Why Bihar’s Door-to-Door Screening Could Be Underreporting COVID-19 Cases

Patna: The Bihar government’s door-to-door screening campaign for COVID-19 is marred by poor adherence to guidelines about data collection, IndiaSpend found in its investigations across four districts. Health workers conducting the screening are skipping entire households and conducting incomplete, perfunctory interviews, we found. 

Bihar is seeing a sudden increase in COVID-19 cases. On May 1, 2020, the state had 466 positive cases and on May 15, 2020, the number of cases was 1010. The spike in cases is being attributed to the incoming migrant labourers and the state is trying to increase its testing and screening operations.

On April 15, 2020, the Bihar government had started door-to-door screening in four cities--Nalanda, Nawada, Siwan and Begusarai. This exercise was extended across the entire state four days later, Chief Minister Nitish Kumar announced

By May 2, 2020, the state claimed to have completed screening in six of the state’s 38 districts--Siwan, Begusarai, Gaya, Nalanda, Nawada and Sheikhpura. We spoke to people in four districts, Siwan, Patna, Rohtas and East Champaran, to estimate the thoroughness of the screening procedure. 

In Siwan, for example, 516,160 households with 3.1 million people were screened in the 17 days, as per official data. The district has a population of 3.3 million, according to Census 2011. However, IndiaSpend investigations in Siwan found little evidence of extensive testing. There were also complaints that mandatory questions about travel and health history were omitted; and that families were asked questions about their neighbours, who were never visited for screening.

"There are around 100 households in my village but not a single one of these has been screened, including mine," said Pratap Singh, a farmer in Bariarpur village in Pachrukhi block of Siwan district. Another resident of Bariarpur, Bittu Kumar, too denied being screened for the pandemic. "So far no one has visited us for the door-to-door screening," said Kumar, a marginal farmer. 

In Bhojpur district’s Masadh village, Shila Devi, 50, said the health workers only took down the names of the family members. “They did not ask if any of us had a travel history or showed symptoms such as cough and fever,” she said. “They even asked me for details about my extended family in the village but did not visit them.”

Officials we spoke to denied these allegations. The Pachrukhi block development officer, Ismail Ansari, maintained that not a single household was left out in the screening. “We completed the screening of every household in our block about a week ago," he said. 

The official data for Siwan are thorough, said Siwan’s civil surgeon Yaduvansh Kumar Sharma. Of the 49 samples forwarded from the district for testing, 43 tested negative and six suspected cases were sent into quarantine, he said.

State epidemiologist and nodal officer for COVID-19, Ragini Mishra, told IndiaSpend that all protocols are being followed. "Under door-to-door screening, blood samples of those with signs of infection are taken and sent to a testing lab," she said.

The reasons for poor screening practices could be multiple, said experts and health workers. It could be that the workers were not trained enough and told how critical their findings would be in the state’s effort to contain the pandemic. IndiaSpend investigations, detailed later, also found that health workers, many of whom have been sent out into the field without adequate safety gear, cut corners because they feared getting infected.

"Door-to-door screening is crucial and any household that is skipped could turn out to be the cause of community spread,” said Ajay Kumar, senior vice-president, Indian Medical Association (Bihar chapter). 

Bihar has seen a surge in cases in recent weeks. As of May 15, Bihar has had 1,010 COVID-19 cases. Munger district topped at 122 cases followed by Patna (98) and Rohtas (76). 

Our two attempts to reach out to principal secretary (health), Sanjay Kumar, remained unanswered. This copy will be updated as and when we get a response.

‘Didn’t ask for symptoms’

Health workers given the task of door-to door-screening are required to visit every household in an assigned area and seek answers to specific questions related to COVID-19 symptoms--cough, fever, or difficulty in breathing--and every kind of travel undertaken by residents. This is apart from recording basic information about name, age and gender.

