Dobe M, Sahu M. How the district in , , fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

CASE STUDY

How the in Andhra Pradesh, India, fought Corona

Madhumita Dobe1, Monalisha Sahu1

1 Department of Health Promotion and Education, All India Institute of Hygiene and Public Health, West Bengal, India.

Corresponding author: Madhumita Dobe; Address: 110, Chittaranjan Avenue, Kolkata - 700073, West Bengal, India; Telephone: +9830123754; Email:[email protected]

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Dobe M, Sahu M. How the Kurnool district in Andhra Pradesh, India, fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

Abstract Background: Kurnool, one of the four districts in the region of the Indian state of Andhra Pradesh, emerged as a COVID-19 hotspot by mid-April 2020. Method: The authors compiled the publicly available information on different public health measures in Kurnool district and related them to the progression of COVID-19 from March to May 2020.

Results: Two surges in pandemic progression of COVID-19 were recorded in Kurnool. The ini- tial upsurge in cases was attributed to return of people from other Indian states, along with return of participants of a religious congregation in , followed by in-migration of workers and truckers from other states and other districts of Andhra Pradesh, particularly from the state of Maharashtra (one of the worst affected states in India) and Chennai (the Koyambedu wholesale market - epicenter of the largest cluster of COVID-19 in ). In a quick response to surging infections the state government launched operation ‘Kurnool Fights Corona’ to contain the outbreak. Kurnool had taken a targeted approach to testing, scaled up testing in areas with high case load, and conducted contact tracing for each positive case, along with requisitioning oxygenated beds in the district hospitals to meet the anticipated spurt in the number of positive cases. This combined approach paid rich dividends and from 26th April to May 9th, the growth curve flattened.

Conclusion: Although the in migration of laborers and return of residents from other Indian states and abroad during the COVID-19 pandemic was a complex challenge, the timely actions of testing, tracing and isolation conducted by the district authorities in Kurnool greatly reduced transmission. Although this response assessment is based on a single district, the perspectives have revealed some important lessons regarding risk communication, preparedness and response for pandemics which will facilitate consolidation of the policy and program response to pandem- ics in future.

Keywords: contact tracing, COVID-19, isolation, Kurnool, preparedness, testing.

Acknowledgement: Dr Sanjoy Sadhukhan (Professor, AIIH&PH) and District Authorities of Kurnool for their support.

Conflicts of interest: None.

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Dobe M, Sahu M. How the Kurnool district in Andhra Pradesh, India, fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

Background nation-wide lockdown was first announced Kurnool District is one of the four districts in on March 24 to contain COVID-19 out- the Rayalaseema region of the Indian break. Over 300 foreign returnees from It- state of Andhra Pradesh (1). aly, UK/Scotland, Saudi Arabia (Mecca) The district is located in the west-central part were under surveillance and the district ad- of the state and is bounded by ministration collected samples for tests. On district of in the north, Raichur March 28 the first case in the district was district of in the northwest, Bel- reported, as a 23-year-old male with a travel lary district of Karnataka in the west, Anan- history to Rajasthan tested positive for the thapur district in the south, YSR dis- virus (3). The number of positive cases re- trict in the South East and Prakasham dis- mained low for the next two weeks. Spikes trict in the east. The district is the second of cases were reported on April 5 and April largest by area and seventh largest by popu- 6 with 49 and 18 cases emerging respec- lation in the state with a total population of tively in those two weeks till April 13 (4). 4.53 million as per 2011 census, 72% of But things changed from April 14 when the which reside in rural areas. The main occupa- numbers kept shooting up. tion and source of livelihood for this dis- trict is agriculture. More than 70% of the The first Surge of cases: During Mid- population in the Kurnool district engages in March, Tablighi Jamaat (religious congre- farming. However, as Kurnool is a drought gation) was held at Nizamuddin Markaz in prone area, many of the villagers are forced New Delhi. Many people from Kurnool had to migrate not only to other states but also attended the congregation. The first alarm to other districts within the state in search of went off when three persons from Kurnool livelihood. The district has three Revenue di- district, who attended the Tablighi Jamaat at visions viz., Kurnool, , divi- Nizamuddin, tested positive for COVID-19 sions with 54 mandalas and 53 Panchayat Sa- (5). The number of positive cases in the dis- mitis (Blocks) under these revenue divisions trict went up from one to four with these (1,2). three persons hailing from Kurnool , and Banaganapalli. District officials Methods felt that the influx of 357 Tablighi Jamaat The authors compiled and reviewed all pub- (TJ) congregation returnees from New licly available information (Government da- Delhi triggered the sudden spurt. The re- tabase, newspaper articles, reports) and inter- turnees and their primary and secondary viewed government officials during field vis- contacts accounted for majority of the cases its on different public health measures taken in the district which had the highest number in Kurnool district to contain the ongoing of Delhi returnees in the state. The chal- COVID-19 pandemic in progression from the lenge was formidable since on one hand, au- month of March to May 2020. thorities were unable to precisely locate all TJ meeting returnees and on the other, those Results traced by them did not come forward volun- Everything seemed in line with the overall tarily for diagnostic tests and were unwill- progress of the pandemic in India when the ing to be taken

