The China outbreak of coronavirus (COVID-19) infection has claimed thousands of human lives so far. The number of people infected is hovering around 1.5 lakh mark, with new hotspots emerging globally. Initially, India — a country that received several thousand people from China during this period — strangely reported just 3 positive cases. All three were from Kerala. While Kerala had predicted that rest of India, including large cities such as Mumbai and Delhi will see a much larger number of passengers touch down from China and it can have more number of suspected cases. Of the 33,500 total suspected cases reported in the country so far, a larger portion was still in Kerala. Given that it is highly unlikely that other states had few suspected cases, Kerala has once again proved its high alertness to pick up every possible case. On the flip side, there is a high chance that there may have been many missed diagnoses in other parts of the country, given the absence of a robust surveillance system.
In Kerala, though the surveillance of suspected cases is still on with an extended quarantine period of 28 days against the 14 days recommended by the Centre, Kerala has bolstered its track record of fighting health emergencies, which received acclaims even from international agencies. It must be adopted by other states in the country as well as other countries. Kerala’s health minister K K Shailaja, who led this mission on a war footing, says that the way the state managed a totally unexpected Nipah outbreak in 2018 was a great lesson. Although handling such a huge load of potential carriers of the virus was not an easy task in the case of COVID-19, lessons from previous experiences helped to make the interventions faster in this case. Edited excerpts of her Straight Talk with Editor.
China is still struggling to contain the virus and its spread. Even deaths are on the rise in Mainland China and Hong Kong. Other countries, particularly those that have active travel links with China, too are reporting a rapid spread of new cases and even deaths. Indian states like Delhi, Punjab, Maharashtra and Kerala too were quite prone to the infection due to travel links with China due to business, trade and educational ties. But Kerala acted exceptionally well in reporting the cases and controlling the spread in a much shorter span of time. How did you manage it differently?
We had expected passenger inflow in large numbers from China and other affected countries since Keralites are spread across the globe. More worryingly, the outbreak in China’s Wuhan campus had sent real shock waves to Kerala as this campus has many students from this state. These students wanted to travel back home as panic-stricken parents had no choice but to call their children back. This was in addition to the normal passenger traffic from China in connection with trade and tourism. So we decided to act immediately after the news of the COVID-19 outbreak reached us. Prevention measures had been planned in the state much before the national alert by the central agencies. We knew that with no known treatment protocols for the infection, it has to be managed with rapid infection control measures like passenger screening, patient isolation and symptomatic treatment, contact tracing, home quarantine and mass awareness.
In fact, we were extra alert as the state has, by now, become an epidemiological hotspot with several sudden health emergencies taking place in the recent past. Moreover, Kerala is always more vigilant as far as healthcare protocols are concerned as compared to any other state because of the higher standards of hygiene and general awareness of the people. To top it all, we had created and executed a foolproof system to take such challenges head-on after the Nipah outbreak.
Immediately after the Chinese epidemic hit the headlines, we contacted the centre for help on passenger screening at all the airports and also to flag off necessary health emergency protocols, including quick sample tests at the National Institute of Virology and the availability of medical supplies if necessary. Simultaneously, the state machinery jumped into action. A rapid response team (RRT) was formed under the health ministry as per special instructions from the chief minister and we also set up control rooms at all districts, along with special squads of health workers and volunteers. The state government also issued alerts asking the public to notify us about the arrival of passengers from China. Medical authorities, hospitals and doctors were given special instruction to notify related symptoms in patients. Since we were also aware that this virus may lie dormant without any symptoms throughout its comparatively long incubation period (14 days) and can easily spread by human-to-human transmission even during the dormancy, isolation wards were set up at all government hospitals and medical colleges. Also, we asked all major private hospitals to prepare isolation wards and allot beds for emergency requirements, to which they readily agreed. Doctors, medical officers, nurses, other healthcare workers and even ambulance drivers across the state were given proper training to handle infected patients. Overall, it was well coordinated and conducted, with full cooperation from district and village level administrations, the medical and healthcare community, Indian Medical Association, NGOs, social groups, media and the general public. There were even street plays organised to spread awareness about this newly found infection and also to promote special hygiene to avoid chances of infection. Other ministerial heads and departments of the state government were also very active and helpful in fighting this emergency, making sure that not even the smallest case is left unattended.
Do you really think positive cases in India were limited only to the three confirmed in Kerala?
Officially speaking, it seems no other confirmed cases have so far been found in the country; rather, we don’t have any proof to claim that there were others. But considering the alarming spread of the community level infection and related deaths in China and in other parts of the world via travel links, it is hard to believe so. A country like India, which has thickly populated cities, high and frequent people mobility and very close travel links with China and other affected countries could have potentially received more carriers.
Since COVID-19 was milder as compared to earlier versions such as SARS and MERS, it is possible that people might have been infected in large numbers, but the symptoms were not really visible. In such cases, it is often difficult to spot the infection unless there is very vigilant passenger screening or contact tracing in place. The other possibility is of missed diagnoses or misdiagnoses. Many might have simply ignored the symptoms or might have mistaken it with common cold or fever. There could be even deaths that have happened in hospitals or homes, but the cause may have been misread as other kinds of fever, cardiac arrest or even other pre-existing diseases of the victim. So we don’t know for sure how many real cases were there. The real danger with such negligence is that the virus can potentially spread to a larger population and things can go completely out of control sooner or later. However, so far, there is no evidence for this.
What was the total number of infections reported so far in Kerala and how many are still under surveillance?
Close to 4,000 suspected cases were kept under surveillance with a quarantine time of 28 days. This includes both home quarantine as well as isolation inside hospitals. Many were discharged as per the guidelines for home and hospital isolation. As of today (16th February), there were about 2,276 people under surveillance. Out of this, 2,262 are under home quarantine and 14 are in designated isolation facilities. Till date, 418 samples from highly likely cases were sent to National Institute of Virology for testing, out of which 405 results were negative. The results of the rest of the samples are awaited. Out of the three persons who tested positive for COVID-19, two have been discharged as their repeated test results have come negative. The third person is stable now and his repeat test results are awaited.
Kerala has, by now, proven that it can handle such health emergencies, containing them within the shortest period before they are blown out to a real epidemic. What would you suggest to the world, given that many countries are finding it difficult to bring it under control and Chinese authorities are engaged in a sort of blame game within as far as the poor management of the outbreak is concerned?
Certainly, there are chances of the rapid spread of such infection at the original source as the authorities had no clue of the situation in the beginning. Disease outbreaks are often unannounced and unexpected. In the case of Nipah outbreak in 2018 in Kerala, it was almost the same situation as we had no clue then on what it was all about and where it has come from. So, there were some deaths that happened before we could discover the virus and assess the real situation. However, a quick and prompt understanding of the disease and an attempt to coordinate with all concerned agencies at the district, state, national and international levels within no time helped us limit the deaths to very few numbers and to bring the situation under control in a short span of time. Understanding the cause quickly and assessing the gravity of the situation was the real turning point in this whole exercise. For this, the help of a well experienced and updated medical team is inevitable. Since many of these newly found viruses have no preventive or curative remedies, the only solution is to prevent the spread and contain the same as fast as possible. My earnest and simple advice for this is: Always be prepared for such situations and keep your people updated, trained and make the necessary infrastructure, supplies and services available at all times; Ensure that the public is aware of the dos and don’ts at the earliest and take care of even the smallest thing with due seriousness.