|Year : 2022 | Volume
| Issue : 3 | Page : 180-184
Symptomatic survey of COVID-19 in the rural health and demographic surveillance site of Maharashtra, India
Jayashree Sachin Gothankar1, Arvinder Pal Singh Narula1, Karamchand Patil1, Rupeshkumar Deshmukh1, Jayesh Patil1, Prakash Doke1, Ajit Karanjkar2
1 Department of Community Medicine, Bharati Vidyapeeth Deemed to be University Medical College, Pune, Maharashtra, India
2 Mulshi Block Medical Officer, Pune, Maharashtra, India
|Date of Submission||21-Oct-2020|
|Date of Acceptance||30-Apr-2021|
|Date of Web Publication||26-Sep-2022|
Jayashree Sachin Gothankar
Department of Community Medicine, Bharati Vidyapeeth Deemed to be University Medical College, Off Pune-Satara Road, Dhanakawadi, Pune - 411 043, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The COVID-19 epidemic is fast-evolving and restrictions to contain it changes quickly. The secondary attack rate (SAR) indicates the infectiousness at the household level, and it provides a clue of load of infections in the community. Rapid implementation of a large scale, but brief survey provides a nationally representative view of the pandemic's progression and impact as well as the effect of the measures taken to control the spread. Materials and Methods: This cross-sectional study was done for a period of 2 months July–August 2020, in one of the rural health and demographic surveillance system (HDSS) site in India among 11,507 households having 46,571 individuals with the objective to determine the prevalence of the COVID-19 infection and to estimate the family SAR. The data were collected using the mobile phone by calling the head of the households registered under the HDSS. The research tool was created using questions based on the guidelines provided by the Ministry of Health and Family Welfare, India. The interviewers were first trained in data collection. Results: The households of 33,780 individuals were contacted and 33 patients were diagnosed as COVID positive, prevalence rate of 0.1% was thus documented through telephonic survey. The mean age of COVID patients was found to be 37 ± 16 years, and 63% of the diagnosed patients were males, majority of them belonged to above poverty line households. During the survey, 46 individuals reported to have the symptoms suggestive of COVID, fever and cough were the most commonly reported symptoms. The family SAR of 17.2% was documented. Conclusion: Thus to conclude a low COVID-19 prevalence rate of 0.1%, a higher family SAR of 17.2% was reported in the current study. Timely diagnosis and quarantine of close contacts should be continued to be implemented rigorously to prevent the spread of the COVID-19 virus. These efforts will be useful to contain the epidemic before it reaches an alarming level in the rural areas.
| Abstract in French|| |
Introduction: L'épidémie de COVID-19 évolue rapidement et les restrictions pour la contenir changent rapidement. Le taux d'attaque secondaire (SAR) indique l'infectiosité au niveau du ménage et fournit un indice de la charge d'infections dans la communauté. La mise en œuvre rapide d'une enquête à grande échelle mais brève fournit une vue représentative à l'échelle nationale de la progression et de l'impact de la pandémie ainsi que de l'effet des mesures prises pour contrôler la propagation. Matériels et Méthodes: cette étude transversale a été réalisée sur une période de 2 mois de juillet à août 2020, dans l'un des sites du système de surveillance sanitaire et démographique en milieu rural (HDSS) en Inde auprès de 11 507 ménages comptant 46 571 individus dans le but de déterminer prévalence de l'infection au COVID-19 et d'estimer le DAS familial. Les données ont été collectées à l'aide du téléphone mobile en appelant le chef de ménage inscrit au HDSS. L'outil de recherche a été créé à l'aide de questions basées sur les directives fournies par le ministère indien de la Santé et du Bien-être familial. Les enquêteurs ont d'abord été formés à la collecte de données. Résultats: les ménages de 33 780 individus ont été contactés et 33 patients ont été diagnostiqués positifs au COVID, un taux de prévalence de 0,1 % a ainsi été documenté par une enquête téléphonique. L'âge moyen des patients COVID était de 37 ± 16 ans, et 63 % des patients diagnostiqués étaient des hommes, la majorité d'entre eux appartenant à des ménages au-dessus du seuil de pauvreté. Au cours de l'enquête, 46 personnes ont déclaré avoir des symptômes évocateurs de COVID, la fièvre et la toux étaient les symptômes les plus fréquemment signalés. Le SAR familial de 17,2 % a été documenté. Conclusion: Ainsi, pour conclure à un faible taux de prévalence de la COVID-19 de 0,1 %, un DAS familial supérieur de 17,2 % a été rapporté dans la présente étude. Le diagnostic rapide et la mise en quarantaine des contacts étroits doivent être poursuivis et mis en œuvre de manière rigoureuse pour empêcher la propagation du virus COVID-19. Ces efforts seront utiles pour contenir l'épidémie avant qu'elle n'atteigne un niveau alarmant dans les zones rurales.
