Origin and Evolution of Public Health in Tamil Nadu along with a case study of handling of COVID-19 –

Building and Preserving a Resilient Health System

DR. J. RADHAKRISHNAN

krith_72@yahoo.com

Principal Secretary to Govt.

Co-operation, Food and Consumer Protection Department

The Tamil Nadu Experience

What is History needs to be remembered and recollected to shape a bright future and prevent any recurrence

07 DEC 2022

Structure of the presentation

The Pre Independence Government further passed some legislation, such as

• The Quarantine Act 1825,
• Vaccination Act 1880,
• Medical Act 1886,
• Epidemic Diseases Act 1897,
• Indian Factories Act 1911,
• Poisons Act 1919,
• Indian Red Cross Act 1922,
• Dangerous Drugs Act 1930,
• Indian Port Health Rules 1938,
• Indian Air Craft Public Health Rules, etc., to streamline health administration. 

The pre independence Government took certain steps which are important landmarks in the history of health administration in India. They are as follows:

• The appointment of Royal Commission to enquire into the health of the Army in India in 1859.
• The report of Plague Commission in 1904 following the outbreak of plague in 1896.
• Reforms introduced by Government of India Act for Health, 1919.
• Reforms introduced by Government of India Act for Health, 1935.
• Sir Joseph Bhore Committee(appointed in 1943) report,1946
• Dr.A.L.Mudaliar Committee Report,1962

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The above reports and Acts created top posts of various categories in the central and state governments, respectively. The Government of India Act of 1919 gave statutory sanction to decentralize the health administration to provinces which included medical administration, hospital administration, etc. The Act of 1935 further granted larger autonomy to provincial legislatures.

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In 1943, the Government of India appointed a Committee called the Health Survey and Development Committee headed by Sir Joseph Bhore and having nineteen other members. This is the only authentic record depicting hospital development and health care system in pre-independence India, that is, before 1947. The report was submitted in 1946.

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The Bhore Committee report recommended upgrading of medical care in various forms, such as medical relief in the form of

primary health centre at the village level,

secondary health centre at sub-division level (Taluka level), and

district hospitals at district headquarters, with all the specialist services. It was anticipated that the bed population ratio could rise to 1.3per 1000 population in 10 years and to 5.6 in 25 years.

Bhore Committee had stated in their report that the health service should be available to all citizens, irrespective of their ability to pay for it and it should be complete medical service, domiciliary and institutional, in which all the facilities required for the treatment and prevention of disease as well as for the promotion of positive health are provided. The efforts of health administrations at earlier stages were directed towards the alleviation of suffering and rehabilitation of the sick.

The idea of prevention came later, partly as a result of the observation that diseases were often communicated from a patient to those in close association with him.

The concept of segregation of the sick and infection control started.

The development of modern sciences, such as bacteriology, parasitology, and pathology in the later half of the last century, brought to the forefront the importance of specific organisms as the causative agents for individual diseases. Similarly, the importance of environmental hygiene was felt.

The coordinated effort of prevention, treatment, and rehabilitation brought out more desired results. 

Dr.A.L.Mudaliar Committee Report,1962 studied the status since the Bhore committee Report and gave its recommendations.

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Health Sector in Tamil Nadu - An unparalleled History

A Rich History in Public Health

• Since the days of Colonel King,IMS., it is perhaps not too much to say that Madras has always given the lead to the rest of India in matters sanitary.--Yours, etc.. - A. J. H. RUSSELL, M.A.. M.D., DPH..Major, I.M.S.,Director of Public Health, Madras Presidency.
• Second oldest Medical college in India and second oldest eye hospital in the world was established in Chennai.
• One of the First women doctors in the world obtained her licentiate in Madras Medical college.

Historical background

• In early 20th century, diseases such as Cholera, Plague, Smallpox has led to a large number of mortality in the state.
• The existing Human resources for health were not trained and skilled enough to manage these epidemics alongside their routine activities.
• This led to need based demand for a dedicated cadre for maintaining sanitation, hygiene and cleanliness and control of communicable diseases

Tamil Nadu Public Health Service

• Separate Directorate of Public Health and Preventive Medicine functions since 1923 – 100 Years
• At all levels the department is headed by Public Health qualified professionals right from Municipal Health Officer to Deputy Director of Health Services at the district, programme officers at the state and the Director of Public Health and Preventive Medicine
• Dedicated Techno-administrative cadre

Public Health Code 1920, �Issued by Director of Public Health, Madras

STATE OF ART INFRASTRUCTURE

SKILLED MANPOWER

HUMAN RESOURCES IN GOVERNMENT FACILITIES

Case Study of handling of COVID-19 in Tamil Nadu

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Building and Preserving a Resilient Health System

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Background

Tamil Nadu and for that matter entire India and the world had been successively combating and overcoming disasters and challenges, which in TN for e.g., was like –

• Preventing Epidemics after the devastating Chennai Floods in 2015
• GAJA Cyclone-2018 and the earlier cyclones such as Thane, Wardha etc striking Tamil Nadu coast from time to time.
• Swine Flu, Dengue, ZIKA etc., and threats of NORO, NIPAH, and other communicable diseases which were successfully warded off in the state of Kerala
• Challenge of Capacities, RTPCR testing labs, ventilators, oxygen beds, oxygen , PPE
• Setting up genome analysis lab for Sero-surveillance.
• Challenges in containment
• Challenges of Lockdown on all aspects including health in respect of other non communicable diseases
• Yet COVID-19 was a challenge to the State too, but it handled it effectively by basing its strategy on the expert advice of Public health and Medical Specialists and also ensured that there were dedicated teams looking into non Medical aspects of the evolving Disaster.