Any household reporting travel history is marked with a white chalk and its details are entered in a register that is submitted to the Sadar (district) Hospital. Doctors study these lists and then inform the block in-charge about vulnerable individuals who need to visit the hospital for sample collection. 

However, we heard many complaints that health workers did not ask “proper” questions. "They just noted down names and ages of my family members and asked if anyone in my family came from outside the state or country," said Brahmdev Ram, a marginal farmer, from Sahibganj panchayat in Forbesganj block of Araria district. "They did not ask if my family members have cough, fever or other symptoms." 

In Rohtas, too, residents said that the questioning was incomplete. The district has witnessed a spurt in COVID-19 cases in the last two weeks, after detecting its first case on April 21, 2020. Now the district falls under the red zone with 76 COVID-19 positive cases.

"The sevika [anganwadi worker] came home and asked for the names and ages of my family members,” said Narayan Giri of Varuna village in Rohtas district. “She didn't ask about COVID-19 symptoms or if we had travelled." The health worker questioned him about his neighbours but did not personally visit them, he alleged.

Why the screening is patchy

The health workers included in the screening programme are accredited social health activists (ASHA), Jeevika workers who are part of the state’s livelihood mission, and anganwadi workers. They have been asked to work as per the guidelines issued under Union Ministry of Health and Family Welfare’s ‘Micro Plan for Containing Local Transmission of Coronavirus Disease’.

The health workers on screening duty are supposed to be given sets of two masks--one for themselves and another for those suspected of being infected, as per guidelines. But workers complained that not all of them got masks for themselves and none for those they found to have symptoms.

Without proper equipment, ASHAs are “in fear of getting themselves exposed to coronavirus”, said Chunni Kumari, an ASHA from Kesariya town in East Champaran district in Bihar. "Very few of them have been given masks to distribute to symptomatic individuals," she said. 

Only about 20% of ASHA workers have been given masks and gloves for their safety, said Shashi Yadav, an office-bearer of the Bihar ASHA Workers Sangh. They have not been given infrared thermometer guns to check for fevers, said Shashi Kumari, adding, “So, we only ask people in the survey whether they have any travel history or if they have a cold, cough or shortness of breath."

Return of migrants

The state government has attributed the spike in cases to the thousands of migrant labourers returning home from states such as Tamil Nadu, Delhi, Maharashtra, Gujarat and Karnataka. So far, 416 migrant labourers who returned from other states have been tested positive for the novel coronavirus.

According to the Chief Minister’s Office, until May 11, 2020, 115 trains had brought 137,000 stranded labourers and workers from different states. The state is expecting 427,000 more people by 267 trains in coming days. The 115 trains have come to Bihar from Gujarat, Maharashtra, Haryana, Delhi, Andhra Pradesh, Karnataka, Kerala, Punjab, Rajasthan, Tamil Nadu, Telangana and Uttar Pradesh.  

The number of positive cases in the state quadrupled to 403 from 113 cases in the eight days to April 29, 2020, and the number of districts that reported them doubled to 29, as per a report in Down To Earth, which traced some of this to migrants returning home, a few of them secretly. On April 29, 2020, the Centre had announced that migrants could return home.  

"We have established 2,000-bed capacity quarantine centres in every block,” said epidemiologist Ragini Mishra. “Those migrants who are returning from other states will be screened and put in a quarantine centre for 21 days."

There are over 2.7 million migrant labourers from Bihar stranded in other states, according to a statement by Deputy Chief Minister Sushil Kumar Modi. “Of them, a majority, 500,000 have applied from Delhi alone, followed by 268,000 from Maharashtra, 100,00 from Karnataka, 200,000 from Gujarat and thousands from other states,” he said. On May 2, 2020, the first train arrived at Danapur Station with 1,174 passengers.

"Once they provide details of their travel, a medical team visits them,” said Shailesh Prasad Singh, Muzaffarpur civil surgeon. “Doctors then screen them and the blood samples of those with any symptom will be sent for testing,” he said. “If a person does not show any symptom he/she will have to spend 21 days in quarantine centres. After 21 days, they will be screened again and then sent home.”

