PB Nooh is the collector of Pathanamthitta district in Kerala, the first COVID-19 hotspot in India. In a few weeks, however, he has managed to turn the tide. He explains to Rohini Mohan that his team’s strategy was tracking down over 1200 contacts, putting them all in isolation, developing an isolation questionnaire to collect information on symptoms, setting up a call centre to monitor those in quarantine, and testing aggressively. Today, the district has only eight COVID-19 positive cases, and has become a model for the rest of Kerala and other states.
Nooh is 40, and lives with his wife, a medical student, close to the district headquarters in Pathanamthitta. He grew up in Perumbavoor, and graduated from the University of Agricultural Sciences, Bengaluru. His older brother PB Salim is also in the civil services, in the West Bengal cadre.
Nooh is a civil servant with a fan page on Facebook called ‘Nooh Bro’s Ark’, formed after he helped rescue over 1.5 lakh people stranded during the floods in Kerala. He was also in-charge of the district when it was the epicentre of violence that broke out after the Supreme Court revoked the ban on women of menstrual age entering the Sabarimala temple.
“Maybe all these situations have prepared me to handle the COVID crisis better,” said Nooh. He credited the focused efforts to contain the coronavirus transmission to the over 1,000 volunteers, health officers, doctors and nurses in his district who “don’t work like it’s a government job”.
Excerpts from the phone interview:
Going from the first COVID-19 hotspot in India, to dealing with many cases, what was your first approach to containing the virus?
Initially, we had five positive cases on March 7. In Kerala, the first cases reported were of three students who returned from Wuhan, on January 30. The direction from the state government was to form a team of officers and monitor people travelling from four different countries. So we had been doing that, but it was not an intensive activity. As the three positive cases turned negative in a month’s time, there were no positive cases in the state altogether. So that was low profile then.
But suddenly, on March 7, we got five positive cases in Pathanamthitta district. Again in three days, we got another six cases— total 11 cases in Pathanamthitta alone. There were no positive cases in any other districts. The results came on March 7 evening, and on the same day, we had a meeting with secretary, director and top officials, and decided on an aggressive contact-tracing strategy. We decided to use all possible means to trace as many people as possible who have come in contact with the family.
I. Contact tracing
On March 8 morning itself we started this work, sent people to the field in two hours, and formed seven teams, with two doctors and two paramedics each. These seven teams collected information by talking to the patients and their contacts.
We also traced the mobile tower location of these guys, and used Google Maps timeline to trace as many locations. Comparing all this information, we prepared a spatiotemporal map, which is in fact a flowchart of events which happened since they landed in Pathanamthitta. What had happened was that a family of three had come back from Italy on February 29, and on March 6, a relative had turned up in a PHC (primary healthcare centre) with slight symptoms of COVID. Based on the contact and travel history of this person, we realised he has come in contact with a family that has returned from Italy. All this information was put in the flowchart without the name of the patients, but the days and times. We released the flowchart to the public, and requested the public to respond if they had any interactions. We earmarked two contact numbers to call us.
We traced 1,254 contacts of this Italian family in four days. In parallel, we had to ensure strict home quarantine of these guys. The problem was that this was an evolving issue and we didn’t know exactly what helps. There had to be a two-pronged strategy. First, a massive awareness campaign about why home quarantine is important, but there should not be any stigma and social ostracization of this family. We gave directions to the media, the health centres, local self governance bodies so that people are aware that it is a serious issue and people have to keep distance.
II. Call centre for quarantined people
Secondly, for the 1,254 people in isolation, we came up with the idea of a call centre. We had more than 200 people sitting in my office, in the halls and all, calling all the families and gather information. Later we switched to the Interactive Voice Response system (IVR), wherein people could call one number and the students could call from their own home, remotely. We had five focus areas for the people in isolation: any medical requirement related to COVID or any other illness; non-medical requirement like food or provisions to be provided through gram panchayat or on payment using volunteers; psychological counselling with initially 30 counsellors and now we have 90 working through IVR.