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Public Health Emergency and Disaster Management (PHEDM) during and beyond COVID-19: Building Resilient Workforce, System, and Infrastructure in India

Weekly Webinar Series and Online Community of Learning and Practice

CoVID-19: Global, Indian and TN Scenario

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• COVID-19 infections are still rising in some countries such as China

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Source: WHO (as on 04.12.22)

COVID 19 –with reference to Tamil Nadu

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• COVID-19 was first noticed in China in December 2019. Government of India also alerted the States on 17-1-2020.

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• Tamil Nadu took note of the developments in China and initiated immediate efforts to prevent and control the spread of the disease since January, 2020. In the meantime, WHO declared the COVID-19 outbreak as “Public Health Emergency of International concern” on 30.1.2020. 

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• Soon after the WHO declared COVID-19 as Pandemic on 11.3.2020. Tamil Nadu took pro-active steps and Corona virus disease was declared as notified disease under Tamil Nadu Public Health Act 1939 and the notification was made on 13.3.2020 vide G.O.Ms No.95 Health and Family Welfare (P1) Department, dated.13.3.2020. 

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• It was also notified vide G.O.Ms.No.96, Health and Family Welfare (P1) Department, dated.15.3.2020, under Tamil Nadu Public Health Act, that there is threat of Corona virus disease outbreak in Tamil Nadu. On 15.3.2020, Further, under G.O. Ms.No.97, Health and Family Welfare Department, dated 15.3.2020, Government prescribed certain regulations to prevent the outbreak of COVID-19 under the Epidemic Disease Act, 1897 and notified in Government Gazette on the same day.

COVID 19 – with reference to Tamil Nadu

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• Lockdown and its enforcement: Considering the need prevent and to arrest the spread of the disease the State moved swiftly and Notification under Epidemic Diseases Act, 1897 was issued on detailing restrictions on the movement of public, except for essential supplies / activities on 23.3.2020, restricting the movement of public from 24.3.2020 to 1.4.2020.

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• Nationwide Lockdown: Subsequent to the Government of India’s order issued by the Ministry of Home affairs through the National Executive Committee enclosing the guidelines under Disaster Management Act, 2005 another notification extending the restrictions up to April 14, 2020 has been issued by the Government of Tamil Nadu under the DM Act,2005 vide G.O. (Ms) No. 172, Revenue and Disaster Management Department, dated 25.3.2020. All the addendums and orders issued by the Ministry of Home Affairs under the Disaster Management Act have been adopted and reissued in the State.

COVID 19 –Time Line with reference to Tamil Nadu

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• December 31^st 2019 – cases of pneumonia of unknown cause was first identified in Wuhan city,China.�
• Jan 7 2020 –A novel coronavirus was the cause and named as “2019 ncov”.�
• Jan 30 2020 – WHO declared it as public health Emergency of International Concern.�
• March 11 2020- Corona declared as Pandemic.�
• Jan 27 2020 – First COVID-19 case Reported In India (Kerala).�
• March 7 2020 –First COVID-19 case reported in TN (Kanco District).

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• March 16, 2020 - First Patient Recovered from Covid-19.

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• March 25, 2020 - First death due to COVID-19 in TN (Madurai).

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First wave Peak in TN

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• May 31^st 2020-1149 cases (Above 1000 cases reported in starting of First wave).
• July 27 2020 -6993 Positive cases (Peak).
• August 15 2020 –127 death (Peak ).
• July 25 2020 – 7,758 Discharge (Peak).
• July 31 2020 – 57,968 Active cases (Peak).
• December 29 2020 – 957 cases (cases below 1000).
• February 20 2021 - 438 cases (Lowest)
• December 14 2020 – A new variant showing a change in spike protein named as Alpha variant was discovered in UK
• December 23 2020 – Person with Beta variant identified in UK who travelled from South Africa.
• Jan 6 2021 - Person with Gamma variant identified in Japan who travelled from Brazil.
• May 31 2021 –Delta was named and First identified in India.

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�Second wave Peak in TN�

• March 19 2021 – 1087 cases (First time above 1000 cases reported in second wave)

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• May 21 2021 – 36184 Positive cases (Peak)

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• May 30 2021 – 493 death(Peak)

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• June 4 2021 – 33,646 Discharge(Peak)

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• May 27 2021 – 3,13,048 Active cases (Peak)

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• June 12 2021 - 1,82876 sample load(Peak)

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• November 1 2021 - 990 cases (Below 1000)

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• December 24 2021 -597 cases (Lowest)

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• November 24 2021 – Omicron first identified in South Africa.�

�Third wave Peak In TN and subsequent humps�

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• Dec 31 2021 - 1155 cases (First time above 1000 cases reported in third wave))

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• Jan 22 2022 – 30744 Positive cases (Peak)

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• Jan 27 2022 – 53 Death (Peak)�
• Jan 27 2022 – 28620 Discharge (Peak)

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• Jan 26 2022 – 213692 Active cases (Peak)

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• Jan 23 2022 – 1,57,732 Sample Load. (Peak)

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• April 15^th 2022 – 22 Cases (Lowest)

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• Cases have started slightly rising again after June 2022 due to circulation of newer variants since May 2022 but has since come down to the lowest level of 10 cases yesterday and very low positivity and nil mortality, Situation in China is under watch.
• Whenever cases rise all measures are put in place to control its spread, especially the continued adoption of the five pronged strategy of Testing, tracing, treatment, Covid Appropriate Behaviour and vaccination of the eligible persons apart from Cluster control and containment as per the decentralized needs.

