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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 6
| Issue : 3 | Page : 156-162 |
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Response to COVID-19: Best Practices From the Department of Community Medicine of a Medical College in Delhi
Nandini Sharma1, Bratati Banerjee2, Shivani Rao2, Amod Laxmikant Borle2, Nidhi Bhatnagar2, Pragya Sharma2, Rajesh Kumar2, Mongjam Meghachandra Singh2, Panna Lal2, Gajendra Singh Meena2, Suneela Garg2
1 Maulana Azad Medical College, New Delhi, India
2 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
| Date of Submission | 13-Jun-2020 |
| Date of Decision | 14-Jul-2020 |
| Date of Acceptance | 25-Aug-2020 |
| Date of Web Publication | 16-Dec-2020 |
Correspondence Address:
Dr. Bratati Banerjee
Room no. 328, Department of Community Medicine, Maulana Azad Medical College, 2, Bahadur Shah Zafar Marg, New Delhi 110002
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mamcjms.mamcjms_56_20
Public health response and measures are vital to contain an infectious disease outbreak/epidemic. The discipline of Community Medicine, which provides comprehensive primary health care to the entire population at all times, plays a crucial role in times of disease outbreak/epidemic also, being equipped with skills in providing managerial, clinical, and community care, through policy making, surveillance activities, preventive strategies, primary care, capacity building, and awareness generation in addition to generation of evidence-based strategies. The Departments of Community Medicine in Medical Colleges can play a crucial role in this direction and should be involved to share the expertise as well as the best practices adopted, which will go a long way in containing an epidemic at the earliest. The Department of Community Medicine of a leading Medical College in Delhi, along with the clinical departments, is playing a stellar role in response to the pandemic of Corona Virus Disease of 2019 (COVID-19). This article highlights the response to the situation, the challenges faced, and the success stories. Activities have been categorized as Fair, Good, and Best. Activities that are routinely performed are taken to be “Fair” and activities that are beyond routine activities have been labelled “Good”. “Best” practices have been identified to be those that involve representation at the national/State/District level, activities for capacity building, contribution toward evidence generation, and work with risk of exposure. The best practices adopted by the Department of Community Medicine of this institution can be collated for future use in teaching hospitals where Community Medicine departments are equipped with manpower skilled to face such a challenge. It will serve as a blueprint for action, if the need be, for handling similar situations in the future.
Keywords: Community medicine, COVID-19, epidemic, medical college, public health
How to cite this article:
Sharma N, Banerjee B, Rao S, Borle AL, Bhatnagar N, Sharma P, Kumar R, Singh MM, Lal P, Meena GS, Garg S. Response to COVID-19: Best Practices From the Department of Community Medicine of a Medical College in Delhi. MAMC J Med Sci 2020;6:156-62 |
How to cite this URL:
Sharma N, Banerjee B, Rao S, Borle AL, Bhatnagar N, Sharma P, Kumar R, Singh MM, Lal P, Meena GS, Garg S. Response to COVID-19: Best Practices From the Department of Community Medicine of a Medical College in Delhi. MAMC J Med Sci [serial online] 2020 [cited 2023 Jun 6];6:156-62. Available from: https://www.mamcjms.in/text.asp?2020/6/3/156/303593 |
| Introduction | |  |
Pandemics and epidemics of infectious diseases have plagued mankind from times immemorial. The world is currently reeling under the pandemic of Corona Virus Disease of 2019 (COVID-19) and India also is bearing the brunt of it to a considerable extent. All efforts to contain the epidemic in the country were initiated at the earliest. In Delhi, a tertiary care government hospital attached with a Medical College was declared as a Dedicated COVID Hospital. Along with the clinical departments, the Department of Community Medicine was also called upon in which, it played a stellar role in response to the pandemic.
This article highlights the response to the situation, the challenges faced, and the success stories. The best practices adopted by the Department of Community Medicine of this institution can be collated for future use in teaching hospitals where Community Medicine departments are equipped with manpower skilled to face such a challenge.
