WITH Kerala reporting the second highest number of COVID-19 cases in India since January 2021, the Left Democratic Front (LDF) government, which had until recently won praise for delaying a peak in the number of cases through its meticulous management of the pandemic, is now being criticised by many, especially opposition parties, for going easy on the control measures it had put it place.
During his visit to Kerala on February 21, Uttar Pradesh Chief Minister Yogi Adityanath taunted the Left government “for its failure to control COVID-19”. Inaugurating the Bharatiya Janata Party’s (BJP) campaign for the upcoming Assembly election, he said: “Not long ago, the Kerala Chief Minister made fun of the health sector in Uttar Pradesh. Uttar Pradesh has a population of 24 crore but it has just around 2,000 COVID cases. We have received appreciation from the World Health Organisation [WHO]. Look at Kerala, the whole world is laughing at the State as it has not been able to contain the spread of coronavirus infection.”
Union Minister V. Muraleedharan and opposition leader Ramesh Chennithala, among others, have similarly attacked the government for creating a situation whereby the State has “one of the highest number of active COVID-19 cases in India when, in most other States, the graph is steadily going down.” .
For several months since the first case of SARS-CoV2 was detected in the State in January 2020, Kerala had utilised its earlier experience with the Nipah virus to prepare its people by creating awareness about the importance of wearing masks and following personal hygiene and physical distancing norms and adopted the containment strategy of isolation, contact tracing, testing, and quarantine of infected persons. The enthusiastic involvement of the public, local bodies and the police, apart from the State’s robust public health system, had helped keep the number of cases low for several months. Also read: Is India on the verge of a second COVID wave?
Rajeev Sadanandan, Adviser to the Chief Minister on COVID-19, said: “We had two options. One, let the pandemic roam free, allow a sudden peak in numbers and with herd immunity setting in, wait for the numbers to go down to zero. Or, two, carefully manage the pandemic in such a way that there will only be gradual rise in numbers, which will keep the number of patients below the surge capacity of our hospital systems so that people won’t die, and allow a slow peak, which will have a long tail. There is nothing surprising about the trajectory of the pandemic in Kerala. We knew it will be a delayed peak, and that disease transmission would be slow but prolonged, like it is now. We chose the second option, and that is why we were able to limit the number of COVID-related deaths in the State.”
Surely, the containment measures seem to have lost their initial rigour as the lockdown has been lifted and people have started taking the pandemic in their stride. But COVID-19 managers maintain that Kerala’s handling of the pandemic should not be judged by the number of daily cases alone, and that other factors, such as the number of hospitalisations, deaths, persons under surveillance, testing rates, COVID-19 care facilities, management structures and patient care and response, should also be taken into account.
A rise in the number of cases began to be reported from the third week of September, just after the Onam festival season. The highest number of cases was reported in October. On October 10, Kerala had 11,755 confirmed cases and 95,918 active cases. An increase in the number of cases was noticed after the Christmas-New Year season in January-February, and thereafter, there has been a decline. “Only on one occasion, briefly during these 14 months, did we feel like the pandemic could challenge the State’s health system. But we have come past the peak and am not worried about the future, with the kind of positive response to vaccine acceptance that we are seeing in the State,” Rajeev Sadanandan said.
The total number of confirmed cases reported in the State until March 1, 2021, when vaccines were being rolled out for the general public, was 10,61,341. Of these, the number of active cases on that day was 47,868 (only 4.51 per cent of the total) with 682 of them treated in intensive care units and 204 put on ventilator support. The remaining 10,08,972 infected persons (95.01 per cent of the total) had recovered. The State reported 4,210 COVID deaths until March 1.
Significantly, the gap between the confirmed and recovered cases has continued to remain constant. The surge in the number of cases was only for short intervals and this did not overwhelm COVID care facilities.
Health Minister K.K. Shaialajah said: “Kerala observed a delayed peak in COVID-19 spread in October 2020, we had the maximum cases in October, some 12,000 people. But later, unlike what was predicted, the number of cases did not increase very much. It went down, reached a plateau. It is a peculiarity of Kerala’s experience that we could control the cases from becoming too large,”. Also read: Kerala moves aggressively to curb the pandemic
She stated that according to a sero-surveillance study by the Indian Council of Medical Research (ICMR), the rate of COVID transmission in Kerala was 11.6 per cent while the national average was 30 per cent. “This is an indication that we could contain the spread effectively. So, over 88 per cent of the people in Kerala have remained un-infected. I must say that this is a very good, relief-giving result. The results are also good on the matter of detection rates,” she said.
