A look at Kerala's ability to catch contagious viruses early and the protocols taken by the state quickly contain them.
Nipah virus.
(Note: This article was originally published on 15 July, 2022, and is being republished on 13 September, 2023, in the wake of the Nipah outbreak in Kozhikode)
With India’s first Monkeypox case detected in the state, Kerala is once again at the forefront of detecting and tracking exotic viruses.
The state has, in the last two decades, been the first to report as many as 10 viral and non-viral disease outbreaks: From chikungunya, dengue, Japanese encephalitis (JEV), and acute encephalitis syndrome (AES) to West Nile encephalitis (WNE), viral hepatitis, Nipah, swine flu, Covid-19, and now Monkeypox.
While it has been looked at as the state that suffers the most from exotic maladies, experts — including virologists and epidemiologists — have hailed its robust surveillance mechanism as well as the state government’s experience in outbreak response and emergency preparedness.
In an article published during the Covid-19 outbreak, WHO praised Kerala for its active reporting strategy and how it managed to keep the numbers in thousands during the initial few months of the outbreak.
“The state used innovative approaches and its experience in disaster management planning came in handy to quickly deploy resources and put up a timely and comprehensive response in collaboration with key stakeholders,” the article noted.
Women waiting for their turn at a health camp in Kerala. (Creative Commons)
Speaking to South First, renowned epidemiologist Dr Giridhara Babu said Kerala should be considered a model state for its ability to catch the virus fast.
“Many times the state has been criticised for reporting an outbreak. That should not be done. Its active surveillance mechanism, capacity-building exercises for healthcare workers, frontline staff, community engagement and strategic interventions have not just been helpful in detecting viruses, but also in keeping the disease outbreaks in control,” he said.
In 2018, when 18 cases of Nipah were reported in Kozhikode, few in the state knew about things like “quarantine”, “PPE kits”, and the like.
Yet, the state had taken note of the Nipah outbreak in West Bengal’s Siliguri in 2001 and its return in 2007 to India when around 50 people were infected in a district bordering Bangladesh.
According to Dr V Ravi, former professor of the Department of Virology, NIMHANS, the state followed protocols established for the Ebola Virus Disease (EVD) of sub-Saharan Africa.
“It was then that the strategy of tracing the contacts of infected persons, putting them in isolation, making of route maps to look for secondary contacts and all that was done. Of course, they would keep nearly 3,000 to 5,000 people under quarantine for nearly a month,” Ravi explained.
Dr Gagandeep Kang, Professor of Microbiology at the Christian Medical College in Vellore. (Twitter/GKangInd)
Renowned microbiologist Dr Gagandeep Kang said: “Nipah kind of strengthened what already existed in the state. Made it more systematic. Kerala got a tiered healthcare system and its referrals are good.”
Professor of Microbiology at the Christian Medical College in Vellore, Kang added: “The National Institute of Virology has an outpost in Kerala in Alleppey. It has a branch there that can do what the state government can’t. In addition, the Department of Biotechnology’s regional Rajiv Gandhi Centre for Biotechnology also has a good virology team. So, all of these taken together mean a strong public health system, good laboratory science, and systems in place for disease detection in travellers. All these together explain why Kerala does better than the rest of the country in detecting viruses.”
Health department officials told South First that the state government has always invested in its post-disease outbreak management systems. There are micro-management plans which are in place that also become the key strategic intervention by the state.
Among other interventions, the early screening of all incoming passengers at airports and seaports was praised by experts.
Given the state’s high literacy rates, educating people, in even remote villages, about the importance of reporting symptoms to ASHA workers and women self-help groups was not difficult. This played a significant role in the early detection of diseases.
Disease surveillance in the private sector during the devastating floods of 2018 was also a learning experience that has been adopted by the state to detect other disease outbreaks.
Nipah Virus spread through fruit-eating bats. (Creative Commons)
Kerala’s geography contributes to the frequency of outbreaks. Wildlife and animal husbandry experts believe the state’s sizeable forest cover — and its intense monsoon pattern — make it susceptible to outbreaks.
The first vulnerability, according to Kang, is travel. She said, “If you look at SARS-CoV-2 or Monkeypox, these came in with travellers. Kerala is a state with a very large diaspora. Whatever happens in the rest of the world could come to Kerala easily. The same could be said of Mumbai or Delhi or places that have a lot of international people coming in.”
Dr K Ravi Raman, a member of Kerala’s planning board concurred. He said, “Unlike other parts of India, Kerala has a huge number of people living across the world as professionals, workers, and students. Whenever a public health emergency strikes such places, these people show a tendency to return home and explore recovery in the company of close relatives. We saw this during Covid-19, and now even the first confirmed case of Monkeypox is reported in a person who returned from the UAE.”
The shrinkage of natural habitats and their proximity to human settlements in a densely populated state has also led to successive zoonotic disease outbreaks.
In regions with dense plantations, a disease-carrying vector — like a mosquito — can breed at multiple locations such as tree hollows and heaps of wet fallen leaves, where nature plays a silent host to disease-carrying vectors.
After the lethal second corona wave in 2021, the state saw a massive bird flu outbreak, resulting in the culling of over 27,000 ducks.
Experts believe that in the case of zoonotic diseases, climate change is also playing a major role.
“Agrarian and forest-fringe areas like Wayanad, Idukki, Palakkad, and Kozhikode are prone to such diseases along the backwater region Kuttanad in Alappuzha. We need to have large-scale solicitation of expert opinions on the preventive measures against zoonotic diseases,” Dr K Ravi said.
According to Dr Jacob John, former head of the Department of Clinical Virology at the Christian Medical College in Vellore: “Monsoon is the time for vector-borne and other diseases. West Bengal to Kerala, the corridor is an outbreak-prone region and must be under constant surveillance.”
“A round-the-clock surveillance mechanism and management to detect cases are important. If an alert system detects a crisis, it should act. Detection sensitivity and the robust public health system to contain outbreaks are significant characteristic features of Kerala,” he had told South First in an earlier interview.
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