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Wednesday, April 08, 2020

3 patients, 2,155 persons under quarantine: Why Kerala could have a lesson on how to contain coronavirus

With three positive cases of coronavirus and 2,155 people under quarantine, Kerala has not seen a virus outbreak of this scale since Nipah in 2018. However, an early start in screening people coming from China and a resolute disease surveillance system has helped Kerala minimise its reach.

Written by Vishnu Varma | Kochi | Published: February 4, 2020 7:01:48 pm
Coronavirus, Kerala coronavirus, coronavirus cases kerala A man wearing a surgical mask makes a child wear one outside the government general hospital where a student who had been in Wuhan is kept in isolation in Thrissur. (AP Photo)

A telling comment by Kerala’s health minister K K Shailaja during a presser on Sunday, perhaps otherwise ignored, was when she said that the health department and the state government is insistent that it know about every patient who may test positive for coronavirus infection in the state.

“Even if there’s one case, the health department is adamant that we know about it,” she said.

This remark alone is a marker of the bureaucratic confidence on the dogged and resolute disease surveillance system of Kerala that has proved to be highly effective in past years when dealing with viral infections like dengue, H1N1 and the 2018 outbreak of Nipah. And this year too, with the novel coronavirus being found positive in three medical students in the state, the surveillance system has been successful in isolating all of them and putting their likely immediate contacts within home quarantine before it could spill into the community.

As of Tuesday morning, three medical students who had returned together from the outbreak epicentre of Wuhan in Hubei province in China, and who later tested positive for novel coronavirus, are being treated within the highly-equipped isolation wards at government hospitals in Kasaragod, Thrissur and Alappuzha districts. Their conditions are said to be stable.

As part of surveillance, a mammoth list of 2,239 people has been charted, all of whom arrived in Kerala from virus-affected countries and a majority of those who are studying to become medical professionals in Wuhan. While 84 of those have been admitted to select isolation facilities across the state, the rest, 2,155 persons, have been placed under home quarantine.

An early jumpstart helped

Workers walk with garbage after cleaning an isolation ward at a hospital for observing people suspected to have a new coronavirus infection in Kochi. (AP Photo/Prakash Elamakkara)

In late December last year, when reports emerged of a new variety of viral infection with its epicentre in Wuhan in China, health department officials in Kerala were immediately alerted. They knew that Malayali students account for a sizeable section of the medical community in Wuhan and if the outbreak isn’t effectively contained, a lot of them could return to the state, triggering a potential health crisis.

And so when the WHO declaration on the severity of the virus came about, Kerala had already begun stacking up a line of defences to counter the outbreak. Preliminary screening procedures were put into place at the four international airports, beginning with Cochin, where returning travellers were handed over strict advisories on contacting medical officials in case of symptoms. If they showed symptoms at the airport itself, a sterilised ambulance was ready to ferry them to the nearest medical college where isolated wards were set up. Travellers were briefed on basic do’s and don’ts’ of home quarantine and their contact details were collected for subsequent surveillance.

“Of these people coming from places like Wuhan, there are two kinds. If they are asymptomatic (producing no symptoms), then they need to be confined to their homes and take a lot of precautions which we have already issued. That’s called house isolation. And if the people are symptomatic, they need to come into the health system by accessing the district hospital or the Medical College,” Rajan N Khobragade, the state health secretary, earlier told indianexpress.com.

Drawing from past experiences like battling Nipah and the floods in 2018, the health department went on to set up Rapid Response Team (RRT) at the state level to finalise guidelines on treatment, isolation of suspected patients and home quarantine measures. Awareness classes for doctors, nurses, ambulance drivers and paramedics were conducted. A pan-Kerala public awareness campaign was also set in motion to prevent miscommunication and fear within the community.

Transparency is key

Journalists wearing surgical masks stand outside the government general hospital where a student who had been in Wuhan is kept in isolation in Thrissur. (AP Photo)

A prime feature of the Kerala government’s response to calamities like the back-to-back floods or the Nipah crisis in 2018 that claimed 18 lives has been its transparency and openness. The tradition continues during the coronavirus outbreak as well. Top officials of the government have shown no reluctance in disclosing key information as and when required and allowing it to percolate down to the public. Press conferences have been routinely held, especially by the health minister herself, when positive cases of infection are reported. Daily bulletins are released on the government’s isolation and quarantine measures.

At the same time, a clear hierarchy has been fixed with certain officials designated to speak to the press on the crisis. This ensures no one speaks out of line.

“What happened in Wuhan is that the Chinese government suppressed the information, whereas Kerala has done exactly the opposite. Right from the beginning, we have been open about the data and cautioned the public. Whenever a case is reported positive, they are informed. Right from my time (as health secretary), the policy has been that we have made it totally transparent. That’s why the bulletin from Kerala is trusted,” said former health secretary Rajeev Sadanandan, who played a major role during the Nipah crisis.

“Anybody who has come and looked at our system has said there’s nothing more to be done. Everything is perfect,” he added.

Tight contact tracing goes a long way

People wearing surgical masks walk out of a government general hospital. (AP Photo)

The declaration of the coronavirus epidemic in Kerala as a ‘state calamity’ by the LDF government late Monday night has been aimed at strengthening surveillance measures at the ground level, ensuring seamless coordination between officials of different departments and making swift decisions. The move can equip district collectors with more powers to take quick decisions as well as bring the administration under the purview of the Disaster Management Act.

The health secretary told reporters, “We are not waiting anymore for positive cases (of infection) to come. We will be prepared to take containment action and will not have lag time.”

Health officers who went on leave have been asked to return to work while the state rapid response team has been expanded. Health officers at the district level will assist with troubleshooting and supportive supervision.

Sources within the health department said they expect more positive cases of infection to emerge, most likely from the pool of 84 patients who, until Monday night, are under isolated care at hospitals. Similar to the case of Nipah outbreak in 2018, but on a much larger scale, health workers are manually and meticulously tracing a list of persons who may have been in contact with the coronavirus positive patients. Immigration data from the passport department at airports are used to trace those with travel history from Wuhan and other places from China.

Another section of workers are also making phone calls, twice daily, to the over 2,100 people under home quarantine in the state. They are advised, often sternly, not to step out of the house, to give public occasions like marriages a miss and stick religiously to government advisories.

Dr Sulfi N, an ENT specialist based in Thiruvananthapuram, explained: “Right from the top to bottom of our disease surveillance system, there are a lot of public health experts. It’s a group of doctors who have done their post grads in community medicine and public health. So they naturally have the scientific know-how and experience of containing an outbreak like this. They have been able to create an effective decentralised model that goes down to primary health centres and health workers at the grassroot level.”

The challenge before the state health department lies now in providing supportive care of the highest standards to those already under treatment and preventing hospital-acquired infection. Since the virus itself has a 2 per cent mortality rate and could only prove to be lethal to those with pre-existing conditions, deaths are unlikely in Kerala, officials say.

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