Again against a virus: How controlling the Nipah outbreak helped Kerala take over COVID-19

Segway-like vehicles were also used by the police to keep an eye on the large crowd on Marina Beach.


On January 30th, the Swaraj Round in the heart of the city of Thrissur was busy as usual. Shops were open and vehicles crowded the streets. Around 2 p.m., however, hell suddenly broke loose. The state’s very calm, yet serious-looking health minister, K.K. Shailaja had just made a formal announcement on television. The first imported case of the novel corona virus (COVID-19) in India has been confirmed in Kerala, she said. The patient was monitored in the city of Thrissur at the general hospital in the Swaraj round. The patient was a student who had returned home from Wuhan, the US epicenter COVID 19 outbreak in China,

When the news spread, panicked people lined up in front of pharmacies to buy face masks. Others covered their faces with dupattas and hurried home. General hospital patients were quickly discharged. Breathless news reporting.

The girl was one of hundreds Malay medical students studying in Wuhan University in Hubei Province. She had come home for the New Year holidays. She had reached Thrissur on January 24th via Kolkata and Kochi. When she saw a warning about the virus, she had gone to the nearest primary health center in Mathilakam to inform the health officials about her trip. Since she had no symptoms at the time, the officers gave her the district surveillance officer number and asked her to dial the officer in case she got the flu. When she got a sore throat three days later, she immediately contacted the officer and was taken to the hospital. She was taken to the isolation station and her blood / throat swab specimens were collected and sent to the National Institute of Virology in Pune for testing. Thrissur was scared and scared, but Kerala was ready.

monitoring strategy

In late December, when news of the mysterious Chinese virus came in, Kerala watched the rest of the world worry about the evolving situation. Days later, as the number of patients with COVID-19 increased steadily, China began to take exceptional measures. It temporarily closed public transport and closed entire cities. Measures for surveillance and emergency preparedness were initiated immediately, also in distant Kerala.

All about the China Coronavirus COVID-19 | COVID-19 patient discharged from Kerala hospital at home

As soon as the World Health Organization (WHO) sent a notification about the disease on January 18, everyone who is part of the Integrated Disease Monitoring Program and district monitoring teams were alerted. They were told that increased monitoring of all SARS (severe acute respiratory syndrome) and flu-like illnesses was needed. WHO guidelines and clinical protocols were distributed to all districts. Kerala was particularly at risk as hundreds of Malay students taking basic medical or nursing courses in China were on their way home. Seventy-two of them came from Wuhan.

Again against a virus: How controlling the Nipah outbreak helped Kerala take over COVID-19

“Airport surveillance began on January 23,” said Amar Fettle, state nodal officer for public health emergencies. “We were surprised by the large number of people we had to monitor from day one. On average, we received a daily list of 100-150 people with a current travel history to China. Anyone with mild flu symptoms was sent straight to the isolation stations of selected district hospitals. They were admitted to special emergency services that had been set up at all airports. Those without symptoms were sent home with instructions to strictly quarantine them at home. ”

It soon turned out that all COVID-19 cases imported to other countries were related to Wuhan. On February 1, the WHO reported that 60.5% of all cases in China had been reported since the Hubei province outbreak began. When the officials saw this, they decided to change their surveillance strategy a little, mainly to watch the people who came to Kerala from Wuhan. All individuals returning from Wuhan, regardless of whether they showed symptoms of the disease or not, were isolated. And those who came to the state from other parts of China were sent home and asked to remain in quarantine if they did not experience any of the symptoms.

Each district was instructed to have tertiary care facilities in at least two public sector hospitals and a large private sector hospital, including an intensive care unit and ventilation support. The state control cell for COVID-19 was established at the Directorate of Health Services in the capital. Multidisciplinary teams have been set up to monitor field monitoring, hospital admissions, logistics, etc. Teams of experts created guidelines for monitoring, laboratory testing and clinical management and disseminated them across all districts. The 24×7 hotline of the Ministry of Health, Disha, was released as the first point of contact for the public to clarify doubts about COVID-19 and related issues.


Although the state was ready to fight any outbreak, the authorities went into high gear when the first positive case of COVID-19 was discovered in Kerala. All of the state’s health personnel were asked to conduct surveillance, surveillance, and contact tracking exercises. The state had learned during the 2018 Nipah virus outbreak how important it is to track down contacts.

The second sample that tested positive for SARS-CoV-2 on February 1, a friend and fellow traveler belonged to the student from Thrissur. The boy’s father recalls the sheer horror with which the family saw the news of the first positive case of COVID-19 in Kerala. “I shiver. I immediately drove my son to the Alappuzha Medical College hospital. The scenes in the isolation station were terrifying. Alien figures in full protective gear and face masks took my son into the house. It felt like a last goodbye, ”he says. The father is currently being quarantined at home. His son, who has recovered well, was released.

