How the Kerala government is shaping and implementing its COVID-19 response

Kerala's minister of health, KK Shailaja (L) and the chief minister Pinarayi Vijayan (C), address the media on 23 March, in the state capital of Thiruvananthapuram, on the government’s handling of the Covid-19 pandemic. The press briefings have been a daily feature of the state's attempt to control the outbreak, and have been helmed by either Shailaja or Vijayan. ARUN CHANDRABOSE
28 March, 2020

As of 28 March, there were 182 identified cases of COVID-19 in Kerala, according to the daily status update by the state’s ministry of health. The state also reported its first fatality from the novel coronavirus that day. In the wake of the nationwide lockdown following the pandemic, more of Kerala’s non-residents, who account for almost five percent of the state’s population, returned to the state, driving a surge in new infections. A total of 45 fresh cases were reported in the state in the last two days, according to the ministry. The state has so far tested 6,067 samples, the highest of any state in the country, and a total of 134,370 people are currently under observation. Of these, 133,750 have been isolated at their houses and 620 have been admitted in designated isolation facilities. Out of all the cases under treatment in the state since the outbreak, 16 people have recovered. In a press briefing this evening, the chief minister, Pinarayi Vijayan, announced that four of them recovered today, including one foreign national. The press conference has been a daily feature of the state government’s response to the pandemic since 30 January, when the first case was detected in Kerala.

Kerala’s first three cases also happened to be India’s first recorded cases. Three Malayali students studying in China’s Wuhan province, the origin point of the pandemic, returned to the state and tested positive between 30 January and 3 February. In a measure of the state’s preparedness, the ministry of health already had a draft policy on the outbreak ready by 26 January. In an article in The Hindu on 23 March, Kerala’s minister of health, KK Shailaja, talked about how her ministry had initiated discussions on the outbreak “as early as mid-January.” She added, “When various countries started confirming cases, Kerala was the first State to draft measures for its containment. The measures became more stringent when the State reported its first case on January 30.”

When the third case was reported on 3 February, the state government declared the Covid-19 outbreak a state disaster. An order was issued to constitute a 24-member State Response Team, or SRT, with Shailaja as its chairperson. The team included senior officials from various departments—epidemiology, community medicine, infectious diseases, paediatrics, drug control and food safety, among others. Eighteen state-level teams were constituted to coordinate various functions such as surveillance, call centres, human-resource management, training and infrastructure augmentation. These state-level teams reported back to a state control room, which is coordinated by floor managers. The control room functions round the clock, in shifts.

According to a health official, who did not want to be named, inter-departmental coordination, which is currently being done by the chief minister, plays a huge role in handling the situation efficiently. Effective implementation of the ministry of health’s policies requires important contributions from the departments of police, revenue, electricity, water and public works. “Once the disaster act comes into being, the revenue department gains prominence. Though the health department is leading, all other departments are working together,” the health official told me. The official added that “if any need arises, the concerned department would be prepared to meet it in no time.”

The Kerala government has also issued clear guidelines for every step in the state’s COVID-19 action plan. These guidelines were prepared after consultation with experts in their respective fields and then issued as government orders. And the process is ongoing and evolving. For instance, the state’s clinical guidelines for dealing with suspected cases and treating confirmed cases have been issued as a “living document”—it is updated regularly depending on “newer discovery and current research.” According to these clinical guidelines, treatment provided to COVID-19 patients has been categorised into three groups based on the symptoms. Right from precautionary measures to cremation of patients, these guidelines are meant to be strictly followed.

Rapid response teams similar to the SRT have been constituted at the district level, too. Each district has been brought under the charge of a minister while the collectors and district medical officers, or DMOs, coordinate activities at the district level. SA Hafiz, a public-health expert in the state’s department of health, told me that “though we did not have to go there yet, if a micro-level planning is required we can extend this model further to sub-district, taluka and ward-level.”

The district-level systems put in place were activated swiftly on 10 March, when it was reported that three members of a family in the Pathanamthitta district had returned from Italy and concealed their travel history. The family had travelled extensively in Kerala and attended public functions. “That is when we activated the whole system,” the health official said.

Sreedevi S, an additional DMO, Ernakulam, told me, “We have a district control room functioning at the collectorate. Two additional DMOs are in charge of the control unit and surveillance unit. The control unit coordinates call centres while we take care of the entire surveillance activities.” She said that her team included public-health experts, doctors, data-entry operators, epidemiologists and technical assistants. Medical students had been roped in to handle calls to helplines. “We have a digital system to maintain data of all people under home quarantine,” she said. This system enables access “to data from panchayat and ward-level, with details such as medical conditions like diabetes, palliative conditions, etcetera.”

