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INVITED PERSPECTIVE
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 138-142

Epidemiological mapping and public mental health skills in preventing community spread of COVID-19 infection: A psychiatrist's perspective


Department of Psychiatry, Government Medical College and Hospital; Director, Government Rehabilitation Institute for Intellectual Disabilities, Chandigarh, India

Date of Submission05-Aug-2020
Date of Acceptance21-Aug-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Dr. B S Chavan
Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh; Director of Government Rehabilitation Institute for Intellectual Disability (GRIID), Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_253_20

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  Abstract 


After the report of the first case of COVID-19 in November 2019 from Hubei province of China, the disease took a pandemic form in a short span of 4 months, and the World Health Organization declared it as a pandemic on March 11, 2020. In India, the first case of COVID 19 was detected in Kerala on January 30, 2020, and by March 15, 2020, there were 107 cases. Fearing further spread, India declared complete lockdown from 24th March, 2020 initially for 21 days and it was further extended from time to time. The early curfew and lockdown by India has been successful in slowing the spread of infection. The other initiatives by the Government of India, namely closing the national and international airports, halting of public transport, screening of passengers coming from abroad, ramping up of testing facility, enforcing of social distancing, and wearing of masks, further reduced the rate of spread of COVID-19 infection. The most crucial component of the intervention by the institutions was tracking, testing, and treatment. For epidemiological mapping and contact tracing, the role of a mental health professional (MHP) as the leader is important during the early stages of prevention of COVID-19 infection. The MHPs are better equipped in contact tracing because of their skill in taking in-depth history, focusing on nonverbal cues during the session, early detection of denial of information, and they are better equipped in rapport building than their colleagues from other medical disciplines.

Keywords: COVID 19, epidemiological mapping, lockdown, prevention


How to cite this article:
Chavan B S. Epidemiological mapping and public mental health skills in preventing community spread of COVID-19 infection: A psychiatrist's perspective. Indian J Soc Psychiatry 2020;36, Suppl S1:138-42

How to cite this URL:
Chavan B S. Epidemiological mapping and public mental health skills in preventing community spread of COVID-19 infection: A psychiatrist's perspective. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 26];36, Suppl S1:138-42. Available from: https://www.indjsp.org/text.asp?2020/36/5/138/297149




  Background Top


According to unpublished Chinese government data and the report in the South China Morning Post, the first case of COVID-19 was detected on November 17, 2019, from Hubei province,[1] and its human-to-human spread was documented.[2] However, the Chinese authorities announced the emergence of the new virus couple of weeks later.[3] The world criticized the Chinese government over attempts to cover up the outbreak in the early weeks. Gradually, the virus has spread to other countries, and according to the latest figures, approximately 10 million persons in 213 countries have been infected with COVID-19 and this contagious virus has already resulted in approximately 5 lakh deaths world over (as on June 29, 2020).[4]

In India, the first case of COVID-19 was detected in Kerala on January 30, 2020, where a medical student who was studying in Wuhan University of China reported with cough, sore throat, and fever, and after multiple samples, she was confirmed to have COVID-19 infection.[5] By 10th March, another 6 cases of COVID-19 infection were reported from Maharashtra and Karnataka and all these 6 cases had a travel history from United States and Dubai. Gradually, more cases figured from other states of India, and by the end of March 15, 2020, there were 107 confirmed cases of COVID-19 in India; this rising number due to travelers forced the Prime Minister of India to hold talks with representatives of SAARC countries to undertake joint efforts for curtailing the deadly virus.


  Initial Initiatives to Control COVID-19 in India Top


Initiatives by the Government of India

  1. India banned all incoming international flights on 22nd March mid-night for curtailing the spread of COVID-19 infection in India as all the positive cases in various parts of India had a travel history of other countries. This ban was initially for a week and later it was extended up to 30th June. However, before suspension of international flights to and from India, the stranded Indians were evacuated from different countries for 2–3 days. After international flights were banned on 22nd March, Delhi Airport operated at least 10 flights to evacuate stranded Indians from different countries
  2. Handling of passengers at the Airport: From January 18, 2020, the Government of India started thermal screening of all passengers coming from China, many days before the official detection of first case of COVID-19 from India. Gradually, the thermal screening was expanded to the passengers coming from countries where COVID-19 cases were detected. The passengers who did not have fever on thermal screening were sent home with instructions of 14-day mandatory home quarantine and passengers having fever and other flu-like symptoms were quarantined in places hired by the government.


