There is a tendency these days to shrug away the near miraculous COVID-19 death rate in Kerala (0.46 per cent) with a remark as flippant as gossip: The Sars-CoV-2 strain that is doing the rounds in Kerala is such a mild one that it can't stand upright even on a 90-year-old's body.
But there is a scientific reason for the low mortality, and it is swift hospitalisation.
The Expert Committee that advises the government on ways to deal with the pandemic has found that a COVID-19 patient in Kerala, on an average, is admitted to a hospital within 2.4 days of developing symptoms.
In the case of western countries with high mortality rates of 3 per cent and above like the US, the UK, Italy and Spain, there is an average gap of five or more days between the onset of symptoms and hospitalisation. Singapore is perhaps the only country with a comparable swiftness of hospitalsation.
Studies on COVID-19 patients have shown that acute respiratory distress begins from Day 5 to Day 8 of the infection, after which chances of survival plummet. In Kerala, the treatment begins long before the deterioration begins.
The 93-year-old Ranni-based patient who recovered was hospitalised the second day he developed symptoms. Early hospitalisation could have been the secret behind the nonagenarian fooling death.
Kerala's 'pace of hospitalisation' was understood from a close analysis of patient case sheets; especially the dates when the first signs of COVID-19 like cold or fever or nausea emerged in patients and the dates on which they were hospitalsed.
Local superheroes
“This quickness of hospitalisation is one of the major reasons why Kerala could keep the severity of the viral attack low,” said Dr K P Aravindan, a leading pathologist and one of the members of the Expert Committee.
He attributes this spotting of the symptom and the quick shift to the hospital to the smooth and effective channels of communication that have been opened at the local level to deal with the outbreak.
There are Covid Jagratha Samithis (Covid Vigilance Committees) at the ward level. Each Jagratha Committee is made up of the ward member, policemen posted in the area, 'Sannadham' volunteers, ASHA workers, Kudumbashree workers, and health inspectors. These are people who have intimate knowledge of people in home quarantine in their ward. The committee will closely monitor homes where people are quarantined.
Each committee has a rapid response team (RRT) at its command. These RRTs are despatched the moment a distress call is received from any of the homes in the ward.
Hope ladies
ASHA workers not only make daily phone calls but also make frequent visits to houses where people have been quarantined. “An average ASHA worker in Kerala is a graduate. It is easy for people to communicate with them,” Dr Aravindan said.
Since they call daily, ASHA workers also keep close track of health-related developments inside a home. Therefore, it is no surprise that it is usually the ASHA worker who first informs the primary health centre or the medical officer about the manifestation of COVID-19 symptom in a quarantined person.
“Most of the time people in quarantine tell us if they have felt any change when we call them daily. There are also times when we pick up something odd when we visit them, like say a change of sound or a general aspect of fatigue the person might have ignored,” said Sindhu B, an ASHA worker who works in Kasaragod's Chemnad gram panchayat.
Rapid response
The ASHA worker's function is tuned to strike a bond with the family. “Once we are informed that a person will be quarantined in a particular ward, we ask the ASHA worker in charge of the ward to go to the house and help the family to make all the necessary arrangements for room quarantine,” said Sreeprasad, the district coordinator of ASHA workers in Malappuram.
Even if the slightest symptom is detected, ASHA workers call up the primary health centre under which they function. “We don't wait to judge whether the symptom is problematic or not. We have been told to just inform,” Sindhu said.
Promptly, an ambulance is sent to the house to take the COVID-19 suspect to the hospital to collect samples.
Samples taken, an ambulance returns the person back home. A day later, if the result is positive, the person is immediately told over phone to get ready for the hospital shift.
Gang of watchers
Dr Aravindan said a system has been put in place locally where it was difficult to miss a symptom. “It is not just the ASHA worker who calls up the person in room quarantine. The person's number will be given to three others, it could be a junior health inspector or ward member or a volunteer or even a neighbour. They, too, will keep calling regularly,” he said. Besides, policemen on duty will also make regular visits to the house.
“What is not fully appreciated is the fact that so many people have been employed to monitor a single family,” Dr Aravindan said.
Fear of failing health
Dr Anish T S, professor of Community Medicine at Thiruvananthapuram Medical College, said that the Malayali psyche, too, had contributed to this quick pace of hospitalisation. One, he said Malayalis had a health-seeking behaviour. “They will not sit on a disease, they want to be freed of it,” Dr Anish said.
Then, he said fear factor, too, pushes the Malayali to find quick remedies for his ailments. “Sociologically, we are a fear-driven society,” he said.
Finally, a receptive health system. “It is not enough for people to want to speak about their illness, there should be a health system willing to respond to their fears. Here in Kerala, unlike in other parts of India or the world, a patient can directly call the government doctor,” Dr Anish said.
In fact, many COVID-19 patients in Kerala had directly called up the doctor at he nearest primary health centre or taluk hospital to inform of the first signs of symptoms.