On May 8, after the first Vande Bharat Mission aircraft carrying Gulf returnees touched down at Cochin International Airport, only a single COVID-19 positive case was reported in Kerala and the state had just 16 active cases. It was from a peak of 266 on April 6 that active COVID-19 cases fell to such a negligible number.
So when the non-resident influx began, as if in welcome, Kerala was virtually scrubbed clean of the SARS-CoV-2 virus, which causes the COVID-19 disease. From then on, the containment plan seemed fairly straightforward: Keep the returnees (both from abroad and other states) and the locals separate, far from each other, like girls and boys in an ultra conservative society.
Beginner's luck
The plan apparently worked. From May 4 to May 31, 827 new cases were reported and 741 (89.6 per cent) of them had come from outside. The remaining 86 cases were immediate contacts, mostly people within the family.
This 'limited transmission' scenario seemed to hold true even a month after the lockdown was eased on June 1. In fact, by the end of June it looked even better.
Over 90 per cent of the 3943 positive cases reported after May 4 were import cases. This meant that even a month after the unlock phase began it were mostly the returnees from hotspots outside Kerala who were turning positive. If at all they were infecting the local community, it was marginal.
Magic wand aka test kits
But from the first week of July, tests were dramatically ramped up and there was an abrupt change.
An alarming number of infected individuals with no travel history or even contacts with returnees began to show up. Contact cases that were limited to within 10 per cent of the total cases till the end of June shot up to nearly 45 per cent in just about a fortnight.
Aggressive testing was the abracadabra that pulled the rabbit out of the hat. Till June 30, 2.25 lakh tests were done in Kerala. But in the next 22 days alone, 1.98 lakh tests were done. In other words, nearly 85 per cent of the tests done in three-and-a-half months were carried out in just 22 days.
This had the effect of switching on innumerable overhead lights simultaneously over the community, revealing hidden cases even in unsuspected corners. Till June 30, only 1.97 per cent of those tested turned positive. But by June 22, 3.57 per cent of those tested were positive. However, after July 1 when more than 10,000 tests were done in a day, 5.36 per cent of those tested turned positive; 10,590 positive cases among 1.98 lakh samples taken in 22 days.
"This increase in number was expected but what was not were the large clusters that came up in certain regions, especially along the coast," said Dr K P Aravindan, noted pathologist and a member of the State Expert Committee on COVID.
Matsya avatar
It became clear that while the government was absorbed in preventing the spread from returnees, it was either unaware or did not take seriously the unconventional pathways the virus was taking to sneak into the state: the informal or even illegal trade routes.
The majority of virus clusters in Kerala – Poonthura and Pulluvila (Thiruvananthapuram), Chavara, Panmana, Kottarakkara Muslim Street (Kollam), Kumbazha (Pathanamthitta), Chellanam, Munambam (Ernakulam), Ponnani (Malappuram), and Pattambi (Palakkad) – have links to local fish markets.
In most of these clusters, fisherfolk – wholesalers, retailers or even artisanal fishermen – who had regular contacts with their counterparts in other states, mostly Tamil Nadu, were the first to test positive.
It is now assumed that it was a fish wholesaler who purchased fish in bulk from Tamil Nadu who ignited the Poonthura cluster. Many others in other parts of the state had travelled in two-wheelers and returned with both fish and the virus.
It was also usual for traditional fishermen who spend days in the sea to have occasional deep-sea get-togethers with friends from other states. They anchor in the middle of nowhere, their boats tickled by the waves, and then indulge in loud banter, and share food, drinks and secrets.
Keeping the door ajar
"We should have anticipated this in advance given the density of population in coastal areas and the links to Tamil Nadu," Dr Aravindan said. "Large trucks carrying essential goods came through the official routes and so were satisfactorily screened. But we were not able to keep an eye on informal routes and also the markets where supplies from these informal routes finally ended up," he said.
By the time it was revealed, the spread had reached an advanced stage.
Even then, it appears that precautions were not taken. Pattambi, for instance, would not have grown into a cluster had pre-emptive steps been taken. "When markets in Ponnani (Malappuram) and Kunnamkulam (Thrissur) were shut, fish and other wholesalers from those areas came to Pattambi market for business," said K S B A Thagal, Pattambi Municipality chairman.
The municipality now has over 160 positive cases.
COVID hyper market
The 'secret' return of migrant workers, especially Tamil Nadu natives, without registering in the COVID Jagratha portal, has set off a major cluster in the heart of the capital district. Over 120 staff of Ramachandran hyper market were tested positive.
Several of them, it is said, had returned from their homes in Tamil Nadu, where they had gone during the lockdown, through illegal routes running parallel to the Inchivila check post at Parassala. It has also been found that they were not even asked to observe the mandatory 14-day quarantine.
