What ails Pune

- May 20, 2020
| By : Prateek Goyal |

From the first patient to 100 cases a day: Pune has become one of India’s first coronavirus hotspots, an audit of the cases in the city, its response, and what went wrong Rubal Agrawal, Pune’s additional municipal commissioner, remembers where she was when she received the news of Pune’s first coronavirus case. It was the […]

From the first patient to 100 cases a day: Pune has become one of India’s first coronavirus hotspots, an audit of the cases in the city, its response, and what went wrong

Rubal Agrawal, Pune’s additional municipal commissioner, remembers where she was when she received the news of Pune’s first coronavirus case.

It was the evening of March 9. Agrawal was attending the inauguration of the Sarsanghchalak Balasaheb Deoras Aviation Gallery in the city’s Shivaji Nagar Gaothan. It was a high-profile event, attended by Maharashtra deputy chief minister Ajit Pawar and the Bharatiya Janata Party’s state chief Chandrakant Patil.

That’s when Agrawal received a phone call from a medical officer, informing her that Pune’s first coronavirus case had been reported. “I just couldn’t believe that Covid-19 had reached Pune,” she said.

It was Maharashtra’s first case as well, and the start of the city’s long fight against the pandemic. Pune is one of the hotspots of the coronavirus outbreak in India. As of May 14, it had recorded 3,161 positive cases with 170 deaths and 1,164 recoveries. It’s reported an average of 100 new cases a day since the last week of April.

The Pune Municipal Corporation pegs the “worst-case scenario” at 10,000 cases by the end of May.

But how did the infection spread in Pune?

Nine hours before Agrawal received that call, Namdev Palve, 51, and his wife Sujata, 43, (names changed) were at their home on Sinhagad Road, preparing to go to the Naidu hospital, run by the Pune Municipal Corporation. Namdev, and then Sujata, would soon become Patients 1 and 2 in Pune. A day later, their daughter tested positive, and then the driver of a taxi they had used.

There are 69 containment zones in Pune

The first patients

On February 24, the Palves – the parents and their daughter – went on a week’s holiday to Dubai, travelling with a group. They visited Dubai’s major attractions – Miracle Garden, Dubai Museum, Bollywood Park, the Burj Khalifa, Jumerati Beach, and more – and took a short cruise as well. The family boarded a flight from Abu Dhabi on March 1 and landed in Mumbai.

“It took us almost 1.5 hours to get through immigration at Mumbai airport. Then we boarded a private taxi and returned to Pune,” Namdev told Newslaundry. The family said they were not screened at Mumbai airport, since Dubai had not been flagged for a potential Covid-19 threat.

That evening, Namdev developed a sore throat and a mild fever. “I contacted my family doctor who told me to complete a medicine course for viral fever. I gave him my urine and blood samples which came back normal,” Namdev said. “In two days, I felt fine and went to work. Three days later, I developed a fever and my doctor asked me to go to Naidu hospital for a coronavirus test.”

It was March 7, a Saturday. Namdev went to the hospital with his wife. At this point, India had 34 cases, predominantly in Kerala, Delhi, Punjab and Ladakh.

“The hospital conducted Covid-19 tests before 9.30 am but we only got there at 11 am,” Namdev said. “The health authorities told us to either stay in the hospital until Monday, or go home and return on Monday since we didn’t have any symptoms.”

On Monday, March 9, Namdev and Sujata returned to the hospital. He was confident his test results would be negative.

Rubal Agrawal, Pune’s additional municipal commissioner

“The doctor there was initially unwilling to administer the test since we had no symptoms. He did a basic check-up and asked why I needed the test,” Namdev recalled. “I told him I had a fever and my personal doctor had advised me to get one done. I also told him that if he’s unwilling to do the test, I’ll leave. But if anything unpleasant happens in the future, I told him I would not hold back in saying that I went to the hospital but they refused to test me.”

The doctor at Naidu hospital promptly conducted swab tests on both Namdev and Sujata. The results came back from the National Institute of Virology at 7 pm: both positive.

“We were not ready to believe it,” Namdev said. “I even told them they might have sent someone else’s samples to the lab. It was unbelievable.”

Namdev and Sujata were immediately packed off to the hospital’s Covid-19 ward. Their children were summoned that night. The daughter, Supriya, had been on the Dubai trip while the son had stayed behind in Pune. Supriya and her brother stayed in the hospital overnight and their samples were sent to the lab in the morning. That evening, she tested positive while he was negative.

“My mother and I didn’t even have any symptoms, not even a fever,” said Supriya. “I was totally fine, and went to my office for almost a week.”

