Covid control conundrum of Kerala explained
Kerala continues to be in the news for high numbers of new cases of coronavirus infection—nearly half of the national total—day after day for the last few weeks. Contrary to popular perception, the fact is that among all states, Kerala had managed the pandemic in the best possible manner and the present conundrum is its consequence.
A team from the Centre visited to advise the state government; we hope the team understood realities and will help with the key remedy—liberal doses of the vaccine.
We present five reasons to prove Kerala had surpassed all other states in pandemic management.
The media had noticed disparities between low numbers of reported Covid deaths and recorded visuals of extraordinarily large numbers of dead bodies given last rites with Covid precautions at burial grounds/cemeteries. Global attention was caught by hundreds of dead bodies floating in North Indian rivers daily. In contrast to this grim picture, Kerala’s magnitude of unreported “excess deaths” attributable to Covid, over and above the total deaths in the Civil Registration System, is the lowest among all states.
The Central and most state health ministries grossly under-reported Covid deaths—partly due to flaws in death-reporting in the health management system and partly for saving face. While India had gloated that only about 4,00,000 Covid deaths have occurred since its onset (claiming the world’s lowest case-fatality ratio), independent investigations estimated nearly 10-fold higher (3 to 4 million) deaths.
The reporting of SARS-CoV-2 infection is based on test-positive status, mostly RT-PCR and partly Rapid Antigen Test. Both have high specificity, hence reliability. Once diagnosed with infection, subjects are followed up until recovery or death. So documented death numbers are reliable, except that we cannot know what was missed. That is where the Civil Registry data comes in handy.
The crux: the lower the discrepancy between the documented Covid deaths and the excess deaths certified in Civil Registration compared to pre-pandemic years, the more complete the counting of deaths and infections in a given state. Kerala has by far the lowest discrepancy and hence the highest score for case detection and death notification.
Second, Kerala’s high alert and contact-tracing skills resulted in detecting the earliest three virus importations into India. The state managed to prevent secondary transmission. The first ICMR sero-survey estimate of 6.46 million infections on 3 May 2020 clearly indicates that many other states missed many importations of infections in March 2020—only this can account for such a large number of infections within two months of epidemic onset.
Third, Kerala has the country’s highest testing rate—78,000 per lakh population—against the national average of about 33,000 (states ranging between less than 30,000 to about 60,000). Higher test frequency means more infections detected.
Fourth, it has the lowest antibody prevalence (44%) among all states in the most recent sero-survey, certifying that Kerala had indeed succeeded in averting lakhs of infections in both the 2020 and 2021 waves (until June 2021). Kerala was under-represented in four ICMR sero-surveys; but samples were always from one district and this was invaluable for comparisons. In every sero-survey, Kerala consistently had the lowest antibody prevalence.
Kerala kept the wolf at bay, waiting for rescue by liberal amounts of vaccine in July—either as a reward in appreciation of the state’s achievement or for the opportunity to prevent infections by the Delta variant that cannot be controlled by any other means.
Fifth, at no time was the healthcare system (well-coordinated public and private sectors) overwhelmed—there was no lack of oxygen or bed availability. Kerala has the most reliable data for case fatality rate in India, which never crossed 0.5%. The national reported average is 1.3%; the true rate was probably much higher. Kerala’s low mortality rate is in spite of three disadvantages—one of the highest population densities, longest life expectancy and one of the highest diaspora densities.
Higher the population density, more rapid the viral spread, yet Kerala managed the epidemic well and flattened the curve in both waves. Higher the life expectancy, higher the proportion of senior citizens at high risk of Covid mortality, but the state succeeded in saving thousands of lives. Higher the diaspora density, the more numerous and repetitive importations of virus variants from overseas; vigilant Kerala mitigated even these challenges posed by Vande Bharat.
The Delta variant is a stealth-spreader—all past prevention strategies are no match to it. The present picture of the infection spread not coming under control with recurrent surges attest to the infectiousness of the Delta variant. Such a contagion could only have been curtailed by mass vaccinations.
A discerning Central government ought to showcase Kerala as a shining example of a state that worked diligently to flatten the pandemic curve and keep the number of infections and deaths down. The current problem is inadequate vaccine supply, not under-utilisation of vaccines already supplied. The vaccine wastage rate in Kerala is the lowest in the country, on par with that of Tamil Nadu.
Having said all these by way of appreciation, of late, Kerala has begun taking hasty and shaky decisions, presumably an emotional reaction of a successful warrior unnerved by undue and unkind criticism. The Kerala government has introduced illogical constraints on normal life. Strict short-term lockdowns, alternate day shop closing, reduced public transport, etc., all meant to reduce social contacts and physical closeness, are measures that cannot stop the Delta variant’s spread. On the contrary, such measures produce exactly the opposite results: If the time or space for procuring essential human necessities—shopping or travelling—is restricted, the duration of contact will increase and crowding will be enhanced, promoting infection spread. Restrictions that are ineffective to control infection but curtail human welfare/well-being are useless and harmful.
The goal of restraining social contact is to protect human welfare/well-being from the pandemic. The present upsurge of the Delta variant is not amenable to the interventions that worked well in the past for the Wuhan virus/D614G variant. According to the Centres for Disease Control (US), the Delta variant has a basic reproduction number (Ro) four times higher than the previous variants. The government should avoid false fault-finding, but be humane to citizens.
Pending wider vaccination cover, there should be no let up on appropriate universal mask use—double-masking with cloth mask over disposable surgical mask or reusable N-95 masks offer some, albeit limited, protection.
Vaccination is the only remedy to stop the epidemic. Vaccination coverage is currently 18% (two doses) and 42% (one dose). If the former is enhanced to 30-40% two weeks prior to Onam, Kerala can relax a bit and enjoy the festival.
About future needs regarding vaccinating school children and booster doses, decisions can be made more leisurely. The time for vaccine supply for wider coverage to consolidate Kerala’s gains in its fight against the pandemic is right now.