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Challenges on handling COVID-19

• Despite the experience of handling Pandemics, epidemics, outbreaks and other Public Health Challenges – COVID-19 did pose a challenge to the World as a whole and India and Tamil Nadu with a clear strategy depending on the evolving situation was able to successfully manage the situation.

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• Lesson for all has to not lose focus on Preventive Medicine as one cannot only depend on treatment of affected people alone be it in communicable and non communicable diseases

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• We need a ready, willing, and able workforce and have in place systems,infrastructure and backup options apart from managing the issue of rapid procurement of essentials.

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• Ideal situation is to have a workforce for excellence that can be called upon to help save lives, reduce disease and suffering, and minimize socio-economic loss to affected communities and countries.

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• Tamil Nadu and by and large India and the World quickly responded on the Health care and Disaster Management work force side.

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• However, the challenge is that in the initial stages many healthcare workers, including those who directly or indirectly deliver care and services to patients, report that they often feel unprepared to effectively respond to major disasters.

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COVID-19 - Facilities, Consumables, Personnel and massive IEC required

While the regular institutional Disaster Management plans provide for emergency response and inbuilt continuity mechanisms, the COVID pandemic highlighted the urgent need for not only rapidly expanding the testing and treatment infrastructure, procurement of consumables, working on development of clinical protocols and vaccines and above all additional personnel but more importantly willing personnel in all categories, such as –

• Doctors, Nurses, Lab technicians, Trained Microbiologists for the RTPCR and diagnostic labs,
• Technicians, Health Inspectors on the Public Health side
• Multi-Purpose Health Workers,
• Sanitary workers,
• Focus Volunteers.
• We also need infrastructure , consumables and equipment and diagnostics apart from treatment protocol and medicines.
• More importantly we needed to follow containment measures to prevent the spread of the disease.

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• Some of the concerns for Human Resources includes:
• Transportation problems
• The safety of self and family members
• Caretaking obligations
• Personal health issues
• Lack of personal preparedness
• Lack of confidence in the medical facility’s ability to respond effectively
• Insufficient training
• unwillingness to report to work.
• The type of disaster may also be a potential barrier for healthcare workers to report to work.

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Tamil Nadu’s Multi-pronged strategies to combat COVID-19 Pandemic

Surveillance– Fever survey workers

Doorstep Testing for COVID

Fever Camps in hotspot streets

Single window system for lab results

Triage- Field-based & facility-based

Zero delay transfers

Accelerated COVID �vaccination drive

Enforcement- Quarantine & isolation

COVID Health centres & Oxygen centres

Symptomatic case management

Lockdown & Mask enforcement

Information, Education & Communication

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This slide itself is evidence enough to show the need of Public Health and Clinical Personnel needed to respond to the Disaster.

Key Strategies - COVID-19 Clinical Management Key Strategies

COVID-19 Clinical Management

Expert Committee on COVID-19 Management

• Experts from Government, ICMR, WHO, Private Health Sector
• Specialization of experts

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• Infectious disease
• Intensive Care
• Emergency Medicine
• Critical Care
• General Medicine
• Virologist
• Epidemiologist
• Thoracic Medicine
• Paediatrician

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Mentoring of Govt. and Private Clinicians on COVID-19

• Video conferencing to clinicians of all COVID-19 treating hospitals
• Govt Doctors: Everyday 1 ½ hour
• Private Doctors: Monday, Wednesday and Friday
• Continuous Mentoring on Treatment Protocols
• Case presentations with clinical findings and treatment given
• Case management advice by expert panel

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Death Audit of COVID-19 cases

• Every COVID-19 death audited by subject experts
• Case sheet analysis – clinical findings, comorbidity
• Treatment given to death cases
• Course correction, if needed

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Initiatives for Health System Strengthening

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• Video Conferencing with the Districts Officials(Dean, Deputy Director of Health Services, Joint Director of Health Services) on alternate days

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• Review of Maternal Deaths during the above Video Conference with Mentor Obstetrician
• Guidelines on Non Essential Services are issued time to time

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Fatality Mitigation by effective Clinical Management�

Strengthening essential non-COVID healthcare services�

Promoting COVID Appropriate Behaviours in the Community

Action Taken for continuing essential Health Services: �12 Expert Committees constituted and Guidelines & Pamphlets released

1.Kidney disease on Dialysis

2. Cancer

3. Hypertension

4. Diabetes

Action Taken for continuing essential Health Services

6. Maternal Health

7. Child Comorbidities

8. Mental Health

5. Cardio Vascular Disease

Action Taken for continuing essential Health Services

9. TB /COPD / Asthma

10. HIV and Comorbidities

11.Geriatric Care

12.Nutrition

Maternal Health

Steps Taken :

• District wise line list of mothers with Expected Date of Delivery obtained from PICME Software and shared to the districts/ Chief District Obstetrician for ready reference

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• Micro-plan worked out at all levels for tracking of Mothers - Mentor OG , Block MO, PHC MO , VHN for follow up

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• High Risk Mothers with EDD during the lock down period followed by 104 / PICME cell

Dialysis Services (DVDMS)

Steps Taken :

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• The list of beneficiaries undergoing dialysis available with CMCHIS as well the list of private cases from all the dialysis centres were collected.