Fewer than 1% tested

Bihar’s first COVID-19 testing lab started functioning on March 7, 2020, five weeks after the first case was detected in the country. Currently there are seven testing labs operating in Bihar--four in Patna and one each in Muzaffarpur, Bhagalpur and Darbhanga. 

Chief Minister Nitish Kumar has instructed the state’s health department to increase its testing capacity from about 2,000 samples to 10,000 a day. However, the availability of testing kits will be a hurdle: The Bhagalpur lab, for example, had to stop the testing after conducting just 350 tests for this reason. As of May 15, all testing at this lab stood suspended.

The Rajendra Memorial Research Institute of Medical Sciences, which works under the central government, has the highest number of samples--22,709 by May 15--tested.

As of May 15, 43,371 samples have been tested in all the seven labs, which is 417 tests per million population (the population of Bihar is 104 million as per 2011 census). This is the lowest rate of testing among the 24 states for which testing data were available, an IndiaSpend analysis showed.

The first case of COVID-19 was reported on March 22, 2020, in Bihar, when the state recorded two positive cases, of which a 38-year-old man succumbed to the illness at the All India Institute of Medical Sciences in Patna. By then, three days before the nationwide lockdown was enforced, Bihar had only one testing centre and three sample collection centres. 

It now has three dedicated hospitals for COVID-19 cases, Nalanda Medical College and Hospital in Patna, Magadh Medical College in Gaya and Jawaharlal Nehru Medical College in Bhagalpur with 2,344 isolation beds. As of May 14, 43 COVID-19 patients were admitted in three hospitals while 552 patients were being treated in district-level isolation centres.

Correction: An earlier version erroneously said we travelled through four districts for this story. This has now been updated to say that we spoke to people in four districts. The village Masadh was earlier misspelt. We regret the errors.

(Ray is Patna-based freelance writer and a member of 101Reporters.com)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Patna: The Bihar government’s door-to-door screening campaign for COVID-19 is marred by poor adherence to guidelines about data collection, IndiaSpend found in its investigations across four districts. Health workers conducting the screening are skipping entire households and conducting incomplete, perfunctory interviews, we found. 

Bihar is seeing a sudden increase in COVID-19 cases. On May 1, 2020, the state had 466 positive cases and on May 15, 2020, the number of cases was 1010. The spike in cases is being attributed to the incoming migrant labourers and the state is trying to increase its testing and screening operations.

On April 15, 2020, the Bihar government had started door-to-door screening in four cities--Nalanda, Nawada, Siwan and Begusarai. This exercise was extended across the entire state four days later, Chief Minister Nitish Kumar announced

By May 2, 2020, the state claimed to have completed screening in six of the state’s 38 districts--Siwan, Begusarai, Gaya, Nalanda, Nawada and Sheikhpura. We spoke to people in four districts, Siwan, Patna, Rohtas and East Champaran, to estimate the thoroughness of the screening procedure. 

In Siwan, for example, 516,160 households with 3.1 million people were screened in the 17 days, as per official data. The district has a population of 3.3 million, according to Census 2011. However, IndiaSpend investigations in Siwan found little evidence of extensive testing. There were also complaints that mandatory questions about travel and health history were omitted; and that families were asked questions about their neighbours, who were never visited for screening.

"There are around 100 households in my village but not a single one of these has been screened, including mine," said Pratap Singh, a farmer in Bariarpur village in Pachrukhi block of Siwan district. Another resident of Bariarpur, Bittu Kumar, too denied being screened for the pandemic. "So far no one has visited us for the door-to-door screening," said Kumar, a marginal farmer. 

In Bhojpur district’s Masadh village, Shila Devi, 50, said the health workers only took down the names of the family members. “They did not ask if any of us had a travel history or showed symptoms such as cough and fever,” she said. “They even asked me for details about my extended family in the village but did not visit them.”

