Proactive Teleconsultation for Coronavirus Disease 2019 Cases Identified Through the Community-Testing Initiative in Karachi,Pakistan: A Low-Cost Value-Added Service to Support a Pandemic Response in a Resource-Limited Setting

Introduction

Coronavirus disease 2019 (COVID-19), a coronavirus infection originating in Wuhan, China, in December 2019, proved to be highly infectious and developed into a glaring pandemic owing to globalization, with >83,859,650 confirmed cases as of December 31, 2020. ¹ Although COVID-19 has a much lower case fatality rate (1.4–3.4%), the total number of deaths from the disease have exceeded 1,825,450, far greater than those caused by severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS) pandemics combined. ² Earlier pandemics of the 21st century did not affect Pakistan ³ ; however, 10 months into the pandemic, Pakistan has had >482,170 confirmed cases with >10,170 deaths. ¹ Karachi, Pakistan's largest and most populous city, hosts the most number of COVID cases in the country. ⁴

Pakistan reported its first case on February 26, 2020 from Sindh province. ⁵ Immediate efforts were established at national and provincial levels to ensure screening, testing, contact-tracing, isolation, and “smart” lockdowns to reduce the infection spread. Indus Hospital and Health Network (IHHN) partnered with the provincial government and other private sector partners to tackle the pandemic, offering integrated services ranging from screening and testing to management of complicated COVID cases. The Global Health Directorate (GHD) of IHHN was uniquely placed to create a “COVID-response team” to provide services to communities through its existing infrastructure used for implementation of public health programs. The “COVID-response team,” based in Karachi, consisted of community health care workers, community engagement teams, program implementation specialists, and clinical teams. The team underwent training in patient screening and nasopharyngeal swabbing based on national guidelines. ⁶ Given the unprecedented circumstances, the approach involved experiential learning, tweaking, and adapting systems and processes to control the pandemic.

GHD, in partnership with the local government administration, rolled out community-based testing initiatives across Karachi where patients were screened and tested and samples were safely transferred to The Indus Hospital (TIH) laboratory. Efforts were made to ensure that the testing locations were approachable and convenient for the majority; targeted hotspots such as madrassas (religious institutions) and community centers were also identified as testing sites after collaborating with district administration teams. Results were shared with the district government within 24–48 h. The aim of the district government was to convey test results to those who tested positive along with relevant instructions on immediate isolation and self-care. However, with escalating tests and a surge in positive cases, an increasing time lag was noticed between testing and results dissemination, with the resultant risk of infection spread by the unaware case and growing anxiety of patients awaiting their results.

Methods

To bridge the gap, occurring due to a delay in transmission of results, a doctor was engaged to communicate the test results to COVID-19 positive patients through a helpline. During the first few calls, the need for revision of strategy was realized. With the spread of the pandemic and consequent panic in the community, people were desperate to communicate with health professionals for guidance regarding isolation and self-care. ⁷ Uncertainties prevailed and people had many queries for which they wanted answers. We had anticipated that each call would last under a minute; however, it extended to a teleconsultation of 5–6 min on average. Subsequently, an extensive document with standard operating procedures (SOPs) was drafted and regularly updated using national ⁶ and Center for Disease Control and Prevention guidelines. ⁸ It contained information regarding COVID-19 testing, retesting, isolation, clinical management of mild to moderate cases, referral in case of severe symptoms, identification of red flags, self-care, disinfection, testing of contacts, and ending isolation. Consultations were tailored to patients' context, background, and needs. Linkages were established with TIH's Infectious Diseases specialists and emergency department (ED) physicians for further guidance in complicated cases. As numbers increased toward late April, a second physician and helpline were added.

Every morning, the list of new positive patients with their medical record number, basic demographic and contact details, was shared by the monitoring and evaluation (M&E) team with the doctors. During calls, key information was collected from cases regarding the possible source of infection, signs and symptoms, comorbidities, and contacts. Data were compiled over Microsoft Excel. All data acquired were manually entered and stored in compliance with IHHN privacy standards. Active M&E was limited because of unprecedented circumstances of operating in a pandemic coupled with lack of resources; however, a call-log was maintained by the doctors daily.

Key challenges included the ever-increasing number of cases, which finally led to the decision to switch to system-generated short message service (SMS) to convey results. An anticipated challenge was the low literacy rate of our population ⁹ and, as expected, there were patients who received the SMS but could not read. An unexpected challenge, however, was that many people could not comprehend the term “Detected” and “Not detected.” Based on patient feedback, the terminology was changed to “Positive” and “Negative,” respectively.

