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The Kerala Conundrum: High daily Covid cases and TPR are a contrast to the rest of India

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It was with a sense of despair that Dr A Shibulal watched people crowding stores and markets in Malappuram, a district in northern Kerala, when Covid restrictions were recently eased across the state just ahead of Bakrid. “The result will be that we will have to spend more sleepless nights, organising ambulances, helping shift patients and arranging for beds with ventilators,” says the district programme manager of the National Health Mission in the district, which has the second highest number of active cases in the state, at 16,885.

That apart, Dr Shibulal is not unduly worried about the number of cases reported daily in the district and the rest of the state, an outlier compared with most parts of the country. “The fact that the numbers are broadly consistent, without sudden spikes, is reassuring. And we have the infrastructure to take care of those who test positive,” he says.

This is the sentiment shared by most experts in health and epidemiology when discussing Covid-19 in Kerala, a state lauded for its ability to manage the pandemic but about which questions are now being raised. Daily cases continue to stay above 10,000 since the peak in May and test positivity rate (TPR) has remained at 10% on average, even as active cases have reduced in most states in India and the national TPR, or the number of those positive of every 100 tested, has been below 3% for the last one month.

“By and large Kerala has plateaued. As long as cases are not a burden on the healthcare system and the state is able to manage the numbers without a surge, that would still be alright””

— Tarun Bhatnagar, senior scientist, ICMR – National Institute of Epidemiology

It might seem that Kerala is marching to its own beat ever since the first case of Covid-19 in India was reported from the southern state — a medical student who had returned from Wuhan who, incidentally, tested positive again earlier this month. Due to strict contact tracing and testing norms, effective containment strategy and adequate preparation, Kerala was able to keep the number of cases in double digits till late June last year. Then, when cases in most other states began coming down after a peak in September, Kerala continued to see daily numbers in the region of 5,000, till about late February after which cases began reducing. By this time, the second wave was beginning in other parts of the country. A similar scenario seems to be unfolding now, too, points out Rijo John, a health economist in Kerala, who has been analysing the progression of the pandemic in India. “Given that Kerala started seeing a surge over a month after the surge in other states, it’s only natural to believe that the state will see normalisation only later,” says John, adjunct professor, Rajagiri College of Social Sciences.

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Rajeev Sadanandan, founding CEO of the non-profit Health Systems Transformation Platform and a former bureaucrat in Kerala who is advising the chief minister on Covid, says other states had sudden surges, after which it came down to near zero. “Kerala has kept even the surges at low level, leaving a larger pool vulnerable to infection. This happened earlier also, a mild crest followed by a long plateau, and the same questions were raised. With the Delta variant, the tail has got thicker.”

It’s more critical to look at a trend over a prolonged period such as 2-3 weeks to get a clear picture rather than daily case numbers, says Tarun Bhatnagar, senior scientist, ICMR-National Institute of Epidemiology in Chennai. “In those terms, by and large, Kerala has plateaued. There are some spikes in between but broadly it’s remaining at a certain level, which is interesting. We are not seeing this in other states,” he says.

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One way to look at Kerala’s relatively high numbers is that the reporting is robust and more reliable than other states, says Bhatnagar. While a TPR of over 10% is high, this, too, has plateaued. “What needs to be analysed is who is being tested: if it is only those who are at very high risk then your positivity will be high,” says the epidemiologist.

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This is the argument health professionals in the state put forward as the reason Kerala is reporting more positive cases. “Our testing strategy is to ensure none of the high-risk groups more vulnerable to infection are missed — that’s more important than going to an unaffected group, finding a low value and developing a false sense of complacency,” says Dr Amar Fettle, the state’s nodal officer for Covid and H1N1. District surveillance units, he says, determine the percentage to be tested and carry out tests among those who have more public exposure, like ration shop dealers and bus conductors. TPR, says a doctor practising community medicine in a Kottayam hospital, depends on the denominator. “Of course, the fact that it’s high indirectly means that there is the possibility of a lot more undetected cases in the community,” she adds, requesting not to be named.

Among the states with the most active cases, Kerala is conducting the most number of tests per lakh population. Following strictures from the Supreme Court which asked why the state had eased restrictions amid a high number of cases, the chief minister’s office has announced it would be increasing the number of tests further and would not ease curbs in the week ahead.

“Our testing strategy is to ensure none of the high-risk groups that are more vulnerable to infection are missed — that’s more important than going to an unaffected group, finding a low value & developing a false sense of complacency that there is no problem””

— Dr Amar Fettle, state nodal officer for H1N1 & Covid, Kerala

“The question of whether you have more cases or not is dependent on whether you are testing really well. In most states, nearly half the testing is done in the capital city. The remaining half is mostly done in district headquarters,” says Dr Giridhara Babu, epidemiologist and professor, Public Health Foundation of India. Testing in rural areas is hardly done although according to the latest sero survey by ICMR, the sero prevalence in rural areas is similar to that in urban areas. In Kerala, in contrast, there is not too much of a distinction between urban and rural testing, he says. Kerala continues to have a larger number of people susceptible to the infection according to the latest sero survey, which found the state had a sero prevalence of 42.7%, considerably lower than the national average of 67.6%. After the first wave, the state’s sero prevalence was 11.6% compared with the national average of 21%.

The key question is whether the state will be able to manage the number of cases which, so far, it has been able to. It was able to avoid the devastation in states like Delhi and Uttar Pradesh during the peak of the second wave when hospital beds and oxygen were in short supply. “As long as cases are not a burden on the healthcare system and the state is able to manage the numbers, without a surge, that should still be okay,” says Bhatnagar.

But successful isolation of those testing positive is turning out to be a challenge, say policymakers and doctors. In Malappuram, for instance, Dr Shibulal says families prefer members to be at home rather having them shifted to a Covid care centre even if that means other members are at risk of infection. “Kerala needs to ensure better isolation at home and contact tracing by the system. It is still doing well in detecting transmission but in terms of interrupting transmission, I don’t see the state making the same efforts as in the first wave,” says Dr Babu. Sadanandan says people don’t seem to be collaborating as much with the government as they did in the first half of last year. “Increased testing does not help, if positive persons and their primary contacts are not quarantined. Kerala is not able to do that.”

“What helped Kerala in May 2020 was the awareness and precautions taken by the people. (Now) people appear to have discounted the threat from the virus and no longer see the need to collaborate with the government””

— Rajeev Sadanandan, honorary adviser to CM on Covid

In the coming weeks, what can make a difference is vaccination. Sadanandan says if the state manages to vaccinate about 70% of the population by the festival of Onam, which falls in late August, it can avoid another surge. So far, about a third of the total population have got their first dose, with doctors saying there seems to be a supply bottleneck.

But many also say the state’s fate is now in the hands of its people. “It’s not just the responsibility of healthcare workers to ensure they don’t spread the disease or try to avoid getting infected. It’s a responsibility that has to be undertaken by each and every person,” says Dr Shibulal. “We are exhausted.”

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