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• The beneficiaries over 10 kms from the Dialysis centres were listed out and a proper route map from the house of the beneficiaries to the concerned dialysis centres was prepared in coordination with the “102” team.

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• Inter-district transfer was also facilitated for patients undergoing Dialysis by utilizing the services of “102” vehicles.

Tuberculosis

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Steps Taken

Vector Borne Diseases

Steps Taken for preparedness:

1. Samples are taken for Dengue, Chikungunya and Japanese Enchephalitis in Govt. Medical college Hospitals and other Govt. & Pvt. Hospitals.
2. Aedes larval survey is carried out in peri domestic areas.
3. Larval density is studied and source reduction activity is carried out.
4. Anti-larval activity is done where ever necessary by the DBC engaged for Vector Borne Disease Control & COVID-19, disinfection.
5. Malaria disease surveillance is based on active & passive case detection. Active case detection is carried out by MPHS/MPHW/VHN through fortnightly house to house visit combined COVID-19 fever surveillance activities.

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Steps taken for migrants in the initial phase and during lockdowns

• 1791 Migrant sites ( district wise ) obtained from Labour Department and verified with the district officials

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• Line List of 1809 Mothers obtained from the districts. 1508 Antenatal mothers were ensured Antenatal services by providing PICME ID and 301 Post natal mothers were provided post natal services.

Steps taken for migrants

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• One Mobile Medical Unit identified as Hospital on Wheels in each 42 health unit districts for providing healthcare services to Migrant labour sites
• Migrant Workers are provided Counselling services through District Mental Health Programme and Satellite out reach Clinics

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• Free ration provided by Labour Department through District Administration

Tamil Nadu became the first State to having leading consultations in the country.

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Tamil Nadu also hold the distinction of maximum consultations done per day (2000 per day)

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Tamil Nadu brought the specialist services also available under e-sanjeevani through Hub and Spoke Model

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e-sanjeevani - Telemedicine

Field level Best Practises of Tamil Nadu in COVID-19 Pandemic

Uninterrupted MCH services

• Antenatal clinics at HSC and out reach sessions conducted in a modified manner with all COVID precautions.
• House visit of High Risk mothers by the VHN in Containment Zone

• Immunisation of Children in the Containment Zone as per GoI guidelines.
• Out Reach sessions conducted in Staggered manner.

NCD tablets distribution by Home Visits

• Implementing an organized system of drug distribution to the needy elderly NCD patients at their door-step during lockdown phase of Covid19 pandemic with the help of Women Health Volunteers and ASHAs working under PBS programme.
• DPO (NCD) compiles Block wise data of default and dependent elderly NCD patients and sends it to the concerned block through whatsapp group which consists of NCD SNs and representative volunteers of the block

• During the lockdown phase of COVID 19 pandemic,our healthcare workers assisted in drug distribution for Renal transplant patients especially for those who are getting drugs from other districts .

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• WHVs are actively involved in screening for Co-morbidities in mild COVID positive patients who were in home isolation.

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Drug Distribution and Co morbidities screening for COVID 19 Positive Patients

Hand Washing Facility & Hand Sanitiser for OPD patients in all HWCs (HSCs and PHCs)

Educating and Practicing of Social Distancing in all healthcare facilities

Yoga & Breathing Exercise in all HWCs

Kabasura Kudinir (AYUSH) medication for Immunity strengthening

Special Medical Camps at Containment Areas

KIOSKS for Sample collection HWCs

Distribution of Masks to Patients

Follow up NCD patients through call Register

Colour Coding of Samples for Testing

• Red – ILI/Primary Contacts
• Orange- Traveller/ Secondary Contacts
• Green-Surveillance Samples

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Survey by VHNs in Containment Zone and Distribution of Zinc & Vit C

Alcohol Withdrawal Management during Lock Down

• Team work by the field level team in managing non-covid essential health services at field level

Video call by Medical Officer – COVID – 19 Patients

• Concerned Medical officers are calling the Covid-19 Positive patient (at Home isolation) and their contact on all days to monitor and get connected to them.

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• Contact of Positive case if they develop symptoms are referred earlier for testing.

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• All the necessary items need for the Contacts are informed to the local body during the call.

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Future Plans at the end of Each Wave

Foundation on which COVID prevention and control has been based

• Direct supervision at the State level of Honble CM including regular SDMA meetings followed by quick decisions.
• Sanction of adequate funds for procurement and services and also for Human Resource’s and quarantining through SDRF, state funds and also under the emergency COVID package by GOI
• Basing decisions on sound public health expert approach including utilisation of state level expertise and experience.
• Regular interdepartmental review by the Chief Secretary
• Field and hospital inspections, visits and reviews by Health department, Collectors and Commissioner Chennai with support from Public health machinery and interdepartmental support including, Police, local bodies, Revenue, Social welfare among many others.
• TNMSC based procurement to address critical gaps in a speedy manner.
• Aggressive RTPCR testing Setting up of fever camps and adjacent sample collection centres
• Augmenting testing facility to facilitate quick communication of results
• 24X& DPH Control Room
• War Room during the second wave
• 104 and 108 control room and augmentation of ambulance facilities.