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Dobe M, Sahu M. How the Kurnool district in Andhra Pradesh, India, fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

to isolation or quarantine wards. Since there was no single source which had details of all par- ticipants and their addresses, there was difficulty in iden- One hundred and ninety-five cases emerged tifying those who attended the meet in in 13 days, making Kurnool one among the Delhi. few districts in to see a dramatic Due to these issues, there was a delay of 10 surge (6). By April 25, the district admin- days initially in identifying the Tablighi Ja- istration had declared 40 red zones in 20 of maat returnees and their contacts which led a total 54 mandalas and urban areas includ- to a spike in the number of cases in the dis- ing Kurnool city with 239 active cases, 9 trict. Also, problem lay in lack of VRDL deaths, and 31 recoveries (4,6). The worst- (Virus Research and Diagnostic Labora- affected areas were Kurnool city and tory) in Kurnool and dependence on labora- Nandyal (Figure 1). tories far away from the district headquar- ters. Sample results were delayed thereby hindering initial contact tracing.

Figure 1. Administrative map of Kurnool District and the COVID-19 affected Mandalas. Data as on 25th April 2020 (2,6)

The district, now accounted for over a quar- The second surge: With the lockdown im- ter of the cases in Andhra Pradesh and fig- posed, the migrant workers from the district ured high on the list of districts with the started to return without effective controls. highest number of COVID cases in South In consequence a fresh upsurge of cases was India after Chennai in Tamil Nadu, Hydera- noted with average daily increase to seven bad in Telangana and Kasaragod in Kerala new cases (from 6th to 21st May 2020). (4). To battle against this, operation “Kur- Most cases were seen among migrant work- nool Fights Corona (KFC)’ was launched ers and lorry drivers returning from Maha- (7). rashtra (one of the worst affected states in P a g e 4 | 9

Dobe M, Sahu M. How the Kurnool district in Andhra Pradesh, India, fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

India) and from Koyambedu (Chennai’s Arrangements for Quarantine were as fol- popular wholesale market, and the epicenter lows: of the largest cluster of COVID-19 in the  Home Quarantine for asymptomatic neighbouring state of Tamil Nadu), along migrants from within state; with their primary and secondary contacts.  Community Quarantine for sympto- Out of 8,069 workers who returned from matic migrants from within state at other states, 236 were tested positive to secretariat level / school build- Covid-19. Similarly, of another 3,337 work- ings; ers who returned from Mumbai, 314 tested  Institutional Quarantine at block positive to the virus (3). However, probably level-School buildings for migrants only those who had reported or were inter- from other Low risk states; cepted during their journey back were tested.  Institutional Quarantine at district level (housing flats) for Migrants In-migration from other districts: By 4th from other High risk states e.g. Maha- May another 40,000 migrant workers re- rashtra and Chennai (Koyembadu); turned to Kurnool district from other dis-  Hotels & Lodges for paid Quarantine tricts in the same state of Andhra Pradesh. facilities for affordable rich persons/ Almost all of them were working in chili Foreign returnees. fields at and Prakasam districts. Most of these migrant laborers had left for The Health, Medical and Family Welfare de- work in January and February. partment of Andhra Pradesh directed all Dis- trict collectors to establish quarantine centers Containment Measures: The District put at district level with 200 beds and constitu- well streamlined contact tracing and quar- ency level with 100 beds each. By March 25, antine measures in place. The state formu- all district hospitals in the state were in- lated an action plan to bring back about structed by the Health department of Andhra 200,000 of its migrants held up in 13 states Pradesh, to setup isolation wards. The state, with well-planned quarantine measures. on 31 March, identified dedicated COVID-19 hospitals- 4 at state and 13 at district level. A. Quarantine Facilities for in migrants On 31 March 2020, all district administration and returnees: Responding to the upsurge, in Andhra Pradesh was directed by the state the existing number of 244 Quarantine Cen- government to prepare shelter with lodging ters were increased to 1 in each village sec- and boarding services for migrant labourers. retariat (one Village Secretariat has been These shelters were managed by individual set up for every population of 2,000), 'Nodal Officer', appointed by the District readying over 100,000 beds at village secre- Collector or Municipal Commissioner. tariats, with nutritious food, hygienic toilets Immediately after their entry into Kurnool, for the returnees (10). Each village secretar- the returnees coming from various high-risk iat was made suitable to accommodate 10- states like Maharashtra-the worst-hit State, 15 people during quarantine. were taken in specially-arranged buses to the institutional quarantine centers set up by the administration in Kurnool and Adoni before returning to their respective homes. COVID- P a g e 5 | 9

