Covid-19: Kerala worried as new cases pop up in green zones, prepares for return of expats

A string of new infections in double digits in districts that had been declared Covid-19-free has heightened worries among health officials in Kerala at a time when the state has been leading from the front in combating the pandemic.

Between April 12 and April 20, the state recorded only 34 new cases of coronavirus in a sign that the curve of new infections was beginning to stabilise. In those days, the number of patients who recovered from the infection each day remained consistently higher than new cases. But between April 21 and April 27, the state saw 74 new cases added to its tally, taking by surprise doctors and health officials in war-rooms who had been keeping a watch on the situation.

In fact, Kottayam district in central Kerala, which had the last of its coronavirus patients getting discharged in the first week of April, accounted for 17 of those new cases. The neighbouring hilly district of Idukki, which was also Covid-free by the second week of April, reported 14 cases. Both districts, plotted under 'green zone' had been enjoying the fruits of lockdown relaxations when they were swept by new cases of infection.

What's especially worrying is that the state's health department has been unsuccessful in pin-pointing the source of infection in at least 10 patients, deepening fears of a silent transmission of the virus within the community. A student from Panachikkad, a headload worker in Kottayam, two nurses hailing from Thiruvananthapuram and a businessman in Vaikkom town are among those where the source of infection hasn't been proved yet. In addition, the state hasn't been able to detect the source of the infection in the four-month-old girl from Manjeri or the 68-year-old man in Thiruvananthapuram, both of whom succumbed to the virus. But when asked about the same, Chief Minister Pinarayi Vijayan at his daily press briefing dismissed reports of 'community transmission', adding that the state hasn't entered that stage yet.

'Virus doesn't understand boundaries'

Dr Abraham Varghese, president of the Kerala chapter of the Indian Medical Association (IMA), said the state government's decision to classify districts such as Kottayam and Idukki as green zones based on the number of infections and offer them immediate lockdown relaxations was not a sensible one. "The virus clearly doesn't understand boundaries. When you classify a district as a green zone, you give the people there a false sense of confidence. They think they are safe and will rush out onto the roads. Such attitudes cannot be entertained," said Dr Varghese.

"It's like a mosquito net. If we end up leaving gaps in the corners, the mosquito will take advantage of the loophole to enter. The virus acts similarly. There cannot be any laxity on our part. We have been able to reduce the mortality rate because of social distancing and a stringent lockdown. Otherwise, the number of cases would have gone through the roof."

With the reporting of new cases this week, the government classified both Kottayam and Idukki as red zones where people can step out only for essential services. Four others – Kasaragod, Malappuram, Kannur and Kozhikode – are also in the red zone. Eight other districts are in orange zone where some relaxations have been offered for the public.

The Kerala branch of IMA agreed with the Kerala government's contention that the national lockdown must not be lifted at once post May 3, but relaxed phase-by-phase. Restrictions must continue in the red zone districts and individual hotspots where clusters of cases are suspected. At the same time, to ease the economic pressure, relaxations on resuming certain kinds of businesses can be applied in other places. But, all social, political, religious and cultural gatherings must be banned. Inter-district and inter-state public transport will be suspended as well.

Asymptomatic cases on the rise

States like Maharashtra and Gujarat detecting the novel coronavirus in asymptomatic patients with greater frequency has made health officials in Kerala sit up and take note too. Though the official daily health bulletins in Kerala do not classify the active cases on the basis of symptoms or the lack of it, a source confirmed that a lot of infections in recent weeks have been detected in asymptomatic patients. When such patients cannot confirm a source of infection such as travel history or contact with a Covid-positive person, it becomes more complicated and dire. Fears of the virus having entered an exponential stage deepens at that point. But both chief minister and health minister KK Shailaja have repeatedly denied such a phenomenon.

Experts say Kerala cannot be complacent with the degree of progress it has achieved. It has to ramp up testing of samples, carry out extensive contact tracing and continue to implement stringent lockdown measures in vulnerable areas.

"The next stage of transmission has begun in Kerala where people coming from other states and foreign-imported cases are testing positive. The community spread is small at the moment, but it's happening. Earlier, we were able to trace the source of infection in 98% of the cases. But now, it has reduced to 80%. So the gap is widening. We have to be more careful," said Dr Padmanabha Shenoy, an immunologist and rheumatologist based in Kochi.

He added, "In a video on January 31, I had said that asymptomatic persons are going to be the challenge in controlling this disease. That's why we are asking to increase the testing rate of samples. When people start arriving from other states and countries and as we move toward a community spread, we have to increase testing. Only when we test a large section of the population will we be able to gauge the problems we face."

States across India have expressed hurdles in ramping up testing, specifically due to the shortage of PCR testing kits. Kerala is no different either. In the initial days of the pandemic, Kerala's testing rate per million was far ahead of the others. But soon, it was overtaken by states like Maharashtra, Gujarat, Delhi and Andhra Pradesh who subsequently reported a spurt in the number of cases, in connection with the Nizamuddin gathering. This week, CM Vijayan said the government has adequate stock of testing kits, procured in part through MPLAD funds of Congress MPs Shashi Tharoor and Hibi Eden, and plans to increase testing. On April 26, as opposed to the under 600 samples it tests on any given day, it sent over 3,000 samples as part of random testing. Available results of those samples showed 2,682 samples negative and just three testing positive.

