Hyderabad, TELANGANA — On March 27 Telangana announced its first COVID-19 related death; but the patient had no recent history of foreign travel, no documented contact with someone who had travelled abroad, and no established exposure to anyone known to be carrying the virus.
Twelve days prior to his death, 74 year old L* had flown to Delhi for a short three-day visit for a congregation, organised by the Tablighi Islam religious order, that was attended by hundreds of preachers and religious scholars from Andhra Pradesh and Telangana.
On March 26, nine days after he returned from Delhi, L was rushed to a private hospital in Hyderabad after he collapsed at home from a bout of acute breathlessness. He was declared dead on arrival, and found to be carrying the novel coronavirus only when doctors tested throat and nasal swabs taken from his corpse, a hospital spokesperson and family members confirmed to HuffPost India. HuffPost India is withholding L’s full name and address to protect his family’s privacy.
At a time when health officials have been mostly successful in quickly tracing all coronavirus infections in the country to foreign travel, or a known patient, L’s case stands out as an anomaly.
Now health officials in Telangana are scrambling to unravel his chain of contacts in the hope of zeroing on precisely who gave L the disease, and preventing more infections from the same source. Yet, his visit to Delhi to participate in a well attended public gathering at the Markaz Nizamuddin, in one of the city’s more crowded neighbourhoods, has revived the persistent fear that the coronavirus may have entered the “community transmission” phase — something health officials are at pains to deny for now.
On March 30, The Hindu reported that over 200 people in Nizamuddin were being tested for COVID-19 symptoms. It is unclear how many of those tested were from the Tablighi Islam’s headquarters, and how many were from the surrounding neighbourhood. On March 25, the paper reported that another person — a 52 year old man from Guntur, Andhra Pradesh — also died of COVID-19 after attending the same function in Nizamuddin.
At a press briefing on March 30, Union Health Secretary Luv Aggarwal stated that the coronavirus was still in the local transmission state, and the government would make clear if and when virus entered the community transmission stage.
Since L’s death on March 26, a senior official in the Telangana Health Ministry confirmed that the state government has tracked down at least 260 people from Andhra and Telangana who attended the same congregation as L. These people, the official said, have been placed under quarantine and are being tested for the coronavirus. Of the results available thus far — forty people have tested negative, while one person has tested positive. But the specific source of L’s infection remains unknown, the official confirmed.
The Telangana government has notified the Delhi government, the source said.
Telangana health officials have echoed their counterparts in Delhi in insisting that the virus has not entered the “community transmission” stage.
At a press conference called to announce L’s death on March 27, the state’s health minister Etela Rajender maintained that, “people who have not been exposed to COVID-19 positive patients have not contracted the virus as of now. No person has got it from unknown persons”.
“The patient had travelled to Delhi and was under treatment for pneumonia,” Rajender said.
As of March 30, India had 1071 coronavirus cases and 27 fatalities. But the country has tested fewer than 30,000 individuals — far fewer than countries such as the United States, China, and South Korea. The strategy of limited testing, Indian authorities have said, is partly because a shortage of testing kits prompted health officials to first focus on those more likely to be carrying the illness.
Last week, the Indian Council of Medical Research (ICMR) published the results of a study suggesting the country’s unprecedented nation-wide lockdown could contain the spread of the coronavirus, but experts told Huffpost India that the scope of the study was too limited to rule out “community transmission.” Widespread testing, public health experts say, is the only way to establish if community transmission of the virus has begun.
In the meantime, India has compensated for the lack of testing by establishing a lockdown far more draconian than countries such as the United States which have far more confirmed cases of coronavirus.
On March 14 this year, L flew to Delhi to attend this congregation of Islamic preachers from Andhra Pradesh and Telangana. He stayed in the city’s Nizamuddin neighbourhood, and flew back to Hyderabad three days later.
When L landed at the domestic terminal of Hyderabad’s Rajiv Gandhi International Airport on March 18, the ICMR had mandated coronavirus tests only for those international travellers with flu-like symptoms such as a cough, cold, fever, and shortness of breath, medical practitioners who had been in contact with those who had tested positive for the virus, and anyone in direct contact with someone who had tested positive. All those who had travelled abroad were asked to self-quarantine at home for 2 weeks. This particular ICMR testing strategy was announced on March 17, and updated on March 20.