  3. Although thermal scanning is a simple and cost-effective screening technique, it has its own limitations.[6] First, a person can have infection without any symptoms including fever. According to the Centers for Disease Control, symptoms of COVID-19 develop within 2–14 days and thus checking temperature before the onset of symptoms will be no use.[7] Second, everyone who gets COVID-19 infection may not have fever. According to a study, only two-third developed fever.[8] Third, many patients may remain asymptomatic despite carrying the virus in their body. Heneghan C, Brassey J and Jefferson T, conducted a literature search of articles which were PUBMED indexed, and based on 21 reports, concluded that between 5% and 80% of COVID 19 patients were asymptomatic.[9] Fourth, persons may be taking fever reducing medication. Finally, thermal scanners may not be very sensitive to pick-up real body temperature

  4. Imposing lockdown in the country: After 14 h of Janta Curfew on March 22, 2020, the Prime Minister of India announced 21-day national lockdown limiting movement of 1.3 billion people of the country as a preventive measure against the COVID-19 pandemic. Unlike many other countries of the world, the lockdown was imposed quite early when the number of COVID-19 cases was approximately 500 in the country. On the advice of experts, the lockdown was further extended on 14th April up to May 3, 2020. The third lockdown was extended up to May 17, 2020. The districts were divided into green, orange, and red zones depending on the COVID-19 cases and green and orange zones were allowed certain facilities whereas red zone areas were declared containment zones and no activity was allowed there except operation of essential services. On 17th May, the lockdown was further extended up to 31st May in the containment zone, whereas certain services were allowed to open with effective from June 8, 2020, in noncontainment zones
  5. Transport services: All transport services, road, air, and rail, were suspended, with exceptions for transportation of essential goods, fire, police, and emergency services. Educational institutions, industrial establishments, and hospitality services were also suspended.
  6. Testing facilities: Since the beginning, India has been focusing on 3Ts: testing, tracking, and treating in order to control the spread of COVID-19 infection. When the first case was detected in January in India, there were negligible laboratory facilities in India and initial cases were sent to the National Institute of Virology, Pune, for confirmation. However, as the number of cases increased, ICMR has increased the testing facility to 1000, out of which 730 are in the government setup and the country can now test over 1.90 lakh samples every day.[10]



  Impact of Lockdown Top


Although experts feel that lockdown has been successful in controlling the speed of spread of COVID-19 infection in India as compared to USA, Brazil, Spain, UK, and Italy, with ban on food delivery services by several states, thousands of migrant workers who lost their jobs and were not able get sufficient food decided to return to their native places from all the major cities. There have been many reports of deaths among migrant workers due to starvation, suicides, exhaustion, road and rail accidents, police brutality, and denial of timely medical care.[11]

Further, liquor shops were closed and break in the supply chain of narcotics in Punjab led to suffering of many patients who were dependent upon various substances. The situation also led to illicit liquor sales and drying up of government revenue.

Role of health-care facilities

In order to implement last two, Ts i.e., tracking and treating, the role of designated COVID-19 health-care facilities was very crucial, both in controlling the further spread and to provide quality care to the persons already infected with COVID-19.

Since there was very little knowledge about the behavior of the virus mode of spread, incubation period, set of clinical symptoms, complications, treatment options, and prevention of spread to health-care workers (HCW), majority of the health-care facilities faced a lot of challenges in the beginning to deal with the unwarranted emergency. As the Head of an Institute which was designated as a COVID testing, treatment and epidemiological contract tracing facility, the author encountered many challenges like setting up testing facility, training and posting of staff, addressing the mental health issues of the staff working in the forefront, contact tracing, shortage of kits, infection among HCWs, concerns of the families etc., The following are the strategies used by Government Medical College and Hospital (GMCH)-32, Chandigarh, to handle these challenges in order to provide seamless services:

