In Kerala’s Alappuzha, automated calls add power to Covid-19 response

Vishnu Varma
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The call, lasting less than a minute, would inform them at the outset that it is part of the government’s disease surveillance system and that they had to listen till the end.

In early February, when a medical student who returned from Wuhan in China tested positive for novel coronavirus in Kerala’s Alappuzha, health officials in the district scrambled to contain the infection. As per protocol, the student’s primary and secondary contacts were immediately identified and subjected to home quarantine. For the next few days, a control cell was opened at the collectorate where the district surveillance officer placed daily phone calls to those under quarantine and checked up on their symptoms.

“There were hardly around 200 people who had to be put under isolation in homes. So it was easy for us to call them regularly,” recalled Dr Sharath Chandra Bose, the chief of the Covid-19 control cell.

But in the next few weeks, as the second wave of Covid-19 infection swept through Alappuzha and the rest of Kerala mostly in the form of expatriate returnees from Europe and the Gulf, the health machinery was suddenly hard-pressed for hands on the deck. In a matter of days, the number of people under home quarantine rose exponentially, from 200 to nearly 6000.

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“Even when we deputed 10 to 20 people to make phone calls to those under quarantine, 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,” he said.

It was at this juncture that the district authorities led by collector M Anjana began pondering about exploring technology to optimise the surveillance data and thus reach a larger section of the quarantined population. That's how they connected with Billion Lives, a Kochi-based technology firm who in turn familiarised them about a product they had devised with the help of interactive voice response (IVR) system which is supported by Centre for Digital Financial Inclusion (CDFI). Both teams got in touch and after a few days of hectic deliberations and coding and programming, they came to a solution that was uniquely designed for Alappuzha.

The technology is simple. 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 questions they had to answer. The call, lasting less than a minute, would inform them at the outset that it is part of the government’s disease surveillance system and that they had to listen till the end. The questions would then 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.

The IVR data from such calls is then processed through an analytical tool and finally reflected on a dashboard where the symptoms, or the lack of it, 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 in near real-time by viewing the dashboard and making informed choices.

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“The IVR system helps us in identifying the symptomatic among the quarantined, isolate them and test them as soon as possible. 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,” said Dr Bose.

“The IVR dashboard is one of the best I have 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.”

Before it’s replication in the Alappuzha control room, the IVR technology was first experimented by the team of Billion Lives in the northeastern state of Meghalaya. Unlike in Kerala, where concrete data exists on those under home quarantine, the Meghalaya authorities, though not as affected by the outbreak by other states, wanted those entering and leaving the state to be tracked at check-points.

“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. Here, we’re using a technology called progressive web app. Anything that a mobile app can do, this technology can do too. 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,” said John Santosh, founder-director of Billion Lives who’s currently based in Bengaluru.

Santosh, who graduated from Palakkad Engineering College and has a career ranging from banking to tech solutions, has offered the IVR system free-of-cost for health officials in Alappuzha and Wayanad, where it began implementation two days ago. Word-of-mouth has led to calls from other districts too.

“Dr Sharath was talking about publicising it, but I wanted to see the results first. After all, this is an experiment,” he added.

In Meghalaya, the IVR system was restricted to tracking people, but when it came to being replicated in Alappuzha, the district health department wanted a few tweaks and modifications such as the categorisation of symptoms and the IVR line to be opened up for inbound calls as well. After all, in a state like Kerala, where the public health system is robust and deep-rooted, technology must be ideally amended to suit the community’s needs.

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“There were initial problems. The biggest one was that since the calls were automated, many weren’t picking up. So we identified those who weren’t picking up and pushed repeated calls in a space of two hours. That worked. There was also the problem of people pressing the wrong entry. 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,” Dr Bose told the Indian Express.

It’s been three weeks since Alappuzha has been using the technology and it certainly seems to have paid off. Quarantine compliance and monitoring has been sharp. At present, only three persons are under treatment for Covid-19 in the district, a sharp contrast to the northernmost district of Kasaragod, where 132 persons have tested positive. And that’s where, Dr Bose feels, a system like the IVR can unveil its true potential to health officials. Kasaragod is a designated hotspot in the country where the threat of community transmission looms large. A massive pool of over 10,000 people are under home isolation.

"There’s not a better tool than this to pick up on people with Covid-19 symptoms in hotspots. In cities like Mumbai and Bengaluru, the response would be so much better as they know how automated calls work. 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.”