Mots-clés: COVID 19, système de surveillance sanitaire et démographique, téléphone portable, prévalence, milieu rural, taux d'attaque secondaire
Keywords: COVID 19, health and demographic surveillance system, mobile phone, prevalence, rural area, secondary attack rate
|How to cite this article:|
Gothankar JS, Narula AP, Patil K, Deshmukh R, Patil J, Doke P, Karanjkar A. Symptomatic survey of COVID-19 in the rural health and demographic surveillance site of Maharashtra, India. Ann Afr Med 2022;21:180-4
|How to cite this URL:|
Gothankar JS, Narula AP, Patil K, Deshmukh R, Patil J, Doke P, Karanjkar A. Symptomatic survey of COVID-19 in the rural health and demographic surveillance site of Maharashtra, India. Ann Afr Med [serial online] 2022 [cited 2023 Mar 21];21:180-4. Available from: https://www.annalsafrmed.org/text.asp?2022/21/3/180/356837
| Introduction|| |
COVID-19 was declared an international emergency of international concern by the WHO on March 11, 2020. Countries across the world had initiated various measures such as limitations on travel both domestic and international travel, stay-at-home orders, closing of schools and colleges, shops, and religious centers.
After a nationwide lockdown in India for 4 months, the unlock process was initiated from July 1, 2020. To contain the spread of COVID-19, a robust surveillance system needs to be in place to predict the spread of the virus infection.
The information about the current situation of COVID-19 is important to initiate the actions to limit the spread of disease, enable public health authorities to manage the risk of COVID-19, and thereby enable economic and social activity to resume to the extent possible.
Rapid implementation of a large scale but brief survey provides a nationally representative view of the pandemic's progression and impact, as well as the effect of the measures taken to control the spread. Such a survey will provide inputs to local level policy-makers such as village local government. The existing technology can be used to conduct the study without using any health resources, which otherwise can be used elsewhere. Phone surveys are faster to conduct but they may have low response rates, and they require an extensive human resource to conduct the interview. The scientific knowledge regarding the household transmission of the COVID-19 through contact with the positive case is sparse. A systematic review has reported a secondary attack rate (SAR) across the countries ranged from 4.6% to 49.56%. While a study in China reported the SAR of 12.4%.
The COVID-19 epidemic is fast-evolving, and restrictions to contain it change quickly. There is no large-scale survey conducted to determine the pattern of the spread of the virus at the household level in the rural areas. The study area is rural and close to the highest affected Pune city in Maharashtra. The SAR indicates the infectiousness at the household level, and it will provide a clue of the load of infections in the rural community.
- To determine the prevalence of COVID-19 and to determine the proportion of currently symptomatic individuals in the households registered under the rural health and demographic surveillance system (HDSS)
- To determine the SAR of COVID-19 among the family contacts of the COVID-19-positive patient.
| Materials and Methods|| |
A cross-sectional and descriptive study.
Selection and description of the participants
All the 11,507 households with 46,571 members registered in 13 villages under Lavale (HDSS) who consented for the study were included.
All the households who could be contacted through the mobile phone numbers available in the existing data base of the HDSS were included in the study.
While the household whose mobile number was found to be not existing or if it was connected as a wrong number or the number was switched off then these households were excluded. For the households whose mobile number was found to be busy on dialling, a second call was given to the same number at a different time on the next day. If during the second call, the number was not connected for any reason, that house was excluded.
The study duration was 2 months (August–September 2020) including a data collection period of 1 month.
Considering the positivity rate of 1%, the precision of 20%, confidence interval of 95%, with a nonresponse rate of 15%, the sample size was estimated to be 11,408, this was further rounded to 11,410.
The tool of data collection
A pretested pro forma was filled by the interviewer by making a telephonic call. The pro forma included general information and information on symptoms based on the Ministry of Health and Family Welfare Government of India guidelines were asked during the call.
The study was approved by the Institutional Ethics Committee.
Interviewers and training of interviewers
There were 10 interviewers. The principal investigator trained all the interviewers regarding telephonic communication (training included Introduction of the interviewer, purpose of the call, questions about the symptoms, testing, and diagnosed COVID-19 patient in the family, at the end, care about the preventive measures for COVID infection was communicated). The hands-on training was given at the end of the training. The total training duration of the interviewers was 2 h.
Methodology for data collection
The current study was conducted in 13 villages under the Mulshi block of the Pune district of Maharashtra. The block falls under the highest rainfall intensity zone. The months of June, July, and August are the highest rainfall month, with an average of 680 mm rainfall in July.