  1. Setting up the COVID-19 reverse transcription polymerase chain reaction (RT-PCR) testing facility: When GMCH was asked to set up the COVID-19 testing facility, the Head of Microbiology Department had gone Abroad to attend an International Conference and on his return, he was home quarantined for 14 days. Since he was not having any symptoms, he wanted to join his duties in public interest so that the testing facility could be started at the earliest, as the only testing lab at PGIMER was overloaded with samples and was finding it difficult to cope. However, as a head of institute, I was duty bound to implement Government of India instructions to enforce a 2-week mandatory home quarantine. Since regular correspondence was required with ICMR for procurement of machines and reagents as well as to set up physical infrastructure in the department, he (HOD) was persuaded to work from home; hence, temporarily shifted his office at home after a lot of reluctance. Subsequently, the second testing lab in GMCH was started on March 27, 2020.
  2. Training of Staff: The biggest challenge before the author was to ensure the safety of the HCW because if they got infected, it would have led to fear among them and their colleagues to come for COVID related duty. Furthermore, it would have depleted the workforce as the infected HCWs would be sent for 2-weeks home quarantine. The report of “more than 1716 medical doctors got infected with COVID-19 in China”[12] was haunting the author as the responsibility of infection among HCWs will fall on the Head of Institute. Thus, training of all categories of staff, i.e., doctors, nurses, technicians, ward attendants, Safai Karamcharis, and security guards, was the top priority. Separate training teams were constituted for each category of staff, namely doctors, nurses, technicians, attendants, and Safai Karamcharis. Each team was given the list of complete staff to be trained in small batches of 10–15 after maintaining physical distance of at least 6-feet. They were asked to provide hands on training (mode of spread of COVID-19, early signs and symptoms, diagnosis, doffing and donning of personal protective equipment (PPE) kit, interview skills, contact tracing) and daily list of staff who underwent training was sent to the office of the Head of Institute (author) where his Private Secretary would update the list to ensure that no one misses the training. This capacity building training not only instilled confidence among the staff but also made them enthusiastic to work and handle the patients with COVID-19 infection. Personal involvement of the Head of Institute (author) in the training further boosted their morale. This was the first step to prepare the Institute to fight with the pandemic as the training tackled the initial fear and apprehension to work in COVID facilities. Motivation of staff and to carry them along as a cohesive team is crucial and the mental health background of the author came handy because leadership is tested during the crisis and not during the period when everything is running smoothly. How a leader behaves and acts during the crisis is not only closely watched but can have serious implications if a problem of this magnitude is not handled properly. In fact, credentials of the leadership get established during a crisis situation (akin to war). It is imperative during such times to lead from front. This was a sudden, unpredictable, and enormous crisis where the Head of Institutes across India did not get adequate time to prepare. Even it was not clear for how long the crisis will last in order to prepare workforce and resources. During these uncertainties, the role of the leader (Head of Institute) is deemed not only essential but crucial.
  3. Availability of PPE: In order to protect the hospital staff from the contagious COVID-19 infection and to instill a sense of security among the HCWs, PPE kits were mandatory. However, in March 2020, there was acute shortage of PPE kits in the country. On 1st March, there was no factory in India which produced PPE kits. However, by May 18, India was producing 4.5 lakh PPE kits per day and today India is the second largest producer of PPE kits in the world. GMCH went out to all the possible government and private sources to procure adequate amount of PPE kits. The shortage was raised in all the administrative meetings and daily E-mails and WhatsApp messages were sent to the authorities to ensure constant supply of PPE kits. The crisis happened at the time when the financial year was near closure and all the funds of the financial year 2019–2020 were already exhausted. Since the budget for 2020–21 had not come by that time, requirement of money for urgent purchase was a major challenge. The author contacted the local MP Ms Kirron Kher to give funds out of MP Local Area Development Scheme and within 2 days, one crore was made available to GMCH for emergency purchase of kits and ventilators. This came very handy to tide over the crisis. Thus, the HCWs were always ensured availability of PPE kits which kept their morale high
  4. Contact tracing of COVID-19 positive cases: Contact tracing is an important strategy to prevent spread of an infectious disease. The strategy involves identifying people who have come in contact with a positive case. The aim is to identify the close contacts, test them, and enforce home quarantine to interrupt the spread of disease. The steps involve:


    • Detailed interview of the person who is COVID-19 positive to identify everyone who had come in close contact with the patient
    • Notifying contacts to the integrated disease surveillance program (IDSP)
    • Referring the contacts for testing
    • Monitoring the contacts for development of any signs and symptoms of COVID-19 disease
    • Providing information and support to help them understand the risk they have and what should they do to avoid risk to others who are not yet exposed and infected. They are educated regarding monitoring their own health, they can infect others even if they are asymptomatic, etc., These persons are further told to stay at home and maintain a distance of at least 6 feet from others for the next 14 days.


The task of contact tracing was handed over to the public health workers from the Department of Community Medicine attached with the medical college. They are trained to build up rapport with the community and to conduct detailed interviews to gather requisite information. However, while supervising the work as Head of the Institute of a designated COVID care facility by the Chandigarh Administration, the author realized that mental health professionals (MHPs) can do an equally good job like their public health counterparts from the Department of Community Medicine. This may be attributable due to their training in taking a detailed history in psychiatry. The author further observed that many COVID patients avoided or were not comfortable giving details of their close contact fearing their isolation and associated social stigma.

The psychiatric history taking, in addition to information provided by the patient, also focuses on other nonverbal cues during the session. Non-verbal cues like avoidance of eye contact when certain information is asked for and display of facial expressions like that of fear, apprehension, evasive gaze etc. are all recorded and probed further. Psychiatrists are also generally better equipped in rapport building than their colleagues from other medical disciplines. In contrast to other medical disciplines, psychiatrists are also unique in being able to handle any personal conflict which might crop up during contact tracing.

