How Corona Breached Kerala

In a press conference on March 8^th, Kerala Health Minister KK Shailaja, now also the state’s face for successfully beating deadly viral outbreaks in the past few years, lacked the composure she usually has during media events. As a minister who has received global attention for her ability to contain fatal epidemics, she had all the valid reasons for losing her cool. On February 29^th, a couple in their fifties and their 26-year-old son had travelled from Italy to Kochi via Doha and dodged screening at the Cochin International Airport despite showing symptoms. They took a car from the airport in Nedumbassery to their home in Pathanamthitta district. Along with them, two others in their family tested positive for coronavirus later. The family had tried to hide their illness, despite instructions to the contrary from the authorities. They not only hid their travel details from the authorities but did not even report at the nearest health centre, as has been instructed. When two of their relatives who started showing symptoms later reported to the health department, the family was exposed. The family was still not willing to be admitted to a hospital. “We had to force them. I can’t say anything more at this stage, but I want to tell the people that this attitude will not be tolerated. Covering up the disease will be considered an offence,” Shailaja said furiously. She added that saving their lives was the top priority and all of them were being given proper medical attention.

The minister’s team has been working on a war footing for contact tracing ever since the family members were diagnosed positive. The father, mother and son had boarded a flight from Italy, landed at Qatar Airport and spent an hour and a half there before taking their connecting flight to Kochi. The family did not even confine themselves once home despite showing symptoms; reportedly, they even travelled to Kollam and Kottayam districts to visit friends and relatives.

March 8^th was declared a high-alert day in Pathanamthitta, with all public programmes including house-to-house enumeration for updating the voter’s list being suspended. All the 182 passengers on that Kochi flight were traced and put under surveillance. Seven teams of eight health workers each were deployed across Pathanamthitta. Within a day of the family’s identification, the government had traced 170 people who had come in direct contact with them, of which 58 have been identified as ‘high-risk’ (on the basis of the intensity of contact). The health department estimates that not less than 500 people who had primary and secondary contact with the family will have to be traced and put under observation. (Initially, this number was believed to be as high as 3,000, triggering a scare across the state.)

On March 10^th, an emergency cabinet meeting was convened, leading to speculation the number of positive cases were rising too quickly. Chief Minister P Vijayan and Health Minister Shailaja held a press conference after the meeting and confirmed six more persons had tested positive—all from among those who had come into contact with the Pathanamthitta family, including the couple’s parents aged 85 and 90 years. Two relatives who received them at the airport and another couple of relatives visited by them have also tested positive.

The Chief Minister announced that all examinations except public examinations including those for the eighth, ninth and 10^th standards were cancelled and educational institutions would be closed for the rest of the month. This is the temple festival season and the Chief Minister asked people to keep religious ceremonies at a minimum and avoid large gatherings. He also requested Sabarimala devotees to postpone their visits. Entry to beaches, waterfalls and tourist locations has been restricted. All government programmes for this month have been cancelled. The Chief Minister pulled up the Pathanamthitta family which has not only increased Kerala’s number of confirmed cases but also doubled the risk of infection. The family had obstructed contact tracing by not revealing details of their local travels since arrival. “We collected information from other sources and probed them again and again. Then only they admitted and disclosed the places they visited and the people they met. This is very unfortunate,” says PB Nooh, the District Collector of Pathanamthitta.

The Chief Minister has criticised the Centre’s decision to restrict the entry of expat Indians in Italy trying to return to India. Indians are stranded at airports in Italy because the Civil Aviation Ministry has made it a requirement that they may enter India only if they carry a certificate of having tested negative for COVID-19. “Not letting our own citizens to come back because they are sick is inhumane and savage,” he said. On March 11th, V Muraleedharan, Minister of State for External Affairs, told the media that the Centre is trying to send a team of doctors to Italy to examine Indians. Those who test negative will be sent back to India and others will be given medical care there itself, he said.

Followed by the Chief Minister’s call to avoid large gatherings, organisations in the Malayalam film industry have decided to shut cinema halls in the state. They have also requested directors to suspend ongoing shootings. The Cochin Devaswom Board has decided to suspend festivals in 403 temples under it. Many churches in Kerala have decided to cancel Sunday masses and other religious gatherings.

As of March 10^th, 1,495 people are under surveillance, of which 1,236 have been quarantined in their homes and 256 are in hospitals, according to the Directorate of Health Service’s daily bulletin. Of the 980 blood samples tested till then, 815 have reported negative while results for the rest are awaited. The total number of positive cases in Kerala was 17 at the time of going to press, of which three—the first three in India—have been cured and discharged from the hospital. According to the health minister, those under treatment are stable; the old parents of the Italy-returned Pathanamthitta family are in the ICU.

In addition to that family, a three-year-old baby who returned from Italy on March 6^th tested positive. The baby was diagnosed with fever during screening at the airport and was moved to a hospital with the parents. Results for the parents’ blood samples are awaited. “Being taken directly from the airport to the hospital reduces the risk considerably. If everyone cooperates like this, we can successfully contain the disease,” says Dr Mathews Numpeli, District Programme Manager, National Health Mission, Ernakulam. Initially there was screening only for passengers coming from affected countries, but from March 3rd, the screening has become mandatory. ‘Arrangements have been made for screening passengers at the domestic terminal too. This is aimed at examining those who travel in connecting flights and land at the domestic terminal,’ says Suhas S, the District Collector of Ernakulam. Without cooperation from citizens, all the government’s precautions will come to a naught. Screening and medical examinations have begun at ports too.