But when L landed in Hyderabad, he did not fit this narrow testing criteria and so got off his flight and went home.
The next day on March 19, L’s son took him to an eye clinic to treat an inflammation in his left eye.
“The clinic’s doctor ruled it an eye infection and prescribed antibiotics and eye drops,” L’s 45 year old son said, explaining that his father had had eye surgery a few years ago and periodically developed eye infections.
L was also running a temperature, his son said, “The mild fever he had at that time was attributed to the infection.”
The swelling subsided over five days; then on March 24 L developed a cough. He was again taken back to the eye clinic where the doctor asked him to continue the antibiotic course for three more days.
The evening of March 25, L developed shortness of breath and started running a high temperature. On the morning of March 26, L’s son took him to a private health clinic in Saifabad in Hyderabad where he was found to have developed pneumonia.
On March 20 ICMR had broadened India’s Covid-19 testing strategy to include testing of people admitted in hospitals for Severe Acute Respiratory Infections (SARI) including pneumonia. L was not tested for COVID-19, despite having pneumonia, as he had been examined by the Out-Patient Department of a private clinic, and had not been admitted in a hospital as the guidelines for testing mandated.
Here, the resident doctor prescribed more antibiotics. Antibiotics are known to be ineffective against viruses like the novel coronavirus.
“I was asked to administer injections thrice a day,” his son said. “He was also asked to use a nebulizer to help with shortness of breath.”
At home, L’s family of seven — his 63-year-old wife, son, daughter-in-law (41) and four grandchildren who are between 16 and 3 years of age —kept him company.
“The only relief right now is that my wife and children were living on the first floor of the apartment while my parents and I kept to the ground floor because we did not want our children to catch a cold,” L’s son said.
By the evening of March 26, L’s condition had deteriorated rapidly. That night he was rushed to a nearby privately run health facility where he was taken to the casualty ward.
“The patient was brought in at 10.19 pm on March 26. We were told that he had collapsed in his home,” a hospital spokesperson said. “There was no travel history for the patient so he was sent to the casualty wing of the hospital”.
He was given an electrocardiogram to measure his heart activity and declared dead soon after. When the doctors learnt L had been diagnosed with pneumonia, they took nasal and throat swabs.
The test results came in twelve hours later, on the morning of March 27, which is when L was found to be the first person in Telangana to have died of COVID-19. Meanwhile, several people — including L’s family members and the doctors who treated him — had potentially been exposed to the virus. A hospital spokesperson said four medical practitioners who had interacted with L at the hospital had been told to quarantine themselves at home.
“All precautionary measures were taken while handling the body. The deceased patient and his relatives were at the hospital only for 45 minutes”, the spokesperson said. The authorities did not divulge details of protocols taken during post-mortem autopsy and embalming.
Once the positive test results came in, L’s family struggled to find an ambulance willing to take the body to a morgue in Gandhi hospital, a designated facility for Covid-19 cases.
“That was the longest night of my life,” his son said.
L’s death was announced on the evening of March 27 — about 24 hrs after his death.
“We were waiting for test results. Primary contacts of the deceased including the doctors who treated him were traced during this time,” said an official from the health department. As of March 30, the state is yet to track down L’s secondary contacts — namely all the patients who visited the same clinics as L in the course of his illness.
Family in quarantine
L was finally laid to rest in a cemetery in Hyderabad on March 28. The Telangana police had handed over his body to a relative who conducted the burial in the presence of a few policemen.
No relatives or immediate family members were allowed at the burial site; much of L’s family is in quarantine.
“We did not insist on Islamic rituals like bathing the body and covering it with white cloth because we wanted to follow the medical protocol,” his son said, explaining that the family offered Gayebana Namaz-e-Janaza or in absentia funeral prayer at home.
As of the morning of March 29 morning, four of L’s immediate family of seven tested negative. L’s wife and two grandchildren are yet to be tested and remain in quarantine at the Gandhi Hospital.