Best Practices Adopted by the Department of Community Medicine
The goal of Community Medicine is promoting health and preventing diseases by utilizing professional management skills and enabling people’s participation. The discipline is concerned with providing comprehensive primary health care, control and prevention of outbreaks or epidemics, community diagnosis, health needs assessment, epidemiological assessment, and research and planning evidence-based health policies and programs.
The Medical College in Delhi with attached Dedicated COVID Hospital is a leading government-run multidisciplinary teaching institution. The Department of Community Medicine of this college consists of highly skilled, research-oriented faculty members and residents. At the time of the current epidemic, the department is involved in various types of activities, thus actively contributing to the national goal of containing the situation [Table 1]. | Table 1 Activities of Department of Community Medicine, MAMC, to combat COVID-19 pandemic
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The World Health Organization (WHO) has defined a best practice as “A technique or methodology that through experience and research has proven reliably to lead to the desired result.” The best practices need to be shared and adopted to benefit more people, so that these can be used to develop and implement solutions to similar health problems in future. Identifying best practices involves judgement that requires analysis using a set of criteria, which includes effectiveness, efficiency, relevance, ethical soundness, sustainability and possibility of duplication, involvement of partners and community, and political commitment.[1]
For the purpose of this article, the authors, being experts in the discipline, identified the best practices out of all activities undertaken by the Department in the present situation. All the activities met the WHO criteria of best practices,[1] being effective in achieving results with available manpower resources and time, and therefore extremely relevant to the present context, ethically sound, sustainable, and can be duplicated by any institution working in similar setting. Being the priority issue in the country at present, political commitment, partner involvement, and community participation were received in every aspect.
In this article, we have presented the activities as Fair, Good and Best. Activities that are routinely performed are taken to be “Fair” and activities that are beyond routine activities have been labelled “Good”. “Best” practices have been identified to be those that involve representation at the National/State/District level, activities for capacity building, contribution toward evidence generation, and work with risk of exposure [Table 2]. | Table 2 Categorization of activities undertaken by the Department of Community Medicine, MAMC, to combat COVID-19 pandemic
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The activities being undertaken by the Department are discussed below in detail.
Health care
The prime role of the discipline is to provide comprehensive primary health care to the community. This department is carrying out these services through its health centers as part of routine health care services during the present situation also. Daily clinics providing comprehensive health care and special weekly clinics for immunization, maternal and child health, adolescent and noncommunicable diseases are held at the health centers. Owing to dearth of manpower as all residents were withdrawn by the hospital, the special clinics were difficult to run initially. With the apprehension of contracting the disease and with the commitment of adhering to government directives regarding lockdown, the attendance in the centers is still low. Regarding the special clinics, however, all registered cases of antenatal women, under-five children, and patients of noncommunicable diseases are being kept in contact over phone. Those who are coming to the centers are attended to and for the others who are not attending the centers, especially patients suffering from noncommunicable diseases, antenatal mothers, and so on, monthly dose of medicines is supplied to their family members on their behalf to avoid interruption of treatment.
In addition to the routine services, dedicated flu/fever clinics have been conducted at the centers since the inception of the problem in the State of Delhi. Patients attending the centers with symptoms of influenza-like illness (ILI) are segregated from other patients and attended to at the flu/fever clinic, where thermal screening is performed. These clinics are conducted daily.
In spite of not being skilled to provide specialized therapeutic care, the department is giving support to patient management at the hospital also. Residents of the department, supervised by the faculty, are taking care of patients admitted in one ward of the hospital identified for suspected COVID-19 cases, where they are responsible for taking samples for COVID-19 testing and also managing the patients, including patients with comorbidity and some patients even on dialysis. The Residents maintain proper universal precaution while handling the patients and till date all except one have tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at the end of their periods of duty. Before the hospital was identified as a Dedicated COVID Hospital, the department was also conducting a fever clinic set up in the hospital.
