Alistair’s unexpected brush with Covid-19
As at end June 2020, around 25 people in Nillumbik had been confirmed cases of Covid-19. Our very own Alistair Inglis was one of those 25 and he has kindly written up his experience for us. There are two versions of his article: a summary version, immediately below; and a full/long version, which is below the summary version.
The introduction of a compulsory 14-day self-isolation period for Australians returning from overseas was not something I was anticipating as I prepared to return from a two-week visit to India in March. As it was, I arrived back in Melbourne on the second day after this came into effect. It was frustrating but, as the number of cases in India was still low, I saw it as merely a formality.
I arrived in Melbourne on Tuesday, 17th March. On the following Friday, I woke up coughing during the night. I knew that one of the symptoms of Covid-19 was a dry cough. However, I didn’t seem to have any other symptoms. The cough persisted over Saturday and Sunday but was not as bad. I began thinking that I should get some expert advice. So on Sunday afternoon I phoned the Coronavirus Helpline. I spoke to a trained nurse who took my details and then recommended that I consult with my doctor no later than the next morning.
The next morning my doctor told me that because of my cough, the fact that I had recently returned from overseas, and my age, I was eligible to be tested and that I should be. That afternoon he took swabs to send away for testing. Two days later, he phoned to tell me the result was positive. He said that he would notify the authorities and that I would shortly receive a call for contact tracing. In the meantime, everyone else in the house needed to go into in self-isolation.
A member of the Contact Tracing Team phoned the next morning. She talked me through my movements over the previous 14 days — where I had stayed, what flights I had used, what seats I had occupied, how I had travelled home from the airport, and how I had been self-isolating. At the end of the interview, she said that I would be followed up by a member of the Coronavirus Existing Cases within a couple of days.
I never received that call. My original self-isolation period was due to end on 31st March so I decided that I would call the Existing Cases Team on that date to ask how I was to get out of self-isolation. By the time I called, the Team was using the time from onset of symptoms as the basis for release and, as I first showed symptoms shortly after arriving back in Melbourne, I already met the 10-day criterion. I was told that I could be released immediately and that I would be sent a letter to confirm this.
My case was very mild. However, the outcome could easily have been different. Most cases of Covid-19 apparently start out as I did. However, a proportion of the cases then become more serious and a patient may be hospitalised, then be moved into intensive care, then be put onto a ventilator. Many of those who are put onto a ventilator do not survive.
So, what can I say about what potentially could have been a fatal encounter with Covid-19? As far as I know, it has not left any physical 'scars'; nor has the experience made much difference to my life., beyond that which everybody has been experiencing. I wasn’t even required to self-isolate any longer than I needed to by virtue of returning from overseas. What I have taken from my experience is a new appreciation of the health risks of travel. I went to India knowing that the virus was starting to spread through Asia, but believing that I knew enough to keep myself safe. I knew about the importance of social distancing and tried to practise it wherever I went. However, what I had not taken into account was that sometimes, when travelling, we can find ourselves in situations where social distancing is just not possible, and in those situations we may be at much greater risk than we would ever believe possible.
Full version – my encounter with coronavirus after a short trip to India
Looking back, it may seem rather rash to have taken a trip to India just as the coronavirus pandemic was getting going. After all, India is a country of around 1.4 billion people with a not very well developed health system. However, back in February India didn’t look like anywhere near as scary a place to visit as it looks today. India did have cases of Covid-19 but only a couple and they were in the South of India. There were no cases in Rajasthan, which was where I was going to be travelling. I booked the trip — with Intrepid — back in November. At the time, the coronavirus was only known in Wuhan and then only as some sort of new infectious disease that seemed to be spreading in the wet markets there.
Shortly after I booked the tour, I booked return flights to Delhi. I had been debating whether to fly with Malaysia Airlines or Southern China Airlines but by the time it came to make the booking the cheap fares that Malaysia Airlines had been offering had ended, so I chose China Southern. I have flown with this airline before and found it to be quite good. The flights would involve transits through Guangzhou each way and because the transits would be long the airline was going to provide complementary hotel accommodation but this would be away from the airport.
Guangzhou is quite a distance from Wuhan but by late January the virus was spreading in China. As the departure date for the trip approached, my concern wasn’t about travelling to India but with my flights. I began to wish that I had booked with Malaysia Airlines before their fares rose. As I was mulling over what to do, I received an email from China Southern notifying me that one of my flights had been cancelled. It said that I could either accept a different flight or cancel all my flights and obtain a full refund. I realised that this was my opportunity to avoid transiting through China.