A second consequence of the teleconsultation initiative was to extend the scope of an existing IHHN tuberculosis (TB) call center to integrate COVID-19-related queries from August 2020 onward. Experience of the doctors conducting teleconsultations was utilized to train the call center team so that people with COVID-related queries could contact the call center for assistance. The top priority identified was early communication of results through SMS, followed by availability of a team of trained health workers at the call center to provide basic guidelines on isolation and self-care, on demand; doctors were the second tier of contact for medical guidance and referrals, whereas specialists were the final tier reserved for serious cases.

We present a retrospective chart review of data collected from April 5 to June 10, 2020, during teleconsultation service for COVID-19 positive cases identified through community-based testing. This was exempted from Institutional Review Board review due to minimal risk.

Results

During the study period, 4,279 tests were conducted in the communities out of which 28% were positive. During the first week of the intervention, an average of 30 tests were performed daily with a positivity rate of 13%, which rose to 78 tests daily with 42% positivity in the ninth week. Out of the 1,196 people who had tested positive, 74.7% (894 people) were contactable over the phone for teleconsultation; 13.5% (162 people) were those who tested positive toward the end of the study period and they were contacted through SMS to inform them of their test results as a backlog of cases was accumulating; and 11.7% (140 people) were not contactable because either they did not receive the call (47 people), their number was switched off (31 people) or the number that they provided was incorrect (62 people). Out of the contactable people, 752 had been tested for the first time and were thus considered as baseline positives, whereas the rest were repeat tests.

The gender and age category breakdown of tested and positive patients is given in Table 1. Among those tested, 68% were males and most patients were between 25 and 44 years; a similar distribution was seen among positive cases. Figure 1 displays the sources of infection, symptoms, and existing comorbidities as reported by patients during teleconsultation. Responses from 4.3% baseline positive patients were documented as “unknown” since they were either under district government surveillance in isolation centers and, therefore, inaccessible for direct communication or they refused to give any information. 76.9% patients reported possible sources of infection as household contacts (30.1%) and close contacts (46.8%), whereas 18.9% could not pinpoint any source of infection. Regarding symptoms, 41.8% of baseline positive cases were asymptomatic, 52.9% had mild to moderate symptoms and 1.1% were referred to ED due to severe symptoms. Ages of these eight severe cases ranged from 42 to 70 years, five were males, and comorbidities (hypertension and diabetes) were present in two patients, both females. Seven percent (318) of the tested population comprised children from 5 to 15 years of age (children <5 years were referred to a hospital for testing). Out of these, 46 children were baseline positive cases and 47.8% (22) of them had no symptoms.

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Fig. 1.

COVID-19 tests conducted between April 5 and June 10, 2020, and data collected from community cases during teleconsultation. ¹ Household contacts include family members or domestic help. ² Close contacts include people encountered at workplace, during travel or socially. ³ Unknown 32 (4%): 23 patients were not directly accessible and were under district government surveillance, 9 refused to answer any queries. COVID-19, coronavirus disease 2019; SMS, short message service.

Common symptoms recorded were fever, cough, body aches, flu-like symptoms, shortness of breath, ageusia, and anosmia; rashes were reported in two patients. Presence of comorbidities such as diabetes, hypertension, TB, or cancers, was documented in 13% of the contactable cases (98 patients).

During teleconsultations, some notable experiences were recorded. They are worth mentioning as they reflect the sentiments and responses of the people from the urban communities in Karachi, faced with the pandemic. These responses could be used to generate specific guidelines that could contribute toward the preparedness of governments to handle similar emergencies in future.

Discussion

Community testing proved convenient to the public for many reasons. Primarily, it was free of cost, accessible (as intracity transport was suspended), and safer since it was distant from crowded hospitals. ¹⁰ The proactive approach of teleconsultation was unique as positive patients were being contacted by doctors for timely communication of results, to provide self-care guidelines, and to refer patients with severe symptoms to ED. This encouraged early isolation and reduced the pressure on hospitals. The community welcomed teleconsultation as a safe, free, and convenient mode of interaction with a doctor in times where access to health care became a challenge. ^{11 –13} This was translated as relief and gratitude, expressed by many patients. It was a low-cost intervention leveraging on existing human resources with a small expenditure to support telecommunication using mobile phones.