Preventive measures
Prevention being the crux of the discipline, adequate preventive measures are being implemented at all centers and also in the department. Every morning the department and the vehicles being used for commuting to field are being sanitized by mopping floors, cleaning vehicles, and cleaning frequently touched surfaces such as door knobs. Earlier disinfectant solution was being prepared daily by adding one tablespoon of commercially available bleaching powder in 1 litre of clean water. However, sodium hypochlorite solution and commercial sprayer are now available. Sanitization of the premises of the health centers is also performed daily. Keeping in view the social distancing measures recommended, outpatient department (OPD) areas have been redesigned to ensure adequate space between two patients. Personal protective equipment (PPE), such as N95 masks, surgical masks, gloves, and face shields, have been provided. Guidelines for rational use of PPE are being followed within the department and all centers under it. Preventive measures such as wearing masks, maintaining social distancing, and following proper hand hygiene and cough etiquette are practiced by all in the department as well as at the centers. The patients are also encouraged to follow the same.
Advisory role
Another important role of the discipline lies in its advisory capacity, which is presently being met by the department at the national, state and district levels in many ways. One senior faculty member of the department, who is the President Elect of the Indian Association of Preventive and Social Medicine (IAPSM), had dialogue with the honorable Prime Minister of India regarding the role of Community Medicine in COVID-19 pandemic. The faculty was also involved in assessment of preparedness of hospitals for COVID-19 pandemic in collaboration with NITI Aayog. A checklist developed by IAPSM on the behest of NITI Aayog and facilitated by this department was filled up for assessment of preparedness regarding the ongoing pandemic. Faculty have facilitated development of post-COVID-19 exit plan and have approached NITI Aayog with tool to be used for assessment of preparedness for COVID-19 in rural and urban areas.
National Centre for Disease Control (NCDC) recommended the formation of rapid response teams (RRTs) for COVID-19 hotspots, with the main purpose of coordinating contact tracing and cluster containment activities. These proposed RRTs were to be constituted at state/UT levels in order to supervise and support the district level RRTs in the above stated activities. One faculty member and one senior resident from this department are members of the State RRT for Delhi, with responsibilities of formulating guidelines for the State regarding containment, de-containment, reporting mechanisms, data quality, and hand-holding with the districts for implementation of the guidelines. The two poorest performing districts in COVID-19 prevention and control activities in Delhi, which are the central and south east districts, have been allotted to this department. Faculty along with other members formulate guidelines regarding various measures to be implemented in these districts. The faculty also serves as link between the district teams and central and state RRT. College RRT was made with the purpose of discussing key issues related to COVID-19 prevention in college and hospital premises on instructions from the Ministry of Health & Family Welfare. The team of college RRT is chaired by Head of the Department of Community Medicine, and a faculty member of the department is the member secretary of the committee with faculty from various other departments as members.
Surveillance activities
Surveillance is the backbone of any public health program and provides information so that effective actions can be taken in controlling and preventing diseases of public health importance, especially epidemic-prone diseases. A national program named Integrated Disease Surveillance Programme (IDSP) is operational in the country for this purpose. IDSP is administratively and financially integrated with the NCDC under the Ministry of Health & Family Welfare, Government of India. IDSP operates through the central, state and district surveillance units (CSU, SSU, and DSU, respectively).
During the current pandemic, the department is actively participating in surveillance activities under the guidance of the NCDC. Teams from this department, comprising of senior residents and interns with faculty members supervising them, have been deployed under the district surveillance officer (DSO) at the DSUs for surveillance activities at the two districts of Delhi, that is, the central and south east districts. Responsibilities of these teams are to obtain detailed history and relevant information for confirmed COVID-19 positive cases including admitted cases in the districts, with contact tracing over phone, for compilation of final reports. The teams also generate reports to track the district’s performance regarding mortality pattern, sample positivity rate, distribution of cases according to containment zones, and demographic variables. Case investigation forms are filled up for confirmed cases and uploaded on the IDSP portal daily by the teams.
