Figure 1: Timeline of Kerala's responses over 100-day period
Kerala registered India’s first COVID-19 case on 30 January. Over the following weeks, the state carried out a comprehensive series of measures, such that by the 100th day of the virus (7 May), it had already seen two consecutive days of zero new cases. In this article we analyse Kerala’s responses over this 100-day period and discuss the measures that likely bent the curve of the first wave of infections.
Through a scan of the Kerala daily bulletins, guidelines, advisories, CoronaSafe network, news media and various departmental websites and social media accounts, we comprehensively documented over 200 measures taken in this 100-day period (see complete list here). We broadly categorise these as:
1) Monitoring and Curbing (Testing, Tracing and Treatment) (jump to section here)
2) Mobilisation of Resources (Medical HR, Infrastructure, Finance) (jump to section here)
3) Coordination and Organisation (Intra-governmental and extra-governmental) (jump to section here)
4) Communication and Engagement (including mental health measures) and, (jump to section here)
5) Relief and Social Protection Measures. (jump to section here)
Figure 2: Cumulative Case Trajectory and Major GoK Policy Measures
Four days before registering its first case, the government of Kerala (GoK) had already released its nCorona guidelines that established case definitions, screening and sampling protocol, hospital preparedness, triage and surveillance. By the time it registered its second case on 2 February (fourth day of the virus), GoK had already revised/extended the testing and tracing protocol twice (each) and initiated local testing labs. The rapid screening and quarantining of patients and isolation of their contacts delayed transmission from imported cases until the 40th day of the virus, when Kerala saw its first cluster outbreak in Pathanamthitta district. 14 confirmed cases were registered over this two-day period. The following day (11 March), WHO declared COVID-19 as a global pandemic.
Within five days, GoK initiated a massive public health campaign called ‘Break the chain’ via all media platforms, communicating important information on hygiene and physical distancing. Two days later, a Rs. 20,000 crore relief package was announced (seven days before the national relief package). Then, on 22 Mar, GoK announced a state of “calamity” and imposed a statewide lockdown the following day — a day prior to the national lockdown.
Figure 3: 5- day Moving Average Doubling Rate in Kerala
By the 58th day of the virus (27 March), daily confirmed cases grew to a peak of 38 cases per day. By this time, GoK had released three revised protocols for testing and tracing (each) and interim treatment protocols. Kerala began rapid antibody testing and allocated a district jurisdiction to the different testing laboratories. On the 59th day, Kerala registered its first COVID-19 death and on the same day, GoK issued advisories on the creation of First-Line Treatment Centres and Corona Care Centres, including treatment protocols. It also issued mental health guidelines for people in isolation, caregivers, the elderly and the general public.
By the 66th day (4 April), GoK had isolated up to 17,000 individuals, a majority of them at home (only 734 were hospital isolated). Arguably, these tracing and isolation measures reduced the burden on hospitals which, at the peak in mid-April, were admitting 200 patients per day. By the end of April, Kerala had also increased per day testing to over 1,500 and made face masks mandatory in public. As of the 99th day of the virus (6 May), Kerala’s doubling rate was as high as 576 days. In the following sections, we describe GoK and partners’ measures in more detail, including some of their slip-ups along the way.
Figure 4: Cumulative Tests and Negative Results Against GoK Testing Policy Measures
Having early definitions for suspect case, laboratory confirmed case, high risk contacts and low risk contract, enabled Kerala to adopt a “matrix” for testing, admission, quarantine, isolation and discharge based on a risk assessment (26 January). This matrix was then continuously revised and updated. For example Kerala updated testing guidelines on 26 January, 1 February, 6 February, 19 February, 12 March, 23 March, 31 March.
Local testing labs, district-wise allocations and later walk-in sample kiosks allowed Kerala to quickly ramp up testing capacity and over time conduct mass screenings and serological tests. Rapid antibody testing to check community transmission began early April with a focus on health workers, government functionaries home quarantined and other vulnerable groups like the elderly. On the 83rd day of the virus, GoK began sentinel surveillance, testing a sample of vulnerable people across all 14 districts of the state.
Figure 5: Cumulative Home/Institutional Isolations Against GoK Containment Policy Measures
Kerala began screening passengers from specific countries as early as 23 January, and then regularly issued specific surveillance criteria for different groups such as returning tourists, railway passengers, health workers etc. More importantly, there were also guidelines instituted for monitoring those under quarantine through telephone and in-person check-ins to ensure that they have access to food and healthcare. By mid-April, GoK classified districts into four zones, based on the number of cases and disease threat. As of its 100th day, GoK had a total of 19,810 persons under home/institutional quarantine. GoK also published detailed locational information of incoming passengers who were not quarantined at the airport. However, patient privacy could not be maintained simultaneously, leading to stigmatisation such as with the Pathanamthitta cluster outbreak.
Figure 6: Hospitalisations Against GoK Treatment Policy Measures
On 24 March, GoK introduced interim treatment protocols based on three categories of patients, classified symptomatically into mild, moderate and critical. The guidelines discuss how to identify each category and the medication to be prescribed. Subsequently GoK released advisories specifically for first line treatment (28 Mar) and for critical care patients (02 April).
