Kerala

On edge, but holding out

Print edition : June 19, 2020

People from the Maldives undergo temperature tests as they come out of the navy ship INS Jalashwa at Cochin Port on May 10. Photo: PTI

Kerala witnesses a surge in COVID cases after a large number of Keralites return from abroad and other States, but the government, which has taken adequate measures to contain the disease, allays fears of community transmission.

SCHOOLS and colleges “reopened” online in Kerala on June 1, coinciding with heavy monsoon rains, even as concerns were growing about the recent trend of high number of COVID cases being reported daily in the State.

On May 24 the Left Democratic Front (LDF) government completed a credible four years in office, but it did not hold any celebrations. The State registered 772 positive cases in May, the highest for a month since the first case in India, a student who returned from Wuhan in China, was reported in Kerala on January 30.

Data released by the government indicate a surge in the number of cases after May 18, when the fourth phase of the lockdown began. In the last 10 days of May, for example, more than 40 cases were reported each day, with the highest single day count being 85 on May 28. As of June 2, the State reported a total of 1,412 cases and 11 deaths.

In all over 210 Keralites died of coronavirus infection abroad, mainly in the Gulf region. Casualties were reported from other States as well. “We are literally going through a miserable period, when the families of those who die in other places are not even able to see the bodies of their near ones,” Chief Minister Pinarayi Vijayan said on June 1.

There has been an increase in the number of COVID-related deaths within the State too, as restrictions are eased and more people have started returning from hotspot regions. The Chief Minister, however, reassured the people that there was no cause for alarm. “The aged and those with serious illnesses have been given priority for travelling back to the State. They come with the disease and some of them have died because of the seriousness of comorbidities as well. It has led to an increase in the death rate. As the number of such vulnerable people returning to Kerala comes down, there will be a reduction in the death rate also,” he said.

The increase in positive cases was also expected with the easing of lockdown restrictions and the return of a large number of Keralites to the State. Although the government says that so far there is no sign of community transmission, doubts have been raised in the media. Some experts have indicated that community transmission cannot be ruled out as several isolated cases have been detected with no known source of infection.

In May, a number of frontline workers too contracted the disease. Doctors and nurses, police personnel and prison staff, among others, were forced to go into quarantine because they came in contact with those who later tested positive. A housewife, who had not stepped out of her home, died of COVID recently. It was found that 11 of her relatives had contracted the disease. A man who was admitted to hospital with an injury after a jackfruit fell on his head tested positive. A pregnant woman tested positive while in hospital. A prisoner, who was in hiding, and his jail mate tested positive, and those with whom they came in contact have been forced to go into quarantine. Two bike accident victims being treated for injuries turned out to be COVID-positive.

In view of the increase in the number of cases, with at least 30 of them with no known sources of infection, the expert committee appointed by the State government suggested ramping up tests.

At his press conference on May 28, Pinaryi Vijayan said: “The majority of positive cases are those who came from other parts of India or from abroad. The number of people who got the disease through contacts is still minimal. What Kerala needs to be careful about now is to make sure that it does not spread from those who have come in with the infection to other people in the State. That is why we are increasing the number of tests.”

He said the tests were being conducted on all people that need to be tested as per Indian Council of Medical Research (ICMR) guidelines. Kerala’s test positivity rate (TPR) is 1.7 per cent. The all-India rate is 5 per cent. The State’s case fatality rate (CFR) is 0.5 per cent.

(TPR indicates the proportion of positive cases among the total number of tests conducted. A higher test positivity rate indicates faster spread of infection. CFR, a measure of disease severity, is the proportion of deaths compared to the total number of people diagnosed with a disease.)

Until June 1, 68,979 samples were sent for testing, of which 65,273 returned negative and 1,326 tested positive. The results of 2,380 samples were awaited. In terms of the number of tests conducted, Kerala has shown a lot of improvement, with 2,335 tests per million people. One positive case is found for every 71 tests. The all-India average was one case for every 23 tests, the Chief Minister said.

In all 1,33,249 Keralites (1,16,775 from other States and 16,474 from abroad) had returned to the State until May 28 after the State reopened its borders. Of these, 73,421 people had arrived from red zones. On May 8, hundred days after it reported the first case, Kerala declared that it had “flattened the COVID curve”. The number of active cases was just 16 then. On June 2, at the time of filing this report, the total number of cases was 1,412.

Of the 86 new cases reported on June 2, 72 were of those who returned to the State. Twelve got the disease through contacts, a trend that was seen in the previous week as well. In the last week of May, the trend was as follows: on May 24, five people got the disease through contacts/unknown sources out of 53 new cases; on May 25, it was six out of 49; on May 26, seven out of 67; on May 27, three out of 40; on May 28, one out of 85; on May 29, five out of 62; on May 30, 10 out of 58 (seven of them Air India staff members); and on May 31, four out of 61. That is, 41 of the 452 new cases had contracted the disease through contacts in the last week of May. The other positive cases had all come from outside the State.

Results of 4,400 naso/oropharyngeal samples in four sentinel surveillance studies conducted in the State found only four positive cases (0.09 per cent). The report of the Health Department study concluded that “there is no evidence for community transmission in the State”.

Samples for the study were collected from non-COVID-19 suspect cases from selected villages in the 14 districts and tests were done using reverse transcription-polymerase chain reaction (RT-PCR) method. The samples were collected from those with acute respiratory infection (but not a COVID suspect); health care workers not involved in COVID-19 treatment; people with high social exposure (including police personnel, community volunteers, food delivery staff and migrant workers); and COVID-19 suspects with mild symptoms). For every positive case found, 25 epidemiological samples were tested from the neighbourhood for two successive weeks.