Teams consisting of residents under the supervision of a faculty member perform supervisory role through visits to containment zones for overseeing the system of reporting of cases of ILI. They have also accompanied representatives from the WHO for assessment of hospital preparedness for COVID-19 pandemic at various private hospitals.
The teams have been involved in preparation of initial draft of micro-plan of containment zones to be subsequently modified according to local needs. Along with other officials, they participate in daily meetings with district magistrate regarding overall performance of the districts and also serve as a link between district and college RRT.
Capacity building
In addition to medical education for undergraduate and postgraduate students and Interns, community medicine specialists also have the responsibility of imparting training to various levels of healthcare providers. Capacity building for handling the epidemic is presently an ongoing activity in the department.
The batch of interns posted currently in the department are being given hands-on training in public health skills, by posting them in DSU and NCDC, for performing duty related to containment of the disease. They assist in contact tracing, filling up of case investigation forms for confirmed cases, and uploading the same on the IDSP portal daily. They are also guided and supervised regarding adherence to PPE and hand hygiene practices. Online classes for MBBS students are being held in the college. From the Department of Community Medicine, two special classes have been taken on COVID-19 to update the students regarding epidemiology and containment measures for the most recent public health crisis faced by the country. Training and sensitization programs regarding COVID-19 have been undertaken for frontline health workers, namely, Accredited Social Health Activist (ASHA) and Anganwadi Workers (AWW), in batches at all health centers.
Awareness generation
The Alma Ata Declaration has placed health education at the foremost of all elements, as people’s health mainly lies in people’s hands. This concept is highly applicable in the present context of COVID-19, as simple behavioral measures can go a long way in keeping the epidemic at a low level. Also, the success of lockdown depends on cooperation of the community to a considerable extent. Hence, generating awareness among all sections of the community is extremely important and essential for inculcating healthy habits and safe behavior.
This department has worked with Federation of Indian Chamber of Commerce and Industry to develop modules on COVID-19 for healthcare workers. The modules were submitted to NITI Aayog for further dissemination and were also hosted on Medvarsity online platform. These modules can be accessed at https://healthedu.co.in/courses/training-of-hcws-on-covid-19/. Awareness generation for the community is done through Information, Education and Communication (IEC) activities using various approaches, media, tools, and techniques. IEC programs are being regularly conducted by the department at all its health centers. Demonstration of the steps of handwashing recommended by the WHO is being carried out regularly. Posters carrying relevant messages through pictorial and literary presentations have been prepared and displayed at all health centers and in the department. A series of short video programs named COVID-19 Series is being prepared by the department, each episode focusing on a particular aspect of the disease discussed by faculty members, with demonstration of safe behavioral practices by the residents. Some episodes of the video have already been uploaded on YouTube channel.
Research
Research for generating evidence is an important responsibility of all disciplines and is carried out by Community Medicine also at both departmental and personal levels. Several funded and non-funded research projects have been initiated or are in the pipeline. Three projects are currently ongoing: hydroxychloroquine prophylaxis sponsored by the Indian Council of Medical Research, COVID-19 epidemiology sponsored by the Department of Biotechnology, and status of preparedness sponsored by the Government of Delhi. Research is also being performed by the faculty members and residents on various groups of population. Sixteen scientific papers on COVID-19 related research have been published and several others are currently in the process.
Challenges Faced
Delivering COVID-19 activities was challenging during the initial phase, which was gradually resolved with communication and coordination with all stakeholders. Challenges faced were mainly regarding operational and logistic aspects.
Operational issues
Operational issues during the pandemic were mostly related to ineffective management of human resources as an immediate response to the crisis situation. Owing to hurried deployment of resident doctors in the field for contact tracing activity, without proper delineation of their roles and responsibilities, they remained underutilized, while the departments in the parent institution faced shortage of manpower. Other concerns were regarding their accommodation, transport, and safety in the process. However, all issues were gradually resolved by communication of the Department of Community Medicine directly with DSOs in the field. College RRT too communicated between departments and district authorities to ensure proper and effective utilization of manpower resources, both at the district and in the parent institution. Vehicles were made available for transport and the Government of National Capital Territory (GNCT) of Delhi made provisions for extra vehicles in order to maintain social distancing norms.