The investigators and the interviewers were well versed with the population dynamics and the gram panchayat member was made aware of the survey before it initiated. The name of the institute which conducted the symptomatic survey was known to the population due to previous interaction with the participants besides the institute have its rural health center providing the facility for screening and referral for testing of suspected COVID patients. The Accredited Social Health Activist (ASHA) and Anganwadi workers from these villages are in continuous interaction with the households as they are the first point of contact for the specific designated COVID center which caters to these villages.
The village Sarpanch (Head of the village) was informed before the start of the study. The community health worker, i.e. ASHA worker of the 13 villages were made aware of this phone survey to ensure the response from the households. The interviewers contacted the head of the household. The information about the current or symptoms in the last week among all the family members was asked. The history of COVID-19-positive family members in the past was asked.
Those reported to have the current symptoms were informed to visit any private practitioner or the nearest government health-care facility at the nearest village, namely Pirangut, Paud, or Lavale for getting medical care. At the end of the interview, respondents/participants gave a brief health talk on the standard precautions for the prevention of COVID-19 infection.
The study was conducted at the time when the unlock phase began in the Maharashtra state, thus the family SAR would be unbiased as they travel beyond the household locality was just permitted at the time of data collection, thus confounding the factor related to travel for determining the SAR was automatically ruled out.
For easy communication, a WhatsApp group of the interviewers with investigators was created and used for daily updates of the number of interviews and issues if any were resolved.
A household SAR is defined as the number of household cases occurring within the incubation period upon exposure to a primary case divided by total susceptible household contacts.
Yellow ration card allotted under the public distribution system indicates below poverty line households. It indicates household with annual income of <15,000 Indian rupees/year.
The HDSS database has a unique code generated for each member of the households in 13 villages. This existing information including the mobile number of the head of the household was used for the data collection.
Quality checks for data collection
One percent of the data was cross-checked and verified for correctness within 1 week of its collection.
Plan of data analysis
Descriptive statistics are presented in percentages. The qualitative data are expressed in mean and standard deviation (SD).
| Results|| |
There are 11,507 households in the study area, of which a total of 8845 households were contacted and 2662 households could not be contacted through telephone.
The baseline demography of all households under HDSS reports that almost one-fifth of the population is below the poverty line, the average age of the household members is 28.4 ± SD 18.7 years with a sex ratio of 935/1000 males. One-fourth of participants were educated until the 10th class [Table 1].
|Table 1: Demographic profile of the individuals in the household contacted through telephone|
Click here to view
Out of total households contacted for the telephonic survey, 33 individuals had one symptom suspected of the details of these 33 with only one symptom is given in [Table 2], whereas 13 had more than one symptom, thus the total number of individuals with at least one symptom suggestive of COVID-19 was 46 [Table 3]. Of the total symptoms, cough (37.0%) and fever (24.0%) were the most common symptoms [Graph 1].
|Table 3: Village wise household members with the presence of at least one coronavirus disease-related symptom at the time of the telephonic survey|
Click here to view
|Table 2: Sociodemographic characteristics of coronavirus disease-positive with only one symptom (n=33)|
Click here to view
The telephonic survey reported 33 individuals from 22 families were diagnosed with COVID-19 from March 2020 onward till the time of survey, i.e. August 2020 thus a prevalence rate of 0.1% is documented.
A total of 99 family members of these 33 COVID-positive patients were tested for COVID by the reverse transcription polymerase chain reaction, out of which 17 were tested positive, thus a SAR of 17.2% is reported in the study.
| Discussion|| |
The COVID-19 pandemic is showing a health transition, i.e. it first appears in developed areas before reaching the rural areas., However, like any other infectious disease, the virus does not differentiate between the rich or poor and urban or rural areas. In the Pune district, out of the total population, 39% of people reside in rural areas. Thus, Pune district is more urbanized as compared to the rest of India, thus a health transition for COVID-19 in the rural area of Pune may occur earlier like other urban areas.
Establishing the true prevalence of COVID-19 is necessary to understand the morbidity and mortality risk. The existing HDSS across India has the advantage of the availability of a defined population base to calculate the morbidity rate in the given geographic area. The HDS system has a complete enumeration of the households along with the family members a unique code is allotted to each individual. Since there are no primary studies about the transmission dynamics, prevalence, and outcome of COVID-19 are not existing, the current population-based study is valuable in providing the ground reality in the rural area adjoining the Pune city which eventually reported the highest infection rate.
The participants were recruited through existing cohorts, i.e. HDSS villages, our results strengthen the concept of the feasibility of mobilizing existing infrastructure at the same time the participants could be engaged in actions leading to the early diagnosis of COVID-19 and further community spread could be prevented, this concept is emphasized by the other studies as well.