KERALA’S HEALTH workers have become famous the world over for containing virus outbreaks almost every year since 2017 when the Nipah virus claimed 18 lives. “A very robust and efficient primary healthcare is our strength,” says Dr Amar Fettle, the State Nodal Officer for COVID-19. In 2018, the state beat back Nipah, recording no deaths. While 2019 was uneventful, the state has been shaken by coronavirus in 2020. The Pathanamthitta family’s case nothwithstanding, the stories of the three coronavirus survivors in Kerala illustrate that strength.

According to the directorate, the state has 6,691 modern medicine institutions, including speciality and taluk hospitals, and primary and community health centres; of the 848 PHCs, 122 work round the clock. Against the National Health Mission standard of a PHC serving not more than 30,000 people, in Kerala it serves 20,506 on average. According to the Rural Health Mission, 1,100 PHCs in rural areas don’t have even one doctor; in contrast, each one in Kerala has a doctor. Every panchayat has one or more health inspectors who are always in touch with households in their area with the support of accredited social health activists (ASHAs). Decntralising PHCs has played a a pivotal role in enhancing the quality of healthcare in the state. Every ward has at least one ASHA, with their total number being 26,000. “Most of the ASHA workers have complete picture of the households in their own wards. They know every family and their profile. This is a major factor that made contact tracing of suspected cases possible,” says Sajna C Narayanan, the District Coordinator for ASHAs in Ernakulam. “Most of the ASHA workers are active workers of Kudumbashree too. This integrated chain of health workers has made preventive healthcare a success in Kerala,” says Narayanan. There are 4.5 million women in the Kudumbashree Project, a poverty eradication and women empowerment programme, the largest of its kind in the world.

As part of their job, ASHAs are responsible for house visits, collection of data on children and pregnant women, and monitoring whether children are immunised and vaccinated regularly and pregnant women get vitamin supplements and medicines. They visit pregnant women in their wards every month. Along with anganwadi workers, they are also responsible for collecting data on fever cases in their localities.

This chain of health workers at the primary level is playing a cardinal role in isolating and quarantining coronavirus-suspected cases. For training health workers, 65 videos have been made so far, uploaded on the directorate’s YouTube channel. For those in isolation, 143 mental health counsellors have been deployed. As of March 10th, 4,350 telecounsellors were available. The directorate has released a flowchart delineating the travel details of the Pathanamthitta family and their relatives who have tested positive. According to Pathanamthitta District Collector PB Nooh, 85 people were contacted on the basis of this flowchart. All the 52 people who arrived from Italy at the Cochin International Airport between March 10^th and 11^th have been shifted to isolation wards. Their blood samples have been sent for tests and results are awaited.

Haseena (name changed) from Thrissur district is a medical student at Wuhan, the epicentre of the novel coronavirus in China. She usually stays back at her university for semester holidays, but this year she had to return to India. “I came back from Wuhan on January 25th and reported at the primary health centre in my panchayat on the very same day. The health inspector in my locality asked me to keep myself in home quarantine. She gave me all instructions for living in isolation at home. She was very caring and supportive. Her daughter is also studying in China. I had no symptoms at that time but still followed all her instructions. She used to call me three times a day inquiring whether I have any symptoms, fever or sore throat. On the 29^th morning, I had sore throat and promptly informed her. She gave me all emotional support and told me that she would pass the information to the authorities and will follow their instructions. On the same day, the district authorities sent an ambulance and I was shifted to the hospital. Even though, I was shifted from the district hospital to the medical college later, my health inspector used to call me everyday till the day of discharge.”

Sheeba, a health inspector, says, “My daughter is in China. She has not returned yet and I was worried about her. Haseena was very cooperative to us. Being a medical student, she was quite aware of the need of following instructions. She has never created any headache to us.” After Haseena’s arrival, Sheeba discovered five more persons had returned from China in her locality. She contacted all of them, put them in home quarantine, traced all their primary and secondary contacts and asked them too to stay in home quarantine for 28 days.

“There is a change in the attitude of the people,” says Joby VJ, who has been working as a health inspector for 23 years in Thrissur. “We regularly conduct health programmes and campaigns. People’s participation has doubled over the years. The lessons learnt from Nipah outbreak have helped a lot. Now we have the confidence that airborne diseases also can be contained,” says Joby. He adds that there is a shift in the ‘class character’ too. “We used to see only people coming to PHCs in bicycles 20 years back. Now we can see people coming in Fortuners.”

Those who are put under home quarantine are regularly contacted by health workers .There are mental health counsellors under every district medical officer for support to people put in isolation. “Being in isolation in a hospital in Kerala is actually fun. There is nothing to be scared,” says Shakir Subhan, a traveller and video blogger who was put in isolation in Kannur district hospital for three days. Shakir was travelling from Iran to Azerbaijan and was prepared to travel to Russia but was denied permission due to the coronavirus outbreak. A school dropout who speaks nine languages including Arabic and Russian, Shakir has so far visited 24 countries across the globe. He has also travelled across 26 Indian states. “In many countries, being in isolation is hard. The priority is to prevent the spread of the disease. The welfare of the isolated person is not given importance,” he says. Shakir’s video blogs from the airport and the hospital during his isolation have become popular.

“We have to strictly follow the instructions given by the government. It is not only for our welfare, but for society too,” says Jafar (name changed), a coronavirus survivor from Alappuzha. He is also a medical student in Wuhan. After surviving COVID-19, Jafar has reset his goal in life: “I have only one mission in life. After completing my course, I want to come back to Kerala and join the health service under the government. I want to give something in return to the government that cared for me like a parent.”

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