Foundation on which COVID prevention and control based

• Setting up screening centres for positive patients and sending them to covid care centres, health centres or hospitals depending on severity.
• Having a clear clinical protocol Expanding the treatment beds and infrastructure- role of DME, DMS, DPH, DMS ESI, private sector.
• Ensuring availability of medicines both allopathy and approved immune boosters from Indian medicine under supervision of doctors from respective fields
• Fever surveillance through house to house visits and fever camps and Catching the positive early, testing tracking and treatment followed by effective contact tracing.
• Tightening laws on failure to flow mask adherence, social distancing, hand washing and standard operating procedures for approved activities released from time to time.
• Ensure gradual uptake of vaccine as per the guidelines released by Government of India.

Challenges

• Keep looking out on Clusters emerging for visits to crowded and closed places - incidents post events involving serving of food in a group such as marriages, birthdays, funerals, social events
• Colleges, schools and hostel based spikes.
• Main market place based challenges
• Being tackled by regular testing of vendors , hotels, hostels especially mess etc.
• Slow uptake of vaccines among the health worker category

Tamil Nadu Medical Services Corporation�Remdesivir ,Tocilizumab, all COVID related drugs and ofcourse scans and testing kits

RT-PCR Laboratory and Testing Centre

AYUSH Care

Focus was always on “Test, Track, Treat, Vaccinate and Covid appropriate Behaviour”

• Testing
• Focus on increase in RT-PCR Tests in all the district
• Tracing, Containment & Surveillance to break chain of transmission
• Containment Zones to be delineated as per proper mapping of clusters of cases & their contacts
• 25 to 30 such close contacts to be treated for each infected person.
• Tracing of close contacts and their isolation to be done in 72 hours.
• Subsequent testing and follow up of all close contacts as per ICMR protocol

• Clinical care, treatment & support: Home/Facility level (as per protocol)
• Increase number of isolation beds, oxygen beds, ventilators/ICU beds, ambulance fleet as per requirement.
• Plan for adequate oxygen supply
• Focus on mortality reduction by early identification & complying to treatment protocols
• Vaccine
• Time-bound plan of 100% vaccination of eligible HCWs, FLWs and eligible age groups effectively implemented – Mega vaccination camps helped a lot.
• Workplace vaccination (both in public and private sector)

Covid Appropriate Behaviour & Clinical Management

• Local political, cultural, sports and religious influencers to disseminate proper wearing of masks and maintaining physical distance.
• Police Act, DM Act & Other legal/administrative provisions for Penal action against defaulters.
• Ensure strict adherence to mask wearing, physical distancing and hand hygiene
• Great vigilance and monitoring at highest levels for all potential events where crowds gather
• Clinical management in all districts especially in district reporting higher deaths.

Social Distancing & Use of Mask can considerably lower the transmission

Source: North Carolina Department of Health & Human Services

Best Practices from Tamil Nadu

• A 24*7 Control Room at the Directorate of Public Health & Preventive Medicine for all epidemic control activities
• Unified Command Centre (UCC) / State CoVID-19 War Room to lead the State’s response to the 2^nd Wave & O2 management
• Decentralised approach through District and Block level War Rooms
• Greater Chennai Corporation and later the districts started analysing street wise data in urban areas and habitation wise data in rural areas to ensure effective containment.
• Setting up of fever camps, house to house surveillance, screening centres, COVID hospitals, Health Centres and Care centres and effective monitoring of Home Quarantine and use of Focus volunteers.
• Tamil Nadu Medical Services Corporation ensuring seamless procurement of all COVID related consumables, drugs and equipment.
• 100% RT PCR Tests and strengthening Govt. Labs : 339 RTPCR labs(70 Govt+ 269 Private)
• Inter-sectoral collaboration across different Departments to address all aspects of the pandemic such as O2 shortage, contact tracing, social welfare measures, lockdown implementation etc.
• Strategic purchasing and close coordination with Private sector hospitals to address the shortage of beds, effective use of CSR and NGO support especially during the aftermath of the second wave.
• Active role of the CM Health Insurance Scheme and augmentation of 108 services during the pandemic.
• Effective utilisation of Siddha, and all branches of Indian Médicines and setting up of exclusive centres.

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Best Practices from Tamil Nadu (Contd.)

• Setting up of Zone level and Block level control rooms during the peak periods.
• Mega Vaccination Camps to enhance immunisation coverage by covering all unvaccinated eligible persons
• Focusing on Non-Communicable Diseases and continuum of care by launching a new scheme «  Makkalai Thedi Maruthuvam » to provide home-based healthcare services like NCD drugs, phsyiotherapy, palliative care, CAPD bags at people’s doorsteps.
• Effective use of telemedicine and other IT platforms
• Constitution of an Expert Committee and regular updation of protocols, guidelines based on emerging evidence and the State’s specific context and needs.

