How Kerala’s Covid situation impacts rest of India

For the past many weeks, the Covid-19 situation in Kerala has been getting national attention. The state has been reporting nearly half of the total daily Covid-19 cases for India and the test positivity rate (TPR) continues to be more than 10 per cent (national average 2 per cent). With Onam just getting over, the TPR has reached close to 18 per cent and the daily cases from Kerala touched around two-third of the cases in India.

Advertisement

In an epidemic or pandemic, an effective response can be assessed on a composite of at least three key parameters. One, the slowing down of transmission (which allows time to prepare health systems). Two, the reducing of the impact on those who develop infections (through better health services, as assessed by case mortality rates). Three, the implementation of measures to suppress the transmission (vaccination, containment and other restrictions).

Kerala has been 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 per cent in Kerala, among the 21 states surveyed. This essentially meant that the state has, proportionately, more susceptible people than any other state. In fact, the Delta variant reached Kerala a little later than the rest of the country and the ongoing sustained transmission is the outcome of the Delta variant spread.

Regarding the second parameter of reducing the impact, the case fatality rate in Kerala has remained nearly one-third at 0.5 per cent of the national average of 1.3 per cent. Even at the peak of the second wave, when there was a crisis of hospital beds, oxygen supply and critical medical supplies in many states, the health system in Kerala was strained but never overwhelmed. The state has a high old age population and a burden of non-communicable diseases, that in a poorly functioning health system, could have resulted in higher deaths. Therefore, the state is clearly doing well on this parameter as well.

About the third parameter of suppressing and halting the spread, the pace of Covid-19 vaccination is also faster in Kerala and nearly 21 per cent population has been fully vaccinated while 58 per cent has received at least one dose.

Kerala is among the very few states that are still doing extensive contact-tracing and targeted Covid-19 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-19 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 an infectious disease in well-functioning health systems. The Delta variant which affected a high number of people in a short time in most states is slow to spread in Kerala and that is a sign of an effective pandemic response.

It is not that Kerala has always done everything right. It had allowed large gatherings for Onam in 2020 and then for election rallies in 2021. Some of these gatherings had resulted in an increased transmission and the consequent rise in cases.

Clearly, there is a need to learn from the mistakes. As long as there is sustained transmission, Kerala (and other states) must stop any such gathering at all costs. However, we need to keep a watch on every setting reporting sustained transmission.

There are a few things that Kerala should consider. First, it needs to develop a more nuanced and dynamic ‘containment and unlock’ strategy, with the 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 relaxations in and around festivals. Fourth, fresh communication campaigns to improve adherence to Covid-appropriate behaviour should be done. Fifth, the pace of Covid-19 vaccination needs to be further accelerated. Sixth, genomic sequencing should be regularly conducted and the data analysed for faster information sharing. Seventh, the state needs to conduct 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 the middle of 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.

That the sustained transmission and higher reporting of cases in Kerala is the outcome of a high proportion of susceptible population is not an immediate concern, but demands watchful intervention. Though the cases in many 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. They should strengthen their health facilities, accelerate vaccination and learn from each other. That is what would guide India to win the fight against the pandemic.