Three reasons why Kerala’s Covid success is beginning to get a reality check 

Kochi: Kerala’s efforts to contain the Covid-19 spread, which have received worldwide acclaim, are now beginning to unravel.

The state has seen a surge in cases over the past week, particularly in capital Thiruvananthapuram and the commercial hub of Ernakulam district, with experts saying that the large clusters point to local transmission.

After recording over 600 cases for two consecutive days (Wednesday and Thursday), the state recorded its highest number of nearly 800 cases in a single day spike Friday. In all, as of Saturday morning, Kerala has recorded 11,000 positive cases, of whom, 6,029 are still active. 

This is a far cry from the low of 608 cases on 1 June, before Unlock 2, when the Kerala model was being lauded.

The surge has come amid questions on testing and the lack of testing facilities even though Health Minister K. K. Shailaja said the state had conducted over 16,000 tests on Wednesday (15 July) alone.

Take the case of Ernakulam district. It recorded 70 positive cases on Wednesday but has just one government RT-PCR testing facility. A new machine was installed just this week but it is yet to start testing.

As some key personnel in the data entry and the laboratory departments of the Government Medical College, Ernakulam, have gone into quarantine, it has led to a backlog of over 2,000 swab samples. The district has been sending less than 800 samples a day for testing even though two large clusters have been reported. 

In the capital city of Thiruvananthapuram, with more than 2,000 tests being conducted a day, there were 322 positive cases on Thursday alone.

In no other district have testing facilities been beefed up as the third phase of the Covid-19 has begun in the state.

Experts are now questioning the state’s low testing strategy, failure to ramp up healthcare capacity during the lockdown and the government’s initial reluctance to involve the private medical sector.

The CPI(M)-led Left Front Democratic (LDF) government, in its daily review by Chief Minister Pinarayi Vijayan Friday, admitted to community spread in Thiruvananthapuram — the first such admission.

The increase in numbers of people without any source of infection shows that there is early community spread, said Dr Abdul Ghafur, an infectious disease expert with the Apollo Hospital in Chennai. He had advised the state in managing the Nipah outbreak in 2018.

There are 42 cases without any epidemiological link in Kerala.

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Lack of Testing

Experts believe that the pattern of low numbers of tests has been one of Kerala’s major strategic flaws as hidden cases were never found at the right time, contributing to the recent explosion across the state.

Dr Ghafur said that while the sincerity of the Kerala government cannot be questioned, it ignored ICMR guidelines to test mild and asymptomatic patients.

“They did not test, justifying the decision on numbers of cases being too low. The numbers of contact cases were never more than 10 per cent for a long time as the government was looking only in one direction,” he said.

“All calculations were made based on that. The positivity rate of returnees from abroad and those from other states were the main concerns, but the lag in surveillance testing kind of hoodwinked the state into not seeing the hidden cases before the surge.”

“The Kerala government strategised to run a sprint when the call was to run a marathon,” Dr Ghafur added.

According to the doctor, when other states were testing 10,000 samples, Kerala was testing 3,000 samples.

Kerala would have anticipated the surge if it had widened the net to catch the hidden cases, he added.

The doctor also said Kerala had spent all its energies on contact-tracing when cases were very low.

“The state utilised all its manpower to contain what was just a test dose, and now, when the actual need has arisen, the energies of the human resources lie spent in the overkill of the last four months,” he said.

According to Dr Padmanabha Shenoy, a Kochi-based immunologist, the state failed to recognise the mobility of people in Thiruvananthapuram, Kochi, Kozhikode and Malappuram areas during the lockdown as well as in the unlock mode.

“Yet another strategic mistake was to conduct antibody testing, which is actually a waste of time and resources,” Dr Shenoy said.

He said antigen assay would have been more appropriate as it has more sensitivity and good specificity.

While the chances of a false negative could be about 10-15 per cent in antigen assay, clinical suspicion of a doctor could be put to use to get the RT-PCR done, he added.

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Lag in capacity-building

Experts say that the lockdown should have been utilised for two things — to prepare and to contain the virus.

