Kerala: Fear over the cities

As ‘triple lockdowns’ and community quarantine increase in Kerala, the question is on whether the State is finally seeing community transmission.

The Kerala State Secretariat locked following the ‘triple lockdown’ in Thiruvananthapuram on July 6.

More than 200 COVID-19 positive cases every day—that is the new normal in Kerala.

The State has so far managed to keep the caseload low, delay the spread of infection and keep the pressure on health facilities down. It reported just over 5,000 cases and 27 deaths in the five months since the first COVID case came to light in the last week of January. But a rising trend has been evident in recent weeks. On July 7, for instance, the State saw 272 new cases, the highest for a day until then.

Cases of local transmission of COVID-19 are increasing steadily. Hotspots are mushrooming where it is no longer possible to identify all infectious individuals and their contacts. Community-wide containment measures are being announced everywhere.

All of a sudden, by the first week of July, there were over 100 positive cases in which the source of infection could not be traced immediately. Such cases are being reported from all districts, and is notably high in Malappuram, Thiruvananthapuram, Ernakulam and Kannur districts.

The State government is warning people to be “extremely vigilant” if things are not to go “out of hand”. But it maintains that there is no evidence of community transmission, yet.

A grave situation seems to be developing in cities that have huge floating populations and daily commuters and in congested “rural-urban” areas where a large number of people go to cities for work or business and where the concentration of expatriates who have come back from various parts of the world is high.

Triple lockdown in the capital

The worsening scene in the capital city, Thiruvananthapuram, was brought into focus on July 5 by the Minister in charge of the district, Kadakampally Surendran, who described it as “a city sitting atop a volcano”. Days ahead of that, several wards in the Corporation area had been declared as “containment zones”, as clusters of people turning COVID positive began to be reported one after the other.

On July 5, as many as 27 positive cases were reported in the city, of which 22 were through local transmission. Two days later, when the city reported 54 new cases, 47 of them were those involving local transmission. It was the first time that the city was reporting transmission of cases beyond family members, number of local transmission cases exceeding the number of imported cases, an increase in containment zones and local clusters, and “super-spreading events”—those involving people who routinely engaged with the general public turning positive and transmitting the infection to many “contacts”.

Soon the situation turned so bad that the government put Thiruvananthapuram under “triple lockdown”, a fancy term to indicate major restriction of movement of people in the entire district, within specific localities, and inside homes. The State Secretariat was shut down. The Chief Minister announced that he would be working from home during the week-long lockdown.

The situation in Kochi, the business capital of the State, and Kannur, a burgeoning but congested urban centre, was no different. In Malappuram, another red spot, several panchayats within the coastal taluk of Ponnani were put under “triple lockdown” for a week until July 6.

The restrictions were announced after tests conducted as part of a sentinel surveillance effort found 10 persons, including two doctors and three nurses of two private, non-COVID hospitals, testing positive for COVID-19. Both hospitals were closed for a while, a measure that invited some criticism later, but the lists of contacts of the two doctors who were asymptomatic throughout were quite long.

An area of concern for the authorities is the string of coastal villages in the State, where the density of population is one of the highest in India. The number of cases reported in a single day (July 6) from Poonthura, a coastal village near Thiruvananthapuram, was 26. The next day over 60 samples tested positive there, a lot of them of people who also had visited a nearby market, closer to the heart of the city.

Another worry was the rise in number of “super-spreading” events in crowded urban centres that saw movement of people to and from other places as part of their official, business or medical needs.

From the last week of June, several such cases of vendors in markets, food delivery boys, wholesale cigarette sellers, provision store owners/employees, fish sellers, personnel on security duty (even before the Secretariat), paramilitary personnel, medical representatives and health workers had been identified as the nucleus of small and large clusters. The contacts’ list at times ran into hundreds.

Areas where these clusters had formed were routinely isolated, widespread tests conducted, and surrounding areas put under surveillance. But fresh clusters were forming in many nearby places.

Community transmission?

The State unit of the Indian Medical Association (IMA) has for some time been saying that community transmission is already a reality in Kerala and that the government must acknowledge it. IMA representatives say that the increase in the number of cases with no known source of infection, patients with no symptoms, health workers in non-COVID hospitals turning positive, and transmission of cases being reported in places such as markets are all worrying signs that Kerala need to take into account urgently.

To support its argument, the organisation has also pointed out instances of people who have returned to the State with no symptoms turning positive later on; of health workers who have had no contact with COVID patients testing positive; of Keralites who left the State testing positive in other States (a proposition challenged by the State Health Department through a study).

Chief Minister Pinarayi Vijayan said: “Even though there is need for heightened vigil, we need to understand that so far in only 2 per cent of the cases does the source of infection remain unknown, while the all-India average is around 40 per cent. However, if we do not bring the situation under control immediately, it will surely lead to a situation of community transmission. That is why we have announced lockdowns in many places even before it reached a point of community spread.”

Meanwhile, the State government has made regulations under the Kerala Epidemic Diseases Ordinance 2020 applicable in cases involving violation of containment guidelines; making wearing of face masks and social distancing norms mandatory for a year; and prohibiting mass gatherings and spitting in public places. Violators will have to pay a fine of up to Rs.10,000 and/or undergo a jail term of up to two years.

With the State experiencing a shortage of manpower to fight COVID, the government announced that its offices would work with only 50 per cent staff and the rest would be reserved to fight the pandemic, for instance, in first line COVID treatment centres and quarantine centres.

As the number of locally transmitted cases rise, the rate of secondary and tertiary transmission is of grave concern. So are the increasing instances of infection among medical workers, shortage of testing kits, and delay in publishing test results that leads to delayed containment of infected people. An important issue the IMA and others have raised is the need to increase the number of tests done in the State.

As instances of triple lockdowns and community quarantine increase, the focus surely is on whether the State is finally seeing wide community transmission and how much is the virus spreading undetected. Meanwhile, the severe economic impact of the pandemic and repeated lockdowns on the people remain submerged, at least for now.