For the last many weeks, the Covid situation in Kerala has been getting national attention. The state has been reporting nearly half of India’s total daily Covid cases and the test positivity rate (TPR) continues to be more than 10% (national average is 2%). With Onam just getting over, the TPR has reached close to 20% and daily cases from Kerala touched around two-third of total cases in India. Is this a cause of concern? Let’s examine it objectively.
In an epidemic or pandemic, an effective response can be assessed based on a composite of at least three key parameters. One, the slowing down of transmission (which allows time to prepare health systems). Second, reduction of the impact on those who develop infections (through better health services, as assessed by case mortality rates). Third, implementation of measures to suppress the transmission (i.e. vaccination, containment and other restrictions).
Kerala was more successful than any other Indian state in slowing down the transmission as noted in the fourth national seroprevalence survey, which found the lowest seroprevalence of 44.6% in Kerala, among 21 states surveyed. This essentially meant that Kerala had proportionately more susceptible people than any other state. In fact, the Delta variant reached Kerala a little later than the rest of the country; the ongoing sustained transmission is the outcome of Delta variant spread.
On the second parameter of reduction of the impact, the case fatality rate in Kerala has remained nearly one-third (0.5%) of the national average (1.3%). Even at the peak of the second wave when there was a crisis of hospital beds, oxygen supply and critical medical supplies in many Indian states, the health system in Kerala was strained but never overwhelmed. The state has a high old-age population and faces the burden of non-communicable diseases, which in a poorly functioning health system could have resulted in higher deaths. Therefore, the state is clearly doing well on this front too.
When it comes to the third parameter, suppressing and halting the spread, the pace of Covid vaccination is also fast in Kerala and nearly 21% of the population has been fully vaccinated, with around 58% receiving at least one dose. Kerala is among the very few Indian states that are still doing extensive contact tracing and targeted Covid testing in high-risk populations and in high transmission settings. This is an explanation for the high TPR. The state has India’s best infection-to-reported case ratio, with one in every six infections being picked up. In many states, only one case in nearly every 100 infections is being picked up.
Nearly half of India’s daily Covid cases coming from Kerala may raise eyebrows; however, the state is detecting and reporting more cases, as any well-functioning disease surveillance system should do. We cannot blame a state for doing what is right. This is at the expected trajectory of infectious disease in well-functioning health systems. The Delta variant, which affected a high number of people in a short time in most Indian states, was slow to spread in Kerala and that is a sign of effective pandemic response.
It is not that Kerala has always done everything right. In the past, it had allowed large gatherings for Onam in 2020 and then for election rallies in 2021. Some of these gatherings had resulted in increased transmission and consequent rise in cases. Clearly, there is a need to learn from the mistakes of the past. As long as there is sustained transmission, Kerala (and other states) have to stop any such gathering at all costs. We need to keep a watch on every setting reporting sustained transmission.
There are a few things Kerala should consider. First, the state needs to develop a more nuanced and dynamic ‘containment and unlock’ strategy, with use of local epidemiological parameters. Second, there is a need for active engagement of community members and local bodies. People need to come forward and unvaccinated people need to avoid attending public functions. Third, the state should avoid giving relaxation in and around festivals. Fourth, fresh communication drives/ campaigns to improve adherence to Covid-appropriate behaviours should be done. Fifth, the pace of vaccination in Kerala needs to be further accelerated. Sixth, genomic sequencing should be regularly conducted and data analysed for faster information sharing. Seventh, the state needs to conduct various epidemiological studies to guide response. Most importantly, these strategies should be implemented in a targeted manner, in settings of high and sustained transmission with a localised approach.
India is still in an ongoing pandemic, with the virus circulating in all states, though with variable rates. There is a possibility of a third wave and it will take many more months before the disease could become endemic. The sustained transmission and higher reporting of cases in Kerala are the outcome of a high proportion of susceptible population—not an immediate concern but it demands watchful interventions. Though the cases in many Indian states are low, the situation may change if another variant emerges, which is a possibility. Therefore, irrespective of the current level of transmission, all states should continue to be prepared for a rise in cases, strengthen health facilities, accelerate Covid vaccination and learn from each other—that’s what will help India win the fight against the pandemic.
Dr Chandrakant Lahariya
Physician-epidemiologist, and public policy and health systems expert
(Dr Lahariya is the co-author of ‘Till We Win: India’s Fight Against The Covid-19 Pandemic’)