Experiences, Challenges, and Lessons Learned During Implementation of a Remote Monitoring Program for Home-Isolated COVID-19 Patients in Chennai, India.

During the early months of the COVID-19 pandemic in 2020, the majority of the identified COVID-19 patients in Chennai, a southern metropolitan city of India, presented as asymptomatic or with mild clinical illness. Providing facility-based care for these patients was not feasible in an overburdened health system. Thus, providing home-based clinical care for patients who were asymptomatic or with mild clinical illnesses was a viable solution. Because of the imminent possibility of worsening clinical conditions in home-isolated COVID-19 patients, continuous monitoring for red flag signs was essential. With growing evidence of the effectiveness of remote monitoring of patients, the Greater Chennai Corporation in partnership with the National Institute of Epidemiology conceptualized and implemented a remote monitoring program for home-isolated COVID-19 patients. The key steps used to develop the program were to (1) decentralize triage systems and establish a home-isolation protocol, (2) develop a remote monitoring platform and remote health care workforce, and (3) onboard patients and conduct remote hybrid monitoring. In this article, we share the pragmatic solutions, critical components of the systems and processes, lessons, and experiences in implementing a remote monitoring program for home-isolated COVID-19 patients in a large metropolitan setting.

Epidemiology of COVID-19 and effect of public health interventions, Chennai, India, March-October 2020: an analysis of COVID-19 surveillance system.

OBJECTIVES: To describe the public health strategies and their effect in controlling the COVID-19 pandemic from March to October 2020 in Chennai, India. SETTING: Chennai, a densely populated metropolitan city in Southern India, was one of the five cities which contributed to more than half of the COVID-19 cases in India from March to May 2020. A comprehensive community-centric public health strategy was implemented for controlling COVID-19, including surveillance, testing, contact tracing, isolation and quarantine. In addition, there were different levels of restrictions between March and October 2020. PARTICIPANTS: We collected the deidentified line list of all the 192 450 COVID-19 cases reported from 17 March to 31 October 2020 in Chennai and their contacts for the analysis. We defined a COVID-19 case based on the real-time reverse transcriptase-PCR (RT-PCR) positive test conducted in one of the government-approved labs. OUTCOME MEASURES: The primary outcomes of interest were incidence of COVID-19 per million population, case fatality ratio (CFR), deaths per million, and the effective reproduction number (Rt). We also analysed the surveillance, testing, contact tracing and isolation indicators. RESULTS: Of the 192 450 RT-PCR confirmed COVID-19 cases reported in Chennai from 17 March to 31 October 2020, 114 889 (60%) were males. The highest incidence was 41 064 per million population among those 61-80 years. The incidence peaked during June 2020 at 5239 per million and declined to 3627 per million in October 2020. The city reported 3543 deaths, with a case fatality ratio of 1.8%. In March, Rt was 4.2, dropped below one in July and remained so until October, even with the relaxation of restrictions. CONCLUSION: The combination of public health strategies might have contributed to controlling the COVID-19 epidemic in a large, densely populated city in India. We recommend continuing the test-trace-isolate strategy and appropriate restrictions to prevent resurgence.

Secondary attack rate of COVID-19 among contacts and risk factors, Tamil Nadu, March-May 2020: a retrospective cohort study.

OBJECTIVE: To describe the characteristics of contacts of patients with COVID-19 case in terms of time, place and person, to calculate the secondary attack rate (SAR) and factors associated with COVID-19 infection among contacts. DESIGN: A retrospective cohort study SETTING AND PARTICIPANTS: Contacts of cases identified by the health department from 14 March 2020to 30 May 2020, in 9 of 38 administrative districts of Tamil Nadu. Significant proportion of cases attended a religious congregation. OUTCOME MEASURE: Attack rate among the contacts and factors associated with COVID-19 positivity. RESULTS: We listed 15 702 contacts of 931 primary cases. Of the contacts, 89% (n: 14 002) were tested for COVID-19. The overall SAR was 4% (599/14 002), with higher among the household contacts (13%) than the community contacts (1%). SAR among the contacts of primary cases with congregation exposure were 5 times higher than the contacts of non-congregation primary cases (10% vs 2%). Being a household contact of a primary case with congregation exposure had a fourfold increased risk of getting COVID-19 (relative risk (RR): 16.4; 95% CI: 13 to 20) than contact of primary case without congregation exposure. Among the symptomatic primary cases, household contacts of congregation primaries had higher RR than household contacts of other cases ((RR: 25.3; 95% CI: 10.2 to 63) vs (RR: 14.6; 95% CI: 5.7 to 37.7)). Among asymptomatic primary case, RR was increased among household contacts (RR: 16.5; 95% CI: 13.2 to 20.7) of congregation primaries compared with others. CONCLUSION: Our study showed an increase in disease transmission among household contacts than community contacts. Also, symptomatic primary cases and primary cases with exposure to the congregation had more secondary cases than others.