Sreedevi said that “contact tracing of confirmed cases” was being conducted very meticulously, and they were following up even “the minutest details available.” Till the airports were functional, all passenger lists were sent to the SRT, which then coordinated contact tracing with the districts. Sreedevi explained how they had been following cases. “Once you get a positive case—for instance, we had a three-year-old girl whose family had come from Italy—immediately, we got the entire passenger list of that flight. Three rows in front and three rows behind are high-risk contacts. After this, we tracked whoever they had been in contact with like doctors, immigration staff. Straight away, the child and parents were brought to the medical college as she had fever. They were kept in isolation, and the later the parents too tested positive.” She mentioned another case of a British national who had come to Thekkady, a tourist destination. “We had deployed five different teams to track his contacts,” she said.

According to Sreedevi, all the people under surveillance are contacted daily by the medical students and staff with the health department, over phone calls. “We have given very clear guidelines to the primary health centres and family health centres in their respective areas,” she said. The state has even put in place 250 teams who have been conducting psychological counselling for the quarantined people over phone calls.

I asked the health official if this was a workable model for contact tracing if the numbers of cases increase drastically. “There is a limitation to how much we can do, those who come from abroad for a short period tend to move a lot abruptly across districts. They have to remember exactly and cooperate with us. As of now, we are doing this for all cases. We are asking people to come forward after publishing the route maps. Teams in districts will gather the data for this,” he said. 

The state’s action plan has also focussed on strengthening and managing human resources. The health official told me that on 26 March, “appointment has been given to 276 doctors, who were in the rank list of the Kerala Public Service Commission.” These doctors were appointed to carry out the preventive measures and plans prepared by the health department. The official said that the state recognised that “we can’t keep doctors and nurses working for three weeks straight.” Consequently, “we have also identified human resources and developed a strategy for managing human resources,” he said. According to a report in the Times of India, a three-tier system has been put in place, which divides doctors into three groups, two active and one on standby. No group works for more than one week and none come back to work for two weeks after that.

The district-level officers are also identifying and integrating private facilities into the state’s efforts to curb the spread of COVID-19. Sreedevi told me that the state machinery was now coordinating with private hospitals. For instance, in Ernakulam, “yesterday, the district administration took over a private hospital which was closed down,” she said. “We are in the process of cleaning it up to make it available for COVID care.” She added, “Before we had to be more careful about people breaking out of quarantine. Now the police is handling it.” The district administrations have also been asked to identify “COVID First-Line Treatment Centres” to treat mild and moderate cases so as to avoid crowding at COVID-19-designated hospitals.

In addition, the state’s disaster response has included extensive social-welfare measures. To ensure food and social security during the 21-day lockdown period, the government opened 4,503 relief camps for migrant workers, set up 500 community kitchens across the state, and provided doorstep delivery of food and essentials. The state has been commended for its planning, which covered the needs of all sections of the population and attention to details such as making provisions to recharge mobile phones.

In order to manage its slew of measures, and to strengthen their functioning at the grassroots level, the government has roped in the manpower associated with various state programmes like Kudumbasree, a women-empowerment initiative; ASHA, a community-health organisation; and the Integrated Child Development Services, a government scheme for children.

Ajitha Kumari S, a 43-year-old member of Kudumbasree from the Chemmarathi panchayat in Thriruvananthapuram, joined as a volunteer with the health department last week. “We attended a training session by doctors on understanding the disease, precautions, and what we need to do. Any person coming from outside in the ward that is assigned to us would be under our surveillance. We have been asked to deliver any essential things that they need and provide food for underprivileged among them,” she told me.

The state has further decided to recruit 235,000 people from between the ages of 22 and 40 as volunteers, through online registration, to support its COVID-19 action plan. Apart from this, by mid March the state announced a revival package of Rs 20,000 crore for health packages, free food-grains, subsidised meals, loan assistance, welfare pensions, tax relief and arrear clearances.

According to Hafiz, Kerala is at an advantageous position for handling the pandemic because of a robust health system in existence for decades, which has ensured high health indices. “Having a well-performing system helps us to meet the emergencies. A fragile health system cannot manage a pandemic or emergency,” he said. “The three layers—primary, secondary, tertiary—are important for handling any emergency situation, be it nipah or corona or H1N1. The crux of the action happens there.”

Hafiz said that at the time of the Nipah outbreak of 2018, “we were facing that kind of a deadly virus for the first time. We had introduced procedures like contact tracing at that time. Because of this we were able to contain it in the second wave of Nipah in the state.” He said that Nipah exposed the state to the strategies needed to face a similar outbreak, and that is when a template came into shape. “When corona came, all we had to do was to re-design and build up on this system.”