A shift from ABCD to 3Ts may solve Kerala’s COVID-19 puzzle

As of 8 am, August 5, there were 411,076 active COVID-19 cases in India. About 43 percent or 176,654 of this were in Kerala, effectively implying that more than four out of every 10 active COVID-19 cases in India were from just one state.

In the last 24 hours (until 8 am, August 5), India reported a total of 42,982 new COVID-19 cases. More than half (52 percent) or 22,414 cases were recorded in Kerala.

This has been a worryingly persistent trend over the last few weeks. During the seven days from July 28 to August 3, Kerala has accounted for half of the country’s total COVID-19 cases.

These numbers present a paradox of sorts. Why has Kerala, the only Indian state equipped with world class health infrastructure, a high per capita availability of health workers, an efficient public health administration, and relatively greater health awareness among people, has remained an contrarian outlier in COVID-19 management?

The puzzle gets even more amplified by Kerala’s vaccination record. The state has fully vaccinated more than a fifth of its population and more than half of the state’s eligible population (52 percent) have received at least one shot.

This may possibly explain lower deaths, and fewer cases of COVID-19 hospitalisation and ICU admission, despite a persistently high state-wide caseload.

The recent nation-wide COVID-19 serological survey also shows some perplexing patterns. Only 43 percent of the state’s population may have been exposed to the virus as opposed to a probable national COVID-19 anti-body prevalence of 68 percent.

A straightforward explanation of Kerala’s relatively lower anti-body prevalence would be that the state has contained the spread far better than the others, and this, therefore, is reflected in the serological survey.

That aside, unlike many states where the health infrastructure was completely overwhelmed during the peak of the second wave, hospitals in Kerala have not been overflowing with COVID-19 patients. Why, then, has Kerala remained one of the major COVID-19 hotspots over the last several weeks?

These questions have been baffling epidemiologists and public health administrators. One possible reason could be that the policy of ‘home quarantine’ as the first line of infection management may not have yielded the expected results.

A case is now being made out that excessive dependence on ‘community surveillance’ rather than moving infected persons to dedicated COVID-19 centres manned by health professionals may have played a part in spreading the virus.

The state government had placed the onus mainly on local bodies with oversight responsibilities to ensure that infected persons quarantined at homes strictly follow COVID-19 protocols to contain the virus’ spread.
The Local Self Government bodies have been classified on the basis of a seven-day average test-positivity rate (TPR). This is also popularly known as the ABCD policy — ‘A’ for those areas with TPR lower than six percent, ‘B’ with a TPR between 6-12 percent, ‘C’ for areas that report a TPR of 12-18 percent, and ‘D’ for those that have a TPR of more than 18 percent.

A central Integrated Disease Surveillance Programme team has obliquely inferred that the policy of home quarantine may have failed, with the concept of ‘community guard’ of home quarantined people failing to live up in practice.

This team cited poor contact-tracing, lack of adequate containment measures and less than effective monitoring of home isolation patients as primary reasons behind the current surge of COVID-19 cases in Kerala.
As opposed to a recommended 20 contacts that need to traced and tested for every infected person, less than two were being traced and tested in Kerala.
Health Minister Mansukh Mandaviya has also written to Kerala Chief Minister Pinarayi Vijayan, flagging that “comprehensive contact tracing of all positive cases through active case search is very low presently (i.e. one is to 1.7 only), which is leading to spread of infection in the community. This needs to be addressed. The percentage of RT PCR testing may be increased keeping in view the high positivity and to aid early identification of positive cases and their isolation.”

Kerala cannot afford to remain locked down for months on end, a move that can devastate the local economy and livelihoods. The containment strategy should decisively shift towards 3Ts — Test, Trace, Treat — from the current ABCD approach of community surveillance.