The sudden and dramatic step up in testing was a clear sign the government had anticipated community transmission in Kerala. But it is still not clear whether Kerala has a strategy in place to put the brakes on indigenous transmission, when the virus spreads outside the official area of surveillance.
Compared to the complications arising out of community transmission, containing the spread of virus imported from outside by foreign returnees can seem like child's play. If one is like driving a car along a busy eight-lane highway with a clear view of oncoming and tailing vehicles, the other will be like trying to negotiate double the traffic along an infuriatingly narrow single lane.
Till now, Kerala needed only to trace the contacts of foreign returnees and isolate them. From now on, with proof of community transmission accumulating, it is not even certain whether the sure-fire remedy of contact tracing would be enough to do the job.
Additional positives in Idukki
Early on Tuesday, three more people were declared positive in Idukki. Their results should have been announced by Chief Minister Pinarayi Vijayan during his sunset briefing on April 27. But since the results came late, they were announced only on Tuesday.
These were samples taken as part of sentinel surveillance done on high-risk groups like health workers, and people's representatives. Meaning, their samples were taken not because they showed any symptoms but merely, as part of abundant caution, to check whether there was silent virus spread in the community.
A male nurse, a ward councillor and a software employee who had sneaked into Maryapuram in Idukki from Bengaluru in the second week of April tested positive.
Danger of public service
The nurse and the councillor were active even after their samples were taken on April 26. It is not clear how both had contracted the infection.
The nurse worked in the casualty wing of Thodupuzha General Hospital, which was cut off from the wing that took care of COVID-19 patients. Therefore, it is assumed that he would have been infected by a disguised virus carrier who had visited the hospital for some other ailments. If so, a clear indication the virus was spreading undetected in the local community.
The Kummakkallu ward councillor, like any well-meaning councillor, was active in providing lockdown assistance to ward members. She distributed food packets and provision kits, visited people in distress and had regularly attended local-level COVID-19 review meetings.
A Tablighi returnee who had tested positive is said to be a resident of her ward but sources said the councillor had no direct contact with the positive case.
Guileless superspreaders
But the origin of infection is not the big worry in the case of both the nurse and the councillor. It is their potential for spreading the virus in the community that would have already knocked the wits out of the district administration.
Unlike in the case of those from abroad, these high-risk groups like health workers and politicians have not been in quarantine, have not even been in lockdown like other ordinary citizens. Because of what they do, they are constantly in touch with patients and people. This makes it virtually impossible, or even futile, to trace their contacts.
Only extreme options, like closing down an entire area that could possibly come under the transmission range of the positive individual, are available for virus containment. But even extraordinary measures look inadequate.
"Sealing an entire area, says a ward or a panchayat or even neighbouring ones, will not be enough. For instance, a patient visiting a general hospital hosting an infected health worker need not necessarily come from a panchayat or ward nearest to the hospital. She can come from far away places. An infected people's representative can also radiate the virus beyond her ward because she could regularly be in touch with other ward members and even MLAs and minsters who spread their influence over larger areas," a top community medicine expert told Onmanorama.
Disease-based containment
A Health Department official, on condition of anonymity, said the government had already begun the shift to a disease-based containment strategy.
"Directions have already been issued to conduct extensive tests in regions where respiratory distress and influenza-like illnesses have shown a large than normal increase. The strategy now is to quickly spot virus spread in vulnerable areas and also in high-risk groups like health workers, those with high social exposure like politicians and migrant workers," the official said.
It is not enough to detect
The trouble but begins after the detection. When a foreign returnee tests positive, the steps to be taken were clear. Trace the contacts, isolate them in homes or hospitals, and once they show symptoms, sent their throat or nasal swabs for testing.
But once a positive case with no known source of infection is found in freely mingling groups like health workers, what next? Contact tracing is unviable. Shutting down large areas, like Kerala is doing now with hotspots, could work but would still not be enough.
"One thing we can do is ramp up testing and quickly find areas where there is silent spread," the official said. For this to be done, there should be enough testing kits.
Post-lockdown blues
After May 3, Malaylis from abroad will troop in. They, too, will have to be tested. From then on, both imported and indigenous cases should be subjected to testing. So we need a large stock of testing kits.
"Fact is, there is a huge shortage of RNA extraction kits in the world. Now, we have stepped up testing. But if we don't conserve the kits, we will be in big trouble in May," the official said.