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Why Kerala accounts for half of India's new COVID cases

Elderly and diabetics, delta variant, international arrivals could be key factors

Migrant workers wait for trains at Kozhikode Railway Station to leave for their homes in May as more COVID cases are reported in the southern Indian state of Kerala.   © Getty Images

NEW DELHI -- India's southern Kerala state, which was lauded for its efficient handling of the coronavirus pandemic early on, is currently battling a rise in daily infections, accounting for more than half of the country's new cases at a time when the devastating second wave of COVID-19 is ebbing nationwide.

The picturesque state, with a population of about 35 million, reported India's first case in January 2020 in a female medical student who had returned from the Chinese city of Wuhan, where the pandemic originated. It soon adopted a strategy of testing, tracing and isolating and was largely successful in preventing the spread of infections during the first wave.

At present, however, Kerala -- India's most literate state, and the one with the highest life expectancy -- is the worst hit by the pandemic, in recent weeks recording a positive test rate of over 10%, more than triple the national average of less than 3%. On Monday, India reported 32,937 cases, of which Kerala contributed 18,582. Overall, the country's caseload stood at over 32.2 million, with 431,642 fatalities.

"Kerala is the only state in the country with over 100,000 active cases," Lav Agarwal, joint secretary in the Indian health ministry, told reporters last week, pointing out that eight states, including western Maharashtra and southern Karnataka, had 10,000 to 100,000 active cases, while the remaining 27 states had fewer than 10,000.

A six-member federal team recently visited some of the worst-hit districts of Kerala, a small but densely populated state, and pointed out some issues unique to the region with respect to controlling COVID-19, including high proportions of elderly or diabetic people, two groups particularly susceptible to transmission of the virus.

Other factors include the presence of the highly contagious delta variant in 88-90% of cases and "substantial national and international migration," Sujeet Kumar Singh, director of the National Center for Disease Control, said, detailing observations made by the federal team. In addition, because only 44% of Kerala's population has been exposed to the virus, compared to 65-70% in rest of India, many people in the state remain vulnerable.

"Kerala showed a very good public health response during the first wave, because of which a large number of its people remained uninfected and are now getting impacted owing to the highly infectious delta variant, which has dominated the country's second wave this year," Rajinder K. Dhamija, head of neurology at New Delhi's Lady Hardinge Medical College, told Nikkei Asia.

However, he pointed out the COVID fatality rate is low in the state -- 0.5%, against 1.3% for the country as a whole. "They are testing more people, as compared to many other parts of India, and that is also one of the reasons behind the current surge in cases there."

Kerala's economy depends heavily on remittances from its citizens working in Persian Gulf nations. Over 1.5 million Keralites have reportedly returned home from West Asian nations since the pandemic struck last year.

"International [arrivals] could have some role in the surge in the state, but it is not the primary factor," Dhamija said, adding that the main reason is the presence of larger numbers of susceptible people in Kerala than other parts of the country.

The state's people are now witnessing pandemic "fatigue" after practicing COVID-appropriate behavior for months, and there is also "abysmally low" contact tracing, with just 1.2 to 1.7 contacts being traced per case, Singh of the NCDC said.

"Intrahouse transmission is very high, often leading to clusters," he said, pointing out that the rural-urban divide is "very faint" in Kerala, unlike in northern India, where high-density townships and villages are usually separated by farmland, creating a "natural barrier" to the spread of the infection.

The easing of coronavirus-related curbs, the festival of Onam this week and the opening of tourism by the state are some of the challenging scenarios, Singh said, referring to the federal team's projection that Kerala could witness a cumulative caseload of 462,000 from Aug. 1 to Aug. 20.

The state is struggling despite having a good vaccination rate -- 54% of its 20 million people who need to be inoculated had received a first dose and over 23% had gotten both doses by the end of July. Nationwide, 121.8 million people had been fully vaccinated as of Monday morning, which is about 13% of the adult population of 944 million.

However, thousands of vaccinated people in the state have tested positive for COVID-19. In the Patnamthitta district, 14,974 people got infected after receiving their first vaccine dose and 5,042 tested positive despite having gotten both doses, according to government data.

"Re-infection cases are high [in the state] in spite of two doses of the vaccine," Singh said.

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