Supriya, Namdev and Sujata were admitted to the Covid-19 ward in Naidu hospital and stayed there for 14 days. They remained in good health, Namdev said, though he had a mild cough. “We were given anti-viral medicines, multi-vitamin tablets, and were asked to drink hot water,” he said. “Sujata and I were discharged on the morning of March 25, and Supriya was discharged that night.” The son had been quarantined in a different building at the same hospital.

Meanwhile, city authorities contacted the tour operator who had organised the Dubai trip. The operator gave them the list of all those who had been on the group tour. Not all of them were from Pune, so district collectors of their respective cities contacted them and got them tested.

In Pune city, under the jurisdiction of the Pune municipal corporation, five people tested positive. Three tested positive in Pimpri Chinchwad, a satellite city in Pune district; three in Nagpur; two in Yavatmal; two in Mumbai; one in Ahmednagar; and one in Raigarh. All of them were asymptomatic, or showing no symptoms.

Three days after the Palves were admitted, 45 people whom they had been in contact with were tested. “Fortunately, all of them came out negative,” Supriya said. “It was a big relief, since by then, our names and address were being circulated on social media. There was stigma towards us; it was mental torture.”

But that wasn’t all. On March 10, the private taxi driver who had driven the family from Mumbai airport to their home in Pune, tested positive. He was discharged on March 25.

‘Most challenging phase of my career’

When Agrawal was told about Namdev and Sujata testing positive, she swung into action.

Considering the high number of cases, Shekhar Gaekwad, Pune’s Municipal Commissioner says, it’s no longer possible to “follow the original spreader” of infection

“There were only six beds for Covid-19 cases at Naidu hospital but in no time, we prepared 100 beds,” she said. “We really thought 100 beds would be more than enough but by the start of April, Pune had a sudden spike in positive cases. After that, the number of beds kept increasing. My target now is to prepare 25,000 beds by May 31.”

According to corporation data, Pune had 4,143 isolation beds and 151 ICU beds till April 30. Fifteen hospitals are now dedicated Covid-19 health centres, and three are dedicated Covid-19 hospitals.

A cause for concern is the “doubling time” of the infection: an indicator of how quickly the virus is spreading is how many days it takes for the number of cases to double. The higher the doubling time, the better. According to the state public health department, between May 1 and May 10, Maharashtra’s doubling time dropped from 15 days to seven days.

Pune’s initial doubling time was five days, Agrawal said, and it now stands at nine days. Her plan is to increase it to 12 days.

“For the last two months, we’ve been working aggressively with a workforce of 20,000 people,” she said. “We are fighting an unseen enemy, but I believe we will win. This is the most challenging phase of my career.”

Right now, the Pune administration is conducting door-to-door surveys and “rigorous testing” of over 1,000 people per day, Agrawal said. “Forty two departments of the Pune Municipal Corporation are engaged in the fight against Covid-19.”

Surveying and testing

Doorstep surveys began in the city in mid-March, conducted within a one-km radius of newly identified Covid-19 patients. Those surveyed are questioned about whether they had symptoms, home quarantine precautions, and travel history, in order to categorise high- and low-risk patients.

The surveys are conducted by a team of around 1,524 people comprising 979 assistant teachers, 200 clerks, 133 nurses, 95 group organisers, 90 accredited health social activists, or ASHAs, 15 ward medical officers, seven food inspectors, and five zonal medical officers.

Kanchan Gaikwad, an assistant teacher who is part of this team, told Newslaundry that they survey around 100 houses every day, filling up forms with names, ages and details of family members.

”We ask about symptoms and get details on comorbidities like high blood pressure and diabetes. We also get travel history details for the past 28 days,” he explained. “If someone has travelled, we follow-up with their movements in their last 14 days. If we find any suspects, we convey it to our higher authorities.”

Abhijeet Barwe is a member of the Rashtriya Swayamsevak Sangh-run Jankalyan Samita, which has partnered with the Pune Municipal Corporation to conduct the door-to-door surveys of 8,000 slum households. Barwe said teams of 240 volunteers and 40 doctors conduct the surveys across Pune’s containment zones. There are 69 containment zones in Pune.

“A single team comprises one doctor, two volunteers and a local guide,” he said. “With the help of a temperature gun, we screen people door-to-door and inform the corporation if we find any suspected cases. The corporation then conducts a swab test of that person and their family members. Those who test positive are admitted to the hospital, those who are negative are home-quarantined.”

Testing rates are alarmingly low across India, and it’s no different in Pune.

“Pune, and the entire country too, lacks testing facilities. Big cities like Mumbai, Delhi and Pune need more facilities since they have bigger populations,” said Abhijit Vaidya, a cardiologist and the founder of the Arogya Sena, a city-based social organisation that works in public health. “Private labs should be allowed to conduct tests.”