The most common symptom found in the suspected cases was fever and cough, these are the same as reported from China in the early phase of the pandemic.
Forty-six participants were suspected to be infected from severe acute respiratory syndrome coronavirus 2, they were advised to visit the nearest health-care center and to get themselves tested. Thus, the telephonic survey with minimal use of resources could be used to identify the symptomatic individuals in the early phase of the disease, thereby reducing further community transmission and thereby mortality.
The current epidemiological study conducted in 13 HDSS village documents a self-reported prevalence of COVID 19 to be 0.1%. Despite being urbanized, the prevalence rate of COVID-19 has not reached an alarming level until August 2020 in a rural area of Maharashtra. The spread of COVID-19 from urban to rural area may not take place as expected, and the prevalence in the rural area may never reach the alarming level in the first wave.
Exposure to an infectious individual is the most important risk factor for communicable disease transmission. The household model provides an estimate of the transmissibility and infectivity of the respiratory virus. In household studies, only individuals who have been exposed or susceptible to the infection are included. These household contacts of the patient are at greater risk of getting infected rather than community contacts due to proximity and being indoors. In the current study, the SAR of COVID-19 among family contacts was 17.2%, while a range of 4.6%–49.56% is reported by other studies., This rate is more than that for Severe Acute Respiratory infections (SARS) and middle east respiratory symptoms., Although the care was taken to involve ASHA, the possibility of a low response rate in the current study cannot be ruled out either due to inaccessible mobile number or due to associated fear and social stigma may have led to the low rates of reporting of infections.
| Conclusion|| |
With a COVID-19 prevalence rate of 0.1%, a higher family SAR of 17.2% was reported in the current study. Timely diagnosis and quarantine of close contacts should be continued to be implemented rigorously to prevent the spread of the COVID-19 virus. These efforts will be useful to contain the epidemic before it reaches an alarming level.
The authors would like to thank Dr Trishna Mohonty, Dr Sana Raffiq, Dr Sumati Sancheti, Mrs Sangita Patil, Mrs Ranjana Rahinj, Miss Geeta Kadam, Namita Kakade, Rushali Masal, Rahul Pawar, Shreya Gawadw, Mohit Wagh, Sourabh Mangade for their contribution, Dr S K Lalwani, Brig. (Retd.) Dr N. S. Mani for their support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Geldsetzer P. Use of rapid online surveys to assess people's perceptions during infectious disease outbreaks: A cross-sectional survey on COVID-19. J Med Internet Res 2020;22:e18790.
Shah K, Saxena D, Mavalankar D. Secondary attack rate of COVID-19 in household contacts: A systematic review. QJM 2020;113:841-50.
Jing QL, Liu MJ, Zhang ZB, Fang LQ, Yuan J, Zhang AR, et al.
Household secondary attack rate of COVID-19 and associated determinants in Guangzhou, China: A retrospective cohort study. Lancet Infect Dis 2020;20:1141-50.
Kumar MS, Bhatnagar T, Manickam P, Kumar VS, Rade K, Shah N, et al
. National sero-surveillance to monitor the trend of SARS-CoV-2 infection transmission in India: Protocol for community-based surveillance. Indian J Med Res 2020;151:419-23.
] [Full text]
Kumar A, Rajasekharan Nayar K, Koya SF. COVID-19: Challenges and its consequences for rural health care in India. Public Heal Pract 2020;1:100009.
Yadav S, Arokiasamy P. Understanding epidemiological transition in India. Glob Health Action 2014;7:23248.
Subramanian SV, James KS. Use of the Demographic and Health Survey framework as a population surveillance strategy for COVID-19. Lancet Glob Health 2020;8:e895.
Laxminarayan R, Wahl B, Dudala SR, Gopal K, Mohan B C, Neelima S, et al.
Epidemiology and transmission dynamics of COVID-19 in two Indian states. Science 2020;370:691-7.
Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, et al.
Risk of COVID-19 among front-line health-care workers and the general community: A prospective cohort study. Lancet Public Health 2020;5:e475-83.
Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, et al.
Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: A scoping review. Infect Dis Poverty 2020;9:1-2.
Pitzer VE, Cohen T. Household studies provide key insights on the transmission of, and susceptibility to, SARS-CoV-2. Lancet Infect Dis 2020;20:1103-4.
Li W, Zhang B, Lu J, Liu S, Chang Z, Peng C, et al.
Characteristics of household transmission of COVID-19. Clin Infect Dis 2020;71:1943-6.
Wilson-Clark SD, Deeks SL, Gournis E, Hay K, Bondy S, Kennedy E, et al.
Household transmission of SARS, 2003. CMAJ 2006;175:1219-23.
[Table 1], [Table 2], [Table 3]