Bengaluru/New Delhi: Hard-learned lessons from the 2018 Nipah outbreak and quick, decisive moves by the chief minister are what helped Kerala get a handle on the coronavirus outbreak in the state early on, said K.K. Shailaja, Minister for Health, Social Justice & Women and Child Development, Kerala.
Affectionately known as Shailaja Teacher, she said Kerala had started preparing for Covid-19 cases much before the central government announced precautions. In fact, they swung into action as soon as they heard talk of a new virus outbreak in Wuhan since many Malayali students were in the Chinese city.
“We were sure that the virus will come to Kerala because so many Malayali students were studying in Wuhan University … When I read the WHO statement on 18 January, that there is a potential virus in Wuhan that is spreading — the WHO had not declared it a pandemic at the time — I discussed these things with our health secretary. We started our preparations here after consulting with experts,” she said. The minister was in conversation with ThePrint’s Editor-in-chief Shekhar Gupta on a digital Off The Cuff event Monday.
Kerala opened its state control room on 24 January, after a meeting with the rapid response team the day before. She said that the state insisted that all of the 14 districts start their control rooms immediately, and it was this preparedness that helped Kerala contain the three cases that surfaced in February.
Lessons from Nipah
Shailaja said the 2018 Nipah outbreak in the state taught Kerala some hard lessons on how to manage a health crisis.
“We were prepared for the virus. The Nipah experience helped us a lot. We started expert groups — one for logistics preparation, one for contact tracing, another for surveillance, and even one for mental health immediately,” she said.
She also credited the relatively successful containment of the virus in Kerala to the hundreds of healthcare workers as well as Kerala Chief Minister Pinnarayi Vijayan. Calling him a brave, decision-making person, she said Vijayan had taken quick charge when the pandemic was declared.
Kerala’s phased response to the disease
As early as 24 January, Kerala’s health ministry had stationed surveillance teams at airports, where they scanned for incoming cases from Wuhan. On 27 January, they identified three symptomatic cases, who tested positive and were placed in isolation wards, she said.
This successfully prevented transmission at the time and the three recovered in two weeks.
While there were no new cases for the two weeks that followed, the surveillance teams at airports continued to operate.
On 3 March, after a pandemic was declared, Kerala started to request people returning from abroad to report to a help desk. Most did, but some didn’t and the disease then began spreading in certain areas, she explained.
When symptomatic people visited hospitals, the staff, who had already been trained to enquire for travel history in case of flu-like symptoms, were able to identify those who had returned from Italy with the virus, she said. There had also been patients returning from UK, France, and the Arabian Peninsula.
Then, contact tracing kicked in, where the govt used flowcharts for each patient and their contacts, keeping everyone’s identity protected. Although many patients suppressed travel history due to fear of stigma, healthcare workers were able to coax them to be honest, she added.
“In total we had 499 patients in the two phases; of these, three died. Our death rate is 0.56,” she said.
Shailaja explained that their contact tracing system, which relies on GPS, is efficient, especially as it is clubbed with door-to-door contact tracing. Today, the state uses the Centre’s Aarogya Setu app along with their own system, she said.
The nationwide lockdown helped contain cases. But since restrictions have eased, more incoming people are overwhelming systems slowly, she said. So the state is taking action to prevent healthcare systems from collapsing.
“This is the third phase now,” she said. “This phase is somewhat difficult from the others because since 7 May, people are now entering the state from hotspot areas, and through land, air, and sea. We had flattened the curve earlier, but now it’s going up again.”
The good news is that the state anticipated this scenario and made preparations to receive those returning from other states.
At airports in Kerala, Shailaja said, there are 10-15 counters to screen passengers, while checkpoints have been set up on roads, and railways and seaports have trained personnel screening all entry points. There are also those entering away from official check posts such as through forested roads.
“We are managing everything through decentralisation,” she elaborated. “Our panchayat system is very strong here. Our chief minister asked each and every panchayat ward to form committees to examine those entering these wards. The panchayats ensure implementation of home quarantines as well,” she said.
Low testing numbers
Kerala’s testing rates today are less than the national average. Addressing this, she said, “We get criticised for low testing, but we’ve been testing strategically.”
Given there’s a general scarcity for tests, Kerala decided it didn’t want deplete tests very early on. “Some states are also doing antibody testing. We got kits from ICMR, but later ICMR itself said those kits are faulty,” she said.
The Indian Council of Medical Research (ICMR) had in April asked states to discontinue using the antibody test kits due to a wide variance in result.
“Breaking the chain of transmission through quarantine and isolation is the key. We do sentinel surveillance and random checking, observing for pneumonia cases. Our approach is multi pronged instead of just focussing on tests,” she explained.
