Recognising its efforts, the WHO, in a statement released on July 2, said, “Five months since [India’s] first positive case of novel Coronavirus disease (COVID-19) was reported in Kerala, the state with over a population of 35 million, has reported 4,189 cases of COVID-19 as on June 30, 2020, and 23 deaths with an impressive recovery rate of 51.7 per cent. The state government’s prompt response to COVID-19 can be attributed to its experience and investment in emergency preparedness and outbreak response in the past during Kerala floods in 2018 and especially, the Nipah outbreak in 2018.” The state used innovative approaches and its experience in disaster management planning came in handy to quickly deploy resources and put up a timely and comprehensive response in collaboration with key stakeholders. “Active surveillance, setting up of district control rooms for monitoring, capacity-building of frontline health workers, risk communication and strong community engagement, and addressing the psychosocial needs of the vulnerable population are some of the key strategic interventions implemented by the state [Kerala] government that kept the disease in control,” the WHO added.

Graphic/Uday Mohite

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Kerala became a “model state” for the nation, and the world. But, the celebration was premature. Almost a year later, the state is back in the throes of the pandemic, registering a record of highest active cases and test positivity rate (TPR). As of February 19, 2021, the state reported 4,505 new infections, which took the total number of confirmed cases to 10,25,938. This means that one out of every 35 persons in the state has been found to be infected with the virus till now. So, what really went wrong?

Experts think Kerala is a victim of its own early success. Rukmini Srinivasan, a Chennai-based data journalist who is analysing Kerala’s COVID-19 numbers, says, “All the things that make a state successful in tackling an epidemic are already underlined. Nobody can bring about huge administrative change overnight. India has a lot of experience in tackling infectious and communicable diseases. So, the structure of people that are meant to cover every household in every village already exists. And, if you are a well-functioning state, you will be able to tackle the issues very well. That is what we saw in the case of Kerala.”

Kerala seemed to have controlled the spread of the disease by early May through an exceptional contact-tracing effort. Route maps were created across all districts. These maps aim to identify primary and secondary contacts of an infected person and place asymptomatic persons in quarantine and test the samples for symptomatic patients. Dr Pradip Awate, Maharashtra surveillance officer, epidemiology department, says, “Surveillance and policing in Kerala have been outstanding, which is why cases were being reported and conveyed by the state through daily bulletins. Their contact tracing has also been extraordinary. So, while they were battling rising cases back then, the mortality rate remained low. People were getting diagnosed, and were also immediately offered the necessary medical treatment.”

A view of soap and water for hand washing on the pier in Kochi. The southern state was lauded by the WHO in July last year for quick action in curtailing the spread of the virus. Pic/Getty Images

Srinivasan says that the whole of Kerala is a continuous city. “Although it has rural parts, you don’t get the sense of having left one city and gone through a rural area. Therefore, having fewer remote areas made it easier for the state government to widely reach every individual. Penetration of smartphones is also high, so the administration could put across a message of strict lockdowns to every household. People were vigilant and stayed indoors. The spread of the virus was, therefore, contained too soon. This meant, fewer people developed immunity. So, when unlocks began, this unexposed, susceptible and protected group started mixing with potential infectors,” she explains.

Dr Amar Fettle, Kerala’s nodal officer for communicable diseases, agrees. “The reason we became a model state is because Kerala adopted strict social distancing, mask-wearing and lockdown measures. There was also some amount of fear and anxiety in minds of the people. So, a combination of these things helped. But, a huge number of the population was left unexposed to the virus. Additionally, about 80 per cent of the people here are asymptomatic. And when this lot started interacting with infected persons or potential infectors again, there was a spike in cases,” Dr Fettle informs. 

On May 7, 2020, the first repatriation flight arrived in Kochi. A week later, the first post-lockdown passenger train from Delhi arrived in Thiruvananthapuram. Two-thirds of the 9,776 cases reported in Kerala from mid-May to mid-July were of incoming travellers, Srinivasan adds, saying, “Then, cases began to rise again as stranded residents returned to Kerala. By June, active cases were up to 700. By July, this had tripled to over 2,100, and this would only multiply five-fold by August.”
And yet, unlocks were announced and people began assembling to celebrate festivals. “Kerala definitely let its guard down ahead of Onam celebrations. These large gatherings, followed by local body polls in December, have now added to their woes,” Srinivasan thinks.

Rukmini Srinivasan and Dr Amar Fettle

But, even then, Kerala’s peak came a month after other large states. While cases in most big states peaked in mid-September and then began to decline, Kerala’s peak came much later, in October. “Unfortunately, this peak was not followed by a decline in Kerala. Their systems began to get overwhelmed. At one point, their efforts of revealing all active cases in daily bulletins had dropped. This indicated that their contact tracing was not able to keep up with the sheer rise of newer cases. And since October, there has been a steady number of active cases. That is worrying,” Srinivasan adds.
 
Kerala is the diabetes capital of India. Diabetics usually have more serious reactions to viral illnesses, and therefore, experts say this could be another reason why the state is seeing a surge in COVID-19 cases today. Dr Adarsh KS, consultant, diabetes and endocrinology, Manipal Hospitals, says, “Diabetes is a known risk factor for severe COVID-19 disease and its associated complications. Kerala has a high burden of diabetes, and hence the risk of severe COVID-19 infection might be higher in this subgroup of population. Having said that, we are seeing a surge in Coronavirus cases at certain places due to several reasons; one of the important factors is the relaxation of travel (international) in vulnerable population.”