Over the years, I had accumulated a lot of frequent flyer points with QANTAS and, out of curiosity, I checked whether it would be possible to reach Delhi by using my frequent flyer points. To my surprise, I found that there were a number of flights in both the forward and return directions with One World partner airlines. In the forward direction, there were flights with Japan Airlines and, in the return direction, with a combination of Sri Lankan Airlines and QANTAS. I decided to cancel my China Southern flights and book these alternative flights.
This change was made only a couple of weeks before my scheduled departure date, which was in the last week of February. If you remember back to that time, the coronavirus was by this time spreading through Hubei province in China but the WHO was still trying to decide whether to declare it a pandemic. The first case in India was identified in Kerala on 30th January. Two more cases were diagnosed shortly afterwards — also in Kerala. All three cases were students who had returned from Wuhan. However, no further cases were reported in India in February. A week before my departure date, I phoned Intrepid to check that there were no alterations to the trip arrangements. They confirmed that their India trips were operating normally and that there had been no cancellations for the departure on which I was booked.
Joining the tour
I arrived in Delhi in the evening before the day that my tour started. The usual practice on an Intrepid tour is for a meeting of tour members to be held at 6 pm on Day 1 to introduce tour group members, review the itinerary, confirm travel insurance and other details, and discuss any other issues that members of the group may have.
One of the issues that I have encountered on small group tours is the spread of respiratory infections within tour groups. A member will join the tour with an active respiratory infection — usually a cold — and by the end of the tour more than half the tour members will have been infected. On one tour a member had to leave the tour before the end because of complications of a cold that had been passed on to them in this way. Coronavirus represented a much greater risk than a cold. So, I decided to make a say something about the importance of infection control at the end of the introductory meeting. I spoke about my experience of travelling on other small group tours and said that respiratory infections would not circulate through tour groups if some very basic infection control measures were taken, especially keeping one’s distance from other members on the first day after becoming infected. I finished up by saying that, although my comments primarily concerned with the risk of transmitting colds and flu, the coronavirus outbreak had been spreading through China and that if it got going in India it could spread so quickly that we could be at real risk of catching the virus before our trip was over. I didn’t realise how prophetic my words would prove to be.
The tour itself turned out to be everything that I had hoped for and more. It went like clockwork. The weather was balmy; our travel was uneventful; our local guides were extremely informative; and, as well as the must-see highlights such as the Taj Mahal and Jaipur’s Amber Fort, we saw parts of Rajasthan that few tourists see. One of the highlights was having a free day in Udaipur for the Holi festival, India’s colour festival, when people go around sprinkling everyone with coloured powder.
As we moved around Rajasthan, we started to feel that the coronavirus was creeping up on us. We hadn’t been travelling many days when reports started to appear in the newspapers of Italian tourists falling ill and being diagnosed with coronavirus. A woman fell ill and her husband continued on with their tour — and then also fell ill. He had visited the Taj Mahal only two or three days after we had been there. Each day the number of Italian tourists being diagnosed with coronavirus was increasing. Every day we would follow the spread of the coronavirus in the newspapers. The Indian government was acting quickly to stop the spread. It instituted testing and immediately isolated the cases that were found. Within a few days it cancelled the visas of Italian tourists and required all Italian tourists to return to Delhi and report to their Embassy. Although the virus was circulating, we didn’t feel that we were greatly at risk — and the numbers were still low.
Meanwhile it became apparent that my warning to other members of the tour group about risk of spreading infection within the group had fallen on deaf ears. Someone who was present at the introductory meeting was infectious with a cold but said nothing. Within a few days the cold was spreading through the group. It wasn’t until it had been passed on three or four times that a person caught it who took my caution to heart and broke the chain of infection. It was fortunate that it was a common cold and not coronavirus that had been brought into the group. By the end of the tour, I was the only member of the tour who had neither caught the circulating cold nor come down with diarrhoea.
I had arranged to stay on in Delhi for two more nights at the end of the tour This would be the second occasion I had spent time in Delhi. On a previous trip, I had three days in Delhi. On that trip I had found Delhi to be a really fascinating city to explore. It was relatively easy to get around and the mass of humanity, the traffic and the pollution were much less confronting than I had been expecting. By booking two additional nights I had three days for sightseeing because my flight departed in the middle of the night. There were more than enough places that I had yet to see to fill the time.
