Kerala: Worrisome clusters

The rapid spread of community clusters and the steady rise in cases of infection are putting Kerala’s public health system under pressure.

Health workers collect swab samples from corporation employees in Kozhikode on July 21.

There were ample warnings, but few in Kerala seem to have thought that a peak in COVID-19 cases was coming. Now, as infections from fast-spreading COVID-19 clusters begin to rise alarmingly, the State is wondering whether this is the beginning of the peak.

The rapid spread of COVID-19 clusters is unsettling for a State that has so far had an exemplary record in the management of the pandemic. Clearly, the nature of the challenge has changed, not just in terms of the number of people getting infected every day, but also in the way it is threatening to overwhelm the State’s decentralised public health system, which is among the best in the country.

The assurance of quality health care for every COVID-19 patient and quarantined person, a promise on which the State was able to deliver in the first five months of the pandemic, suddenly appeared a bit uncertain. Instead, concerns about a possible shortage of hospital beds, respirators, intensive care units (ICU), doctors, nurses and other health workers are already dominating official discussions.

However, in response to some media reports which suggested that “Kerala’s COVID success story” has already come “undone”, Chief Minister Pinarayi Vijayan said: “The fight against COVID-19 is not like a 100-metre or 200-metre dash that you can win at a stretch. This, like a marathon race, is a long haul. What is being tested is our endurance, not just that of the health system, but of society in general and the people as a whole. Our patience and endurance are being tested. Each of us needs to have this awareness. Only then can we run the race till the end, without falling down.”

Kerala had received world attention for limiting the number of cases to just over 5,000 and deaths to 27 in the first five months. But from the second week of July the State saw a sudden spurt in COVID-19 clusters everywhere.

As on July 21, Kerala recorded 13,994 confirmed cases, 8,056 active cases, and 44 deaths. The capital district of Thiruvananthapuram had the highest number of active cases at 2,179, and the highest number of deaths, nine. The daily caseload rose steadily from 435 on July 12 to 821 on July 19, which was the highest single-day rise till then.

The steady increase in COVID cases with unknown sources of infection was evident by the end of June. But the majority of the cases reported at the time were of people who had travelled from other parts of India or abroad. (More than 6.62 lakh people, including 2.3 lakh from abroad, have returned to Kerala so far.) The number of people who had contracted the disease locally was minimal then.

From the first week of July, more than 200 new cases began to be reported every day. Within a fortnight, there were more than 700 new cases a day. This spike in numbers occurred in small and large COVID-19 clusters. As on July 21, there were 101 clusters with 18 of them classified as “large community clusters”. The origin of many of the clusters could be traced invariably to ‘super-spread’ locations, such as fish and vegetable markets, densely populated coastal villages, entrance examination centres, hyper markets, bus depots, police camps and stations, and invariably, a chain of hospitals across the State.

Paradoxically, on July 17, Kerala also became the first State to announce the community transmission of COVID, in the coastal areas of Poonthura and Pulluvila in Thiruvananthapuram district. Both areas had a common super-spread trigger: a whole-sale fish market on the highway to the city.

Although the two areas were shut down completely, the number of infections kept rising there. The infection spread rapidly along the coast and into the urban and suburban regions of Thiruvananthapuram. Within two days, Thiruvananthapuram had 2,179 active cases, followed by the districts of Ernakulam 792, Alappuzha 665, Malappuram 596, Kollam 499 and Pathanamthitta 454.

Clusters have now been reported in almost all the districts along the coast and in inland areas. The most worrisome clusters are in Kollam, Cherthala, Kayamkulam, Changanassery, Pathanamthitta, Adoor, Kumbazha, Chellanam (a locked-down area facing the additional threat of sea erosion), Keezhanaum, Aluva, a Border Security Force camp in Thrissur, and Pattambi.

Many areas of the State are on lockdown and despite the cluster containment/management strategy unrolled by the government, local transmission cases have been rising steadily, making it difficult to identify all infected individuals and their contacts.

In Pattambi, a wholesale fish merchant was found to have spread the infection to over 100 people, a case described as the “most dreadful” by Minister A.K. Balan. Nearly 90 employees of a hypermarket in Thiruvananthapuram were found to be infected, even as the store, like another one nearby, continued to function normally without adhering to precautionary measures.

Kerala’s biggest worry, however, is elsewhere. By July 21, as many as 136 health care workers in various government and private hospitals tested positive; a large number of them were working in non-COVID wards/hospitals. This led to the closure of several hospitals or wards. The functioning of three major tertiary care COVID hospitals, the medical college hospitals in Thiruvananthapuram, Ernakulam and Kozhikode, were also affected, with patients or health care workers infecting a sizable number of hospital staff, forcing them to go into quarantine.

An important concern raised by the Indian Medical Association’s (IMA) State unit representatives was whether the ongoing number of tests was sufficient to understand the real nature of the spread and to take informed decisions. The Chief Minister said Kerala was way ahead of other States in this regard. He said: “For one positive case we are conducting 44 tests. In comparison, it is five in Maharashtra, seven in Delhi, 11 in Tamil Nadu, 17 in Karnataka, and 11 in Gujarat. Those who say that Kerala is lagging in this matter are merely looking at the number of tests. That is not the scientific way. What is important is how many tests are being conducted in proportion to the number of positive cases.”

As the number of cases kept rising, Kerala launched its First Line Treatment Centres (FLTCs) under the local bodies, with a proposed total bed capacity of 50,000, to treat asymptomatic patients and those with mild symptoms. The government is also roping in private hospitals for COVID care. The treatment costs and modalities are being finalised.

In the long term, in order to provide treatment to the critically ill without straining the capacity of hospitals, the government may suggest home isolation for asymptomatic patients.

Government doctors, nurses and health care workers say that their biggest concern now is the rising rate of infection among their colleagues, inadequate staff strength, system fatigue and stress and exhaustion from overwork. They have raised several demands, the important ones being recruitment of more trained doctors and health care workers and better remuneration to the new recruits. They say that even if only a small percentage of the new cases require critical care, it may still be large enough to overwhelm the existing hospital facilities.

The Chief Minister, however, said that there was no need for concern that hospitals would be overloaded or that the facilities would be inadequate.

Making predictions about how the pandemic will progress can be hazardous. If in early July the concern was about those who were returning in large numbers to the State, today it is about local transmission. As the government slogan says, “vigil has the value of life”.