Surveillance for face mask compliance, Chennai, Tamil Nadu, India, October-December, 2020.

PURPOSE: Government of Tamil Nadu, India, mandated the face mask wearing in public places as one of the mitigation measures of COVID-19. We established a surveillance system for monitoring the face mask usage. This study aimed to estimate the proportion of the population who wear face masks appropriately (covering nose, mouth, and chin) in the slums and non-slums of Chennai at different time points. METHODS: We conducted cross-sectional surveys among the residents of Chennai at two-time points of October and December 2020. The sample size for outdoor mask compliance for the first and second rounds of the survey was 1800 and 1600, respectively, for each of the two subgroups-slums and non-slums. In the second round, we included 640 individuals each in the slums and non-slums indoor public places and 1650 individuals in eleven shopping malls. We calculated the proportions and 95% confidence interval (95%CI) for the mask compliance outdoors and indoors by age, gender, region, and setting (slum and non-slum). RESULTS: We observed 3600 and 3200 individuals in the first and second surveys, respectively, for outdoor mask compliance. In both rounds, the prevalence of appropriate mask use outdoors was significantly lower in the slums (28%-29%) than non-slum areas (36%-35%) of Chennai (p<0.01). Outdoor mask compliance was similar within slum and non-slum subgroups across the two surveys. Lack of mask use was higher in the non-slums in the second round (50%) than in the first round of the survey (43%) (p<0.05). In the indoor settings in the 2nd survey, 10%-11% among 1280 individuals wore masks appropriately. Of the 1650 observed in the malls, 947 (57%) wore masks appropriately. CONCLUSION: Nearly one-third of residents of Chennai, India, correctly wore masks in public places. We recommend periodic surveys, enforcement of mask compliance in public places, and mass media campaigns to promote appropriate mask use.

Epidemiology of COVID-19 and effect of public health interventions, Chennai, India, March - October 2020 (preprint)

Objectives: To describe the public health strategies and their effect in controlling the COVID-19 pandemic from March to October 2020 in Chennai, India. Setting: Chennai, a densely populated metropolitan city in Southern India, was one of the five cities which contributed to more than half of the COVID-19 cases in India. Participants: We collected the de-identified line list of all the 192,450 COVID-19 case-patients reported from 17 March to 31 October 2020 in Chennai and their contacts for the analysis. We defined a COVID-19 case-patient based on the RT-PCR positive test in one of the Government approved labs. Outcome measures: The primary outcomes of interest were incidence of COVID-19 per million population, case fatality ratio, deaths per million and the effective reproduction number (Rt). We also analysed the indicators for surveillance, testing, contact tracing and isolation. Results: Of the 192,450 RT-PCR confirmed COVID-19 case-patients reported in Chennai from 17 March-31 October 2020, 114,889 (60%) were males. The highest incidence was 41,064 per million population among the 61-80 years. The incidence peaked during June 2020 at 5239 per million and declined to 3,627 per million in October 2020. The city reported 3,543 deaths, with a case fatality ratio (CFR) of 1.8% and the crude death rate was 431 per million. When lockdown began, Rt was high (4.2) in March and fluctuated from April to June 2020. The Rt dropped below one by the first week of July and remained so until October 2020, even with the relaxation of restrictions Conclusion: The combination of public health strategies controlled the COVID-19 epidemic in a large, densely populated city in India. We recommend continuing the interventions to prevent resurgence, even as vaccination is being rolled out.