The Kerala government is also hoping to get formal approval from the Indian Council of Medical Research (ICMR) for the indigenous testing kit developed by a team of scientists and clinicians at the Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) in Thiruvananthapuram. The diagnostic test kit showed 100 per cent accuracy during trials at NiV, Alappuzha and matched with testing results conducted using RT-PCR. It can detect two regions of the gene, which will ensure that the test does not fail even if one region of the viral gene undergoes mutation during its current spread. The process of testing can be done in under two hours and the cost incurred for testing will be less than Rs 1000.

The iceberg phenomenon

Dr Abey Sushan, district programme manager with NHM in Pathanamthitta district, said all indications show that the coronavirus pandemic displays an 'iceberg' characteristic where clinicians and doctors can see the tip of the iceberg which represents the symptomatic and diagnosed cases. But the large submerged, hidden portion of the iceberg contitutes the asymptomatic, unrecognised portion of the disease among the population.

"This is actually the nature of the epidemic. There will be a large percentage of people who are asymptomatic and not being tested. There will be such people within the community…so first, we have to find all those people who are likely to test positive and isolate them. But however much we try to isolate, there will be some entropy. Some people are likely to fall out of the surveillance net because people move around a lot. These are inter-district or inter-state travellers such drivers of goods carriers. They are at high-risk," he said.

"Our strategy in Pathanamthitta is to identify a lot of these people driving into the district with essential goods and then find people who may have had social interaction with them."

So far, Kerala hasn't entered the exponential phase of the pandemic where case numbers will double in 3-4 days, said Dr Sushan. But it is an eventuality for which the state needs to prepare.

"When we go into the phase, we will see overwhelming of the health system in districts where the machinery is not adequately prepared. In Pathanamthitta, we think the peak will come in mid-June to mid-July and we hope that it will be over by September," he said.

Even in Japan, where social distancing is a norm and not a newly-acquired trend, the coronavirus has entered the expoential phase. India, in comparison, is a country where social interactions between people are much higher.

"The idea is to prepare the health system for such a phase. We are focusing on training the people and ensuring that infection control practices are being adhered to. So that when the exponential period sets in, we can be as prepared as we can be," he said.

The inward flow of expatriates

Even as it continues to snuff out new infections in the state, the government's toughest challenge is yet to come. Nearly three lakh Malayali expatriates, a majority of them from the Middle East, have registered themselves on a government website to come home when international flight operations to India will resume. That's about 13% of the estimated 22 lakh Malayali expatriates settled around the globe.

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For a severely-strained health machinery that has been working round-the-clock to tackle Covid-19, a huge flow of people into the state at a time like this is further strain on resources. But the chief minister has been clear about the government's task at hand. "This is their home. This is where their families are. They have every right to come home. And when they do, we will be ready to arrange facilities for them," he said at a press briefing this week.

Though the Centre hasn't given the green signal yet, Kerala has already begun to prepare the groundwork for facilities to quarantine a vast majority of them when they arrive. Instructions were passed to all district collectors to find such facilities. These include government and private hospitals, hostels, schools, hotels and lodges, resorts, Ayurveda retreat centres, auditoriums and stadiums. For those willing to pay for better facilities, such options will be available too.

But can the government afford to house everyone who arrives from abroad? That's the major bone of contention. Doctors at IMA argue that foreign returnees must not be released into home quarantine as that could jeopardize the surveillance measures and foil the success the state has achieved till date.

Dr Varghese said, "Allowing them to go home is suicidal because they might go around visiting people. Their quarantine has to be institutional, for a period of 28 days. Also, everyone who comes in must be investigated, not just the symptomatic ones . Even if they are asymptomatic, they can turn out to test positive later."

Dr Fazal Gafoor, president of the Muslim Education Society (MES) and a member of the Covid-19 task force constituted by the government, said the administration also faces a logistical dilemma in bringing these expatriates home.

"Even when you bring them home on flights, safe distancing has to be practiced. There has to be a minimum of 3-ft distance. Only two out of the six seats can be occupied. So on a 200-seater aircraft, you can bring only about 70-80 people at a time. Therefore, there's the question of how many flights we will have to operate to bring thousands of these people home. It will take months," he said.

The cost of air tickets will naturally go up as airlines will not only have to sell fewer seats but operate empty flights from the state to Gulf countries to bring them back, he added.

The government on its part has indicated that it will have to accord priority to those who have legitimate reasons to come home. These include pregnant women, handicapped persons, elderly people who need medical treatment, students, those on visiting visas and finally those who have lost their jobs and a place of residence. An extensive screening will be conducted at the airports therefore to prioritise among the travellers.

Dr Gafoor said there was a key difference in the attitudes of the Gulf states, where 2 million Malayalis live and work, and that of Kerala.

"Their attitude is that in case of an outbreak, people who contract the disease will be treated. But some people will die. So it can be dealt that way. That's why we hear some complaints of people there who test positive being told to remain at home. But our attitude (in Kerala) is that we don't want a single person to die."

(Inputs and image from theindianexpress.com)