Kerala Covid curve has flattened, despite recent spike. Doctor who handled Nipah explains how

Dr Anoop Kumar, chief of critical care medicine at Baby Memorial Hospital, Kozhikode, was instrumental in detecting the first Nipah case in 2018.

Critical care specialist Dr. Anoop Kumar | By special arrangement

New Delhi: In early March, Kerala was one of the worst affected states with the highest number of coronavirus cases. Over a month later, the state has managed to flatten the Covid-19 curve, one of the first to do so. Now ranked 12th, Kerala has recorded the slowest increase in new cases, despite a spike in the number in the last few days.

As of 24 April, Kerala reported 448 cases and three deaths — a fatality rate of 0.66 per cent as against the 3.08 per cent nationally. At least 324 patients (72 per cent) have already recovered, leaving the state with 124 active cases. This, even after Kerala detected 43 new cases in the last four days.

On 20 April, the Ministry of Health and Family Welfare said Kerala had among the slowest doubling rates in the country with cases doubling every 72.2 days as compared to 7.5 days nationally. In contrast, Maharashtra, which had the second highest number of cases until March, has seen its cases rise exponentially to 6,430 as of 23 April, with 283 deaths.

So how did Kerala manage to keep its death rate low?  

The answer lies in detecting the cases early, said Dr Anoop Kumar, chief of critical care medicine at Baby Memorial Hospital, Kozhikode.    

“All of our patients who have been hospitalised have come for the home quarantine group,” he told ThePrint. Closely monitoring home quarantine patients and ensuring their swift transfer to hospitals with trained doctors has been instrumental in saving lives, he added.

Kumar was instrumental in detecting the first Nipah case in Kerala in 2018 and has been helping the state government in its efforts to fight Covid-19. He was also portrayed by actor Rahman in the Malayalam film Virus, which chronicles the state’s fight against the Nipah virus. 

Kumar spoke to ThePrint about the various proactive steps Kerala has taken to help contain the spread of Covid-19. 

Kerala’s Covid-19 graph | source: https://dashboard.kerala.gov.in

New cases a cause for worry?

While Kerala had been reporting an increase of two to three cases for some time until 19 April, it detected 43 new cases in the following four days. One of the patients was a four-month-child with a heart defect from Malappuram, who was admitted to hospital for breathlessness and then succumbed to the disease.

Kumar said the surprising aspect was that these cases were asymptomatic, and the patients had been in quarantine for more than 28 days. He, however, said the positive results may not mean active infection. 

Since the current guidelines recommend conducting RT PCR (real time polymerase chain reaction) tests between five and 14 days of coming in contact with the confirmed cases, the results are showing presence of virus particles that may not be infective, he said. 

“Until we do a viral culture in this case, we cannot say if the patients are infectious,” he added. 

Experience with Nipah helped

Kerala claims it had been vigilant and its response to Covid-19 proactive since 30 January, when the first case was reported.

By the beginning of February, Kerala had a plan to screen all those who were returning from China and began keeping them in strict quarantine. This is how the three medical students who returned from Wuhan were detected, Kumar said. 

Also, the state decided to keep the travellers in 28-day home quarantine instead of the 14 days followed in the rest of the country. 

The experience of facing the Nipah outbreak in 2018 and once again in 2019 had made the system aware of what it needed to do, Kumar said. “Our public health system already knew about contact tracing, quarantining and infection control,” the doctor said.  

Not just those with foreign history, even those who had travelled from other states were quarantined, according to the plan.

Kerala was also helped by the fact it has the country’s best public healthcare system and health and social indices, and its primary care centres are also among the best. The coordination between public and private healthcare facilities is said to be good, and Kerala also regularly records its cases on the Integrated Disease Surveillance Programme, which detects disease trends and prevents outbreaks.

And a slew of welfare measures, advance pensions, home delivery of meals for children, shelter and food for migrant workers, cushioned the weakest.

The state had enforced a partial lockdown a few days before the national lockdown was declared on 24 March.

Getting to the patients early

The state had put over 1.8 lakh people in home quarantine and under observation, all of them getting a call regularly asking if they experienced any symptoms, Kumar said.  

“If they said yes, they were immediately picked up by the Jan Maithri police or the people-friendly police,” Kumar said, adding this was why patients could reach hospital early and prevent complications.  

Even though Kerala had a cohort of patients with comorbidities, there were not many critical cases. “We had a 92-year-old with acute respiratory distress syndrome who survived,” Kumar said, adding that less than 5 per cent of the cases were critical.  

“If a state is recording more critical patients, then it is not detecting all its Covid-19 cases,” Kumar said.  

Critical care training

Not just focussing on the ramping up of ventilators, Kerala also began training its doctors on critical care. The government formed a separate group of critical care physicians to train all doctors working in the ICU on managing Covid-19 patients, Kumar said. 

“Kerala started this when no other state or even the Centre was even talking about it,” he added. Since corporate hospitals had the expertise and infrastructure, they were given the opportunity to train doctors. 

Convalescent plasma therapy and delay

Even though the state does not have enough critically ill patients, it was among the first to get clinical trial approval for convalescent plasma therapy. The procedure involves treating critically ill Covid-19 patients with plasma from a recovered patient.

Led by Kumar, the procedure had the nod to begin in the government-run Sree Chitra Tirunal Institute for Medical Sciences but the plans have been shelved as the the Indian Council of Medical Research (ICMR) has brought out clinical trial guidelines that only allow the Covid-19 designated hospitals to take part in the trial. 

“We are disappointed but I am hoping that they would not keep it restricted to institutions but pooled in areas because recovered patients can be spread across the state,” Kumar said.

His team is also awaiting ICMR’s communication on using new drugs such as remdesvir, first touted as a cure for Ebola, the rheumatoid arthritis drug, tocilizumab, antimalarial drug hyrdroxychroloquine and interferon as part of a solidarity trial — a multi-country trial under the World Health Organization.

“We have been regularly in touch with ICMR but are yet to hear from them on when the trials can start,” Kumar. Kerala wanted to begin the trials for the drugs independently but can now only participate as part of ICMR’s trial.