Over the past 25 days, Kerala has been reporting daily COVID-19 cases ranging between 10,000 and 15,000, without any dip. Kerala is one of the few states with a high number of COVID-19 cases in India in the past few weeks – on July 8, as many as 13,772 people tested positive for coronavirus. In many other parts of the country, the daily caseload has been steadily declining. Maharashtra, for instance, which has been accounting for the highest COVID-19 cases since the pandemic started, reported 9,083 COVID-19 cases on July 8.
According to the Ministry of Health and Family Welfare, as of July 8, Maharashtra had the highest number of active COVID-19 cases (1,17,869), followed by Kerala (1,08,400). However, on comparing the previous day’s data, Maharashtra’s total active COVID-19 rose by 333, while Kerala’s active cases rose by 3,823, which is the highest in the country for that day. It is also important to note that in Kerala, the number of deaths is lower compared to Maharashtra, and the recoveries are high compared to other states.
Incidentally, although Kerala’s daily COVID-19 cases remain high, it has been plateauing (a period of stability) since mid-June, while other states are witnessing a decline. For instance, between May 1 and 7, when COVID-19 infections were at their peak across the country, Karnataka and Kerala recorded an average 46,045 and 36,239 daily cases respectively. Over the last few days, between June 30 and July 6, Karnataka and Kerala recorded an average daily case of 2,646 and 12,226 respectively.
Dr Jayaprakash Muliyil, an epidemiologist, explains that the reason Kerala has had a steadier curve as opposed to a rapid fall and decline could be due to two reasons. “One, the number of undetected COVID-19 cases in Kerala must be lower. And two, it could be because behaviourally, more people are going and getting themselves tested when they have symptoms, rather than hiding it. If most people have mild symptoms, they will not get admitted to the hospital, but the case will be recorded,” he says.
The sharp rise and decline COVID-19 cases in places like Delhi and Karnataka is because of rapid spread of the virus, and then because the number of people infected is more, a threshold immunity is reached. “Simply put – there are fewer people left to infect, which causes a sharp decline. Another way to make the number of cases fall is to enforce a fairly serious lockdown,” says the epidemiologist.
Health experts say that Kerala was largely able to contain the sudden spike by slowing down the pandemic’s curve. “While most of the states witnessed a rapid change in the pandemic's curve in the first wave with a rapid rise and fall, Kerala saw a slow rise in cases,” says Kochi-based rheumatologist Dr Padmanabha Shenoy, who has been analysing COVID-19 data.
Dr Arun NM, a Palakkad-based Internal Medicine expert who has been tracking the COVID-19 data, drew a few similarities between the first and second waves in Kerala and other states. Kerala witnessed the first wave of high COVID-19 cases only after September 2020, when other states were reporting a decline in the daily infections.
“In the first wave, Kerala did not witness a rapid spike in cases like other states. The same is happening in the second wave, too. In the first wave, Kerala’s daily COVID-19 cases plateaued out for a few months, from around 5,000 to 6,000 cases between November 2020 and January 2021. It is by March that the daily cases dipped to the range of 2,000,” explains Dr Arun.
Dr Shenoy also concurs. He argues that, unlike Kerala, most states are seeing a rapid decline in COVID-19 cases as they are supposedly at the threshold of obtaining herd immunity by way of exposure to the virus. However, exposure to the virus is not a long-term and safe yardstick to obtain herd immunity.
Herd immunity offers a proportion of the population indirect protection against a disease, based on the immunity due to previous exposure or vaccination. However, since the virus is constantly mutating and persons with weak immunity can be re-infected, vaccination offers better protection against SARS-CoV-2. As of July 7, Kerala has administered 1.51 crore doses of COVID-19 vaccines, covering 43% of the population above 18 years with a single dose and only 14% with two doses.
Dr Muilyil does point out though, that because of new coronavirus variants like Delta, the herd immunity level we need to reach has gone up to a little over 80%. “However, as long as the vaccine coverage picks up, the mortality rate shouldn’t rise,” Dr Jayaprakash says.
While in the first wave, the daily cases during the plateau period were between 5,000 and 6,000, this has doubled in the second wave, ranging between 10,000 and 15,000. However, since the state has largely been able to steadily expand its healthcare requirements, the active cases are yet to put pressure on the health infrastructure in the state. “That is why the plateau is not a concerning factor now. It becomes a concern when the critical care units get filled up,” says Dr Arun.
Dr Muliyil says, “It also looks like the healthcare system in Kerala could handle the caseload throughout. The price of this management is that you have a prolonged epidemic. My guess is that in Kerala, there are not very many repeat infections, but that it is mostly the new infections that are getting recorded. They have done a good job of flattening the curve.”
Meanwhile, experts also caution that it would be a cause for concern if the COVID-19 cases were to spike exponentially. “The pandemic curve is called a plateau when a uniform range of cases are reported for weeks. It will remain so for some weeks, before normally coming down. However, it becomes a problem if there is a spike in cases before the pandemic curve declines since the cases are high as it is,” pointed out Dr Sulphi Nooh, a member of the Indian Medical Association (IMA).
Dr Arun notes that the current plateau is likely to continue for one or two months more. However, he views this plateau as an advantage. “If the maximum number of population can be vaccinated during this time, before the next spike, it can be beneficial for us,” he says. Health experts also add that conducting seroprevalence surveys — estimating the proportion of the population that has antibodies against coronavirus — at this point can also be an effective method to understand the trajectory of the pandemic.
Experts also stress that lockdown restrictions and relaxations should be implemented more scientifically during this period. “If the existing perfunctory control continues, it will drive Kerala to the state that we witnessed post the Assembly polls when cases started to spike again. In such a situation, cases will go back to 30,000-40,000 (as against the average of 12,000 daily cases now),” says Dr Sulphi.
Many also point out that the implementation of basic regulations – such as physical distancing, wearing face masks and, more importantly, contact tracing – in Kerala has become weak now.
Meanwhile, in a letter to nine states with high COVID-19 cases — Kerala, Arunachal Pradesh, Assam, Manipur, Meghalaya, Nagaland, Odisha, Tripura and Sikkim, the Union Health Ministry, on July 7, asked officials to ramp up testing and vaccination, plan healthcare infrastructure effectively, follow COVID-19-appropriate behaviour and effective clinical management.