taking measures against nations which had local transmission of the virus, perhaps explaining why the Middle East was not paid enough attention," Public health expert T Sundararaman, who is the former director of the National Health Systems Resource Centre, told TNM.
He also noted that even before the number of positive cases rose in India, many of the infected people would have been asymptomatic when they arrived. “These asymptomatic carriers must have been cleared at the airports and later developed symptoms of the virus, infecting others. This makes it a tricky situation for airport and health authorities to identify and observe passengers,” he explained. The only way to solve this problem is for the government to test all international travelers arriving in India.
“Rigorous testing should be sustained for nearly six months for best results. And we simply do not possess that many test kits to carry this out,” he explained.
Kerala screened and observed Gulf returnees
With cases of COVID-19 among Gulf travelers rising in the state, Kerala resorted to a two-pronged approach to screen and isolate passengers from the Middle Eastern countries, among others.
Speaking to TNM, Dr Amar Fettle, Nodal Health Officer for Communicable Diseases in the state said, “Even before the Government of India focused on the USA and Middle Eastern countries, we were keeping a track of passengers. We would collect arrival information of international passengers from the airport. This included those traveling to Tirunelveli and Kanyakumari in Tamil Nadu, who landed at Thiruvananthapuram International Airport. With Kannur, many passengers land at Mangalore International Airport and then drive down. We were also in touch with airport officials in Mangaluru.”
The second step was collecting information and observing persons with recent foreign travel history in their houses. This was done by local health workers, Kudumbashree and ASHA workers and communities in each panchayat.
“Local health workers would be informed of any foreign returns, including Indians, who have arrived in the locality. A designated team from each ward would then brief them about home quarantine and best practices to stop spread of the virus.. We had roped in the District Health Officers to coordinate and collect information from each district ,” Dr Amar added.
In districts such as Kozhikode, which has a large native population working in Gulf countries, the administration placed all persons with international travel history on mandatory home quarantine, despite reporting less than five cases of the virus.
Was focus on Gulf countries delayed?
On March 13, while the Pinarayi Vijayan-led government imposed a mandatory 14-day home quarantine for travelers from Gulf countries where local transmission was reported, a day after the first two Gulf returnees tested positive in Kerala, the Central government took longer to turn its focus on to the Middle East. It was only on March 17, a GoI advisory imposed a mandatory 14-day home quarantine to passengers, including Indian nationals, who had returned from Kuwait, Qatar, UAE and Oman.
Speaking to TNM, Sundararaman, former director of the National Health Systems Resource Centre and former Dean of School of Health System Studies at the Tata Institute of Social Sciences (TISS) said, “We cannot say that the government overlooked the Gulf countries. The nature of the virus's spread was such that the focus was first on China, and then Singapore, Malaysia, European Union countries particularly Italy. In many of the Gulf countries, such as Saudi Arabia, local transmission of the virus was not reported and hence missed being put under the list of vulnerable countries."