Kerala is in the news, but for bad reasons. The COVID-19 caseload is increasing. The test positivity rate (TPR) and the cumulative death count show no respite. The cumulative deaths due to the virus as on August 24 in the State is only 19,757, compared to its neighbours — Tamil Nadu (34,761) and Karnataka (37,184). But, when adjusted for the total population, deaths per million is high in Kerala. Increased attention to vaccination coverage, and inadequate home quarantine and isolation measures may be the reasons.
Kerala’s rising COVID-19 cases explained
All these indicators are in spite of its excellent case containment measures and its low case fatality rate (CFR) during the first wave in 2020 through its strong public health system and community-involved disease surveillance measures. The methods adopted by Kerala are globally well-established pandemic control measures and as per the guidelines of the Indian Council of Medical Research (ICMR) and the Union government. The State should boldly assert this and ignore Opposition parties making it an opportunity for political mileage. Blind criticism by outsiders should not fog these facts.
Up to the third ICMR sero-survey in February 2021, Kerala did exemplary case containment by protecting 88% of its citizens from COVID-19. Seroprevalence was only 11.6% compared to the national figure of 21.5%. This became 10.76% after a wider sero-survey done by the State government in Kerala in March 2021, which covered all 14 districts and had around 12,000 samples. A similar survey in Tamil Nadu showed a seroprevalence of 67% for the State, with a seroprevalence of 82% in Chennai.
The fourth round of the ICMR sero-survey, which covered three districts in Kerala, revealed that the State had a seroprevalence of 42% compared to the national level of 67%.
The State is going through a surge due to the mutant Delta variant and the “don’t care” attitude of the public. COVID-appropriate behaviour and vaccination are key to containing the pandemic. The State must hold on to aggressive testing, genomic mapping, monitoring the TPR and the CFR for new infections, and conducting sero-surveys for assessing past infections or community transmission. It should continue uploading the data daily and holding briefings weekly, if not daily, by the Chief Minister and the Health Minister for better transparency.
The State also has to admit certain policy errors, including loosening their guard during the Assembly election and festivals.
Alter testing strategy
Kerala’s testing strategy is more dependent on the Rapid Antigen Test (RAT), which comprises 60% of the testing, than the Reverse Transcription-Polymerase Chain Reaction (RT-PCR) test. This was a critical observation made by a team sent by the Union government. This has to be so because the capacity for RT-PCR testing is only 75,000 per day in the State and 1,65,273 samples were tested on August 25 itself. But, if a RAT is negative, the mandatory RT-PCR test for confirmation is not strictly followed. Moreover, a number of false negatives escape the net. Most of the RT-PCR testing is done for certification to resume duty and for travel purposes rather than case detection.
Ground Zero | The complex story of rising COVID-19 cases in Kerala
An ideal scenario would be to strictly stop RATs like in Tamil Nadu. In this case, the State would need to rope in more testing centres with adequate equipment for RT-PCR testing. Capacity-building of these new labs in the private or government sector is an urgent requirement. Authorities may also request the neighbouring States to lend their lab equipment on a returnable basis.
The time has come for the fire brigade to pay equal attention to saving lives and minimising casualties, while also dousing the fire. The State has to carefully divide the staff and resources for both contact tracing, testing and vaccination.
Vaccination is gaining momentum after the initial supply concerns were sorted out. Kerala has achieved around 75% coverage of the first dose of the vaccine and 28% coverage of both doses. This vaccination spree did have a deleterious effect in case detection and containment.
What is needed now is to entrust the vaccination responsibility to the Junior Public Health Nurses (JPHNs), health supervisors and staff nurses, and a few doctors. Accredited social health activists (ASHAs), field supervisors, Rapid Response Teams and doctors should focus on screening symptomatic patients, sample collection, contact tracing and active surveillance. Telephonic follow-ups practised during the first wave is disappearing. With vaccination getting all the attention, ignoring contact tracing is not wise.
Though the State had issued home isolation guidelines, it is not effectively followed. Persons found positive for COVID-19 were compulsorily shifted to First-Line Treatment Centres in all the districts last year. This prevented further spread of the virus in a family or a neighbourhood. Later, institutional quarantine was replaced with home quarantine, which caused an abnormal spike among contacts within a family.
A television channel highlighted the shocking 444 home-level deaths and 1,795 deaths during shifting or soon after arrival to a hospital among domiciliary care patients. The complications were recognised too late among those positive in home quarantine, as the scheduled visits of the health staff to domiciliary care centres and remote monitoring had weakened.
It is also high time to revert to institutional instead of domiciliary quarantine and the doubtfully-effective lockdowns and night curfews. A surge may happen soon with mutant variants overwhelming the health system. Mobilising extra intensive care unit (ICU) and COVID-19 hospital staff, and putting them on a “reserve list” is necessary.
Having a floating assembly of equipment like ventilators and oxygen cylinders, which can be moved to any hospital in any district within 24 hours, should also be prepared. Skill upgradation and honing case management efficiency in COVID-19 hospitals and district headquarter hospitals must also continue. Liquified medical oxygen production units and carriers should also be ready.
Israel is facing a surge in cases and scientists there have found a new sublineage of the Delta variant known as the AY.12 lineage. For now, what is happening in Kerala and not happening in Bihar and Uttar Pradesh are epidemiological mysteries. We may get the answers someday.
Dr. K.R. Antony is a paediatrician, public health consultant and independent monitor, National Health Mission