Fourth, we had an isolation survey questionnaire prepared by Trivandrum Medical College, and it would be filled by the call centre people based on responses from the people in isolation. If it was found that they are breaking quarantine, that information would be passed to the police department to take legal action. Fifth, we would screen them for symptoms. Now, in the questionnaire we have included questions that ask if they have developed any symptoms. If so, our medical team will talk to them further. If the symptoms are related to COVID, they would decide if they need to be shifted to the hospital or sent for taking samples. Using the call centre we ensured that these guys are staying back home.
III. Screening travellers from outside
Later, as a lot of people were coming in from other states and countries, by March 24, when national lockdown was declared, we had more than 4,100 international travellers in Pathanamthitta district alone.
From March 7, in two weeks’ time, we had developed a mechanism to screen all the people who come to the district through buses, trains or flights, from abroad or other states or districts. On March 24, the people we had were around 3000 people from other states. We had a total of 7,361 who had to be strictly quarantined at home. So, we had to widen the call centre facility. By this time, the call centre received more than 10,000 calls everyday. And we continued to focus on the 5 areas, and widen them.
IV. Migrant labourers
Another problem was the migrant labourers. We had more than 25,000 in the first week of March, and by the lockdown, 16,000 labourers were stranded in our district. We formed six teams for each of the taluks, each team with one doctor, one paramedic, one medical student, policeman and few others per team. These teams were sent to screen the 16,000 migrants alone— twice. Once with an infrared thermometer to scan them for fever and two, with a questionnaire for symptoms or travel history to another state. On March 24, the cut off date, we screened 1,426 migrants in a single day. On average, 1,000 migrants were screened every day. We identified 15 migrants with symptoms.
V. Testing protocol
We took samples from all international travellers, and of them, people coming to our district from hotspots like Italy and USA would be given more preference. Then national level travellers, other district travellers and then migrants. Then, health workers who are among these international and other state travellers.
The total number of cases who have turned positive so far is 16. And of this, 8 have recovered and gone back home.
VI. Three-tier healthcare
As per state government protocol, we have formed the three-layer health system. The top-most is COVID care hospital (where people with severe symptoms will be treated), then COVID first-line treatment centre (where we will treat positive people with mild or no symptoms), and COVID care centres (where people from other states and districts would be kept in isolation for 14 or 28 days depending on place of origin).
As on today, we have located 8,000 rooms in different locations in the district which can be converted into any of these three facilities.
Is a lot of the strategy based on anticipating a high number of cases?
Exactly. As of today, if you ask me what is the total number of people I expect in my district to be positive, if nobody comes in in the coming two months, I would say about 100, in a population of 12 lakhs. The moment a lot of people start coming from other states and countries, the number may go higher. The state government has to give us a direction on this, but it is ideal to keep all those who come in isolation before sending them back home, so we must earmark facilities for them already.
The most important strategy is going to be to ring fence vulnerable people. In my district, the population is 11,97,000 as of the 2011 census, and the present senior citizen population is 2,44,599. I want to form a ring around them. That is, we will provide all the requirements for them inside their home, so that they don’t have to come out.
Medicines can be supplied through PHCs, do medical tele-consultation, counselling, give food through gram panchayat, provisions through volunteers, and pension also through gram panchayat. All these mechanisms will be ready in a week’s time. If we provide these six items, a majority of the elders can be kept back home.
For how long are you planning to keep the aged people at home?
A month’s containment definitely, but we are developing a strategy for three months. They have to keep a strict home isolation at home also. They should not interact with people going out, they shouldn’t entertain relatives. This is going to be tough. Volunteers will call every senior citizen in my district to keep a close personal rapport with them, so that they will stick to the directions.
Where are these ideas like call centre, isolation survey forms, ring fencing etc. inspired from?