Within the duration of the study period, the number of tests being conducted in the communities increased by 2.6 times, whereas the positivity rate increased more than threefold (3.2 times), which became a challenge to handle. Through word of mouth, more people were coming to get tested, but the increase in positivity rate indicated spread of the disease. Forty-five percent (1,916 individuals) of those tested were in the age category of 25–44 years and 69.4% (1,329 individuals) of these were males. Reasons for such age and gender distribution could be that this is the working age group exposed to risk due to their professional activities linked to medical practice, banking, social activism, or simply because females had less access to walk-in testing facilities due to a gender-based difference in health-seeking behaviors prevalent in our culture. ^14,15 Similar age and gender distribution was seen among the positive cases in our cohort and it is also reflected in Pakistan's COVID-19 national statistics dashboard, maintained by Pakistan Institute of Development Economics. ¹⁶ More than three quarters of the positive cases were able to identify the source of infection as household or close contacts; this indicates the need for imposing strict SOPs such as isolation of cases and wearing of masks to contain the spread among people in proximity.

In our cohort, a large number of the contactable baseline positive cases were asymptomatic, similar to findings stated in a narrative review. ¹⁷ Since all patients were contacted only once, there is a possibility that some or many would have developed symptoms after they were contacted, as depicted in the meta-analysis conducted by He et al. ¹⁸ This meta-analysis of 41 studies with a total of 50,155 patients with confirmed COVID-19 showed a pooled percentage of asymptomatic infection to be 15.6%. Another study conducted on Japanese nationals who were evacuated from Wuhan, China, on charter flights reported the asymptomatic proportion among evacuees to be 30.8%; however, the small sample size was mentioned as a study limitation. ¹⁹ Children were reported to often be asymptomatic or have a milder course of COVID-19 in a systematic review ²⁰ ; a meta-analysis revealed that 17.4% of children had asymptomatic infection. ²¹ Our study demonstrated that nearly half (47.8%) of the contactable children with positive test results showed no symptoms. Asymptomatic patients pose a greater threat for virus transmission as they fail to isolate in the absence of symptoms and continue to shed the infectious virus. Widespread and increased testing to identify asymptomatic patients and ensuring that they isolate and follow the infection control protocol is the only strategy that will prove to be effective in limiting this mode of virus transmission. ²² More than half of the baseline cases reported symptoms of mild to moderate intensity. Counseling these patients regarding isolation and self-care helped divert a large volume of patients away from hospitals unless essential.

National statistics reveal that the highest mortality rate occurred in the age ranges of 40–79 years with a predominance of males. ¹⁶ Our data show that the small number of eight patients with severe symptoms who were referred to ED belonged to the 42–70 years age range and were mostly males. Since we were unable to track their progress, we cannot comment on their prognosis. Comorbidities existed in two out of the eight severe cases; however, the number is too small to deduce any conclusions.

We feel that dissemination of evidence-based knowledge allowed patient empowerment and encouraged behavioral change. The pandemic taught us the importance of “preparedness” in the face of challenge. With a bigger organized and trained team, the service could have handled the rising numbers with follow-up calls to ensure continuity of care and proper referral mechanisms for serious or worsening cases. Owing to limited capacity, our focus was positive cases; however, people who had tested negative also needed to be informed of their results. Noncontactable patients (12%) were recognized as a major limitation as this number represented the unaware cases that were possibly contributing to the spread of infection in their communities.

To our knowledge, there are no published data from any developing country capturing clinical and demographic information first-hand from COVID-19 positive cases tested in the communities. By compiling this information, we hope to share our insights with a wider audience (clinical professionals, public health officials, and policy makers) to help develop evidence-based policies and clinical guidelines to effectively tackle the current virus spread or future threats in Pakistan and similar settings. Contributions from studies conducted in other urban and rural communities across the country could prove valuable in informing policy-making, considering the differences in terms of infrastructure and literacy.

Our teleconsultation intervention has opened avenues to explore the scope of proactive telemedicine in resource-constrained settings, in the event of future epidemics. ^10,23 Patient satisfaction and feedback could provide insights on the value of this service.

Conclusion

Pandemics create a sense of uncertainty, panic, and anxiety, fuelled by factual and incorrect information; affectees of the pandemic need reassurance, medical help, and guidance, even if they are mildly or moderately affected. In resource-constrained settings, hospitals are burdened by active critical cases and access to health facilities becomes a greater challenge during pandemics. An organized trained teleconsultation team backed by an M&E team, can satisfactorily inform positive cases in the community of their test results and equip them with knowledge regarding isolation and self-care or provide further guidance based on their clinical condition.