The two key indicators Kerala relies on to assess disease spread is case fatality rate (the number of people dying among those diagnosed positive) and basic reproduction number R0, which denotes the number of people one person can infect.
The calculation of R0 (pronounced R naught) varies with human behaviour and physical distancing measures. When the value falls under 1, a disease is no longer considered to be an epidemic in the region.
In Kerala, both the case fatality rate and R0 are low. In fact, its R0 is below 1, and this helps her sleep at night, Shailaja said.
Aid from Centre and aid to states
Shailaja noted that the central government is closely monitoring the situation in all states through meetings with health and state officials.
“The central government is conducting meetings and helping facilitate exchanges. Prime Minister Modi conducted two video conferences with all chief ministers and health ministers, where I was also present. The health secretary Preeti Sudan has also constantly been in touch,” she said.
As far as Kerala is concerned, the state is struggling financially, she said, and has requested monetary aid from the Centre.
However, its expertise in handling the virus has been sought by others.
Shailaja said Maharashtra had approached Kerala for help in tackling the outbreak in Dharavi, infamously known for being Asia’s largest slum.
“We’re in discussions and trying to help,” she said. “Our system is difficult to apply to slums as the communist government has prevented the formation of slums here. Since 1957, through land reform acts, eviction of poor tenants has been prohibited and many individuals were able to acquire land as well.”
To tackle the challenging situation in a tightly congested Dharavi, Shailaja said the first step forward should be to cut off entry and exit into the slum and isolate it as a whole, while ensuring doorstep delivery of essentials by healthcare workers.
She added that although Kerala is suffering from a healthcare worker shortage, they are figuring out how to send help to Maharashtra.
“All states are working hard, but socioeconomic and wealth disparities remain,” she said.
Drugs and trials
On the much touted hydroxychloroquine (HCQ), Shailaja said Kerala is as yet unsure of the drug’s efficacy and is concerned about the reports of side effects.
“We first decided to use HCQ for high-risk healthcare workers, but we have since decided to focus on personal protective equipment (PPE),” she explained. “If there’s PPE, there’s no need for prophylaxis (treatment). We’re not sure if HCQ is preventive, we can’t yet believe it’s good.”
She said that private hospitals are following both what the state says and what the Centre has said. Some are prescribing HCQ as prophylaxis while some are attempting their own trials. But none are registered or completed yet, and there have been no results from any, she added.
Shailaja also said that Kerala is incorporating the AYUSH sector by helping create indigenous Ayurveda medicines.
“We are not using them to treat positive cases as they are no Ayurvedic or modern medicine drugs to treat Covid,” she clarified. “We are giving Ayurveda to boost immunity at the grassroots level. The project also includes Unani and Siddha, but it’s primarily Ayurveda to prevent flu-like conditions.”
She added that Ayurveda and modern medicine work in conjunction, where diagnosis, medication and treatment is through scientifically-backed modern medicine only, while “Ayurveda is about lifestyle” and is supportive care.
Way forward is community care
The way forward is for each citizen to act responsibly to contain the virus, she said. Breaking the chain of the virus’ transmission is key, and people must wash hands, wear masks, and practice physical distancing, she said.
Though a lockdown is ideal, it can’t continue forever, especially since the virus could circulate for over a year, she said. Since there is no treatment, the focus is to get a hold on the virus and its transmission.
“Containment areas need to be sealed and there should be a strategy for testing. We first test symptomatic, including pneumonia, anywhere in the state. Asymptomatic cases are being observed through travel and contact history. Random surveillance of healthcare workers through pooled testing is also ongoing,” she said. “We are also implementing reverse quarantine, where we’re monitoring comorbidities and people who are more vulnerable.”
Addressing the fact that the Centre requested for seven days of institutional quarantine and seven days of home quarantine, she said that institutional quarantine is difficult as numbers get overwhelming. “There’s no point if we can’t provide a separate room with attached bathrooms for families or individuals, so we’ve shifted focus to implementing strict home quarantine,” she said.
The monsoon rains are due in less than two weeks, and the season is prime for dengue, leptospirosis, and H1N1 in Kerala, Shailaja said.
“In the last two years, we declared a campaign called Aarogya Jagratha for year-round health awareness and every day prevention activities,” she said. “In two years, we reduced infectious disease-caused deaths.”
After the monsoon floods, usually come the real floods — of SARS-CoV-2’s “brothers and sisters”, i.e, other infectious diseases, especially leptospirosis, she said.
“Amidst Covid-19, we’ve already starting training and source reduction in anti-infectious disease campaigns. We have district surveillance officer for Covid and one for other infectious diseases in each district,” she said.
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