BMC scrambles to contact trace in cramped slums of Mumbai; lack of personnel, unique challenges hamper efforts, say experts

The coronavirus pandemic has posed an unprecedented public health challenge to authorities in Mumbai, the city the most severely affected by the disease in the country. Till 16 April, Mumbai reported 2,043 cases, and the infection also appears to be spreading at a rapid pace. The city reported over 1,000 new infections in just six days between 11 April and 16 April.

The Brihanmumbai Municipal Corporation (BMC) has attributed the steep rise in reported coronavirus cases partly to “vigorous contact tracing efforts” by its health workers. However, civic authorities and voluntary organisations leading the process of contact tracing are having to contend with enormous challenges, including staff shortages, risks due to inadequate personal protective equipments (PPEs) and the population density.

Daksha Shah, deputy executive health officer with the BMC, said, “As per the official protocol, if a person tests positive for COVID-19, we test all the high-risk contacts of the patients for the disease. Low-risk contacts are tested only if they develop symptoms. This process is more challenging in densely-populated areas such as slums, as it is difficult to ascertain who came in contact with whom.”

As per the health ministry’s guidelines, high-risk contacts broadly include family, caregivers and people who came in contact with a patient for a prolonged period (more than six hours). Low-risk contacts are those who have shared the same space as the patient (such as colleagues, classmates or those who travelled in public transport along with the patient).

Official guidelines further state that all high-risk contacts of confirmed coronavirus cases need to be home quarantined for 14 days, and health workers are expected to follow up with them for 28 days.

Health workers apprehensive

Implementing the protocol is not an easy task, as public health professional Vaishali Venu emphasises. Venu works with NGO Doctors For You, which is presently involved in contact tracing efforts in slum clusters in Govandi’s Shivaji Nagar and Bandra’s Behrampada.

Speaking to Firstpost, she noted, “There have been several instances recently in which entire hospitals have had to be sealed off because a few doctors tested positive for coronavirus. In such a scenario, some doctors and nurses are apprehensive about working on tracing contacts of COVID-19 patients. Sometimes, when doctors associated with us go to communities for this purpose, local medical staff members discourage them, saying that there is a high risk of them catching the infection. They also point to shortages of PPEs such as masks and gloves. We have had many cases where doctors went to a community for contact tracing and then came back after an hour, saying that they cannot work there. In such cases, we cannot really force them to do so.”

Describing challenges that are unique to slum communities, Venu said, “As of now, public transport is closed, as are other public spaces such as schools and colleges and many workplaces. However, there are several public places in slum communities where there is a risk of catching the infection, as people continue to gather at such places. For example, in Shivaji Nagar and Behrampada, an average of about 5,000 people use the same public toilet, and it is not possible to know who comes in contact with whom at such places.”

She added, “However, such areas can be turned into containment zones to ensure that if some people have the infection, they do not spread it beyond a particular geographical area. Also, if some people do display symptoms of coronavirus, testing can be carried out in that community. Considering the huge population of Mumbai, it is not possible to test each and every person. Therefore, keeping in mind the resources at hand, this seems to be the best option.”

Speaking about the sections of society that are more vulnerable to contracting and spreading the COVID-19 infection, Venu said, “Self-employed people such as vegetable vendors, who still need to be out and about, are at a greater risk, since they come in contact with more people. The same goes for people who are working on essential services and going out of their homes. Further, even if such people experience symptoms such as cough or fever, there is a possibility that they may hide them, since it is a question of their livelihood. This increases the risk for those people as well as the ones around them.”

Till now, 38 people have tested positive for coronavirus in Shivaji Nagar and one person has tested positive in Behrampada. These clusters have emerged as new areas of concern after Dharavi, the city’s biggest slum. Till 16 April, 71 cases were reported from Dharavi.

Staff shortages

Another concern in carrying out contact tracing to combat coronavirus is that there simply aren’t enough front line personnel. Speaking about this, Mathew George, professor at the Centre for Public Health, Tata Institute of Social Sciences, said, “The healthcare work force that is meant to do the actual task of house-to-house contact tracing is woefully inadequate. In urban areas, health posts constitute the most local units of the public health system. As per norms, there should be one health post for every 50,000 people, but in reality, some parts of Mumbai have one health post for over 3 lakh people.”

The recommendation for a primary urban health centre, with outreach and referral facilities, for an average of 50,000 people was made by the National Urban Health Mission (NUHM) in 2008.

Mathew also noted, “Further, the staff members from the health posts work mostly with slum communities, and not with middle class and affluent people. The existing mechanisms are curative in nature, and we do not have enough infrastructure to take preventive measures.”

Speaking about research that needs to be conducted on the spread of coronavirus, Mathew said, “For any infectious disease, possible sites of transmission would include families, workplaces, public transport, essential services and recreation. In the context of coronavirus, it is important to identify exactly which sites of transmission among these are more responsible for the spread of the disease.”

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Neerad Pandharipande