Pune has no separate testing strategy for hotspot areas, Vaidya added. “In fact, there is no strategy at all. The municipal corporation has created a couple of testing centres but they are overloaded and unable to cope with the number of patients. They have asked people with mild symptoms not to come to them.”

Importantly, Vaidya said, Pune and the rest of India officially does not conduct antibody testing, relying instead on swab tests. “The swab method of testing is very cumbersome, and the person who takes the swab has to wear personal protective equipment kits. But still, the government has not allowed antibody testing. The specificity of antibody testing may not be on par with swab testing but it gives an idea. It should be part of primary screening.”

Timeline of Covid-19 cases in Pune

March 9: Namdev and Sujata Palve tested positive on March 9. Their daughter Supriya tested positive the next day.

March 11-13: Two people who returned from the United States tested positive and were admitted to the Naidu hospital.

March 13: A family of four tested positive in an area that falls under the jurisdiction of the Pimpri Chinchwad Municipal Corporation, which is part of Pune district. They had no travel history and were infected through a relative, who was part of the Dubai tour group and tested positive too.

By March 13, Pune district had 13 Covid-19 patients.

March 14: A resident of Pimpri Chinchwad tested positive after traveling to Dubai and Japan.

March 30: Pune reported its first death: a 52-year-old man admitted to the Deenanath Mangeshkar hospital with pre-existing medical conditions and no travel history. By then, nine others had died in Maharashtra.

By March 31, sporadic cases were reported and there were 28 coronavirus infections in Pune.

The first week of April saw a substantial rise. Patients were admitted at Naidu hospital, Yashwantrao Chavan medical hospital, KEM hospital, Sahyadri hospital, and Jehangir hospital, as well as others roped in by district authorities to handle Covid-19 cases.

Until April 1, Pune had an average of four new cases a day. This subsequently rose 20-fold. Twelve cases were reported on April 4 and thereafter increased to 41, 38, 51, and 63 per day. On May 14, 224 new cases were reported in Pune.

Senior officials with the municipal corporation and the district collectorate told Newslaundry that cases in Pune spiked after city residents attended the Delhi congregation in March. Most of them lived in clustered areas and the virus began to spread by the time they were tested.

“Many of the returnees stayed in slums,” a corporation official told Newslaundry on the condition of anonymity, “and in slums, it’s not possible to follow the normals of physical and social distancing.”

Outbreak in Pune’s slums

The majority of Pune’s coronavirus cases are in its slums. There are 69 containment zones in these areas.

Bhavani Peth, a cluster that comprises over 20 slums, including Kashewadi and Lohiya Nagar, has 511 cases as of May 11, the highest in the city. This is followed by Dhole-Patil Road, including the slums of Khajagi road and Tadiwala road, with 409 cases; and Shivaji Nagar-Ghole road, including slums of Patil Estate and Kamgar Putala, with 326.

Newslaundry spoke to residents of a slum in Shivaji Nagar’s Patil Estate, which lies in one of Pune’s hotspot containment zones. Nestled between the College of Engineering and highrise buildings, around 8,000 people live in its 10 lanes spread over four acres. There are roughly 1,200 houses – measuring 10×10 sq ft, with family members multiplying over generations – and five community toilets, two ration shops, and a handful of grocery stores.

Sultana, a resident of this area, has two relatives who have tested positive for coronavirus: her father and her brother-in-law. Seven other members of her family, including her, tested negative but were quarantined at a hostel on Sinhagad road.

“My brother-in-law is 40 years old and works as a construction labourer. My father is 70 and stays at home,” Sultana said. “Except for going to the common toilet in our area, my brother-in-law has not gone out anywhere since the lockdown began. My father has paralysis so he hasn’t gone outside too. We don’t know how they got infected.”

Many residents have Covid-19 stories. Maruti Gaikwad, 36, went to Sonawane hospital in Bopodi on April 22 after a friend tested positive for coronavirus. Maruti had met the friend the previous day, and wanted to get a test done.

“Fortunately my test came back negative, but I was quarantined at a government facility in Balewadi for 14 days,” he said. “There was very little management there as there were more people and fewer staff members. I came home on May 4 but the fear of getting infected is always in my mind since our area is a red zone.”

The neighbourhood is very congested, Maruti added, and it isn’t possible to practise social distancing. “Seven or eight people live in a 100 sq ft room,” he pointed out. “But we keep our faces covered and try to sanitise our hands as much as possible.”

The 10 lanes in the Patil Estate slum have been barricaded. “Most of the people in our area are daily wagers,” said a resident on the condition of anonymity. “Because of coronavirus, we have become jobless. Even the women of our area who work as household help have been told by their employers not to come, as this is a red zone.”