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Best Practices from Tamil Nadu-continued

Key Challenges Tackled

• Sudden need to upgrade infrastructure and employ personnel and procure Equipment
• Initial reluctance of Private sector in the first wave to participate in COVID treatment, underscoring the need in long term, not to reduce the availability of Public Health facilities
• Lack of compliance to Covid Appropriate Behaviour (CAB) and other CoVID-19 restrictions due to the decline in cases after the end of each wave.
• Oxygen Issues: Demand – supply mismatch (2^nd wave).
• Tackling severe Vaccine hesistancy in the initial few months and vaccine apathy subsequent to the drop in cases after the second and third waves.
• Ensuring vaccination of vulnerable persons and focussed vaccinations and regular random testing in markets, restaurants, hotels, bus depots, auto drivers, courier and food delivery boys, teachers, migrant labourers, pregnant and lactating mothers etc., within the available doses.
• Ensuring the tracking of other concomitant seasonal diseases like Dengue also ensuring that people are provided access to treatment of other Non-communicable Diseases and all kinds of accidents/emergencies and also deliveries during this period.
• Social & Economic Challenges.

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Oxygen capacity

Key Lessons

• Considering the recent trend of spread of Transboundary and zoonotic diseases such as Coivd-19, Swine flu, Monkey pox, Bird Flu, Nipah, Noro, West Nile Fever, Zika we need to be constantly prepared with the required infrastructure and personnel
• As despite the Pandemic the regular Maternal and Child health Services, emergency services and need to also address other diseases including Non Communicable diseases makes this field a highly sensitive field with need for a long term vision. Covid Pandemic for e.g needed the following apart from the basic need to follow the evolving and available Public health guidance - Aggressive and focused testing is crucial for early detection
• Early identification, Contact Tracing and Strict Quarantine measures must be followed
• Regular updation of clinical management protocols and death audits
• Ensuring bed capacity in all districts and at all community levels
• Inter departmental co-ordination is key to the effective handling of pandemics and crises.
• Enhance multisectoral action through Private sector & NGO involvement
• Cocooning of the Vulnerable by “Reverse Quarantine” is highly necessary
• Both social mobilization & community participation are critical.

Building Resilient Health Systems

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THE WAY FORWARD….

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Immediate and Long-term policies & strategies needed to enhance preparedness and combat future waves:

Vaccination, Testing, Gene Sequencing & Sero Surveys

• Expanding vaccination coverage particularly among vulnerable population groups; Demand-supply issues to be resolved nationally and globally.
• Conduct adequate gene sequencing and strengthen in-house facilities to do gene sequencing.
• Regional Laboratories to be established to support Microbiology, Pathology and Biochemistry testing needs.
• Sero-surveys to be conducted every 6 months.

Tamil Nadu COVID 19 Vaccination Programme

02-12-2022

Cold Chain Preparedness which helped in Vaccinations

• 1 State Vaccine Store
• 50 dedicated walking coolers for Covid Vaccination under TNMSC
• 10 Regional Vaccine Store
• 44 District Vaccine Store
• 24 Government Medical College Hospitals
• 303 Government Hospitals
• 2286 Primary Health Centers ( Urban & Rural)
• 27 Private Medical College Hospitals
• Cantonment Hospitals

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COVID 19 Vaccination Coverage (as on 02-12-2022)

(Source – Google Sheet)

COVID 19 Vaccination Coverage (as on 02-12-2022)

(Source – Google Sheet)

# Precaution Dose

Due as on 02-12-2022 - 4,76,60,846

As on Performance - 93,76,532

Balance due to be covered - 3,82,84,314

SERO SURVEY REPORT: INFERENCES

• Serosurvey phase-1 was conducted by Directorate of Public Health and Preventive Medicine in Oct / Nov 2020. Out of 22,690 samples tested, 6,995 were found to be reactive for SARS CoV-2 lgG antibodies. The overall seroprevalence was 31%.
• Serosurvey phase-2 was conducted in similar way by Directorate of Public Health and Preventive Medicine during April 2021 (except Chennai). A total of 765 clusters were included covering 22,904 samples. Among the 22,904 samples tested, 5,316 individuals had lgG antibodies against SARS-Cov-2 Virus.
• The overall Seroprevalence was 23%
• The highest and lowest Seropositivity was observed in Tiruvallur District (49%) and Nagapattinam District (9%) respectively.

SERO SURVEY REPORT: INFERENCES

Attributable features / reasons with respect to Serosurvey – 2 findings:

• Timing of Serosurvey
• Waning of antibodies
• Vaccination coverage
• Emergence of SARS CoV-2 Variants.

Third serosurvey intended to be carried out in July / Aug.2021 which is the most appropriate time considering the current declining trend of COVID-19 cases coupled with intensified vaccination drive being carried out among those aged >18 years in Tamil Nadu.