When I arrived back in Delhi at the end of this tour, the number of people wearing masks had noticeably increased since I passed through the city at the start of the tour. People wearing masks were still very much a minority but no longer a rarity. What also was noticeable was the absence of foreign tourists. The number of arrivals had fallen right away as the virus had spread.
My time in Delhi was as enjoyable as my earlier stay had been. Having already learnt how to navigate the Metro system and having previously familiarised myself with the layout of the city I was able to get to most of the places I had wanted to see. What I hadn’t been expecting was that, during this time, the Australian government would declare a 14-day self-isolation period for Australians returning from overseas. My two-night stay in Delhi was going to result in my having to go into self-isolation immediately upon my return to Melbourne.
Returning to Melbourne
I flew out of Delhi just after midnight on Monday, 16th March. Indira Gandhi International Airport was still thronged with people arriving and leaving but it was not as busy as I had previously seen it. What I was not to know was that only a week later the Indian borders would be closed.
As a result of relying on frequent flyer points, my trip home had three legs. The first leg was to Colombo. The flight was just under four hours long and arrived just after 4 am. I had been to Sri Lanka only two years previously and was familiar with the terminal but I didn’t know what it would be like during the pandemic. As we exited the plane there was a line of officials in gowns and masks and, as I entered the aerobridge, I was pulled out of the line and asked where I was going. I explained that I was in transit to Singapore. I was asked for my passport and my ticket. They were satisfied and let me go.
The layover in Colombo was to be eight hours. I had a transit visa which would have allowed me to leave the airport but, given the circumstances, I decided to remain in the terminal. The airport authorities had set up a thermal imaging camera in the main concourse of the terminal and everyone walking down the concourse was required to be scanned. Most of this time was spent sitting in the concourse watching the flow of passengers and reading the news on my iPod Touch.
The second leg was to Singapore. This was another short flight — again, just under four hours. However, the transit through Changi Airport was only two hours. As anyone who has transited through Changi knows, the airport is huge. The arrival and departure lounges were in different terminals and almost a third of the transit time was spent getting from one to the other. Unlike the situation at Colombo Airport, there was no evidence of any special precautions even though the coronavirus was already spreading in Singapore.
The flight back to Melbourne was on an Airbus A380 which seemed to be only half full. I was pleased to discover that I would have a row of three seats to myself. This meant that, as well as not being in close contact with someone else in the row, I could also keep away from the passageway and minimise the risk of catching the virus from someone moving up or down the plane.
I arrived back in Melbourne at 6 am on Tuesday, 17th March and headed straight home. Upon arriving home I went immediately into self-isolation. I was happy to conform to the requirement, but considered it to be simply a precaution. At that stage I believed that I had successfully avoided the virus and just needed to wait out the self-isolation period.
At around 2am on Friday morning I woke coughing. I don’t have a chronic cough. However, after a cold, I often develop bronchitis. I hadn’t had a cold, though, so this was unusual. My thoughts turned to the possibility that I had caught the coronavirus. I knew what the symptoms were and began to check whether I had any of them. Did I have a runny nose? No. Did I have a temperature? No. Did I have shortness of breath? It didn’t seem so. I began wondering whether I had had a sub-clinical instance of the cold that had circulated amongst the members of the tour group and this was now the bronchitis that usually follows a cold in my case. Eventually, I drifted back to sleep.
In the morning, I still had a cough but it wasn’t quite as bad as it had been during the night. I did nothing about the cough on the Friday but on the weekend a friend emailed me the link to the Australian Government coronavirus web page which gave the number of the National Coronavirus Helpline. On Sunday afternoon, I decided to phone the Helpline and ask for information on the specific symptoms for which I should be watching out. The people who were staffing the Helpline were, at least then, not medically trained. Their function was just to dispense the standard information. However, the person to whom I spoke suggested that he switch me through to another helpline that was staffed by trained nurses. I agreed. The next person I spoke to asked me for detailed information about where I had been, what my symptoms were, and how long I had been back in Australia. She took my name and contact details. She then said that her advice was to contact my doctor, or, if my doctor was not available, to after hours clinic — within the next two to four hours. I wasn’t expecting such advice. I said that my doctor would not be on duty but that, given the mildness of my symptoms, would it not be safe to speak to my doctor the first thing the next day. She said that if my symptoms didn’t get worse that would be OK, but that if I started experiencing any shortness of breathe I should call an ambulance immediately.
