A medic administers Covaxin to a health worker during its trials, at the Gujarat Medical Education & Research Society in Ahmedabad. Photo: Reuters
Kerala has the highest active COVID – 19 tally in India, with almost half of the daily reported cases being from the state. This is an unfortunate scenario, considering Kerala’s sincere efforts to control the state’s pandemic situation. From the early stages of the pandemic, Kerala received national and international acclaim for the early success in controlling COVID – 19. It is only ironic that Kerala now faces the worst COVID – 19 situation in the country. An extensive debate on what went wrong is the need of the hour. Moreover, rectifying the course will not be possible unless we analyse the past strategies and design new plans based on the prevailing scenario.
Containment measures such as route mapping, facilitated by law enforcement agencies, can be useful in outbreaks such as Nipah which have lower transmission potential. Kerala faltered in imitating the same steps as in the highly successful containment of the Nipah. Though it generated success in the early days, such unrealistic measures resulted in a burnt-out of the system in the long run. The authorities and the public were less vigilant of the preventive measures at a later stage. This fatigability was inevitable even in Kerala, a state with an optimally functioning health care machinery.
The state tried to delay the peak of COVID – 19 cases, and in effect created an unmanageable number of COVID – 19 cases that now show no sign of recession. Kerala has succeeded in maintaining the case fatality ratio low (the number of deaths as compared to the number of confirmed COVID – 19 cases). Simultaneously, the number of fatalities per million population is creeping up daily, with a persistently high number of COVID – 19 cases and the subsequent deaths.
If Kerala had realistically managed COVID – 19, the state could have witnessed a peak mid of 2020 which may have been far smaller than the present one. The case fatality ratio could be very similar to the present value and overall death per million populations could have been far lower. Kerala’s health care system is more robust and uniformly distributed than in many other states and could have easily absorbed the impact of a peak mid – 2020.
The present situation in Kerala has implications for the nation at large. As most other states have a far lower number of cases, a second wave can spill over from Kerala. Hence it is the nation’s responsibility, not just of the state, to launch all possible measures in controlling the COVID – 19 situation in Kerala. The Union health ministry and other relevant ministries must support the Kerala government in a big way to bring down the number of cases over the next few weeks at best or a couple of months in the worst scenario.
The most critical measure is to expedite the vaccination of the population at-risk in Kerala as compared to other states. Kerala has always maintained a position of lead in the vaccine compliance list of the universal immunisation programme. Unfortunately, the COVID – 19 vaccination among healthcare workers has just amounted to 47% so far. This slow rate is very surprising considering the gravity of the pandemic in the state. We must shortly vaccinate the maximum number of at – risk individuals, which includes health care workers, other front line workers, individuals older than 50 and those below 50 years who have comorbidities.
Also read: Tackling Coronavirus Pandemic: Is the Kerala Model Really Working?
We should consider vaccinating these groups simultaneously – rather than sequentially – as a unique strategy in the state. We may have to preferentially allocate a lion’s share of the COVID – 19 vaccine supply to Kerala. Though this strategy may appear to unduly favour the state, the protection this provides to the neighbouring states from a COVID – 19 justifies the preferential allocation. We should also drastically increase the vaccination centres and mobilise the stakeholders to get vaccinated by organising a high impact vaccination drive in the state. The Union Government must support the state by allocating the necessary resources.
Further, we must consider increasing the COVID – 19 testing in Kerala to 1.5 lakh a day. There is no drastic need to increase the proportion of PCR testing. Antigen testing is more suitable for screening asymptomatic individuals in the community in a high prevalence setting. PCR should be limited to testing symptomatic individuals if the antigen test is negative. It should also be extended to close contacts of people tested positive for COVID – 19, where isolation of the contact after an initial negative report or sequential testing is not feasible.
Our aim should be to identify as many cases with symptomatic and asymptomatic contacts with high viral loads and transmissibility as possible.
It is now well established that a PCR test may have a positive readout even after clinical recovery. This undesirable effect is due to the high sensitivity of the test that can amplify very low levels of the virus or even the dead virus. Hence the test will unnecessarily detect asymptomatic individuals with low viral load and low transmissibility. These individuals are not infectious and accounting for these as active cases has no epidemiological significance. Testing with RT – PCR can increase the total number of daily positive cases, but we will be unnecessarily utilising our resources and also have a misleading epidemiological stance.
Such an increase in the number of positive cases, many with low viral load and transmissibility, will result in a deceptively low case fatality ratio. The turnaround time and cost for PCR testing is also several times higher than antigen testing. So we must consider organising antigen tests at the rate of one lakh a day and PCR at a third of fifty thousand a day.
The public should continue to follow hand washing, masking and distancing measures with greater awareness. The rest of the country may be experiencing a sigh of relief with a low number of cases. However, Keralites are at the centre of the fire and are exhausted from a year – long measure of physical distancing with no sign of respite. COVID – 19 hasn’t gone away and still looms large.
Dr Abdul Ghafur is the Coordinator of the Chennai Declaration for antibiotic resistance crisis and a consultant in Infectious Diseases, Apollo Hospital, Chennai. The views expressed here are the author’s own.