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In Kerala district, a low-tech solution that offers high success rates on keeping tab of patients
When the number of home quarantined in Alappuzha shot up from 200 to 6,000 it seemed humanly impossible to keep in touch with them via daily phone calls. Perhaps, only a machine could have done the job. And that is exactly what happened.
KOCHI: When the calls were at 200, it was manageable. But as the cases increased, so did the calls — hundreds became thousands, and that is how Dr Sharath Chandra Bose, in-charge of COVID Control Cell in Kerala’s Alappuzha district, suddenly found himself in a fix.
When in early February, the first case of COVID-19 was reported in Kerala’s Alappuzha district (a medical student, who returned from Wuhan in China), the patient’s contacts were immediately identified and quarantined.
In the next few days, as health officials scrambled to contain the infection, a control cell was set up, and the district surveillance officer made daily phone calls to those under quarantine, following up on their symptoms. “There were hardly around 200 people who had to be isolated in their homes,” recalled Dr Bose, who was overseeing the operations. “So it was easy for us to call them regularly.”
However, when the second wave of infections hit in the weeks that followed, the number of people under home quarantine rose exponentially — from 200 to nearly 6,000.
“Even when we deputed 10 to 20 people to make phone calls, we couldn’t reach enough people. On a regular day, with about 10 lines, we could call only about 600 people. That means, if we had to make a repeat call to a person, we could do so only after 10 days,” said Dr Bose.
The task, it seemed, was humanly impossible. Perhaps, only a machine could have done the job. And that is what exactly happened.
Billion Lives is a Kochi-based technology firm. The health department, through a mutual contact, got in touch with the Billion Lives team and when they heard about IVR, they decided to experiment with it.
The founder was an engineering graduate, John Santosh, who had previously worked in banking and tech solutions. When Dr Bose reached out, the firm had customised an IVR technology model to track people entering and exiting the Northeastern state of Meghalaya.
The model for Alappuzha, however, would have to be different, keeping in mind the requirements. After a few days of non-stop deliberations, frantic coding and programming, a solution was found: instead of wasting human labour on making thousands of manual calls, automated calls through IVR would be placed to those under quarantine, with a set of pre-recorded questions.
The call, lasting less than a minute, would inform the receiver at the outset that it was part of the government’s disease surveillance system and that they had to listen till the end. The questions would follow. If they were experiencing mild cough, fever or sore throat, they would be asked to press 1. In case of severe versions of the above symptoms, they had to press 2. If they discovered blood in sputum, indicating extreme pneumonia, they should press 3. For any other symptoms, they could press 4.
“In a situation of a community spread where people would feel the need to tell us their symptoms, placing manual calls is not practical. That’s where this system becomes more relevant,” explained Santosh, who graduated from Palakkad Engineering College.
The number of people who answered calls saw a dip with the implementation of the IVR system
The IVR data from such calls is then processed through an analytical tool and finally reflected on a dashboard where the symptoms of every single person on quarantine can be plotted. On a daily basis, doctors and health officials can assess the quarantined population’s medical conditions almost in real-time by viewing the dashboard and making informed choices.
“The IVR system helps us in identifying the symptomatic among the quarantined, isolate and test them as soon as possible,” said Dr Bose, “A person with mild cold, fever and sore throat falls under category A and doesn’t require intervention. Those with severe cold and fever are under category B and require hospitalisation. Category C is for people reporting breathlessness and blood in sputum which can indicate extreme pneumonia and therefore need medical help.”
According to Dr Bose, the IVR dashboard created by Billion Lives was “one of the best” he had ever seen. “Each category of symptom is colour-coded and plotted on bar graphs. With the change in colours over time, we can assess if the symptoms are aggravating in people and therefore rush medical help,” he said.
The technology didn’t come without its initial problems. Since the calls were automated, many tended not to answer. “So we identified those who weren’t and pushed repeated calls in a space of two hours. That worked,” said Bose, adding that there were instances of people accidentally keying in the wrong response. “If they pressed 2 indicating severe symptoms, we would manually call them up to check. Such calls were very less, maybe a 100 odd out of 5000,” he said.
According to Santosh, the Meghalaya experiment — where the authorities wanted to track those entering and leaving the state at check-points — was entirely different.
“Everyone was thinking about launching mobile apps to track people. But in a state like Meghalaya, getting people to download apps was impossible. So I started thinking the other way round and came to IVR,” said Santosh, currently based in Bengaluru, “Here, we are using a technology called progressive web app. Anything that a mobile app can do, this technology can do too.”
HEALTHCARE AT YOUR DOORSTEP
In the short time that the district health department has been using the technology, it certainly seems to have paid off. Its popularity has spread through word-of-mouth, leading to calls from other districts in Kerala too.
Quarantine compliance and monitoring, too, has been sharp. So far, only five persons have tested positive in the district, a sharp contrast to the northernmost district of Kasaragod, where 175 had to be treated.
And that’s where, Dr Bose feels, a system like the IVR can unveil its true potential to health officials. In initial days in Kasaragod, dozens of people who came from abroad and through primary contact, tested positive. But through stringent vigilance, tight contact tracing and high testing, the number of infections reduced substantially in the district. On April 28, only about a dozen people remained under treatment.
Dr Bose also that in a city like Mumbai — densely-populated and a designated hotspot — officials were still painstakingly making manual calls to those under quarantine.
The popularity of the IVR system has spread through word-of-mouth, leading to calls from other districts in Kerala too.
“In cities like Mumbai and Bengaluru, the response would be so much better as they [the population] already know how automated calls work,” said Dr Bose, suggesting that such places pick up on the technology too.
“In such a situation, a person doesn’t have to worry about where to get tested or which hospital to go to. All he has to do is respond to the call and the healthcare system will be at his doorstep,” he said, adding, “There’s no better tool than this to pick up on people with Covid-19 symptoms in hotspots.”