Between June 18 and September 3, as per data provided by the state government, 9,195 people had died of COVID-19 in Kerala. A 'Death Analysis' carried out by the health department shows that at least 2,799 or 30.44% of them could have been saved had they been hospitalised early.
Far more lives, perhaps 60-70% of those who had died in this 78-day period, could have been saved yet another way: vaccination. More than 90%, or 8,290 of the 9,195 who had died of COVID-related complications between June 18 and September 3 had not taken even a single dose of vaccination, and were above 60 years of age.
Silver bullet to end COVID deaths
The 'death analysis', therefore, has offered the government a sure-fire strategy to prevent COVID deaths: prompt hospitalisation and wider vaccination coverage of especially the older population.
As it stands, the vaccination coverage looks promising. By September 16, more than 95% of those aged above 45 have been vaccinated with at least a single dose. “Nonetheless, we encounter vaccination resistance in certain pockets of Kerala. The analysis should work as an eye-opener. This should make the people realise the importance of vaccination,” Dr K P Aravindan, noted pathologist and member of the COVID-19 Advisory Committee, said.
Delay in hospitalisation
It is the second component of the death-reduction strategy, the swiftness of hospitalisation, that the government might struggle to achieve.
In May last year, during the peak of the first COVID-19 wave, the average time between the emergence of first symptoms and hospitalisation was less than two-and-a-half days. Now, this average has widened to nearly five days.
Studies on COVID-19 patients have shown that acute respiratory distress breaks out from Day 5 to Day 8 of the infection, after which chances of survival drop steeply. As per the analysis, 2799 patients who had died in the period from June 18 to September 3 were brought to the hospital after seven days of the onset of symptoms; 146 had died in transit, on the way to the hospital, 794 on the first day of hospitalisation, 705 on the second and 640 on the third day after admission.
Home remedy
Various factors have contributed to what doctors term 'hospital aversion'. During the early stages of the first wave, when cases came in trickles, quick hospitalisation was a viable strategy. Then, every single patient who had tested positive was admitted to the hospital.
Gradually, when the hospitals got crowded, the government had to tweak the policy to allow asymptomatic patients to quarantine themselves at home, just the way primary contacts did.
To manage the rush at hospitals, COVID First Line Treatment Centres (CFLTCs) were also opened in most of the local bodies. Asymptomatics and those with mild symptoms were accommodated in dormitory-like halls, which was supposed to be a kind of 'waiting area' for patients. Those whose condition worsened were shifted to COVID hospitals, while others were sent back home.
Dislike for dormitories
“The home isolation strategy suddenly made the virus look less deadly. A feeling gained ground that COVID-19 was just like any other viral fever that is best contained by taking rest at home,” a top health department official said. “The CFLTCs, on the other hand, were shunned by both the middle-class and the underprivileged. These facilities were seen as crowded and unmanned. Even the seriously ill felt home was a better option. Ward members and panchayat presidents have complained that they were finding it increasingly hard to persuade people to shift to CFLTCs,” the official said.
No wonder, the number of CFLTCs, which were initially opened in almost all the local bodies in Kerala, has shrunk to 130 and not even 70% of the beds in these drastically dwindled facilities are occupied.
It is not as if these CFLTCs are functioning effectively. “Most of these CFLTCs fail to detect the deterioration in a patient and, as a consequence, the patient was not being promptly referred to hospitals where effective treatment could be given,” said Dr Anoop Kumar A S, a critical care specialist and a member of the COVID-19 Advisory Committee.
Top-down disconnect
Dr Anoop also feels that there is not enough awareness among health workers at the local level about the government's isolation and quarantine guidelines. “Those with comorbidities should not be kept in home quarantine,” Dr Anoop said. Onmanorama talked to five ASHA workers from various districts and all of them said they were unaware of such a guideline. “These days when a positive patient says she would prefer to remain at home, we don't normally insist even if she is a diabetic or has heart trouble. Sometimes even cancer patients are reluctant to move out,” an ASHA worker in Kannur said.
Ignored home truths
The guidelines are very clear. Home care and isolation has been prescribed only for asymptomatic patients. Asymptomatics with no facilities for home quarantine, like a dedicated bathroom, will have to shift to a domiciliary care centre (DCC). Then there are Category A patients (those with mild sore throat or cough or diarrhea or running nose). They should shift to a CFLTC.
As for Category B patients (those with fever or severe sore throat or cough or diarrhea or Category A with comorbidities like liver, kidney, heart or neurological disorders, diabetes, hypertension, cancer and HIV), they should shift to COVID Second Line Treatment Centres.
Category C patients should be compulsorily placed in COVID hospitals. They include patients with 'red flag signs' like breathlessness, chest pain, drowsiness, fall in blood pressure, coughing up blood, blue skin as a result of low oxygen in blood.
Dr Anoop, who has by now treated over 850 ICU patients, said that pneumonia would develop in five to seven days. “If fever persists after five days, if you experience difficulty in breathing, and if you start panting while walking, these are telltale signs of pneumonia. The patient should be immediately hospitalised,” he said.
Revive neighbourhood watch
Fact is, in most cases, these signs are being missed. Patients quarantined at home are not being regularly supervised like in the initial days of COVID. Then, COVID Jagratha Samithis (COVID Vigilance Committees) at the ward level were very active. Each Jagratha Committee is made up of the ward member, policemen posted in the area, 'Sannadham' volunteers, ASHA workers, Kudumbashree workers, and health inspectors.
The committee will closely monitor homes where people are quarantined. Each committee has a rapid response team (RRT) at its command. These RRTs are dispatched the moment a distress call is received from any of the homes in the ward. ASHA workers not only make daily phone calls but also make frequent visits to houses where people have been quarantined.
This 'neighbourhood watch' is now practically defunct. “Of course, there is system fatigue. The members would have lost the alertness with which they had worked at the start,” said Dr Aravindan. “Even then, constant supervision, at least frequent calling up of these homes, should be revived at the local level,” he said. Early this month, Chief Minister Pinarayi Vijayan, too, had asked local bodies to revive Jagratha committees.
Wonder treatment
If signs of disease progression are detected early, there are what seems like wonder treatments to prevent the viral attack from causing death. Dr Anoop speaks of the infusion of monoclonal antibodies. It is costly, between Rs 60,000 to Rs 70,000 a dose. “But these are available in government COVID hospitals, too,” he said.
Problem is, small hospitals at the periphery are not even aware of the existence of such treatment. “If the infusion is provided within five days of the onset of symptoms, disease progression can be effectively checked. It is said that the treatment has 70% efficacy. But I myself have given it to over 100 patients and have found it effective in 95% of the cases,” Dr Anoop said. “Just one dose and the patient can be discharged the next day,” he said.
But for wonders to happen, Kerala's highly feted local level healthcare network will have to reassemble and perform.