Actually, we have a wonderful team. More than 1,000 volunteers are working dedicatedly for the last 35 days. Today is a Sunday, and Easter, and I have over 150 volunteers at the district headquarters right now. I have 15 inter-district border screening teams, working 24/7, manned by volunteer students from medical and engineering colleges. Second, we are in touch with 58 health institutions, peripheral and all.
At least once in three days, I have a Zoom meeting with the medical officers. So is the case with gram panchayat secretaries, presidents, my revenue team. At the headquarters, there is a team of 40 doctors, and every morning the top officials will have a 30-minute meeting and evening we’ll have a detailed meeting of an hour or more. This is an evolving scenario in which we have to track every development, internationally, nationally or in the state. Whatever strategy people are following elsewhere that works, we are copying it here after good discussions.
How do you decide whom to test for COVID?
For sampling, everyday, we add a new hotspot based on what’s happening in other states. After many cases occurred in Nizamuddin, we tracked 27 people in Pathanamthitta district who came from there, and tested all of them. Similarly, when a lot of cases turned positive in Kasargod, we found that the majority of them had come from Deira and Naif in Dubai. So, we added that to our hotspot list, and tracked 300 guys who had been to Deira and Naif before coming to Pathanamthitta district. We also started sending samples of people who have travelled in trains that started from Nizamuddin to Kerala. We located three persons who were asymptomatic but positive. An 18-year-old girl came back from Delhi and stayed in home isolation for 19 days. When we realised she had travelled in the Nizamuddin Express, we tested her. To our surprise, she also turned positive. So, we are keeping a strict vigil, and if there’s any connection with the hotspots, we test.
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Do you think digital apps for contact tracing will help?
Initially, these kinds of apps might have been of use, but as the number of cases increase, contact tracing is not going to be the main strategy. Isolation and treatments will be more important. In my district, for up to 100 cases, contact tracing might be really useful. But if cases go higher, area-testing will be better. Isolate everyone in an area where someone has tested positive. And say, 3 km around the area, everyone is tested - or something like that. That’s what will give better results.
Do you think there is community transmission now?
There is no community transmission in Pathanamthitta district so far, because of the kind of tracking we have done and the vigil we are keeping. All the 16 cases who had turned positive, we could track where exactly they have contracted the disease.
Is this response unique to Kerala? What capacities are required for other states to be able to replicate your model?
This is an extraordinary situation that requires extraordinary attention. Nobody is working here like it’s a government job. They are putting 100 percent effort 24/7. So, the first thing is to build a team, with members who understand the seriousness of the situation and play their own role well.
Second, as a leader you have to address a lot of issues. For example, my medical officers told me in a video conference 15 days back that they were worried about their own safety. They wanted masks, PPE kits, the sanitisers, and face shields. It was my own challenge to find those items. So, we got more than 2,000 litres of sanitisers made in my district alone, and supplied over 1,000 face shields and are preparing 10,000 more using 3D printing technology. We are also making face masks, PPE kits. These are all in addition to the state government supply. The field officers going to ensure quarantine should also be provided masks but also transportation, accommodation, food - everything is a problem in a lockdown.
Everybody is stressed out. All officers are working for 10-12 hours a day for the last 35 days. They require a lot of support at this point. We are even planning a counselling session for all my officers. Other districts should ensure this too.
You have had back-to-back issues in Pathanamthitta - the floods, Sabarimala violence, and now the virus.
(Laughs) Yes. I came here in June 2018, and in August, there was a massive flood here with more than 1.5 lakh people under water. Then, in November came the Sabarimala issue. By January 2019, that was over. Then there was Lok Sabha election from March to May 2019. Then July 2019, another flood, then again, another Sabarimala. And now, this is the seventh episode we have, coronavirus. It’s been back-to-back for two years.
So it’s an extraordinary situation all the time?
I feel now that all these situations have prepared me to handle (the COVID crisis) better.