Getting tested for Covid-19
I called my doctor at 9am the next morning and told him about my conversation. He said that, as I had recently returned from overseas and was in the high risk category because of my age, I was eligible to be tested and that I should be tested. He said that the clinic had test kits and that I could be tested there. However, he asked me not to come into the clinic but to remain in the car in the car park and phone to say that I was there. He said that he would come out to the car park to take the sample. Later that day, I had two swab samples taken. The experience was as intrusive as others have said, but at least it was quick. I was told that it would take time for test results to come back and that I might not receive the result until the end of the week.
Late on Wednesday afternoon, I received a call from my doctor. He went straight to the point: “The result of the test has come back — and it’s positive“. By this time I had become convinced that I didn’t have Covid-19. I still didn’t have a fever; I didn’t have a sore throat; and even the cough was beginning to subside. So, I certainly wasn’t expecting this result. My doctor went on to say: “What this means is that everyone else in the house now has to go into self-isolation“. He indicated that he would notify the Victorian Department of Health that I had tested positive and that I could expect to receive a call from the contact tracing team the next day.
Sharp at 9am the next morning I received the call from a member of the contact tracing team. For the next three-quarters of an hour, I was quizzed on my day-to-day movements over the past fortnight — what flights I had taken, what seats I had occupied on the flights, how I had come home and what I had done since arriving home. At the end, the contact tracer told me that member of the Existing Cases Team would contact me sometime in the next two days to find out how I was progressing.
Several days passed and I received no follow-up. My cough persisted but I still had no other symptoms. I emailed the other members of the tour group to find out whether any of them had caught the virus. None said they had. Eventually my doctor phoned to find out what had happened. I explained that I had been interviewed by a contact tracer and had been told that I would receive a follow-up call but that no call had come. I said that I was beginning to wonder how I was supposed to get released from self-isolation. He said that if I wasn’t contacted within the next five days to call him and he would follow up.
Gaining release from self-isolation
The following Tuesday was the day that I would originally have been due to leave the self-isolation I had entered as a result of returning from overseas. I had decided that I would phone the Existing Cases Team, if I had not heard from them beforehand, to find out what the process was to obtain release from self-isolation. The person to whom I spoke when I called apologised for the fact that I had not been followed up. He took my details and said that someone would call me back. The call came a few minutes later. The person calling apologised the fact that I had not been followed up, explaining that they had been very busy. She then asked me whether I had any fever or shortness of breath. I replied that I had never experienced these symptoms and that my only symptoms had been a persistent cough and, briefly, diarrhoea. She said that in that case she could release me immediately. She said that, as I had not had a fever or shortness of breath, the criterion that they were using was that at least ten days had passed since the first onset of symptoms and I already met that criterion. She said that she would send me a letter to confirm that I had been released. I asked about the others in my home who had been in compulsory self-isolation. She said that, if we had been practising social distancing, they could be released also but that they would need to obtain confirmation separately.
Being released so easily came as a big surprise to me. I had expected that I would need to be retested. However, the procedure for release from self-isolation was being revised as the understanding of Covid-19 was increasing and the length of time for which people remained infectious became better understood.
So where was it likely that I caught the virus?
It is only normal when one contracts a serious infectious disease like Covid-19 to begin to wonder when and from whom one has caught it. To work out the source of an infectious disease, one has to know what the incubation period is. From knowledge of the incubation period and the date of first onset of symptoms one can work out when one is likely to have been infected. Knowing the incubation period is particularly important when one has been travelling because a difference of twenty-four hours can correspond to a difference of hundreds of kilometres in terms of location. Back in March there was not much authoritative information on Covid-19. Media reports at this time seemed to indicate that the incubation period for Covid-19 could be around two weeks. That would have put the time of infection mid-way through my tour. I emailed the other members of my tour group to find out whether any of them had caught the virus. None said they had. That made it unlikely that I had caught the virus during the tour. We had been travelling in minibuses and cars and therefore were in close contact in circumstances where a virus as infectious as the coronavirus would be passed on very easily.