The high number of cases in these urban areas points towards community transmission, with no clear source of infection.

Contact tracing and community transmission

The Pune Municipal Corporation’s data from April 30 shows that out of 1,518 cases, a majority of the patients – 1,253 of them – did not have a travel history, or contact with anyone with travel history. Nineteen cases were categorised as travellers, their contacts who tested positive, and their sub-contacts, and 246 were traced to those who visited the Delhi congregation.

Contract tracing was not aggressively pursued in Pune. Shekhar Gaikwad, the commissioner of the Pune Municipal Corporation, told Newslaundry that contact tracing in the city was “comparatively less”.

“We used to track 11-12 contacts of a confirmed case. We would take swab tests of family members. Neighbours, who were low-risk contacts, were given medical advice, and were only tested if they showed symptoms,” Shekhar said. “But then we increased the testing and began taking swabs of both high- and low-risk contacts.”

Considering the high number of cases, Shekhar said, it’s no longer possible to “follow the original spreader” of infection.

Naval Kishore Ram, the Pune district collector, said as much. But he added, “Still 71 percent of contact tracing is happening. We are ready to tackle any situation, even if another spike comes.”

Does Pune have enough testing kits? “We are not lacking kits but yes, there is a capacity issue because the National Institute of Virology, Pune, gets samples from other districts as well,” he said. “They have advised us to send them 600 samples a day only. We have started a testing centre at BJ Medical College which takes around 300 samples a day.”

Till May 14, at least 27,349 tests were conducted in Pune, according to data from the municipal corporation’s health department.

Evidence of community transmission is also laid out in a report by the Maharashtra Public Health Analysis Group, a voluntary group of health professionals. Using government data, it concluded that in late March, 80 percent of Maharashtra’s Covid-19 cases were recent travellers and their contacts. This rapidly changed over the next 10 days, with traveller cases and their contacts levelling off.

By the beginning of April, “awaited” and “inconclusive” cases – presumably those who are not travellers or their contacts – comprised 81 percent of all cases. As on April 26, at least 87 percent of cases in Pune were of people with no travel history and known contacts.

The report also notes that the case fatality rate in Maharashtra is higher compared to states such as Tamil Nadu, Kerala and Delhi, meaning the proportion of deaths is larger among Maharashtra’s Covid-19 patients.

Need for an ‘intensive strategy’

Dr Abhay Shukla, a public health specialist and a member of the Maharashtra Public Health Analysis Group, said that Kerala, and not Maharashtra, initially implemented five measures to contain the epidemic: wide-scale testing and identification of cases, isolation and treatment, meticulous contact tracing, home quarantine of traced contacts, and testing and follow-up of quarantined contacts.

“If you look at the graphs of coronavirus cases in Maharashtra and Kerala for March, they were almost parallel,” he said. “In fact, Kerala was more affected; it had a similar number of cases and only one-third the population of Maharashtra. But what Kerala did in March was remarkable. It worked on this strategy and contained the epidemic.”

He added: “Unfortunately, this intensive strategy was not emphasised in Maharashtra…Using these intensive measures, the epidemic could have been better controlled.” The strategy also could have been implemented in Pune until early April, Shukla said, but now, “community transmission is underway on a large scale in the clusters of some areas of Pune.” And once that happens, it’s difficult to control the outbreak.

Shukla said that neighbourhoods like Aundh, Baner and Kothrud are “track two” areas in Pune, where the number of cases is low. The five-point intensive strategy needs to be adopted in these areas, while roping in civil society groups and volunteers to help the health department in contact tracing.

“The epidemic was brought by people with passports, but has now spread among people with ration cards,” Shukla said. “It’s a microbe that cuts across the classes, and no social group should be stigmatised for it…Pune has the capacity to control this epidemic but an intensive strategy needs to be adopted.”

The containment of cases in Islampur, in Maharashtra’s Sangli district, is a good example of how district authorities used this strategy, Shukla added. Twenty-six cases were detected by March 23 after four members of a family tested positive after traveling abroad. All contacts were traced, symptomatic contacts were put in isolation, and asymptomatic contacts were put in institutional quarantine. A one-km containment zone was creating, with entry and exit points sealed, and home delivery of essential items organised. This led to effective containment, with positive cases recovering and practically no further cases in the area.

Newslaundry asked Shekhar Gaikwad, the corporation commissioner, why a track two strategy is not being followed in areas with fewer cases. Can the Islampur model be replicated in Pune?

“We are taking swabs of high-risk patients but we are not isolating anybody who is not positive,” he said. “Islampur is a very small place whereas Pune is a big city with a huge population. Some slums in Pune have a population of five lakh. It’s not practical to compare Islampur with Pune.”

Names of patients have been changed to protect their identities.