Dobe M, Sahu M. How the Kurnool district in Andhra Pradesh, India, fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

19 tests were done for all the migrants and in the communities. Even healthcare work- they were allowed to go home only after 14 ers, sanitary workers and police, who were days of quarantine as per the protocol. Coun- in the frontline for management of the out- selling and other support systems were also break, were facing discrimination on ac- being arranged by district authorities in the count of heightened fear and misinfor- quarantine centers to help people cope up mation about infection. District authorities the stress and anxiety. addressed these issues through busting the myths and sharing accurate information Limitations: On the flip side, mandatory about how the virus spreads and does not quarantine was accompanied by fear, alarm, spread. They used news media and social and panic. This, augmented by media, media, to speak out against stereotyping spread farther and aggravated the risk of be- groups of people who experience stigma be- ing stigmatized. Field workers reported that cause of COVID-19 and spoke out against those returning from quarantine were dis- negative behaviours and statements. criminated in the form of:  Other people avoiding or rejecting B. Contact Tracing Activities: Contact them; tracing teams were put in action, manned by  Verbal abuse; or medical doctors and health workers. The  Physical violence. data base and line listing was maintained This led to isolation, depression, anxiety, or rigorously by the contact tracing team (11). public embarrassment for these individuals The Line listing of the cases is presented in sometimes leading to challenges in contact Table 1. tracing as reported by community health workers participating in active surveillance

Table 1. Line listing of the cases among returnees in Kurnool by 19th May 2020

Category Total No. Total pos- Primary Primary Secondary Secondary Of per- itives contacts contacts contacts contacts sons traced positive traced positive Foreign Re- 840 1 2 0 12 0 turnees Delhi Return- 361 114 1048 35 2786 44 ees Delhi Return- 3834 79 718 0 1756 1 ees-Contacts Koyembedu 473 12 69 0 324 0 returnees Total 5508 206 1837 35 4878 45

After receiving line list of positive cases, contacts. The information of the contacts the positive cases were contacted through was shared with the Sample Testing Team, phone calls. They were extended support Home Isolation Department, Integrated Dis- and were inquired about their contacts. The ease Surveillance Program and Municipal contacts were listed, identified and classi- Health Office to eensure they have access to fied into primary, secondary and tertiary medical care and social services. They are P a g e 6 | 9

Dobe M, Sahu M. How the Kurnool district in Andhra Pradesh, India, fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

notified about their exposure, offered treat- sellers had travelled to the market even dur- ment if required and instructed to limit their ing lockdown period for business purposes contact with other people. Medical officers and as vendors and market laborers includ- and Auxiliary Nurse Midwives (ANMs) ing load men returning from Koyembadu were informed to acquire further infor- began to test positive, tracing and testing all mation on the contacts including associated index cases was aggressively undertaken, comorbidities. Follow up of the contacts for what marked the beginning of a challenging testing, quarantine and isolation was done process was contact tracing. The cluster was by the local teams. Monitoring of actions in different owing to the massive crowds in- collaboration and coordination with Munic- volved (8,9). In a normal situation, a person ipal Health Officers, Medical Officers, who tests positive for COVID-19 will have Auxiliary Nurse Midwives and Ward Vol- 20 to 30 contacts but this was not the case unteers was done on regular basis. with the Koyambedu cluster where some who tested positive had roughly 200 to 250 Special Challenge of contact tracing of contacts. Koyembadu market returnees: This combined approach paid rich dividends Koyambadu market complex is one of and from 26th April to May 9th, the number Asia’s largest hubs for perishable goods. of new cases gradually declined with a Dou- Retail vendors come from a minimum ra- bling Rate of 25 (Figure 2). dius of 100 km. Kurnool is one of the main sources of Onion for Tamil Nadu, and many

Figure 2. Graph representing temporal variation of new cases, cumulative cases and active cases from Kurnool District till May 5th 2020 (Source: District data provided by Nodal Officer)

