Why Have COVID Cases in Kerala Not Dropped Like Rest of India?

Experts suggested that continuous sero-surveillance of antibodies will help in early detection and disease control.

Kerala is witnessing an episode, similar to the situation in January this year, with a significant rise in coronavirus infections, while the rest of the country is seeing a sharp decline.

Since 15 June, Kerala has accounted for the largest number of COVID cases in the country. For the last two days, more than a third of all cases reported in the country have been from the state. At its peak, Kerala was contributing less than 10 percent of all the cases in the country.

So what went wrong with the state that was once hailed for handling the pandemic better than majority of the other states? The Quint spoke to virologists, scientists and health officials to understand the reasons for the high positivity rate.

1/3rd of COVID Cases in India, But Low Mortality Rate

On 1 June, the state recorded 19,760 positive cases, but the number began declining, reaching 14,424 on 10 June. For almost a month now, Kerala has been reporting between 11,000 to 13,000 cases every day. On 7 June, 1,50,630 samples were tested, of which 15,600 tested positive for COVID. The Test Positivity Rate (TPR) is at 10.36 percent, whereas the national average is 2.43 percent.

Virologists across the country have appreciated Kerala for being one of the most ‘honest’ in terms of reporting. This has been corroborated by sero surveys as the latest national sero survey showed that for every infection that gets detected, about 25 go unreported.

However, in Kerala, it was found that only about five infections go unreported for every reported case. But this still doesn’t explain the increase in infection rate.

Senior virologist Dr Jacob T John explained, “The fast pace of infection is due to the Delta variant. The earlier Wuhan B614G variant showed how one infected person could infect two others. The Delta variant has showed, one person that infect six people.”

Over 30 lakh people have been infected in Kerala, the second highest in the country after Maharashtra. But what is quite concerning is that Kerala has a population of about 3.5 crores, which is nearly four times lesser than that of Maharashtra.

Kerala has recorded over 90,000 confirmed cases per million population, way above the country average of about 24,000.

Kerala, however, has been reporting a low mortality rate, which is being cited as evidence of the state’s efficient handling of the pandemic. The state has a fatality ratio of 0.47, against the country average of 1.32, which can be partly attributed to the large number of cases.

Reason 1: Unlocking Kerala Has Left Many Susceptible to COVID

Virologists across the country collectively agreed that the main reason for Kerala to record this surge is because the number of people who are susceptible to COVID is much higher than other states. This is because of their 'good handling of the pandemic'. Dr Swapneil Parikh, physician and author of 'The Coronavirus Book,' pointed out that this trend is being observed in Britain, Thailand, Indonesia and Taiwan.

“Kerala managed COVID very well in the first and second wave. So since lesser people were infected back then, there are more immunologically-naive people now.”

Dr Swapneil Parikh, Scientist

Former head of the Indian SARS-CoV-2 Consortium on Genomics (INSACOG) and virologist, Dr Shahid Jameel explained, “The virus can only spread if there are enough vulnerable people and if they are not following protocol. In the first and second wave, people followed the stringent lockdown rules obediently. So a number of people were not exposed, let alone infected by the virus. And now, since March, we are encountering a variant that is far more infectious than what we've seen before and people are not following COVID appropriate behaviour.”

Virologists suggested that increasing testing is the only way of understanding the spread of the virus. Testing in a community has two purposes – one to identify the positive cases so as to stop further spread and two, the number of people tested positive can be used as an indicator of epidemiology spread.

Some experts said that preventing the peak at the cost of a raising TPR is a good sign and also shows how well the containment measures have been.

Reason 2: Rural and Urban Areas Tested & Treated Alike

An interesting observation made by health experts was that unlike the rest of the country, Kerala has ensured that testing is extended to cities and villages uniformly. This substantiates the claim made by health officials that the state is projecting fairly honest numbers and also has a clear understanding of the proportion of infection in the community.

“Kerala is unique with no divide between the urban and rural areas and so there has been no partiality when it comes to testing or treatment. In North India, the virus transmission rate was much higher earlier because of uneven testing….in fact, it was almost negligible in rural areas, and so they recorded a surge in cases, a few months back. But that is not the case in Kerala,” epidemiologist Dr Chandrakant Lahariya told The Quint.

“Then there is the high frequency of people traveling across the border. Though we are doing over 1.30 lakh tests per day for the past one or two months, we recommend doing at least two lakh tests for early detection and control.”

Dr Sulphi Noohu, Secretary of the Kerala chapter of the Indian Medical Association (IMA)

Reason 3: Elderly Continue to be Vulnerable, Even After Vaccination

Of the 3.5 crore population of the state, the geriatric population accounts for about 45 lakh. They are vulnerable with co-morbidities such as diabetes, hypertension, and cardiovascular diseases.

Dr Sulphi Noohu explained that since the unlock a number of elderly people have been stepping out, as 'they are confident after getting both the COVID vaccine shots. But they are forgetting that they are most vulnerable and this is not the time to be complacent.'

How Can Kerala Do This Right?

Doctors warned about plateauing of cases, and said if a third wave hits soon, it will have repercussions on the health infrastructure.

The good news is that almost 45 percent of the state’s population has received at least one dose of the vaccine. About 10 percent has got the second dose as well, which is much better than states like Maharashtra or Tamil Nadu.

“Vaccination process is picking up. We need to do it at lightning pace because this is the only modality to defeat the surge in coronavirus cases. And if we continue doing it at this pace, we will take a much longer time to reach the herd immunity threshold.”

Dr Sulphi Noohu, Secretary of the Kerala chapter of the Indian Medical Association (IMA)

An expert pointed out that the strategy of the health department is to keep most people susceptible till they get the vaccine immunity.

“Infection rate is not much to worry because the severity of the illness is low. However, we should not be complacent about it as people may have long term implications,” said Dr Shaheed Jameel.

Dr Swapneil Parikh insisted on the use of medically approved masks and urged the state to pay attention to ventilation and air filtration in public spaces.

All experts pointed out that the only trump card we have to manage this pandemic is to scale up vaccination.

“Vaccination was ready by September 2020 but we didn't plan to utilise the vaccine to fight this pandemic. And so, we didn't order for the vaccines and are staring at a shortage during this crucial time. Also, the government needs to explain to the public the risk of community spread,” said Dr Jacob T John.

The IMA Secretary and senior doctors in government hospitals said that while the number of cases were high, the severity of the illness has been comparatively low and so the pressure on the healthcare system has not been much.

“We cannot afford another lockdown. We should look at increasing number of vaccination centres to avoid crowding. Casualty wards of several hospitals were once completely shut down because they couldn’t handle the number of cases. We can't go back to that situation because we will be pushed to a place where we won't be able to even accommodate daily road accident cases,” he added.

While experts are demanding a thorough assessment of Kerala’s anti-Covid strategy, the state government has issued orders to re-categorise the local self-government institutions on the basis of a seven-day average TPR of Covid-19 cases.