The The third positive case was confirmed on February 3rd. This patient was also a student from Wuhan and was kept isolated in a district hospital in Kanhangad in the Kasargod district.

“It is true that we were a little over the top, focused on all of the Wuhan returnees and immediately isolated them,” said R. Aravind, head of the Infectious Diseases Department at Thiruvananthapuram Government Medical College. “However, the additional measures we took paid off because all three people who tested positive were already isolated when we discovered the virus. We would have missed these cases if we hadn’t immediately isolated the Wuhan returnees because their symptoms were very mild. They would not normally have been hospitalized. ”

According to Aravind, an aggressive surveillance and quarantine strategy has been developed after reporting that even asymptomatic patients could spread the disease. “An asymptomatic transmission could have changed the game. That would have gotten all our control strategies out of hand. Given the large number of potential returnees from China to the state and the high population density here, we were ready to play it safe, ”he says.

The approach may not have been evidence-based, but the situation required the state to always be one step ahead. The guidelines developed by the team of clinicians were more detailed and more stringent than those of the WHO. The guidelines have also been continuously revised. While the center proposed an incubation period of 14 days, the state extended it to 28 days. Test samples were only needed by those admitted to hospital with symptoms. However, when the debate over a possible asymptomatic transmission raged, the authorities in Kerala decided to collect test samples from everyone who returned from Wuhan after January 15.

Monitoring and quarantining were difficult in the first few days, said V. Meenakshy, additional director of public health health services: “Most people thought our response was exaggerated. We appealed to people to volunteer if they had a travel story to China because monitoring is not always easy. But people tried to avoid us so that they weren’t forced into quarantine. Everything changed after the first positive case of COVID-19 surfaced. Suddenly, self-reporting increased. Our helplines were flooded with calls. ”

A nightmare called contact tracking

Surveillance officers had to perform the meticulous contact tracking exercise. According to the WHO, people who are in close contact with someone infected with a virus like SARS-CoV-2 are at higher risk of self-infection and possibly further infection of others. The authorities had to monitor the patient’s contact with friends, fellow travelers, taxi drivers, cleaning staff in hotels, people on the street, etc. The list of contacts was, of course, endless. For the first positive case in Thrissur, 82 contacts were identified; 52 contacts were followed up for the infected person in Alappuzha.

But it was the pursuit of the third patient’s contacts in Kasargod that turned out to be an exercise in patience and tenacity, says Meenakshy. “The patient had traveled from Wuhan to Calcutta and then took a flight to Bengaluru. He took a taxi and stayed in a hotel. The next day, he took another taxi to the airport and boarded a flight to Kochi. From the airport he took an auto rickshaw to Angamaly, stayed in a hotel and later took a train to Kanhangad. His friend and uncle met him at the train station and took him home. It was really a nightmare to retrace your route and identify potential contacts, ”she says. Flory Joseph, the epidemiologist who heads the Kasargod District Hospital surveillance team, says they have successfully identified 186 people who may have come into contact with the patient. “With each person, we had to explain the situation, dispel their fears, and call them daily to make sure they were fine,” she says. This is not an unusual exercise for the Kerala Health Department, which caught more than 2,500 people during the 2018 Nipah virus outbreak.

An isolation ward in the General Hospital in Alappuzha, Kerala.

An isolation ward in the General Hospital in Alappuzha, Kerala.
| Photo credit: Suresh Alleppey


Rely on the experience of Nipah

In fact, the entire framework of Kerala’s response to the potential for a possible public health emergency due to COVID-19 is based on his experience in managing the Nipah outbreak. The Nipah outbreak surprised the state health system. With a high mortality rate of 88.9%, the virus caused a lot of panic. By the time the outbreak was contained, 17 people had died.

Although the state identified the infectious agent in the second case and initiated control measures, Nipah had already spread to several locations from the index case (the patient in an outbreak that is first noticed by health authorities). Epidemiological studies later revealed that the index case was a “super spreader”; He had spread the infection to 19 people. The lesson from the episode was strong: simple and universal protocols for infection control in hospitals would have prevented human-to-human transmission and saved lives.

“Subsequently, hospitals became more aware that simple infection control measures such as hand washing and the use of personal protective equipment can ensure the safety of health workers. The nurses in all of our hospitals received intensive training in infection control protocols after Nipah, ”says Aravind.

Outbreak monitoring units were set up in all state medical schools in the past year to improve disease surveillance. These units examined patients in emergency wings and isolated patients with acute respiratory symptoms as soon as they occurred. Nipah struck again in 2019, but this time the health authorities managed to immediately identify the isolation case, isolate it, and treat it. No one else was infected.

When the COVID-19 alarm sounded, all of these basic preparations collapsed. The rest of the measures involved logistics and management, which were well managed by the state health administration. Overnight, the state control cell set up 18 subdivisions (for surveillance, training and awareness, sample tracking, transportation and ambulance, etc.), set the roles and responsibilities of each team, and managed almost everything down to rappelling in local government agencies for help and ensure that families who have been quarantined at home receive adequate food and supplies.