But even after 160 days, there is a lacuna in preparation.

The first line treatment centres (FLTCs) are not ready, even in Thiruvananthapuram. The FLTC is a large secured area such as a convention centre or a community hall converted into a healthcare facility for Covid management. Only asymptomatic and mild cases are sent to these centres where there are round-the-clock nurses with doctors taking the rounds twice. Those showing a change from mild to moderate symptoms are transported to Covid treatment hospitals.

A public health expert working closely with the state government said that except for Ernakulam, where the district administration prepared a surge plan and identified Covid FLTCs to accommodate 25,000 patients, no other district has any such plans ready.

The expert said patients reaching primary health centres have to be transported to taluk or district hospitals to have their swabs collected for testing.

This is a serious lapse in capacity building that could have been achieved by the state with such a good network of infrastructure, he added.

A state health official, on the condition of anonymity, said the government’s communication strategy was not being transparent about the state’s capacity in terms of availability of hospital beds and ICU beds with ventilators.

“People kept thinking that everything was going well and that Covid-19 will be beaten as the state came out of lockdown,” the official said.

The state government has now asked all panchayats to create FLTCs but according to Dr Joseph Chacko, president of the Kerala Government Medical Officers’ Association, there is a dearth of doctors and nurses.

“We are running short on manpower in our own hospitals, at times forced to abandon a primary care centre so that the services in secondary and tertiary hospitals are not affected,” he said.

There has been no capacity building in manpower or training existing personnel in all categories, like nurses and paramedics, even in collecting swabs for testing.

Dr Chacko questions the need for doctors to be the only ones collecting swabs for testing when, he adds, nurses are adept in removing and inserting catheters in seriously ill patients.

It could save time especially when doctors are busy at the casualty or outpatient departments, he added.

The state is hard pressed for medical hands but there are fewer takers for the contract jobs in the State National Health Mission because of low pay.

“This extreme shortage of manpower should have been foreseen in the epidemic control,” Dr Chacko said. “Another huge problem the government would be facing is the waste management at FLTCs.”

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Keeping private hospitals away

Keeping the private hospitals away was yet another strategic error, experts say.

About 65-70 per cent of Kerala’s population depends on the private sector, according to Dr M.I. Sahadullah, chairman of the Association of Private Hospitals in Kerala.

He said that while the private sector had been kept away so far, the government has now sensed the urgency of the situation and had on Thursday (16 July) communicated to them to keep aside at least 20 beds per hospital for Covid-19 patients.

“The private sector has to gear up psychologically too as Covid management reaches another phase,” he said.

Dr Sahadullah does not blame the government for the situation as, according to him, the surge “is the natural course of the virus”.

He, however, believes a consensus could have been built for managing the disease.

“The government never thought it (virus) would go overboard,” he said.

We have worked efficiently: Health minister

Kerala Minister for Health, Social Justice and Woman and Child Development K.K. Shailaja told ThePrint that testing has been increased in line with requirement and that the test positivity rate and cases per million have been low.

“We have raised the numbers of government testing facilities and are testing to the maximum capacity,” Shailaja said.

According to the minister, the numbers of laboratories for Covid-19 testing in the state has been increased to 23 RT-PCR facilities, 13 TruNAT and 8 CB-NAAT facilities. There are also seven RT-PCR laboratories, four TruNAT and six CB-NAAT testing facilities in the private sector.

“Treatment in our hospitals has been good with the mortality rate as low as 0.37 per cent,” the minister said. “As far as our efforts to control the cluster spread is concerned, we are effectively doing our best.”

There have been a lot of people from Tamil Nadu reaching our markets and coastal belts since the unlock, the minister said, adding that the increase in clusters, especially in the coastal belt and market areas, was primarily because of such movement of people.

“We are moving into yet another Break the Chain campaign,” the minister said. Such waves in the pandemic are being seen across the world and Kerala is not alone in this, she added.

(The author is a Kochi-based journalist who has reported on health for the last 20 years.)

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