When a new virus is discovered, research reports describing the characteristics of the virus begin to appear in the scientific literature fairly quickly. It is possible to peruse such reports if one knows where to look for them. I devoted some of the considerable spare time I had during my self-isolation to finding out what was being published on the subject. Amongst the reports, I found was a review paper that had been published by a group of doctors and medical researchers that covered what had been discovered about the disease from the first 450 or so cases diagnosed in Wuhan. One of the pieces of information it contained was that the average incubation period for these cases was just over five days. Counting back from when I first showed symptoms and allowing for the timezone difference, a five day incubation period put the most likely time of infection as the day after the tour ended — Saturday, 14th March. I thought back over what I had done on that Saturday and with whom I might have been in close contact. By close contact what is normally meant is being within 1.5 metres of a person for at least 15 minutes. While one will often come within 1.5 metres of people throughout a day, being in close contact for at least 15 minutes happens relatively infrequently unless one is with a person one knows. In Delhi, after the tour ended, I was on my own. Moreover, because I was aware of the importance of social distancing, I had been consciously trying to keep my distance from those around me. However, there were two occasions when my efforts in to keep clear of other people were thwarted. Both instances were on Saturday and both involved security guards.
I spent the whole of that Saturday visiting a number of historic sites. Late in the afternoon, I went to a park that contains a large number of ancient monuments of which one of the most historic is a step well. A step well is a well that has steps down to the level of the water table and which was originally built to enable water to be collected for domestic use. I visited the park especially to see the step well. The step well is surrounded by buildings and there were people walking around on the roofs of these buildings but I couldn’t see how they had got up there. Just as I was about to leave, I noticed that the security guard had gone up onto the roof, and then, as I was watching, he came down. So I decided to return to the step well and climb up onto the upper level. No sooner had I climbed to the upper level than the security guard returned to the upper level also. He seemed interested in me and a few minutes later approached me and started to talk about the step well. After a few minutes I realised that why he was trying to be an unofficial guide was so that he could demand a tip, which he did.
After leaving Mehrauli Archeological Park. I walked back to the nearest Metro Station. On my way I passed another ancient monument, a historic mosque. I went in and as soon as I entered the grounds a security guard came up to me and, like the first security guard, insisted on acting as an unofficial guide — with the same intention. Thinking back to these encounters I realised that any other foreigners who visited these sites would also have been seen as potential sources of additional income and that if such a tourist had Covid-19 would have been quite likely to have passed on the in virus. A few days the security guard would have become infectious and in turn would have started to infect other tourists. I think that that is quite likely how I picked up the virus.
I could think of only one other possible source. At the end of our tour we took a seven hour train ride back to Delhi. We had assigned seats on the train but we were not all seated together. As it happened I was seated next to a young Italian woman who was returning to Delhi as the Indian government had directed. This woman was away of the part that Italian tourists had played in spreading the virus in Rajasthan, but told me that she couldn’t have brought the virus from Italy because she had been away from Italy for more than two months. However, between leaving Italy and arriving in India she had spent time in Thailand and the virus was circulating in Thailand at that time. However, she wasn’t displaying symptoms and to have been the source I would needed to have been incubating the virus for longer. This would still be within the range for incubation periods but is not as likely. So while this person was a possible source I feel that the two security guards were more likely candidates.
What I learned from my experience
I count myself very fortunate that mine was only a mild case Covid-19. From my reading, it seems that mine was a mild example of a mild case. Even mild cases often display symptoms of fever, headache and extreme tiredness. What I didn’t know when I tested positive was that even those who end up on ventilators, or dying, the start off with symptoms that are initially quite mild. It is usually only after a week or so that the infected person’s condition may begin to deteriorate if they are going to become a serious case. The disease progresses in stages. As it progresses one may need first to be hospitalised, then to go into intensive care, then to be ventilated. A significant proportion of those who need to be ventilated do not survive.
So, what did I learn about what potentially could have been a fatal encounter with Covid-19? As far as I know, my encounter has not left any physical “scars” and it didn’t have a dramatic impact on my life. I wasn’t even required to self-isolate any longer than I needed to by virtue of having returned from overseas. The most important point I have taken from my experience is a new appreciation of the health risks of travel. I went to India knowing that the virus was beginning to spread throughout Asia, but believing that I knew enough to keep myself safe. I knew about the importance of social distancing and I tried to practise social distancing wherever I went. Doing so kept me from catching the cold that circulated within the tour group. However, what I had not taken into account was that, when we travel, there can be times when our circumstances are beyond our control and in those situations the risks we run may be much greater than we may have ever have believed possible.