Since January 30, when the first positive case of novel coronavirus was reported in Kerala in a medical student from Wuhan, 241 persons have tested positive so far in the state as per data till March 31. At present, 215 of them are under treatment in isolation at hospitals while 24 have been discharged after full recovery. Two others have succumbed to the illness.
Across India, Kerala stands second in terms of confirmed cases, just behind Maharashtra with 302. Kerala’s reporting of a large number of cases are ascribed to multiple reasons. A majority of the persons who have tested positive in the state are those who have returned from countries in the Middle East, Europe, US and UK. Kerala has a high density of emigrants particularly in the Middle East, followed by the US and Europe. A second reason is the state’s early preparedness and its robust and decentralised disease surveillance system that made it possible to track down primary and secondary contacts of the foreign returnees and monitor them for symptoms quickly. The third, and perhaps the most important reason, is Kerala’s early efforts to step up testing of all those who fit its criteria and ramping up on opening more testing centres and labs.
As per a release on March 31, the state has sent a total of 7,485 swab samples for testing, out of which 241 tested positive and 6,381 have returned negative. The results of the remaining are yet to arrive. This works out to above 188.7 tests per million people, the highest rate in the country now. In contrast, Karnataka’s testing rate stands at a paltry 47.4 per million people, followed by Maharashtra with 29.3 per million people.
But despite having a clear edge over other states in terms of testing rate, doctors and experts in Kerala, wary over the extent of possible community spread in the state, are asking the government to avoid being complacent at this juncture. Only a combination of intensified random testing along with strict lockdown and social distancing measures in the coming weeks can help the state tide over the crisis. The first week of April is doubly crucial for Kerala: it is the last week of mandatory home quarantine for those who returned from foreign countries in the final lot before airports were indefinitely shut. If there is a possibility of exponential rise in cases, it is now.
The general reasoning is that more cases will tumble out of the closet only if states test more. Otherwise, the risk of asymptomatic people spreading the infection unknowingly within the community is high. When more positive cases are discovered, they can be immediately isolated and treated, preventing the virus from transmitting to high-risk category persons such as elderly people, those with underlying conditions like diabetes and cardiac issues and others with prior respiratory illnesses.
“If I ask you to check for diabetes in Kerala by testing among 100 people and you get 5 positive cases, does that mean there are only five diabetic patients in Kerala? No. So you have to test as many people as possible. Right now, we have to ramp up testing by at least 30 times. We’re at a testing rate of nearly 200 per million. We need to reach a stage of 5000-6000 per million,” said Dr. Padmanabha Shenoy, a renowned rheumatologist and immunologist.
Even though the ICMR maintains there is no shortage of testing kits for Polymerase Chain Reaction (PCR), the confirmatory test for Covid-19, several states are reportedly feeling the pinch and are even stocking them up for the most severe cases.
Dr. Shenoy added, “Yes, the number of testing kits are less. But the Centre has to step it up. This is a necessity. Make bulk orders in advance and there are companies that can manufacture and supply them within a week or 10 days. You may have to pay a higher price when you order in bulk, but you need to have the political willpower to do it.”
Dr. Amar Fettle, state nodal health officer (public emergency), said Kerala would certainly want to test more in an ideal world, but that this isn’t one. “In an ideal world, we can do as the WHO chief says. But there have to be resources for that. We’re not the only demanding people. Whatever resources the government of India gets divided among different states. So we have to strike a balance somewhere,” he said.
“Compared to other states, we are doing better. We have tested quite a large absolute number. And the more you test, the more you will uncover. If you have 10 test kits, you may have to prioritise the kits for the most deserving people. In that case, we may not be able to test every person. What will you do with those people? You go for the isolation method. We need tight quarantine and tight management.”
The Kerala health department’s guidelines for testing, quarantine and hospital admission to fight Covid-19 were revised in the second week of March in a potential bid to ease the pressure on the public health system. It laid down specific definitions for a ‘suspect’ case as well as high-risk and low-risk ‘contacts’ of the infected. In a circular on March 12, the government said, “The epidemiology of Covid-19 shows that 75-80 per cent of the affected will develop only mild symptoms which do not require hospitalisation. Severe infection and mortality are seen only in high risk groups like elderly and those with underlying health conditions.
“Just like any viral infection, Covid-19 will also resolve by itself in the majority of the patients. Epidemiology of Covid-19, SARS and MERS clearly demonstrate that hospitals act as amplifying centres for the epidemic. This happens due to the mixing of patients with different risk categorisation in the busy outpatient areas of designated Covid-19 centres. So patients with mild symptoms are advised not to come to hospitals for testing and treatment. Testing is not going to change either the clinical course or management of the patient with mild symptoms,” the circular read.
This change in strategy was seen as allowing more room for the health machinery to focus on those with severe respiratory illnesses and prevent hospitals from getting bombarded with people of all symptoms.
A senior doctor with the national health mission in Pathanamthitta district concurred with the plan. “It is the right way, because we don’t want to overburden the system right now. At least 80 per cent of the people who may have the illness will have mild flu-like symptoms which resolve on its own. They do not require hospitalisation. What they require is only testing for diagnosis.”
“At the moment, since the system is capable, we are admitting them till they test double negative. But there may be a situation in the exponential phase of the epidemic where we may not be able to handle all the positive patients in a single centre,” he said.
Doctors like him are still not able to assess whether the state is testing enough, simply because it has not entered the exponential phase of the pandemic. “We are still in the lag phase where the number of cases being reported per day has not increased significantly.”
In districts like Pathanamthitta, one of the hotspots in the country, doctors said more samples are being sent for testing each day than before, primarily to test the infection among healthcare personnel who have arrived from other states and foreign countries. During the initial phase of the outbreak, Kerala began testing samples only at the NIV lab in Alappuzha. But now, samples are being tested at eight other labs, most of them set up at medical college hospitals. There are also plans to set up corona first-line treatment centres in each district to treat those with mild symptoms in isolation.
So far, the government has ruled out the chances of community transmission in the state sorely on the basis that it has been able to detect the source of infection in every positive case. But the recent sudden death of a 68-year-old in Thiruvananthapuram, allegedly without any foreign travel or contact with infected persons, has roiled doctors and officials. As an emergency measure, the residents of the locality of Pothencode have been asked to go into quarantine.
In cases like this, where the source of infection becomes hard to trace, the idea of conducting ‘rapid antibody tests’ as a preliminary screening test is on the mind of the health department. The ICMR doesn’t recommend antibody tests for diagnosing Covid-19 as it can give false positives and negatives. But Kerala believes it can help throw up those with a recent history of any viral infection and who can subsequently be subjected to a PCR test for confirmation.
Dr. Joseph Chacko of the Kerala Government Medical Officers Association (KGMOA) supported the idea. “We have to start rapid tests immediately to check for community spread. The kits have to be procured immediately and begin to be implemented. If a rapid test is positive, we have to do a confirmatory test. 80 per cent of the patients may be asymptomatic, but they can be carriers of the virus. So randomised rapid tests must be conducted within the community.”
In a release on March 29, the health department said it had obtained approval from ICMR for conducting rapid tests and plans to procure kits that have been given the go-ahead by ICMR and NiV, Pune. But in the days since, the department has not clarified when it plans to begin the process or whether it has obtained the kits.
Dr. Abraham Varghese of the Kerala chapter of IMA acknowledged that rapid tests can give out false alarms. But he added that it could serve as an effective screening test to identify infection within the community. “No test is foolproof. Even then, if we can identify 50-60 per cent of the cases through it, that itself is worth doing it.”
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