The southern state of Kerala is seeing a rapid rise in COVID-19 cases. Barring August 3 when the state reported 13,984 cases, the state has been reporting over 20,000 cases for the past week. Kerala's cases represent close to 45 per cent of the daily cases being reported in India leading to questions on why Kerala has failed to control the pandemic.
As the state is normally the highest ranked when it comes to lifestyle index as well as tackling health outbreaks, be it Nipah or Zika, the inability of the state to control the COVID-19 pandemic in the second wave has surprised many people. The first three cases of COVID-19 that were reported in India on January 30, 2020 were from Kerala.
Although other states such as Maharashtra, Tamil Nadu, Karnataka, Delhi, started reporting a higher number of cases across both the waves, their case count has decreased. Kerala's increasing cases continue to worry the Ministry of Health and Family Welfare who sent an expert committee to monitor the situation.
Public health experts are of the opinion that Kerala has had several hits but equally many misses. The state's sero-positivity, case fatality rate, targeted testing, and proportion of vaccination are some of its hits. Relaxation of lockdown restrictions, high test positivity rates, and following only home isolation have been its misses.
BOOM contacted Dr. Chandrakant Lahariya, public health expert, and Dr. T Jacob John, virologist to understand the trajectory of cases in the southern state. Both of them agreed that the Delta variant of SARS-CoV-2 is causing the trajectory across the state.
The Hits- Where Kerala Did Well
"To understand if a territory is doing well to control the pandemic, the focus is on three things- what has been done so far to contain the spread of the virus, the number of those actually infected and reported, and long-term containment strategy. Kerala has done well on all three measures," Lahariya said to BOOM. These three measures are expressed by the sero-positivity, mortality and case fatality rate, not having a higher number of undetected cases, and vaccination proportion.
Only 44.9% of the state's population was found to have COVID-19 antibodies in the fourth sero-survey. This fourth round conducted by the Indian Council of Medical Education found that one in three were still susceptible to the virus. A lower sero-positivity here showcases that the infection did not spread rampantly in the population and that the virus was limited to clusters. A larger population although susceptible has never been exposed to the virus due to the state's strategies.
Lahariya and John believe that the state has contained the infection well if an estimated 55 per cent of the state's 3 crore population has still not been exposed to the virus.
Moving on to vaccination, the state has managed to fully vaccinate 20% of its people and 38% - including 70% of people over 45 years - have received a single dose of the vaccine, which is above the national average. This proportion of vaccination, John notes, is even though the state was allocated lesser vaccines by the Centre.
"Why did Kerala receive a lesser number of doses? In comparison to other states, could the disaster management official not have transferred doses to the state?" John asks.
According to the Ministry, as per an answer in the Rajya Sabha, as of July 25, Kerala had received only 1,81,94,310 COVID-19 vaccine doses, lesser in comparison to the other states. In the daily state-wise COVID-19 vaccine administration maintained by the MOHFW, the state had given over 1.84 crore to its residents till July 25. During the early months of vaccination, the Kerala government was using left-over vaccines to vaccinate its residents and had negative vaccine wastage. Even the private players gave close to 30 lakh doses.
John's concern warrants questioning the vaccine allocation as the neighbouring states of Karnataka and Tamil Nadu with a lesser COVID-19 burden, received over 2.98 crore and 2.15 crore vaccination dosages in the same period.
Kerala's COVID-19 performance has also been compared to other North Indian states which are reporting less than hundred cases daily. But while during the peak of the second wave, social media was filled with complaints of shortage of oxygen and hospital beds, there were not many complaints from patients or their relatives in Kerala. Even now, when the state is reporting higher cases, there have been no social media outrage of shortage of oxygen or hospital beds across the state.
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"Nobody feels that the state has underreported cases or deaths. Its case fatality rate is below 0.5 per cent. Can other states claim this statistic? We see reports of underreporting being highlighted in every state," added John. The country's case fatality rate- deaths per total cases, India's CFR rate stands at 1.34 per cent.
Lahariya concurs to the finding that Kerala has performed better in detecting and reporting cases when compared to other states. In a crude analysis, by his own admission, using the sero-survey proportions and using the census 2021 population estimates, Lahariya calculated an estimate of cases that were missed and not accounted for.
According to his analysis, Lahariya found that for each positive case, Kerala missed only 6 other positive cases, but states like UP, Madhya Pradesh, and Jharkhand have missed 98, 83, and 63 for every positive case.
Furthermore, both the experts believe that Kerala has a better performing surveillance system which is robust and capable of detecting as well as containing the spread.
Additionally, Kerala's targeted testing approach has also helped the state to do better. Kerala chooses the districts showing a high total positivity rate following which it concentrates on testing people who are more likely to face issues of physical distancing and tests them.
The Misses- Where Kerala Let COVID-19 Get The Better Of It
Kerala's state elections were held in April 2021 when India was showing signs of stepping in to the second wave of the pandemic. Along with the elections, the state also relaxed its restrictions for the annual Thrissur Pooram festival on April 23. Following these events, the state witnessed a surge in cases.
The Kerala High Court even reprimanded the government for wanting to relax further restrictions for Bakri Eid when the state was handling the outbreak of cases.
To understand and strategise to bring the situation under control, the Health Ministry sent a team of experts to the state under the leadership of Dr. Sujeet Singh, Director of National Centre for Disease Control. Sharing what the team felt were the issues in the state, Lav Agarwal, joint secretary, MOHFW, said that the Centre is asking the state to accelerate its tracking, testing, treating, vaccinating.
"Most of the infected, close to 91 per cent are practicing home isolation in the state. That leaves most of the family members as high risk. If there is not enough space for following isolation, these high-risk contacts will be infected. They need to improve their containment strategies," Agarwal said.
Agarwal asked the state to choose places that could act as containment centers for the infected to be isolated there as well as separate isolation centers for the contacts to isolate as well.
The ministry believes that the rising test positivity rate of over 10 per cent indicate that although targeted, there needs to be an increase in testing. The WHO states that the infection is under control if the positivity rate is below 5 per cent.
The Future- What Can Kerala Do Now?
"Kerala has a well performing surveillance system and it has to now use its data to strengthen its containment and vaccination strategies," Lahariya shared.
John believes Kerala needs to wait it out. He also feels Kerala will see more cases rising due to its low sero-positivity. "Such a large group of people continuing to be uninfected after targeted testing will be infected or vaccinated."
"Tamil Nadu has issued that the number of people that visit shops has been limited according to the shop's floor index. Kerala can learn from them, " John added. The virologist feels that Kerala should follow an arrangement like this.
To ensure that the danger decreases, John adds that the state should ensure that double masking and a 10-day lockdown is enforced in the state.
