Aggressive testing, contact tracing, cooked meals: How the Indian state of Kerala flattened its coronavirus curve

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NEW DELHI – For hours, the health worker ticked through a list of questions: How is your health? What is your state of mind? Are you running out of any food supplies? By the end of the afternoon, she had reached more than 50 people under coronavirus quarantine. Weeks earlier, that number was 200.

Sheeba K.M. was just one of more than 30,000 health workers in the Indian state of Kerala, part of the Communist state government’s robust response to the coronavirus pandemic. Other efforts include aggressive testing, intense contact tracing, instituting a longer quarantine, building thousands of shelters for migrant workers stranded by the sudden nationwide shutdown and distributing millions of cooked meals to those in need.

The measures appear to be paying off. Even though Kerala was the first state to report a coronavirus case in late January, the number of new cases in the first week of April dropped 30% from the previous week. With just two deaths, 34% of positive patients have recovered in the state, higher than elsewhere in India.

The success in Kerala could prove instructive for the Indian government, which has largely shut down the country to stop the spread of the contagion but continues to see the curve trend upward, with more than 6,700 confirmed cases and more than 200 deaths. Its challenges are plenty – from high population density to poor health care facilities – but experts say Kerala’s proactive measures like early detection and broad social support measures could serve as a model for the rest of the country.

“We hoped for the best but planned for the worst,” said K.K. Shailaja, the state’s health minister, while cautioning that the pandemic is not yet over in Kerala. “Now, the curve has flattened, but we cannot predict what will happen next week.”

Kerala’s approach was effective because it was “both strict and humane,” said Shahid Jameel, a virologist and infectious disease expert.

“Aggressive testing, isolating, tracing and treating – those are ways of containing an outbreak,” said Jameel, who is also the CEO of Wellcome Trust, a health research foundation.

Henk Bekedam, the World Health Organization’s representative in India, attributed Kerala’s “prompt response” to its past “experience and investment” in emergency preparedness and pointed to measures such as district monitoring, risk communication and community engagement.

The state faced a potentially disastrous challenge: a disproportionately high number of foreign arrivals. Popular for its tranquil backwaters and health retreats, the coastal state receives more than 1 million foreign tourists a year. One-sixth of its 33 million citizens are expatriates, and hundreds of its students study in China.

Screening at airports was tightened, and travelers from nine countries – including coronavirus hotspots such as Iran and South Korea – were required to quarantine at home starting on Feb. 10, two weeks before India put similar restrictions into place. In one instance, more than a dozen foreign nationals were removed from a flight before takeoff because they had not completed their isolation period. Temporary quarantine shelters were established to accommodate tourists and other nonresidents.

Still, some slipped through. The arrival of a local couple from Italy in the last week of February who did not report to health officials caused an alarm. By the time they were detected, the couple had attended several social gatherings and traveled widely. Nearly 900 primary and secondary contacts were traced and isolated.

Robin Thomas, 34, the son-in-law of the couple who returned from Italy, tested positive for coronavirus, as did his wife and his wife’s grandparents. He said apart from the “excellent treatment” he received, the medical staff also helped them overcome stigma.

“People were blaming us on Facebook and WhatsApp,” he said. “The counselors called us over the phone regularly and gave us confidence.

Shailaja, the health minister, said six states had reached out to Kerala for advice. But it may not be easy to replicate Kerala’s lessons elsewhere in India.

In more than 30 years of Communist rule, the state has invested heavily in public education and universal health care. Kerala has the highest literacy rate and benefits from the best-performing public health system in the country. It tops India’s rankings on neonatal mortality, birth immunizations and the availability of specialists at primary care facilities.

The strength of its health care system allowed it to follow the World Health Organization’s recommendation on aggressive testing, even as central agencies maintained that mass testing was not feasible in a country like India. Through the first week of April, Kerala had conducted more than 13,000 tests, accounting for 10% of all tests done across India. By comparison, Andhra Pradesh, a larger state with a similar number of cases, had carried out nearly 6,000 tests while Tamil Nadu, with more than double the number of cases, had done more than 8,000 tests.

The state took the lead in deploying rapid testing kits, which officials say they continue to use in hotspots to check community spread. This week, Kerala began walk-in testing facilities, which reduce the need for protective gears for health workers.

Kerala also announced an economic package worth $2.6 billion to fight the pandemic days before the central government instituted a harsh lockdown that left many states scrambling. It delivered uncooked lunches to schoolchildren, liaised with service providers to increase network capacity for Internet at homes and promised two months of advance pension.

But there have also been some blips. The state was criticized for going ahead with a local festival in early March that drew thousands of people. Amar Fettle, the state officer responsible for health emergencies, said there was still room for improvement on aspects like social distancing in markets, cough hygiene and lockdown implementation.

Thomas and his wife have recovered, as have his wife’s elderly grandparents – 88 and 93 – who were discharged this week.

“We were very worried about them and thought they may not survive,” Thomas said. “Even when grandfather had a heart attack, the doctors told us they will keep trying.”