Figure 7: Managing Covid Care Centres in Kerala
The GoK was proactive in mobilising human, financial and infrastructural resources from the very start. The secret for success lies in meticulous preparation, perhaps a lesson learned during the Nipah outbreak. The state planned its healthcare infrastructure based on existing availability, prepared an ambulance network and monitored supplies of medical items such as oxygen, protective gear, and other essentials. The state also expanded internet bandwidth, prolonged the opening hours of its Primary Health Centres and strategically capitalised on digital solutions to provide telemedicine services. Kerala augmented its human resources, by enlisting retired and volunteer doctors, framing special recruitment measures for health inspectors and creating coordinating committees at district and state level.
One of its flagship measures was the development of the Covid First Line Treatment Centers and COVID-19 Care Centers. Kerala was a pioneer in thinking through models for isolating and treating suspect and positive patients, illustrating the coordination at all levels of the state including civil society particularly individual volunteers and private institutions (See Figure 8). This subsequently guided other States in developing similar care centres.
In terms of financial resource mobilisation, GoK requested the centre for redirection of disaster relief funds toward COVID-19 response and an upward revision on state borrowing ceilings. An ordinance was approved to defer six days of government salaries per month and a “Salary Challenge” was initiated. By mid-April, with most of its resources mobilised and deployed, GoK shifted focus to monitoring the services on-ground and creating transparency.
Figure 8 : Various GoK COVID-19 Coordinating bodies and their composition
(when viewing on phone, please click out-ring cells to view team composition)
A large part of Kerala’s success in containing the first wave of the virus has stemmed from its ability to convene and coordinate across various intergovernmental and external teams. District governments and local government bodies were involved from the very beginning. 24/7 Control rooms were created at the state and district levels on 1 February. Following this, state level committees and rapid response teams were constituted for managing surveillance, call centre, human resources, training, documentation, psychological care, ambulance, finance etc.
The external expert groups met twice a day; one of these meetings was with the Health Minister. A portal called CoronaSafe network was created to develop open source public utilities for logistics, personnel management and communications and statistical analysis. Volunteers were mobilised for a gamut of tasks such as running community kitchens and aiding the elderly.
Following this, COVID-19 cells were created within ministries of Transport, Tourism, Higher Education and General Education. Uniquely, GoK held a press conference seeking joint efforts with political opposition party leaders at state, district and ward level.
Figure 9: IEC Material from Kerala's Break the Chain Campaign
In order to ensure the public’s well being during the spread of the highly contagious COVID-19, Kerala responded quickly and effectively with a strong communication strategy. The first step was to disseminate facts about how the disease spreads and dispel the misinformation around it. Efforts were then directed at making the communication material accessible to citizens as well as healthcare workers. This was done by releasing information through multiple media and translating central and global portals as well as all local advisories into local languages. Kerala also employed creative strategies such as quizzes for citizens, animated videos, audio messages, as well as the ‘Break the Chain’ campaign to educate people about the importance of public and personal hygiene.
A key aspect of Kerala’s communication strategy was its focus on mental health. Kerala was proactive in addressing the stigma around COVID-19, releasing guidelines for people in isolation and their families, and also on reassuring citizens in general. Social media platforms such as WhatsApp and Twitter, realtime data dashboards (with case and institutional data) as well as other mobile phone applications were used to disseminate information effectively to a large number of people. The state also issued FAQs and advisories, and listed the policy action taken by the government to minimise panic among citizens and relay helpful information.
Figure 10: List of Social Protection Measures taken by GoK
The ability to provide regular public services is an important factor in assessing state capacity. In times of crisis, this expands to undertaking relief actions effectively and ensuring adequate social protection. Migrant workers, women, stranded citizens, elderly, children, poor communities and slum dwellers, frontline workers were among the most socially vulnerable to the COVID-19 outbreak. For instance GoK extended particular support to the families of police personnel.
Kerala was capable of organising its response in multiple ways. First, by developing digital solutions through various apps and taking help of/leveraging the police forces for helping the poor and frontline workers. Second, the state undertook multiple financial relief measures including an overall healthcare package, facilitating loans, relaxing bill payments and transportation taxes, bolstering existing programmes by advancing payments, offering direct assistance to sellers, fishermen, professionals, and facilitating cash transfers. Third, Kerala managed food availability by enabling free provision of take home rations and doorstep delivery of mid-day meals. GoK used multiple apps to arrange provisions for families under surveillance and quarantined, provided food kits to the transgender community, created community kitchens and allocating community duties in the housing colonies.
Last but not least, GoK took specific care of the migrant workers who were referred to as “guest workers”. The State set up camps to host them, ensuring their wellbeing in multiple ways including through the provision of entertainment.
All in all, not only did the Kerala government manage to curb transmission of the first wave of virus through appropriate containment measures, adequate testing, tracing and treatment, it was able to make this process amenable to health workers, guest workers, isolated patients and other vulnerable communities by taking considerate measures to socially and economically protect them.
News Media : Livemint, Manorama, Telegraph etc.
Acknowledgments : We are grateful to Harsh Pachisia,Vikram Sinha, Priya Vedavalli and Archana NK for their editorial and data inputs.