The author would like to mention two specific cases here to support these claims. These are special cases where the field staff from the Community Medicine failed to find the source of infection (contact). Written consent was obtained from these cases for reporting here. At that time, majority of the cases were the contacts of positive persons, largely of persons who had recently returned from abroad:

Case 1

A 41-year-old male from Derabassi (a satellite town about 8 km from Chandigarh) came positive on RT-PCR and his case was referred to the field team from the Department of Community Medicine for contact tracing, i.e., the source of his infection as well as the list of persons who had come in his close contact in the previous 2 weeks. The team informed that there was no known contact from where he could have contracted the infection and there were just four family members who are his close contacts. Somehow, this was not acceptable to the author as this case was different from the earlier approximately 56 positive cases where the source of infection was traceable and there was also a long list of persons who had come in close contact in last 2 weeks. The case was also discussed in the daily COVID-19 review meeting and after the meeting, the Nodal Officer of COVID 19 cases in GMCH again informed that there is no known source of infection and the patient has not met any person other than family members in last 2 weeks. However, the author was not convinced and had a strong feeling that the team was missing something, at this stage. Hence the field team from the Community Medicine who had carried out the contact tracing were called and given a set of 5 questions to ask:

  1. Where does he work/had worked earlier?
  2. Who are his colleagues/friends?
  3. Where has he gone (locally and outside the city) in last 2 weeks?
  4. What are the complications of COVID-19 disease to him and his family members in case they also become positive?
  5. What are the legal consequences under Disaster and Emergency Management Act 2001 if someone deliberately hides the information?


During the reply to above questions, it was found that he works in a factory in a nearby village Jawaharpur as an electrician. However, the factory was closed due to lockdown. However, the owner called people in a group of 8–10 workers to disburse their salary for March 2020. On further probe, he informed that one of his colleagues who also came to collect his salary is a Jamaati and he had recently returned from Delhi. It gave us a clue and information was passed to IDSP of Mohali district to test all the workers of the factory. To our surprise, 40 workers of the factory turned out to be positive. Since this factory was located in the outskirt of the village and many workers were from the same village, it was decided to screen all the houses of Jawaharpur village. There were many persons who had flu-like symptoms and on testing all of them turned out to be positive. This village was declared as 'red zone' and curfew was imposed to restrict the movement of persons. The author feels that it was this inquisitive nature borne out of his training in psychiatry that helped to unearth the information about contact tracers, thereby helping to contain the further spread of infection to the neighboring villages. Luckily, all the COVID-19 cases from the village recovered and subsequently lockdown has been lifted. However, the village has learnt to prevent further infection by social distancing and hand washing. The village Panchayat decided that who so ever was suspected of having infection or has returned from other areas where cases have been detected should be taken for testing.

Case 2

A staff nurse of the hospital become positive. She was posted in the COVID-19 ward till June 5, 2020, and developed fever with cough on June 27, 2020. After 5th June, she was posted in the non-COVID ward. When her case was referred to the Department of Community Medicine to trace the source of her infection as well as her close contacts, the field staff gave a list of 10 persons who came in her close contact. However, they were not able to trace the source from where she got infection and attributed it to her posting in COVID-19 ward. The author was not convinced as the symptom started after 22 days of her being posted in the COVID-19 ward. The incubation period of COVID 19 is between 5–14 days and the onset after 14 days is very rare (1 in 100).[13] Thus, her case was referred to Nursing Superintendent to provide her posting details after 5th June, which revealed that on 20th June, she took station leave and went to Sangrur district of Punjab where she met many persons in the Court. On enquiry, it was revealed that they were not wearing masks and were not maintaining social distance. Thus, there was a very high possibility that she acquired infection from Sangrur where many positive cases had already been reported.


  Conclusion Top


One of my teachers used to say “rare things and events are rare” and we must first try to fit in the events into scientifically known facts.

MHPs can be good public health leaders. They can also be better head of institutions because of their intensive training in dealing with human conflict, rapport building, and empathizing with other people's sufferings. All these qualities help in building a cohesive and responsible team. The skills of psychiatrists to understand each event and conflict in details help them to be good public health workers and public health leaders. The above two examples have demonstrated this explicitly.

Declaration of patient consent

The author certifies that he has obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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[PUBMED]  [Full text]  
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Available from: https://en.wikipedia.org/wiki/COVID-19_pandemic_lockdown_in_India-cite_note-67. [Last accessed on 2020 Jun 29].  Back to cited text no. 11
    
12.
Xiang YT, Jin Y, Wang Y, Zhang Q, Zhang L, Cheung T. Tribute to health workers in China: A group of respectable population during the outbreak of the COVID-19. Int J Biol Sci 2020;16:1739-40.  Back to cited text no. 12
    
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Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: Estimation and application. Ann Intern Med 2020;172:577-82.  Back to cited text no. 13
    




 

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