Managing Covid-19: Lessons From Kerala’s Nipah Outbreak
Medical staff members wear masks and protective suits, outside the special isolation ward of a district hospital in Kochi, Kerala, on March 12, 2020. (Photograph: PTI)

Managing Covid-19: Lessons From Kerala’s Nipah Outbreak


When the coronavirus outbreak was reported from China in December 2019 Taiwan, Hong Kong, and Singapore were expected to have similar epidemics. They had the same diaspora and shared close links with China. This did not occur. They were able to avert it by acting on what they had learned from managing the fall out of the SARS epidemic which too had spread from China. Kerala too had learned valuable lessons from managing the Nipah outbreak and gained the confidence to handle future epidemics from unfamiliar pathogens. That is standing the state in good stead in managing Covid-19. Kerala did not underestimate the threat and mounted a response commensurate with the threat perception, from the time the first reports came in. Whether even that would be adequate remains to be seen.

Unlike Nipah, which emerged out of nowhere, the origin of Covid-19 was known. Since there was only one epicentre to begin with, Kerala could focus on returnees from Wuhan. This helped the early identification and management of patients. Thanks to this there was no spread at the initial stage. But as more epicentres developed and as persons from these centres who could have been infected began to visit Kerala, the task became exponentially more difficult and the possibility of missing cases increased.

For the cases missed at the entry stage, the state now has to depend on the vigil of the community and the clinical acumen of the health care providers.

One case was missed leading to five additional infections before they were identified by a vigilant clinician. Robust response of the health system ensured that the spread has been confined to the initial six cases.

A medic wearing protective suit, outside an isolation ward,  at a government general hospital in Kochi, Kerala, on March 15, 2020. (Photograph: PTI)
A medic wearing protective suit, outside an isolation ward, at a government general hospital in Kochi, Kerala, on March 15, 2020. (Photograph: PTI)

Adopting Local And Global Learning

The system used to track the contacts of infected persons, a basic public health strategy, was perfected during the Nipah outbreak. Every contact of each positive case for the 14 days prior to the person showing symptoms is identified, contacted and home quarantined. They are followed up morning and evening for the entire incubation period over the phone by health workers. If they report any symptoms, they are presumed Covid-19 positive and transported in designated ambulances to the isolation ward in the designated treatment centres and tested. They remain in isolation until their test results return negative. If a person tests positive the cycle begins again: all his contacts are now identified and followed up. This resource-intensive process started in January and will have to be maintained until the threat of the epidemic is over.

Since global public health emergencies have been recurring repeatedly in recent years, there is an increased understanding of what works. In 2002 China suppressed information on SARS and Asia paid for it. There are allegations that this was repeated in the case of Covid-19 too. During the Nipah outbreak Kerala had learned that transparency is a necessary condition for an effective response. Regular and accurate information was made available on the number of persons under observation, numbers tested, positive and deaths. In Kerala, traditionally mainstream media is co-opted as a partner in public health emergencies, a practice from the time Kerala faced the threat of HIV in the nineties. In return, the media ensures that sensationalism is avoided and carries out health education for their audience. A new phenomenon during the Nipah outbreak was the role of social media. The government had built up its presence in social media to answer queries and to counter fake messaging. Punitive measures were taken to deal with messages that provided wrong information or were intended to create panic.

However, Kerala does not appear to be using social media during the current outbreak.

The psychosocial needs of the quarantined and isolated persons were another need identified in the Nipah period. The quarantined and isolated persons and their families go through a great deal of stress. Trained psychologists and psychiatric social workers provide telephonic counseling and support to persons in isolation and quarantine. Families that are quarantined were distributed free rations during the Nipah period. Now they are provided support to procure supplies.

 Medics screen passengers  at a railway station in Kozhikode, Kerala, on March 16, 2020. (Photograph: PTI)
Medics screen passengers at a railway station in Kozhikode, Kerala, on March 16, 2020. (Photograph: PTI)

Also read: Coronavirus Brings Renewed Reminder For Prioritising Public Health

Mobilising Communities

Management of Nipah demonstrated that government could not manage the response alone. The tremendous social capital of the state came in to support the government effort. Kerala’s robust panchayat raj system—and urban local bodies—mobilised support for the contact tracing and support to affected families. Non-government organisations arranged for supplies including protective gear. Opinion leaders, religious leaders, media, civil society organisations were all co-opted into responding to the threat. This led to the community trusting government and coming forward to provide the needed information, volunteering to provide resources and following directions of the government even it was painful for them. A touching instance was when a Muslim family allowed a Hindu doctor and other health staff to perform the last rites of one of their members in the interest of safe burial practices. The same group is active in Covid-19 management too. As in Nipah management, the private sector will be an active partner in managing the case-load that may emerge.

Transparency, while it is needed to control the epidemic, comes at a tremendous economic cost. During Nipah, advisories were issued against travel to Kerala even though only two districts were affected. Kerala Tourism, a significant contributor to the state’s economy, was badly hit. The export of fruits and vegetables from the state was banned by the importing countries. Economic activity came to a standstill in affected areas. Similar reactions occurred when the state identified three positive cases of Covid-19 through proactive surveillance. While such actions made Kerala safer, many tourist bookings were canceled.

But this time around, the state had anticipated the reaction and decided that saving lives was more important than protecting the economy.
A medic wearing protective suit interacts with patients outside an isolation ward, at a government general hospital in Kochi, Kerala, on March 15, 2020. (Photograph:  PTI)
A medic wearing protective suit interacts with patients outside an isolation ward, at a government general hospital in Kochi, Kerala, on March 15, 2020. (Photograph: PTI)

Also read: Coronavirus: The Economic Impact Of COVID-19 On India

The Next Challenges

The most valuable resources in a health emergency are also the most vulnerable. Hospital staff, who are the last guard against death from the infection, are vulnerable to infection themselves. If and when health workers get infected and have to be quarantined the capacity of the system to respond, already strained, is diminished further. Health workers will have to be protected against burnout from the increased workload, compounded by the discomfort of working wearing protective gear and fear of infection. Kerala will need to augment its workforce to deal with the increased number of patients.

The confidence with which Kerala has responded to the Covid-19 epidemic is based on the capacity the health system has to handle the load that may emerge if prevention does not succeed entirely. Managing two Nipah outbreaks, and the health consequences of the flood of 2018, has given the state the systems and confidence to deal with the new threat. However, Covid-19 is an epidemic that has defied all predictions. Whether Kerala will manage the epidemic the way Taiwan, Hong Kong, and Singapore have done or be swamped by the effort of dealing with the burden is too difficult a call to make at this point.

Rajeev Sadanandan is the CEO of Health Systems Transformation Platform, a not-for-profit company working in health systems research. Prior to that, he was the Health Secretary of Kerala where he successfully managed the Nipah outbreak in 2018.

The views expressed here are those of the author and do not necessarily represent the views of BloombergQuint or its editorial team.

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