Stigma and fear

The families of those who had tested positive went through difficult times on site. “We were already worried about our son, but what really hurt us was the lack of support from the local community,” says the boy’s father in Alappuzha. Shortly after he tested positive, the boy’s picture on a family photo spread on social media. Not only was he accused of spreading the virus, people even started avoiding his grandfather’s shop, causing him huge losses in the business. The Nooranad police have since arrested two people related to the family’s social exclusion. The opposition of the local population to the family only waned when the health department started to organize awareness campaigns at the grassroots level. The department also mobilized its district mental health teams to provide psychosocial support to stressed families who have been quarantined for 28 days.

News of the virus has also affected local businesses. Parassini Prakashan, a bus conductor, says he has trouble operating from the Kanhangad bus stop through the district hospital because no one wants to travel on this route anymore. Almost all small and medium-sized companies in the region of the district hospital are affected. COVID-19 has also written bad news for tourism in Kerala that has been hit by two consecutive floods and the Nipah outbreaks. There were mass cancellations of tour packages after SARS-CoV-2 was reported.

Too early to celebrate

On February 3, when the third positive case of COVID-19 was reported, the government declared the virus a country-specific disaster. The statement that raised many eyebrows was hastily withdrawn four days later when there were no more positive cases. Kerala is still on high alert and surveillance is ongoing. However, the government’s rapid response team, which met on Wednesday, decided to relax the quarantine guidelines and release over a thousand people from their ordeal.

There is high spirits now. Some say it is overly confident that “everything is under control” and that it has successfully managed to limit the outbreak in the state to just three cases without spreading from person to person. However, epidemiologists and public health experts warn that it is too early for the state to blow its own trumpet, as the situation around COVID-19 is still fluid and evolving. The epidemic continues to spread in China and beyond, but much is still unknown: what are the virus reservoirs? What is the transmission dynamics like? What is the time of infectivity?

“We have to closely monitor the recovery of the positively tested patients. We have to monitor them and their contacts for four weeks and make sure that they do not develop new diseases. How sure are we that we only have three positive cases or that there are no cases in the rest of India? We have no idea how environmental factors affect virus behavior. It’s still early for Kerala, ”says E. Sreekumar, senior scientist at the Rajiv Gandhi Center for Biotechnology in Thiruvananthapuram.

A long way to go

No surveillance is ever child’s play. The key question is whether the state will take the gaps in the surveillance into account and be ready with Plan B if the scenario changes and the disease is transmitted locally. “Kerala has a very responsive health system that has gone into fire fighting mode. It has mobilized all of its resources to detect and contain COVID-19. However, this is not a sustainable model. The system will wear out soon. The real strength of a health care system is its ability to keep its regular disease monitoring system alive and active year-round, capture unusual disease trends and undiagnosed deaths, and analyze data meticulously so that it is ready for surprises without taxing anything System, ”says G. Arunkumar, director of the Manipal Institute of Virology. Neither of the two episodes of Kerala in Kerala were addressed by the Integrated Disease Surveillance Program, which means the state still has a long way to go, he says.

“While we are pleased with the” success “of containing the Nipah outbreak in the Lone Index case in 2019, we have to understand that not every case of Nipah becomes a” super spreader “,” says he. In 2019, the index case did not lead to further infections because the patient had encephalopathy and no respiratory symptoms. Arunkumar, who led the epidemiological investigation that unraveled Kerala’s first Nipah encounter, warns the state against relying too heavily on its Nipah strategy when dealing with COVID-19. “It’s okay to have experience in the fight against Nipah, but it’s important to understand that Nipah and COVID-19 don’t have the same epidemiology. The monitoring and control strategies are different. Nipah is unable to make a permanent transmission and disappears when the virus takes its natural course. However, COVID-19 is a multifocal outbreak with the potential for sustainable transmission. The likelihood that this is a long-term problem that requires long-term engagement is very high. Kerala would do well to be prepared for it, ”he warns. Because of the mild nature of the disease caused by COVID-19, the system is also unlikely to be currently transmitting low-level virus transmission in the community. In China, too, the outbreak was only taken up when a sudden accumulation of cases of viral pneumonia occurred in hospitals. The next step for Kerala would be to set up a surveillance mechanism to detect viral pneumonia clusters, especially in the elderly, in hospitals, Arunkumar said. Testing all x-ray positive cases of viral pneumonia in hospitals for COVID-19 would help the state recognize the first case of viral disease when the virus is active in the community, he says.

While Kerala is happy, it would be good to prepare for the long haul China continues to report more deaths due to COVID-19.

With contributions by Mini Muringatheri from Thrissur, Sam Paul A. from Alappuzha and C.P. Sayit in Kasargod