“In the sentinel surveillance (pooled) conducted among returnee non-resident Keralites, 29 were found positive. It is on the basis of these figures that we say that so far there has been no community spread in Kerala,” the Chief Minister said.

Twenty-eight health workers, including those involved in patient care, and public health workers, were infected through direct contact with COVID patients.

The Chief Minister said that this was a sign that surveillance and testing were taking place properly, that suitable guidelines had been provided and the health system was running efficiently, that the disease was being detected even in people who showed no symptoms, and those who had come in contact with them were being put in quarantine. “Kerala’s case is quite different from that of other States. The basis of our achievement is our advanced public health system, efficient contact tracing and scientific quarantine method.”

But he also said that if there was an increase in the spread through contacts, the current restrictions might prove inadequate.

Spike in Kannur, Palakkad

In May, Kannur and Palakkad districts reported the maximum number of COVID cases in Kerala. The average number of people getting the disease through contacts was more in Kannur, 20 per cent as against the State average of 10 per cent. Of the 93 active cases in Kannur as on May 28, 19 were through contacts. (As on June 2, there were 146 positive cases in Palakkad, 113 in Kannur and 98 in Kasaragod.) The Chief Minister said the government was thinking of introducing more restrictions, including, if needed, triple lockdown, in many such places.

But with the forecast of a severe monsoon season ahead, the State authorities have warned of a possible spike in contagious diseases such as dengue, leptospirosis and H1N1, with fever as the main symptom, as is the case of COVID, making detection difficult for doctors. It is likely to increase the workload and pressure on doctors and other Health Department personnel, who already have their hands full with the increase in the number of cases in the State.

The government is preparing an action programme to rope in the services of private hospitals for treatment of non-COVID diseases. The State also plans to enlarge telemedicine facility, phone/online consultation. There are also plans to start mobile clinics at the local level with the cooperation of the private sector. It has also launched a performance assessment drive for non-COVID disease management in all government health facilities.

As of June 2, Kerala has 1,47,010 people under surveillance and in quarantine, of whom 1,340 are in institutional quarantine and the rest are under surveillance at home.

The State has 1,31,606 hospital beds, 7,428 ICU beds and 2,623 ventilators. By the end of May there were 1,264 COVID patients or those showing mild symptoms in government hospitals.

The 1,296 government hospitals in Kerala have 49,702 beds, 1,369 ICU beds and 1,045 ventilators. In all, 12,191 isolation beds are ready in government hospitals. The government has also established 851 corona care centres. In addition, the 866 private hospitals in the State have 81,904 beds, 6,059 ICU beds and 1,578 ventilators.

Every day several cases of people disregarding COVID containment norms and violating quarantine regulations imposed on those coming in from abroad or other States are being reported. Kerala complained to the Centre when the Railways continued to send in trains from various parts of the country, with passengers violating State guidelines.

All those coming from outside the State, by any mode of transport, are required to register themselves in the government’s online portal and apply for an entry pass before travelling to the State. The government said this was to ensure that sufficient arrangements were made for quarantine or hospital facilities for those entering the State, so that they do not pose a threat to those in the State.

But, despite the Chief Minister’s assurances, the major worry in the State is whether, with such blatant flouting of regulations and the opening up of the economy and restoration of transport facilities, the threat of community transmission can be kept at bay for long, if indeed it has not already happened.

Five elements in strategy

Perhaps answering these concerns, the Chief Minister gave a lengthy explanation at his June 1 press conference.

Pointing out that the basic reproduction number (or BRN, which indicates the number of new cases that could be infected by one positive case in a population and shows how readily an infection is spreading within a community) is 0.45 in Kerala, while the world average is three, he said very few countries could achieve such a feat. Kerala had a system in place to prevent the transmission of the disease even as the first positive case came to the State from Wuhan.

He said Kerala’s strategy had five elements: trace, quarantine, test, isolate and treat. In most parts of the world where the disease had spread, they had avoided the first two elements of tracing and quarantining. They gave importance only to testing and treatment. They could not, therefore, control the spread of the disease. Kerala could control the transmission of the disease to a large extent because of the strategy it adopted. Kerala’s biggest strength is its decentralised public health system.

People should consider what would have been the case otherwise, he said. The serial interval of COVID 19, that is the time taken for its spread from one person to another, is five days on an average. If we assume a BRN of three (the world average) for Kerala, the State would have had about 25,000 positive cases in about two weeks. If we take the average death rate as 1 per cent, the number of deaths in Kerala would have been over 250.

“But we know that is not what happened in Kerala. The reason is that we could effectively implement tracing and quarantining which were necessary to curb transmission of the disease. This is how we prevented a big hazard. Therefore, we have to go ahead by strengthening home quarantine and contact tracing in the coming days,” he said.

The Chief Minister said the 30 positive cases whose origin remains unknown could not be considered as a sign that social transmission was taking place. “However much we try, an individual may not remember all the persons whom he had come in contact with in the two weeks before he tested positive. So some persons may not be linked to his route map. If such a person gets the disease, we will indeed have to say that there is no epidemiological link. But we cannot ascertain it as a sign of social transmission either. So, as a next stage, we have to check whether there are more such instances and conduct tests on more people in that locality. We have examined and ensured that no such cluster of cases without an epidemiological link, that is cases where we don’t know where they got the infection from, has been found in any particular locality in Kerala.”

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