Officials we spoke to denied these allegations. The Pachrukhi block development officer, Ismail Ansari, maintained that not a single household was left out in the screening. “We completed the screening of every household in our block about a week ago," he said. 

The official data for Siwan are thorough, said Siwan’s civil surgeon Yaduvansh Kumar Sharma. Of the 49 samples forwarded from the district for testing, 43 tested negative and six suspected cases were sent into quarantine, he said.

State epidemiologist and nodal officer for COVID-19, Ragini Mishra, told IndiaSpend that all protocols are being followed. "Under door-to-door screening, blood samples of those with signs of infection are taken and sent to a testing lab," she said.

The reasons for poor screening practices could be multiple, said experts and health workers. It could be that the workers were not trained enough and told how critical their findings would be in the state’s effort to contain the pandemic. IndiaSpend investigations, detailed later, also found that health workers, many of whom have been sent out into the field without adequate safety gear, cut corners because they feared getting infected.

"Door-to-door screening is crucial and any household that is skipped could turn out to be the cause of community spread,” said Ajay Kumar, senior vice-president, Indian Medical Association (Bihar chapter). 

Bihar has seen a surge in cases in recent weeks. As of May 15, Bihar has had 1,010 COVID-19 cases. Munger district topped at 122 cases followed by Patna (98) and Rohtas (76). 

Our two attempts to reach out to principal secretary (health), Sanjay Kumar, remained unanswered. This copy will be updated as and when we get a response.

‘Didn’t ask for symptoms’

Health workers given the task of door-to door-screening are required to visit every household in an assigned area and seek answers to specific questions related to COVID-19 symptoms--cough, fever, or difficulty in breathing--and every kind of travel undertaken by residents. This is apart from recording basic information about name, age and gender.

Any household reporting travel history is marked with a white chalk and its details are entered in a register that is submitted to the Sadar (district) Hospital. Doctors study these lists and then inform the block in-charge about vulnerable individuals who need to visit the hospital for sample collection. 

However, we heard many complaints that health workers did not ask “proper” questions. "They just noted down names and ages of my family members and asked if anyone in my family came from outside the state or country," said Brahmdev Ram, a marginal farmer, from Sahibganj panchayat in Forbesganj block of Araria district. "They did not ask if my family members have cough, fever or other symptoms." 

In Rohtas, too, residents said that the questioning was incomplete. The district has witnessed a spurt in COVID-19 cases in the last two weeks, after detecting its first case on April 21, 2020. Now the district falls under the red zone with 76 COVID-19 positive cases.

"The sevika [anganwadi worker] came home and asked for the names and ages of my family members,” said Narayan Giri of Varuna village in Rohtas district. “She didn't ask about COVID-19 symptoms or if we had travelled." The health worker questioned him about his neighbours but did not personally visit them, he alleged.

Why the screening is patchy

The health workers included in the screening programme are accredited social health activists (ASHA), Jeevika workers who are part of the state’s livelihood mission, and anganwadi workers. They have been asked to work as per the guidelines issued under Union Ministry of Health and Family Welfare’s ‘Micro Plan for Containing Local Transmission of Coronavirus Disease’.

The health workers on screening duty are supposed to be given sets of two masks--one for themselves and another for those suspected of being infected, as per guidelines. But workers complained that not all of them got masks for themselves and none for those they found to have symptoms.

Without proper equipment, ASHAs are “in fear of getting themselves exposed to coronavirus”, said Chunni Kumari, an ASHA from Kesariya town in East Champaran district in Bihar. "Very few of them have been given masks to distribute to symptomatic individuals," she said. 

Only about 20% of ASHA workers have been given masks and gloves for their safety, said Shashi Yadav, an office-bearer of the Bihar ASHA Workers Sangh. They have not been given infrared thermometer guns to check for fevers, said Shashi Kumari, adding, “So, we only ask people in the survey whether they have any travel history or if they have a cold, cough or shortness of breath."

