Kerala has been reporting sustained SARS-CoV-2 transmission, nearly half to two-thirds of daily new cases in India, and the highest test positivity rate (TPR) in the country. Enough has been written on the need to pay attention but not get overwhelmed by the Kerala numbers. In this piece, we analyse the COVID-19 pandemic situation in Kerala from a solution perspective, and propose a few ways forward.
First, suppressing and halting the transmission has to be immediate priority and the state needs to develop and implement a more nuanced and dynamic ‘micro-containment and unlock’ strategy. For this, local epidemiological parameters need to be followed. There is limited value in night curfew, reducing opening hours of shops and weekend lockdowns. In fact, these can actually result in paradoxical overcrowding—and should be avoided. Instead, businesses could be encouraged to extend their opening hours to the pre-pandemic period, to reduce crowding. Indoor crowding is far more dangerous than outdoors, and this must be the chief scientific foundation of such restrictions.
During the pandemic, there has always been a spike in cases after a long festival season, in any part of the country or world. Therefore, a linked aspect is that the state should avoid initiating sudden relaxation measures in and around festivals. Instead, a gradual relaxation is preferred which will prevent a sudden spurt in crowding.
There should be ban on large gatherings regardless of their purpose—political, business, entertainment, social or religious—until the caseload drops significantly. The state government needs to adopt strict adherence to restrictions, which should be scientifically designed and based on review of local data, aiming to identify activities that involve greatest risk. Without review, the same mistakes get repeated endlessly.
Second, there is a need for active engagement of community members, local bodies and civil society organisations to achieve citizen participation in pandemic response. For instance, unvaccinated people voluntarily need to avoid public functions and gatherings even in open spaces. The partially vaccinated individuals can avoid gatherings in closed spaces, while open spaces are less risky. With citizen engagement, this is more likely to succeed than through government mandate. Community and local elected representative participation would be needed for ensuring that any religious and social gathering does not result in violation of COVID-appropriate behaviour.
Third, communication is an important aspect of the pandemic management, and flawed communication has resulted in problems even in developed nations. The knowledge of epidemiology means little unless it translates into practical solutions for implementation and public messaging. Innovative communication drives/campaigns to improve adherence to COVID-appropriate behaviour (CAB) should be undertaken. The learnings from other settings, such as free mask distribution and correct mask wearing, need to be repeatedly followed. The assistance of professional agencies in designing communication strategy and material should be explored.
Fourth, the pace of COVID-19 vaccination in Kerala needs to be further accelerated. As central government has promised to supply as much vaccine as needed, the state government should optimise this opportunity and consider a mass vaccination drive and achieve maximum possible coverage, initially with one shot of vaccine. Vaccination roadblocks must be removed and the entire infrastructure in both public and private sector must be geared towards completing vaccination at a smooth pace. Interventions should be designed to address vaccine hesitancy. Customised strategies for incentivising vaccination will help boost acceptance, particularly in the vulnerable population which faces a greater risk of death by staying unvaccinated.
Fifth, there is a need to step up genomic surveillance and conduct epidemiological studies about various aspects of vaccines. Kerala is doing better than many states on genomic surveillance. Nonetheless, there is imminent need to step up genomic sequencing, analyse data regularly and disseminate the information efficiently. The genomic surveillance data need to be linked to clinical outcomes and studies for guiding public health response.
Alongside, the extensive medical and public health expertise of leading academic institutions needs to be utilised to conduct pertinent epidemiological studies to guide response. Epidemiological research, including population-based vaccine effectiveness studies, should be planned. The local data on transmission, morbidity, vaccination-related statistics, including adverse outcomes, and the efficacy or pitfalls of various treatment measures need to be regularly shared with doctors so that everyone is kept updated.
Many of these interventions need to be implemented in a targeted manner, in settings of high and sustained transmission with a localised approach.
Plan for Weeks and Months Ahead
Although this may not be a right time to open schools in Kerala, guidelines should be drafted and strategies prepared in advance to re-open schools after consulting domain experts. Teachers must be vaccinated so that along with them, students are safe too.
As the SARS-CoV-2 virus spreads primarily through air in indoor spaces, ventilation of closed spaces needs to be assessed and modified—it must be prioritised in schools and crowded office buildings. Schools should be inspected by qualified experts and suitable modifications done to make them safer from a ventilation/air exchange standpoint. If this is carried out now, the state and districts would save time when the current spike eventually normalises and schools can be opened. We need to plan for long-term. Likewise, office spaces and workplaces have to be made safer, to minimise risk of airborne spread.
The government of Kerala also needs to have continued social security measures for various vulnerable populations in the state and those who are severely impacted by COVID-19 pandemic. The economically vulnerable segment needs to be shielded despite tightening restrictions, so that their livelihood is not compromised.
The post and long COVID-19 clinics and services need to be expanded, brought closer to the people; these services can be delivered through family health centres (FHCs). Mental health services need to be stepped up, particularly for children who, unlike adults, do not have a voice to speak up for themselves.
Next Few Weeks are Crucial
Kerala is doing well in pandemic response, the proof being that its healthcare system, so far, has never come under extreme pressure, which is also reflected in the low overall COVID-19 mortality. With a high baseline caseload and a relatively high unexposed and thus susceptible population, the weeks to come are crucial. Kerala has an opportunity to prove that it can continue to do well, but this requires a scientific and evidence-based approach, applying the principles of epidemiology, and with meaningful input from a range of domain experts.
Chandrakant Lahariya, a physician-epidemiologist, is a public policy and health systems specialist. Rajeev Jayadevan is medical doctor and member, Indian Medical Association’s National Task Force for COVID-19 pandemic. The views expressed in this article are those of the author and do not represent the stand of this publication.
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