The story so far: Plaudits won by Kerala for stamping out the COVID-19 pandemic appeared premature when in early July, a superspreader event in the densely-populated coastal villages of Poonthura , Manikyavilakam and Puthenpally (on the outskirts of Thiruvananthapuram city) led to a spike in infections through local transmission. Very soon, the cluster grew over a fairly large population and similar clusters mushroomed in Chellanam and Aluva in Ernakulam . Daily cases of local transmission exceeded imported infections within a week. An alarming 81% of the cases reported on July 24 were through local spread of the virus. The total number of cases leapt from 6,166 on July 8 to 16,995 on July 24 , with 9,371 active infections. There were 453 containment zones, triggering discussions about a potential Statewide shutdown, but the suggestion was put on hold almost unanimously at an all-party meeting chaired by Kerala Chief Minister Pinarayi Vijayan.
Was Kerala’s early success a fluke?
India’s first COVID-19 case was detected in Kerala on January 30, when a medical student from Wuhan in China tested positive in Thrissur. The State’s health apparatus had stayed alert with customised containment guidelines and protocols and the first wave ended with the recovery of all three imported cases. A middle-aged couple returning from Italy gave the surveillance team at the airport the slip, causing another bout of infections. More instances of quarantine violations came to the fore as the number of cases grew to 499, 33% of which was on account of local spread.
Data | COVID-19 resurges in Kerala as migrants return, testing rate drops
However, the State leveraged its epidemic management skills gleaned from two Nipah outbreaks , the ingenious technology-driven use of ‘contact-tracing’ using spatiotemporal data, social capital and decentralised governance to tether the daily figures to zero all over again in the first week of May. On May 4, just 16 patients (3.5% of the total cases) were under treatment in hospitals. Deft planning and execution and enthusiastic people’s participation ensured the success of the ‘break-the-chain’ of the coronavirus campaign, the community kitchen initiative to feed the needy, psycho-social counselling to alleviate stress and rationing of essentials. People lapped up the government’s socio-economic interventions during this period.
Spirits were still high and the government began to open up sectors on priority in a phased manner from mid-May with the twin aim of reviving economic activity and to ease the burden on the labour class, farmers and the self-employed.
Was the third wave entirely unexpected?
When the Centre was contemplating repatriation missions from abroad, the pandemic had straddled the continents. Kerala, which has a large population of overseas Indians, wanted tests to be conducted at the port of origin so that travellers who were suspected to have contracted the infection could be segregated and ferried separately. When that did not happen, passenger handling policy at Kerala’s airports was revised with the aim of multi-layer screening to isolate people with symptoms and shift them to designated COVID-19 hospitals, which were already up and running.
Also read | 70% of new Kerala cases due to local spread
The local bodies were tasked with readying institutional quarantine centres for the returnees, a policy which made way, in the wake of an influx of people starting from May 7, and with hiccups in the arrangement, to ‘paid quarantine’ for those who could afford it and home quarantine for all others except those with no home isolation facility. The State has so far received 6,03,199 people in the post-lockdown repatriation exercise. It became a vexing political question when the government insisted that everyone desirous of entering the State mandatorily register themselves on the COVID-19 Jagratha portal and get passes.
A prescient warning had been sounded by the experts’ panel advising the State on corona containment strategy; the planning wing had presented projections and the State braced itself for a surge in cases. In fact, extreme shortage of testing material — swab, medium and kit — in May-end and early June determined the way the State modulated its strategy. “We chose to test only those likely to have been infected and used the kits sparingly. Meanwhile, sentinel surveillance among the high-risk sections like health workers and the police was kick-started to detect social spread,” said a top official.
A bouquet of tests — RT-PCR (reverse transcription-polymerase chain reaction), antigen, antibody, TrueNat, CBNAAT (cartridge-based nucleic acid amplification test) and the like — was introduced to monitor trends even as a decision was taken to test everyone with influenza-like illness (ILI).
What went wrong?
As more relaxations kicked in and with the ‘success stories’ inducing a degree of complacency and false sense of safety in people, several chose to throw caution to the winds, violating social distancing and quarantine norms with alacrity. Unannounced entry of people through the porous borders of Thiruvananthapuram, Wayanad and Kannur made tracking difficult. Ceremonies such as marriages, with hundreds in attendance, were held against stipulations leading to spread of the infection.
By the end of June, sentinel surveillance indicated a wide cluster of infections in Ponnani taluk in Malappuram following which a lockdown, of the kind earlier successfully experimented with in Kasaragod, was clamped in the taluk. Meanwhile, infections with no known source of origin emerged, prompting the government to admit community transmission in the coastal pockets of Thiruvananthapuram.
Also read | COVID-19 threatens to engulf Kerala’s coastal belt
Misleading campaigns and the fear of another imminent lockdown upsetting their livelihoods turned the people restive in critical containment zones such as Poonthura until they were reassured and the government announced relief measures. That a good number of the new patients were asymptomatic required the health officials to convince them that they were indeed sick and could infect others.
How serious is the situation?
Kerala’s vulnerability to the pandemic is compounded by its ageing but active population, a high degree of comorbidities in its people, and population density. Despite spiralling cases of community transmission, it has been able to maintain a cumulative test positivity rate of 2.6%. Says Rijo M. John, health economist, “But the cause for concern is the current positivity rate of 4.6%, which although much better than the national average of 11.7%, calls for doubling the rate of testing. It’s also ominous that cases are now doubling in 10 to 11 days whereas nationally it’s 18 to 20 days. That apart, case fatality at 0.32% is among the best.”
The State has been able to augment its testing by adding over 80 testing centres, with 25 RT-PCR stations. The rate of testing has steadily increased through July to cross 25,000 in a 24-hour cycle on July 24. The Kerala Medical Services Corporation has stockpiled adequate number of testing material for 30 days, and “the tests will be further ramped up in containment zones”, according to Dr. Mohammed Asheel, part of the State’s COVID-19 taskforce.
A doctor spearheading a major component of the battle against COVID-19 said the public health-care staff in Kerala are on the verge of exhaustion, having been on their toes since January. “There’s definitely a shortage of skilled human resources on the medical and non-medical fronts and this issue was flagged a few months ago, with the government making stand-in arrangements.” A COVID Brigade comprising trained medical professionals, skilled citizens and volunteers will be pressed into service at the COVID First-line Treatment Centres (CFLTCs) being set up by the local bodies.
“A total of 69,800 beds are getting ready at CFLTCs by the third week of July for treatment of asymptomatic patients,” Dr. Asheel said. The Chief Minister said a pool of 30,000 employees to man the CFLTCs have been selected and assigned to respective districts. “An additional 50,000 have been identified.”
Also read | Shortage of staff, funds at COVID First-line Treatment Centres
Have the tables turned in favour of COVID-19?
The Kerala government still believes it has a fighting chance. “The immediate aim is to prevent deaths,” says a senior official, “and to ensure that the health system doesn’t breach its capacity threshold”. While the CFTLCs, which have already begun functioning, will ease the burden on the tertiary COVID hospitals, the State could consider asking asymptomatic patients, about 60% of the total, to stay at home, with some mechanism to monitor them in case the daily infection tally crosses 2,000, which is not unlikely by early-August. Over the past few months, the State has added more ventilators and ICUs in the public sector, but it must be noted that 60% of the State’s major health-care facilities are in the private sector. The government has held talks with some 1,129 of them about pricing and some 200 of them would be making their services available at the CFLTCs, says the Chief Minister.