The ICMR Serological Surveillance Survey was done in Kerala after the peak transmission period in October last year. Among other things, it found that Kerala’s sero-prevalence as of December was half that of the national average; the proportion of unidentified cases in Kerala was lower than the national average; that a huge proportion of its citizens were still susceptible to COVID-19, ironically because of the good containment measures adopted by the State; and that Kerala would continue to have new cases unlike other places where a good proportion of people had already been infected.
At a press conference in Thiruvananthapuram on February 25, Chief Minister Pinarayi Vijayan quoted experts as saying that many States were close to the next COVID-19 wave, and that in the previous week there was a 31 per cent increase in the number of patients in India. “The rate of spread has increased in 16 States, of which five have shown an increase of over 10 per cent. In Kerala, however, we are seeing a gradual decrease in the number of COVID-19 patients,” he said.
Lowest COVID mortality rate
According to the Health Minister, Kerala’s gains are best illustrated by the low number of deaths. “The COVID-19 mortality rate in Kerala is 0.4 per cent, the lowest in the world. People ask, have all deaths been reported? We try to understand it by doing an ‘excess death analysis’ —by looking at the ‘all-cause mortality’ during the pandemic, we will understand the impact of the pandemic. Some prominent foreign universities have conducted excess death analysis in 77 countries, and a disturbing picture has emerged. In 51 countries, deaths increased substantially than in the previous years. In Peru, there was a 72 per cent increase in the number of deaths in 2020 than in 2019. In the United States., it was 11 per cent, in the United Kingdom it was 13 per cent, in France it was 8 per cent, and so on. Excess deaths had come down only in six countries. The figures for India are unavailable. Kerala’s performance stands out.” Also read: Kerala CM on increase in cases
In the context of Karnataka placing restrictions on the entry of people from Kerala in view of the high number of cases here, the Chief Minister said: “This act has no justification. There was a time when Karnataka used to report over 150 deaths and over 10,000 active cases. It meant that nearly three crore people would have had COVID-19. Kerala has not had even one-tenth of those infections among its people. We also have to take into account the better reporting system in Kerala. In Karnataka, when 30 people get infected, only one case is reported. In Kerala, one out of three cases of infection is reported. The impression that the number of cases is higher in Kerala than in other States arose because Kerala is determining more cases, more efficiently. But many people are trying to tarnish Kerala by hiding the fact that Kerala is the State with the least number of COVID-19 deaths, a State that tracks infections efficiently and gives its patients the best of treatment and care. But nothing can hide the experience of the people of Kerala.”
Report on testing strategy
In recent months, Kerala has been facing criticism for its over-reliance on antigen tests, instead of on the more sensitive RT-PCR tests, which critics said had led to an increase in the number of cases in later months. But a technical paper on COVID-19 testing strategy published by the State Department of Health and Family Welfare, has refuted this claim and says that antigen tests have good potential in determining contagious individuals. To quote: “After collection, PCR samples typically require transport to a centralised lab staffed by experts, which drives up costs, drives down frequency of testing, and can delay results by one or more days. This can delay rapid isolation of individuals who are actually infectious. Testing regimen using rapid antigen tests that can be performed at the periphery and give results within 30 minutes is more sensitive than testing based on PCR techniques for containing the transmission.”
The paper pointed out that the testing strategy of the State recommended rapid antigen tests at the periphery for individuals with influenza-like illnesses and asymptomatic people in clusters and RT-PCR-based tests for individuals with definite contact history and severe acute respiratory illness, symptomatic travellers, health care workers and before a surgical procedure. It, however, noted that symptomatic individuals who tested rapid antigen negative should necessarily undergo RT-PCR tests.
The report said the key question is not how well molecules could be detected in a single sample but how effectively infections could be detected in a population by a given test as part of an overall testing strategy—and that the sensitivity of the testing regimen was more important than the sensitivity of individual tests. “For an effective COVID filter that will stop this pandemic, we need tests that can enable regimens that will capture most infections while they are still infectious. Unwarranted use of RT-PCR as a routine test will detect people who are non-infectious and add unnecessary burden to the people and system,” it said. Also read: COVID-19 and the danger of complacency
“Infection does not happen because antigen tests are done or not done. RT-PCR test are done or not. Infections happen because people are complacent to the need for absolute follow up of COVID appropriate behaviour,” the report cautioned.
Kerala has now launched a “Back to the Basics” campaign, insisting that people strictly follow the norms of wearing masks, maintaining physical distance and using sanitisers. It calls for minimising social interactions and a change in the mode of social interactions. And, importantly, it exhorts health functionaries to “ensure that the screen, test, isolate, contact trace, quarantine, symptom surveillance, hospitalisation, treatment and care and post-COVID care continuum” is followed.