Indian coronavirus: how the Kerala Cora “success story” was undone

Today, there is anxiety and confusion among people living in a bustling coastal village in the southern state of Kerala, India.

The 4,000 families in Poonthura, a fishing village next to the capital city of Trivandrum, have received strict orders to stay home. No one can enter or leave the place. Companies are closed and transport suspended. Commandos and police have patrolled the streets to enforce a strict blockade.

Earlier this month, more than 100 people in the densely populated villages of Poonthura hugging the Arabian Sea contracted Covid-19 after some of them visited a fish market. This contributed to a sharp increase in infections in a state that, in May, seemed to have domesticated the virus.

“People are confused, isolated and tense,” Father Bebinson, the vicar of the local church, told me. “They can’t tell what suddenly hit them.”

He is right. Just two months ago, Kerala seemed like a striking outlier in the battle against the coronavirus in India. But cases have increased in recent weeks, and the state government is now saying that the virus is transmitted locally through coastal communities, the first such admission by officials in any state since the start of the pandemic in India.

“The real surge in Kerala is happening now. The virus had previously been curbed in a controlled situation when the state borders were closed,” Dr. Lal Sadasivan, a Washington-based infectious disease specialist, told me.

In January, Kerala reported India’s first Covid-19 case, a medical student who returned from Wuhan in China, where the pandemic began. The number of cases steadily increased, and it became an access point. But in March, half a dozen states reported more cases than the picturesque southern state.

By May, faithfully following the contagion control playbook of evidence, tracing, and isolation and involving grassroots networks, Kerala dramatically reduced its case count – there were days when it reported no new cases. “The zero mark,” the Hindu newspaper rhapsodized in an editorial about the containment effort. There were breathless stories about the state paving the curve. “I remember saying that Kerala had accomplished a viral miracle,” says Jayaprakash Muliyil, a leading epidemiologist.

The celebrations were clearly premature. Kerala took 110 days to report its first thousand cases. In mid-July, he reported around 800 infections per day. As of July 20, the number of cases in Kerala had crossed 12,000, with 43 deaths reported. More than 170,000 people were quarantined, in their homes and in hospitals.

One reason, experts say, for this sharp increase is that nearly half a million workers returned to the state from the Gulf countries and other parts of India after the nationwide patrol shutdown, which closed businesses and left people behind. of their jobs. About 17% of Kerala’s working-age population works out of state.

As expected, more than 7,000 of the cases reported so far have a history of travel. “But when the blocking travel restrictions were lifted, people returned en masse to the state and it became impossible to stop the re-entry of infected cases,” says Shashi Tharoor, a leading Indian opposition politician and member of Parliament in Trivandrum.

Tharoor recalls a conversation he had with Prime Minister Pinayari Vijayan shortly after the first repatriation flights carrying Keralites working in the Gulf countries landed in Kerala. “He lamented that not only was the virus entering, but infected people were transmitting the contagion to other passengers on the plane.”

“I think this was inevitable, as all citizens have a constitutional right to go home in India, even if they are sick. But that made a big difference,” Tharoor told me.

The influx has possibly caused an increase in transmission from the local community: since the beginning of May, reported cases without any travel history have increased. More than 640 of the 821 new cases reported Sunday, for example, were hired locally, authorities said. The source of 43 of them is impossible to trace.

The relaxation of the blockade led to many people moving out of their homes and not taking enough precautions. “Some laxity was expected as people started going out to work in most areas. We are trying to motivate them to be safe,” said B Ekbal, head of an expert panel that advises the government on prevention of virus.

Some critics say the tests slowed down after the number of cases fell in what they think is a sign of complacency. These days, Kerala is testing more than 9,000 samples a day, up from 663 in April.

Its evidence rate per million population is lower than in states like Andhra Pradesh, where cases are also increasing rapidly, or Tamil Nadu, which has long been a hot spot. But it is ahead of Maharashtra, the country’s largest access point so far.

Kerala is running a suite of tests: rapid diagnosis, clustering, antigen and antibody, among others, but it is unclear how many cases are being detected in each of these tests. This increases the test numbers, but may not reflect the correct image. “The tests have increased. But it is never enough. No state can perform the tests as widely as necessary,” says Dr. A Fathahudeen, who heads the critical care department at Ernakulam Medical College.

Most epidemiologists believe that Kerala has done a good job overall. The fatality rate (the proportion of people who die among those who tested positive for the disease) is one of the lowest in India. Hospitals are not yet overwhelmed by a surge of patients. The state has the most robust public health system in India. The government has begun implementing first-line Covid-19 treatment centers with oxygen-equipped beds in hundreds of villages.

Kerala is also a warning story against premature media statements about flattening the curve, which involves reducing the number of new cases from one day to the next.

Experts say flattening the curve is a long and winding journey. Gabriel Leung, an infectious disease epidemiologist at the University of Hong Kong, says “the restrictions should be lifted and reapplied, and lifted and reapplied, provided the general population develops sufficient immunity against the virus.”

T Jacob John, a retired professor of virology at Christian Medical College, Vellore, offers an interesting analogy. “Fighting Covid-19 is like running on a treadmill whose speed is accelerating. As the virus spreads, you have to run faster to tame it. It is exhausting, but there is no other option,” he says. “It is a stress test.”