Mysterious outbreaks
In certain regions, the outbreak is a puzzle. Take for instance Thuneri panchayat near Nadapuram in Kozhikode. It is now presumed that a 25-year-old youth who attended a funeral had transmitted the virus to 42 people in the panchayat. The youth has no travel history and has not come into contact with known positive cases.
The dangers of not taking social distancing norms seriously, as if it was something meant for the faint-hearted, have also manifested in shocking ways. There are at least 30 people above 70 who have tested positive even without venturing out of their homes. Narayanan of Idukki died of COVID though he had not stepped out of his house.
"Others in the family went out and brought home death," said Dr P K Jameela, a member of the expert committee advising the government on COVID matters. "Narayanan's death should shock us into wearing masks inside houses, especially when there are old people around," she said.
Cardboard promises
The sudden spurt in cases also tested the solidity of official assurances. Some sounded hollow.
Chief Minister Pinarayi Vijayan had consistently said that Kerala was ready with not just Plan A but also plans B and C.
On June 25, the chief minister said 15,975 hospital beds were already identified for COVID-19 patients across the state. This was said to be in addition to the 8,537 beds in the 29 COVID Care Centres and 29 First Line Treatment Centres already operational in 14 districts.
This was impressive, but only in the way film sets are when seen on screen. The hospitals were unfit to live in. On July 22, there were 8,818 COVID patients in hospitals and yet the strain on the system could be felt. In many hotspots tests were not conducted for two or three days fearing there would not be enough beds to accommodate the patients.
Unkept word and a coastal rebellion
The beds the chief minister said were already identified proved woefully inadequate. The lockdown violation staged by Poonthura residents on July 10 were partly on account of the trauma their relatives and neighbours suffered in rigged up hospitals.
Those tested positive in Poonthura were taken to hospitals that had been long dysfunctional but were hastily converted into COVID treatment centres. More than 30 patients were stuffed in non-ventilated wards with just two bathrooms, and there were not enough nurses either. The food was so bad that children preferred to go hungry.
What happened was disastrous. People in coastal hotspots like Poonthura, Pulluvila, Kottukal and Puthukurichy refused to take COVID tests saying they don't want to suffer far away from their homes in such crowded places.
Balm of neighbourhood hospitals
This prompted the quick opening of COVID First Line Treatment Centres (CFLTCs) in all panchayats so that asymptomatic patients or those with mild symptoms can be near home.
The chief minister said 742 CFLTCs with a combined bed strength of 69,215 will be ready by July 23. It is still not clear how these CFLTCs will be staffed. Post-graduate medical students have refused to take duty at CFLTCs. The government will now be forced to employ homoeo and ayurveda doctors, or conduct mass recruitments.
Even if oxygen cylinders cannot be provided, these CFLTCs should be stocked with at least pulse Oxymeters. "At CFLTCs only those with mild symptoms or none at all are admitted. But oxygen levels can plummet quickly in COVID patients and so we need to constantly monitor their oxygen levels," Dr Jameela, who drew up the guidelines for CFLTCs, said.
Fall of the front-line warriors
While more needs to be done for CFLTCs to become effective, COVID has struck at the foundations of premier medical institutions. Nearly 50 health workers, including 15-odd doctors, have tested positive in Thiruvananthapuram Medical College. Other government hospitals, too, have found their staff contracting the virus, and double the number pushed into quarantine.
"It is doctors in non-COVID wards who are finding themselves infected. This is because precaution is high in a COVID ward. Even a doctor in a medicine ward will be careful as most of the patients would be suffering from some respiratory problems. But a doctor in a surgery ward does not suspect COVID in a patient coming with a tumour in the stomach or a wounded or broken leg and they interact with the patient more closely than is warranted in a situation like this," said Dr T Aneesh, a community medicine expert.
Equally dangerous is the easy unfettered bonding among doctors. "A doctor might use a mask in front of a patient but not before other doctors. These doctors come from various wards and gather at a common place, say a cafeteria, where they chat over tea and snacks without observing any social distancing norms," Dr Aneesh said.
Doctors have already demanded PPE kits for the medical staff in non-COVID wards of medical colleges and general hospitals. "It is high time we realised that there is community spread and did everything possible to insulate health professionals. Providing PPE kits to all doctors in the Medical College is a major step in that direction. Or else there will be no doctors left to treat," said Dr Ajith Prasad, a senior surgeon in Thiruvananthapuram Medical College.
Secret of the slums
So before things could come to such a pass, the virus has to be reined in. Dr Jameela said strict social distancing was the only way out. "If hand washing and the proper use of masks were promoted in coastal regions we could have prevented this crisis. It is still not late. The country's biggest urban slum, Dharavi, survived the virus only because of hand washing and use of face masks," Dr Jameela said.
"We should also not forget that Rajaji Nagar Colony (the largest urban slum in Kerala) where houses are jammed close to each other like in any urban slum has not reported a single COVID case," she said and added: "The colony residents observe social distancing like it is a sacred duty and it looks like they have been saved."