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Dobe M, Sahu M. How the Kurnool district in Andhra Pradesh, India, fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

Conclusion outbreak. In summary Kurnool had taken a Although the in-migration of laborers during targeted approach to testing, scaled up testing the COVID-19 pandemic was a complex in areas with high case load, and conducted challenge, the timely actions conducted by contact tracing for each positive case, along the district authorities in Kurnool greatly re- with requisitioning oxygenated beds in the duced transmission. Hundreds of migrants district hospitals to meet the anticipated spurt and those who had close contact with the pos- in the number of positive cases. This com- itives among them, were placed in quarantine bined approach paid rich dividends and centers run by the government. Hot spots from 26th April to May 9th, the growth curve with high case load were locked down imme- flattened. diately, and the government communicated Although this response assessment is based frequently with citizens to keep them in- on a single district, the problems faced by formed and involved in the public health re- Kurnool have revealed some important les- sponse. sons regarding risk communication, prepar- Also, in a quick response to surging infec- edness and response for pandemics which tions the state government launched opera- will facilitate consolidation of the policy and tion ‘Kurnool Fights Corona’ to contain the program response to pandemics in future.

References with-over-279-coronavirus-cases-in- 1. Government of Andhra Pradesh. one-month-govt-steps-up-fight-to- Kurnool District. Available from: stop-spread-2135834.html (ac- https://kurnool.ap.gov.in/ (accessed: cessed: July 17, 2020). July 17, 2020). 5. The Hindu.70 Nizamuddin’s 2. Government of Andhra Pradesh. Tablighi Jamaat returnees identified Andhra Pradesh Space Applications in Kurnool district. Available from: Centre. Available from: https://ap- https://www.thehindu.com/news/na- sac.ap.gov.in/ (accessed: July 17, tional/andhra-pradesh/70-ni- 2020). zamuddin-returnees-sent-to-quaran- 3. The Times of India. Kurnool reports tine/article31215260.ece (accessed: first corona positive case. Available July 17, 2020). from: 6. Arogya Andhra on Twitter: “Kurnool https://timesofindia.indi- district has the highest number of atimes.com/city/vijayawada/kurnool- #COVID19 positive cases in the reports-first-corona-positive-case/ar- state.” Available from: https://twit- ticleshow/74867409.cms (accessed: ter.com/ArogyaAndhra/sta- July 17, 2020). tus/1254039414956625920 (ac- 4. The New Indian Express. Battle of cessed: July 17, 2020). Kurnool: With over 279 corona- 7. The Times of India. Operation ‘Kur- virus cases in one month govt steps nool Fights Corona’ launched; 14 up fight to stop spread. Available new cases in district, 24 patients 24 from: https://www.newindianex- patients discharged. Available from: press.com/states/andhra-pra- http://timesofindia.indi- desh/2020/apr/27/battle-kurnool- P a g e 8 | 9

Dobe M, Sahu M. How the Kurnool district in Andhra Pradesh, India, fought Corona (Case study). SEEJPH 2020, posted: 18 November 2020. DOI: 10.4119/seejph-3963

atimes.com/arti- market-impacts-four-districts-in-an- cleshow/75383053.cms?utm_source dhra-pradesh/article31569117.ece =contentofinterest&utm_me- (accessed: July 17, 2020). dium=text&utm_campaign=cppst 10. Deccan Hearald. Andhra uses vil- (accessed: July 17, 2020). lage secretariat buildings to ready 1 8. The Hindu. What turned Ko- lakh quarantine beds for people re- yambedu, Chennai’s popular whole- turning to state. Available from: sale complex market, into a https://www.deccanherald.com/na- COVID-19 hotspot? Available from: tional/andhra-uses-village-secretar- https://www.thehindu.com/news/na- iat-buildings-to-ready-1-lakh-quar- tional/tamil-nadu/coronavirus-what- antine-beds-for-people-returning-to- turned-koyambedu-chennais-popu- state-833076.html (accessed: July lar-wholesale-complex-market-into- 17, 2020). a-covid-19-hotspot/arti- 11. Government of Andhra Pradesh. cle31546292.ece (accessed: July 17, Department of Health & Family 2020). Welfare. Available from: ArogyaAn- 9. The Hindu. Koyambedu market im- dhra (@ArogyaAndhra) | Twitter; twit- pacts four districts in Andhra Pra- ter.com › arogyaandhra. desh. Available from: https://www.thehindu.com/news/na- tional/andhra-pradesh/koyambedu-

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© 2020 Dobe et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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