While there isn’t any evidence proving a direct relation between diabetes and COVID-19, the kidney ailment definitely does put these patients in the high-risk category. He explains, “Diabetes, especially poorly controlled, has already been a known risk factor of severe COVID-19 illness. Patients with diabetes-related kidney disease are at a higher risk than the rest of the population. Hence, adequate control of diabetes and its complications can help by reducing the burden of severe COVID-19 disease.”

Dr Ranjit Mohan, Dr Pradip Awate and Dr Adarsh KS

The prevalence of diabetes in Kerala is as high as 20 per cent—double the national average of eight per cent. The high literacy rate in this state does not seem to translate to health literacy. The high prevalence of diabetes is accompanied by poor detection. In one study, a surprising 11 per cent (55 per cent of all diabetes) were newly diagnosed.
 
Recently, Dr Randeep Guleria, director of All India Institute of Medical Sciences, had hinted at the possibility of an undetected mutant strain of COVID-19 virus circulating in Kerala and Maharashtra, states with the highest number of novel Coronavirus cases in the country. Dr Awate confirms, “This is a possibility we need to look at, both in Kerala and Maharashtra.”

Dr Ranjit Mohan, consultant, internal medicine, infectious diseases, Manipal Hospitals, says, “Since both Kerala and Maharashtra receive large numbers of international travellers and also have a significant population of non-resident Indians, it is entirely possible that the known mutant strains of the COVID-19 virus, and even hitherto unknown variants, may have entered these territories.”

While testing figures in Kerala are now at around 3.7 lakh a week, the state has been prioritising antigen tests over the RT-PCR. Dr Mohan says, “The choice of antigen tests over the gold standard RT- PCR test for COVID-19 will inevitably lead to genuine cases being missed by epidemiologists. This, in turn, will hinder contact tracing, and ultimately result in the less efficient control of the spread of the infection. Many states and countries have successfully achieved rapid increases in the levels of testing with the RT-PCR.”

Therefore, the plan of action, according to him, is to expand testing with the RT-PCR. “In addition to this, strengthen contact tracing measures. Stringent screening of those travelling out of these states, and effective monitoring of international visitors arriving in these states should be done. The vaccination drive for healthcare workers should proceed with adequate impetus,” he suggests.
 
In the last one week, Mumbai and Pune have both reported more than 600 cases in a day, something that they had not done in at least a month. Dr Awate says, “Surveillance in Maharashtra, just like in Kerala, is up to the mark. This is why the state is reporting the maximum number of cases. Our data is transparent, and that is crucial. Till you measure the exact problem, finding a solution becomes difficult. If you hide the number of patients, you are just pushing the fire under the carpet. And that is hazardous.”

The cold wave from northern India has reached several parts of Maharashtra, adding to our woes. He adds, “In the past 15 days, the cold wave has reached many districts, including Pune and Satara. Secondly, just a month ago on January 15, gram panchayat elections took place and over 14,000 villages went into polls in Maharashtra. People who had left these villages for cities like Mumbai and Pune returned home to cast their vote. And so, the transmission has increased. Thirdly, in many places like Amravati, Nagpur, Pune and Satara, people are holding weddings as they did in pre-COVID times. Over 1,000 guests are invited, making transmission of the infection faster.”

Resuming local trains in Mumbai, however, was a tricky decision the government had to take, and it cannot be undone. “We cannot stop economic activities for a long time. But as citizens, we need to implement COVID-appropriate behaviour. Unnecessary travel plans need to be cut down. Don’t leave home unless it is an emergency. Don’t go on picnics with friends and families,” Dr Awate warns.
 
Whether Kerala succeeded in containing transmission or not, is related to whether the rest of the country failed or not, Srinivasan says. “I think we have a problem with how we diagnose success and failure. Going by the numbers, it feels like the rest of the country has been successful in tackling the virus as cases have dropped since September. And, Kerala is a failure because cases have not dropped steadily. But, if Kerala is getting more cases now because they did a great job at the start of the pandemic, then can we say the state failed overall?”

Srinivasan says that the second  COVID-19 sero-prevalence data from the three Indian Council of Medical Research surveys revealed that there was lower spread in Kerala than in other parts of India. “National sero-prevalence was at seven per cent in August, while in Kerala it was 0.8 per cent. By then, Mumbai had displayed sero-prevalence levels at 40 per cent. Between Deember and January, the national sero-prevalence touched 22 per cent, while in Kerala it was 11 per cent. The fact that the state jumped from 0.8 per cent to 11 per cent is extremely worrying.”

Dr Fettle argues there is “no surge in cases in Kerala”. “When you see spike in cases in other cities, you see people running from one hospital to another to get a vacant bed. Kerala’s healthcare resources are not at all overwhelmed right now. At least 50 per cent of our hospitals are empty. Here, the public has never been put to distress. Yes, there is a slight rise in numbers, but the plan of action now is to start a grassroots level campaign and have a stronger advocacy to warn the masses. Imposing a draconian lockdown again will not take place in Kerala,” Dr Fettle concludes.

Kerala’s case fatality rate, as of February 10, stands at 0.4 per cent, as against the national average of 1.4 per cent. It has seen a total of 4,062 deaths due to COVID-19 since the beginning of the pandemic.
 
20 per cent
Population in Kerala diagnosed with diabetes against national average of eight per cent