A staff member walks inside an empty classroom at a school after the Kerala government ordered all schools in the state to be shut, in Kochi, March 2020. Photo: Reuters/Sivaram V.
Kerala did a remarkable job of controlling and treating COVID-19 in the early days of the pandemic. The secret to its success was the collaborations among various stakeholders. But today, it is unfortunate now that the number of COVID-19 cases in the state is climbing steeply. Several epidemiologists had predicted this delayed peak, and at least a few had recommended the state would have to change its strategy in response.
Indeed, Kerala’s strategy had its advantages and disadvantages. And at this stage, when the state is in a precarious position, staring as it is at a runaway epidemic, it needs to consider a prospective approach.
Every major transformation needs an attitude change. While the government is responsible for reducing the COVID-19 mortality rate, it’s the people’s responsibility to reduce the case-load. The people should realise and acknowledge the responsibility of every citizen to protect herself as well as her family and peers. Washing, masking and distancing together can’t be effective if the people don’t take active interest and ownership of this agenda. In turn, the government should create awareness about what should and what shouldn’t be done. Punitive measures like imposing fines for not wearing masks or for not abiding by other preventive measures won’t work.
Several months of intensive lockdown and restrictions have precipitated a lax attitude among the people. The government should not blame them or opposition parties for the virus’s spread. Instead, it needs to convince everyone that the novel coronavirus will be with us for a very long time and that the only way to survive it is to learn to live with it. Without acknowledging this, the COVID-19 case load will continue to increase at an alarming level.
Axiomatically, it is also unfair to blame the government for the increasing case-load. We have already crossed the red line and should not indulge in unproductive blame games. Right now, Keralites should stand united and launch a second attempt to defeat the virus. Visual and print media should be effectively utilised in communicating the message of ownership to the people.
The government’s responsibility is to reduce mortality. No doubt several months of the lockdown had given us sufficient time to step up our healthcare facilities and prepare for all eventualities. Unfortunately, that has not been not the case. The earlier success instilled a sense of premature contentment among stakeholders. At this juncture, we need to concentrate on stepping up the facilities at government and private hospitals to accommodate the potentially high demand for the ICU beds. After a year or two, the pandemic will transform into an endemic form, with intermittent waves of epidemics. Every hospital should have the facilities and training to accommodate and manage COVID-19 cases.
The concept of COVID-19 and non-COVID-19 hospitals is not sustainable. COVID-19 patients with mild or no symptoms do not need in-patient care, except in cases where there are not enough facilities available for home isolation. Next, we must change our testing strategy. The focus of testing should be shifted from the community to the hospital. All hospital admissions should be screened for COVID-19. RT-PCR tests should be used for those patients with symptoms suggestive of COVID-19, and the rapid antigen tests should be used in other cases.
At this stage of extensive community spread, testing everyone in the contact-tracing chain is unproductive and impractical. We should focus more on identifying ‘super-spreader’ events. Every individual with COVID-19-like symptoms should consider herself to be ‘positive’ and must self-isolate. Confirming the diagnosis in asymptomatic or mildly symptomatic individuals will not serve any constructive purpose at this stage. Instead, resources can be better spent on hospitalised patients.
Recent data has shown that up to 50% of people who test positive on RT-PCR tests in the community have a low viral load and hence lower transmissibility, as these people have been identified at the later stage of the disease cycle. Identifying these individuals as positive does not serve any epidemiological or clinical purpose. Instead, rapid antigen tests can be deployed in the community. These tests have lower sensitivity than the RT-PCR and will detect only those individuals with higher viral load and high infectiousness.
In fact, while the lower sensitivity of antigen tests has been projected in the media as a disadvantage, it is in fact a blessing in disguise. Antigen tests are rapid, significantly less expensive, more economical and can be used for mass-testing. The change in testing strategy will free up much-needed resources that can be better used to ramp up tests of hospitalised patients.
And at this critical juncture, Kerala must change its COVID-19 in the above-described way. A paradigm shift in the testing strategy, admission policy and an attitude change in the ownership and demarcation of responsibility of the people and the government is the need of the hour. I am confident that the Kerala Government and the public have the efficiency and the motivation to implement this essential task.
Dr Abdul Ghafur is a consultant in infectious diseases, Apollo Hospital, Chennai.