COVID19 - SERO SURVEY – I (OCTOBER 2020) – �TAMIL NADU DISTRICT WISE SERO POSITIVITY

(n=22690)

COVID19 - SERO SURVEY – II (APRIL 2021) - TAMIL NADU DISTRICT WISE SERO POSITIVITY

(n=22904)

DIRECTORATE OF PUBLIC HEALTH AND PREVENTIVE MEDICINE

WGS_SARS CoV-2 Variants Reported in Tamil Nadu

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(as on 24/11/2022) (n=8617)

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January – October_2022

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DIRECTORATE OF PUBLIC HEALTH AND PREVENTIVE MEDICINE

WGS_SARS CoV-2 Variants Reported in Tamil Nadu Month wise Distribution

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(as on 24/11/2022) (n=8617)

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January – October 2022

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DIRECTORATE OF PUBLIC HEALTH AND PREVENTIVE MEDICINE

WGS_SARS CoV-2_Variants of Concern Reported in Tamil Nadu

(as on 24/11/2022) (n=8548)

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January – October_2022

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BA.2 115 (21%)

BA.1.1 259 (48%)

BA.2 1268 (83%)

BA.1.1 39 (3%)

BA.2 507 (84%)

BA.3 14 (3%)

BA.2 339 (76%)

BA.2 226 (35%)

BA.5 25 (4%)

BA.2.38 219 (34%)

BA.1.1 11 (2%)

BA.2.38 274 (23%)

BA.2 226 (19%)

BA.5 568 (47%)

BA.2.12.1 55 (9%)

BA.2.12.1 29 (2%)

BA.2.38 84 (5.1%)

BA.5 1285 (77.9%)

BA.2.12.1 3 (0.2%)

BA.2.76 46 (2.8%)

BA.2.75 70 (4.2%)

BA.2.75 54 (19.1%)

BA.5 187 (66.3%)

BA.2.74 6 (2.1%)

XBB 48 (3.6 %)

BA.2.75 1072 (79.8%)

BA.5 204 (15.2%)

BA.2 13 (4.6%)

BA.2 7 (0.5%)

XBB 165 (52.4%)

BA.2.75 80 (25.4%)

BA.5 61 (19.4%)

BA.2 81 (4.9%)

DIRECTORATE OF PUBLIC HEALTH AND PREVENTIVE MEDICINE

Re-emerging of BA.2 Variant & its Sub lineages Reported in Tamil Nadu

(n=1369)

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September & October_2022

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Decentralised Mitigation Measures

• Utilising Self Help Groups (SHGs) / Community Health Workers in rural and urban areas. For example, school-teachers can act as the front face of Government who will screen, refer and follow up all the risk population.
• Having at least one health volunteer per 1000 population
• Syndromic surveillance: Early identification and Initiation of protocol-based treatment at primary care level itself
• Innovative and effective Information, Education & Communication (IEC) strategies at all community levels.
• Decentralised measures for effective mitigation:
• Micro-containment measures
• Decentralised drug delivery (eg: MTM)
• District / Block war rooms

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Develop a district or city-level plan for public health emergencies like Covid-19

• Augment Health Facilities at the district and city levels to strengthen Health System preparedness.
• Set up and increase testing facilities.
• Steady supply of oxygen to dedicated hospitals – focus on Paediatric units as well
• Set up permanent Quarantine facilities for migrant laborers and vulnerable groups like the homeless population.
• Develop a local and dynamic plan for lockdowns (in case of another wave)
• Effective utilisation of Telemedicine which has emerged as an important alternative in service delivery
• The district / city administration should increase the strength of multi-disciplinary experts from the areas of epidemiology, public health, and preventive medicine.
• Plans for the safety and well-being of the health workforce, including social security measures
• Regular capacity building and training for all health workforce.

Adopting a Decentralised Mitigation Strategy will be the only sustainable solution !!

Long-term Strategies

• Invest in Disease Surveillance and Health Information Systems

A network of laboratories, not less than one per million with adequate staff and the capacity to monitor a wide range of diseases ranging from antibiotic resistance patterns to viral zoonosis.

Real-time availability of mortality data along with the presumptive cause of death (not necessarily medically certified) but with age and gender and residence patterns.

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• Invest in Comprehensive Primary Health Care

A much higher level of financial and political investment is needed towards primary health care.

The objectives set out for the provision of Universal Healthcare Coverage should be literally and comprehensively met.

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Long-term Strategies -Continued

• Increase in deployment of Trained Human Resources for health

Consistent efforts must be made to fill in the vacancies at the earliest.

It is necessary to revisit the norms currently in place for the deployment of human resources across the delivery system.

• Public Investment to lower attrition in rural, remote and under-serviced communities.

Sponsoring candidates from under-serviced areas for suitable training and conditional licensing/bonds.

Special compensation packages and appropriate incentives and building a positive workforce environment that can help in retention.

Long term Strategies -Continued

• Care for elderly citizens, differently abled and need to focus on Mental Health: Cocooning of vulnerable
• The health of the elderly continues to be neglected area in India.
• Targeted policies & interventions are needed due to their increased vulnerability to the virus.
• Special attention is also needed for differently abled
• Addressing the Mental health to keep pace with the challenges also is the need of the hour.
• Promote domestic capacity for medical technology
• COVID 19 has shown us that global supply chains are unreliable and inequitable.
• A special investment in developing domestic manufacturing and building innovative ecosystems is required for health security and self-reliance.
• We need to rebuild our domestic capacity!

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Long term Strategies - Continued

• Strengthen Social Security Mechanisms

The COVID 19 pandemic has brought home to us an unduly high price that people pay for the absence of social security.

These social security benefits which include cash benefits for unemployment, sickness, disability, loss of life, accident compensation, occupational disease etc. are to be made comprehensive.

• Scale-up the Public Health Cadre

It is important to enhance the quantity and quality of public health professionals substantially to further build the public health workforce capacity right up to Block level administration.