Involvement with district RRTs was also challenging as it required intensive engagement and follow-up. Mechanisms were set up with the district team wherein social media groups were created for sharing information, circulars, and relevant reports. Direct interaction was limited to once a week, adhering to infection prevention and control guidelines. These meetings and communication helped timely dissemination of important and relevant information, which would have been missed otherwise.
Logistic issues
There was acute shortage of logistics at the outset and due to unavailability of sanitizer, bleach solution was prepared in the Department. Subsequently, Head of the Department personally communicated with the stores and ensured provision of N95 masks, surgical masks, gloves, and sanitizer, but the supply of PPE was still inadequate. However, donations mobilized by the Faculty Association of the College did not let any stock outs happen. The Faculty of Community Medicine also procured commercial disinfectant sprayer, pulse oximeter, thermal sensors, face shields, and other PPE items, as donations from COVID Task Force for use at the health centers under the Department.
| Discussion | | |
The skilled faculty and residents of the Department of Community Medicine of the Medical College in Delhi with the attached Dedicated COVID Hospital have been contributing to the national goal of containing the situation through specialized public health services in terms of health care, preventive measures, advisory role, surveillance activities, capacity building, awareness generation, and research.
“Best practice” is not a state of perfection, nor is it the gold standard. But documenting and applying lessons learned is important for future programs and projects. Documentation should start early enough to ensure that all important ongoing activities are included so as to avoid retrospective or recalled reporting as this may be incomplete or inaccurate.[1] With this idea, this article intends to document the activities of the Department, which might serve as a blueprint during similar situations in the future.
History of public health goes a long way back to the nineteenth century. During the early nineteenth century, cholera, which was till then an endemic disease of South Asia, moved to the European countries and caused wide-scale epidemics.[2] It was a common belief in those days that most of the diseases were caused by inhaling infected air. In the mid-nineteenth century, Edwin Chadwick, a lawyer in England, reported filth to be the main cause of diseases. This gave origin to the concept of public health that recognized the role of environment in causation of disease and led to enactment of the Public Health Act in England in 1848. In 1854, a cholera epidemic occurred in London, when a British Anaesthetist John Snow established the role of polluted drinking water in causation of the disease.[3] Following these events, efforts started being directed toward improvement of the environment and the discipline of public health came into focus. Around the same time, William Farr, a British epidemiologist, brought a revolution in the medical literature through use of available statistical data to test social hypothesis, which helped identify causes of disease and death by linking them to broader determinants of health.[4] public health has since then played a vital role in prevention and control of infectious diseases as existing endemic conditions and also during outbreaks, epidemics and pandemics. Subsequently, seven pandemics of cholera occurred globally, which brought revolutions in public health.[2]
The movement of public health in England was reflected in India too with establishment of the All India Institute of Hygiene & Public Health and the School of Tropical Medicine in the then Calcutta. However, in independent India, public health and preventive services were merged with curative services, thus losing its importance. Public health and community medicine have gradually been driven to the backseat with continued negligence.[5] The discipline of public health and public health experts can lead the way in policy making and strategy formulation. The engagement with expert technocrats in the areas of epidemiology, public health, preventive medicine and social scientists, and data sharing with such experts, can bolster the government efforts to combat the present pandemic of COVID-19.[6]
The WHO has described four main phases of an epidemic before it is brought under control, namely, introduction or emergence, localized transmission, amplification, and reduced transmission. The dynamics of epidemics define the response and the sequence of interventions that then becomes necessary, which requires coordinated public health efforts.[7] The Department of Community Medicine and the discipline of public health are crucial in implementing most of these measures.