Return of migrants

The state government has attributed the spike in cases to the thousands of migrant labourers returning home from states such as Tamil Nadu, Delhi, Maharashtra, Gujarat and Karnataka. So far, 416 migrant labourers who returned from other states have been tested positive for the novel coronavirus.

According to the Chief Minister’s Office, until May 11, 2020, 115 trains had brought 137,000 stranded labourers and workers from different states. The state is expecting 427,000 more people by 267 trains in coming days. The 115 trains have come to Bihar from Gujarat, Maharashtra, Haryana, Delhi, Andhra Pradesh, Karnataka, Kerala, Punjab, Rajasthan, Tamil Nadu, Telangana and Uttar Pradesh.  

The number of positive cases in the state quadrupled to 403 from 113 cases in the eight days to April 29, 2020, and the number of districts that reported them doubled to 29, as per a report in Down To Earth, which traced some of this to migrants returning home, a few of them secretly. On April 29, 2020, the Centre had announced that migrants could return home.  

"We have established 2,000-bed capacity quarantine centres in every block,” said epidemiologist Ragini Mishra. “Those migrants who are returning from other states will be screened and put in a quarantine centre for 21 days."

There are over 2.7 million migrant labourers from Bihar stranded in other states, according to a statement by Deputy Chief Minister Sushil Kumar Modi. “Of them, a majority, 500,000 have applied from Delhi alone, followed by 268,000 from Maharashtra, 100,00 from Karnataka, 200,000 from Gujarat and thousands from other states,” he said. On May 2, 2020, the first train arrived at Danapur Station with 1,174 passengers.

"Once they provide details of their travel, a medical team visits them,” said Shailesh Prasad Singh, Muzaffarpur civil surgeon. “Doctors then screen them and the blood samples of those with any symptom will be sent for testing,” he said. “If a person does not show any symptom he/she will have to spend 21 days in quarantine centres. After 21 days, they will be screened again and then sent home.”

Fewer than 1% tested

Bihar’s first COVID-19 testing lab started functioning on March 7, 2020, five weeks after the first case was detected in the country. Currently there are seven testing labs operating in Bihar--four in Patna and one each in Muzaffarpur, Bhagalpur and Darbhanga. 

Chief Minister Nitish Kumar has instructed the state’s health department to increase its testing capacity from about 2,000 samples to 10,000 a day. However, the availability of testing kits will be a hurdle: The Bhagalpur lab, for example, had to stop the testing after conducting just 350 tests for this reason. As of May 15, all testing at this lab stood suspended.

The Rajendra Memorial Research Institute of Medical Sciences, which works under the central government, has the highest number of samples--22,709 by May 15--tested.

As of May 15, 43,371 samples have been tested in all the seven labs, which is 417 tests per million population (the population of Bihar is 104 million as per 2011 census). This is the lowest rate of testing among the 24 states for which testing data were available, an IndiaSpend analysis showed.

The first case of COVID-19 was reported on March 22, 2020, in Bihar, when the state recorded two positive cases, of which a 38-year-old man succumbed to the illness at the All India Institute of Medical Sciences in Patna. By then, three days before the nationwide lockdown was enforced, Bihar had only one testing centre and three sample collection centres. 

It now has three dedicated hospitals for COVID-19 cases, Nalanda Medical College and Hospital in Patna, Magadh Medical College in Gaya and Jawaharlal Nehru Medical College in Bhagalpur with 2,344 isolation beds. As of May 14, 43 COVID-19 patients were admitted in three hospitals while 552 patients were being treated in district-level isolation centres.

Correction: An earlier version erroneously said we travelled through four districts for this story. This has now been updated to say that we spoke to people in four districts. The village Masadh was earlier misspelt. We regret the errors.

(Ray is Patna-based freelance writer and a member of 101Reporters.com)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.