Long term Strategies -Continued

• Regulation of a Clinical Establishment Act or Equivalent
• Constant monitoring of quality of care in both public and private sector
• Private sector management & regulation

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• Promote health literacy and awareness
• Roll out an innovative & long-term IEC strategy to bring about a positive change in people’s minds and to ensure collective action and collaborative efforts.
• Renewed efforts needed to engage community health organisations for promoting patient empowerment through health literacy and awareness.
• An effective IEC policy can be a potent preventive and promotive tool!

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• Covid 19 underlined the validity of the One Health concept in understanding and confronting global health risks.
• COVID-19 reinforces the fact that emerging zoonotic infectious diseases are here to stay and fighting new disease threats requires one Health collaboration across human, animal, and environmental health organizations.
• One Health investigations and animal surveillance are crucial in evaluating transmission of SARS-CoV-2 between people and animals.

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Long-term Strategies - COVID -19 and ONE HEALTH

• Prevent outbreaks of zoonotic disease in animals and people.
• Improves food safety and security.
• Reduce antibiotic-resistant infections and improve human and animal health.
• Protect global health security.
• Improving Human and Animal health globally. �

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Non-Health Interventions Needed

• Ensure food security for poor and vulnerable households.
• Converging all the flagship health, social & economic programmes of the State to help communities affected by Covid-19.
• Set up an institutional structure for psycho-social care.
• Ensure knowledge transfer and sharing of best practices.
• Carry out a sustained risk communication campaign.
• Involve Local Self-government Institutions.
• Expand the number of volunteers for community-level outreach and activities.
• Seek the support of Women’s Self-help Groups.
• Strengthen data collection and ensure robust data management systems.
• Set up sustainable fund flow mechanisms and contingency funds at the district level to ensure rapid response in times of crisis.
• Strengthen the institutional framework at the District level for Covid-19 management.

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Conclusions

• Having a coordinated approach and guidance by the Health Experts both at National level and the State levels was the key along with timely interventions and guidances (NTAGI and NEGVAC examples apart from regular meetings by Hon’ble PM with the States and similar meetings at the State level by the Hon’ble CM and the Medical experts committee).
• Empowering, retaining and enhancing Human Resources to Combat Public Health Emergencies and Disaster Management is the need of the hour.

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• Health sector needs effective capacity building to prepare to handle all emergencies whether, Natural or Manmade, Biological of other causes.

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• Need to retain the capacity after the end of the disaster or during the lull is very critical.

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• Ensuring effective capacity building of the private sector and the NGOs who are active and willing to contribute in this sector equally important.

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• Even in the larger Disaster Management and Mitigation sector addressing all Disasters, the focus should be to develop and retain capacities in normal times - whether it is to augment early warning, search and rescue, organizing relief and rehabilitation and working on early and long term recovery and mitigation apart from improving coping capacities based on a proper Hazard and Vulnerability analysis.

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• Heeding to expertise on respective fields is also the key and retaining the surge capacity of people gaining expertise helps in quicker response.

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Snapshots of Public Health,clinical measures and enhancing of Human resources and infrastructure related activities undertaken during this Pandemic

Snapshots of Public Health, clinical measures and enhancing of Human resources and infrastructure related activities undertaken during this Pandemic - Continued

Snapshots of Public Health,clinical measures and enhancing of Human resources and infrastructure related activities undertaken during this Pandemic -Continued

Patient Information and Help centre

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Appoinmtment of Contract doctors and human resources

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Snapshots of Public Health and enhancing of Human resources and infrastructure activities undertaken during this Pandemic -Continued

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24,006 Oxygen Concentrators mobilised

Setting up of temporary oxygen beds/hospitals

Snapshots of Public Health,clinical measures and enhancing of Human resources and infrastructure related activities undertaken during this Pandemic -Continued

Setting up of Oxygen Generators including through PM cares

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Recovered patients being discharged

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Snapshots of Public Health,clinical measures and enhancing of Human resources and infrastructure related activities undertaken during this Pandemic -Continued�

Snapshots of Public Health, clinical measures and enhancing of Human resources and infrastructure related activities undertaken during this Pandemic -Continued

Visits by Hon’ble CM and Hoin’ble Union Health Minister to various facilites.

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Future Scenarios

• Global health risk is increasing due to New, Emerging and re-emerging diseases will continue to keep us on our toes.
• Compounded also by drug resistant organism
• The trans-boundary diseases due to increased international trade and travel and the zoonotic and other diseases jumping species will make the need to constantly keep up the surveillance and work on strengthening systems on preventive strategies.
• Need to also ensure that we don’t lose focus on other communicable and non communicable diseases and allow a drift on the Maternal and child health issues.
• Need to keep working on vaccines and repurposing of drugs and encourage more translational research and knowledge sharing.
• Capacities developed has to be included as part of surge capacities and not forget their contribution as there is a constant need for trained interoperable and scalable to deploy HR at all levels.
• Mankind cannot take chances as it directly impacts the sustainable development goals.
• Need to have effective culturally acceptable timely, relevant, understandable information and communication focused on change in behaviour and not limiting it to creation of awareness only after a crisis has developed.

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Snapshots of Public Health,clinical measures and enhancing of Human resources and infrastructure related activities undertaken during this Pandemic -Continued

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THANK YOU