India has faced outbreaks/epidemics of several infectious diseases, the most recent one prior to COVID-19 being the Nipah virus infection (NiV) in Kerala in 2018. This was the third of NiV outbreak in India, the earlier being in 2001 and 2007, both in West Bengal. The outbreak in Kerala reported 23 cases, including the index case, of which 18 were laboratory-confirmed cases and 17 deaths. The outbreak was managed by the state government and central government agencies and has been acknowledged as a success story.[8]
An immediate public health response helped in containing the NiV outbreak in the two affected districts of Kerala. Epidemiological investigation found that only the index case was infected in the community from fruit bats. All the other cases occurred due to transmission of the virus in three public hospitals. Containment measures implemented included early detection of the outbreak, early laboratory confirmation, prompt isolation of cases, triaging as per case definition, reporting of cases, contact surveillance for early detection, strengthening of infection control practices, and barrier nursing.[9],[10] All these measures are currently being implemented for COVID-19 containment.
Kerala has a very good health system and the best health indicators in India. With a robust public health system and using the lessons learnt from previous outbreaks, the NiV outbreak was contained in Kerala.[11] In the present COVID-19 situation too, Kerala, with its active surveillance efforts, was the first to report presence of the infection in the country with a cluster of three laboratory confirmed cases.[12],[13] Though initially affected to a considerable extent, Kerala has been able to control the rising epidemic of COVID-19, being currently placed at the eighteenth position out of 35 affected states in the country, in terms of case load.[14] Lessons from Kerala indicate the importance of utilizing public health expertise and mobilizing resources in any public health emergency situation. Departments of Community Medicine in Medical Colleges can play a crucial role in this direction and should be involved to share the expertise as well as the best practices adopted, which will go a long way in containing an epidemic at the earliest.
| Conclusion | | |
Public health response and measures are vital to contain an infectious disease outbreak/epidemic. The discipline of Community Medicine, which provides comprehensive primary health care to the entire population at all times, has a very important role to play in times of disease outbreak/epidemic also, being equipped with skills in providing managerial, clinical, and community care, through policy making, surveillance activities, preventive strategies, primary care, capacity building, and awareness generation, in addition to generation of evidence-based strategies through applied and operational research.
The Department of Community Medicine of a leading Medical College in Delhi is carrying out all these responsibilities in the critical time of a pandemic. The best practices adopted by this department in the present situation of COVID-19 in the country will serve as a blueprint for action, if the need be, for handling similar situations in the future.
Acknowledgement
The authors thankfully acknowledge the contribution of all the medical officers, senior residents, junior residents, field staff, and administrative staff of the department in the fight against COVID-19.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 3. | Halliday S. Death and miasma in Victorian London: an obstinate belief. BMJ 2001;323:1469-71. doi: 10.1136/bmj.323.7327.1469  |
| 4. | Whitehead M. William Farr’s legacy to the study of inequalities in health. Bull World Health Organ 2000;78:86-7. |
| 5. | Dastur FD. Public health − the ‘black hole’ in Indian Medical services. J Assoc Physicians India 2016;64:70-2. |
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| 9. | Thomas B, Chandran P, Lilabi MP et al. Nipah virus infection in Kozhikode, Kerala, South India, in 2018: epidemiology of an outbreak of an emerging disease. Indian J Community Med 2019;44:383-7. doi: 10.4103/ijcm.IJCM_198_19. [ PUBMED] [Full text] |
| 10. | Arunkumar G, Chandni R, Mourya DT et al. Outbreak investigation of Nipah virus disease in Kerala, India, 2018. J Infect Dis 2019;219:1867-78. doi: 10.1093/infdis/jiy612. |
| 11. | Chatterje P. Nipah virus outbreak in India. World Report. Lancet 2018;391:2200. |
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| 14. | MOHFW. COVID-19 INDIA. Ministry of Health and Family Welfare, Government of India; 2020. Available at: https://www.mohfw.gov.in/. [Accessed on June 08, 2020]. |
[Table 1], [Table 2]
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