Reverse quarantine in Kerala: managing the 2019 novel coronavirus in a state with a relatively large elderly population

Kerala, a densely populated coastal state in south‐west India, is a popular tourist spot. The state is more prone than others to getting infections from outside not only because it is a tourist destination, but also because a large number of Keralites who live abroad or in other states make frequent visits to their native state. Kerala also has the highest proportion of aged individuals in India relative to other states (12.6% (per the 2011 census) vs 8.6%). ¹ , ² Not surprisingly, Kerala was the first state in India to get affected by the 2019 novel coronavirus (COVID‐19)—a disease to which the elderly population is particularly susceptible. Indeed, an elderly couple—an 88‐year‐old woman and 93‐year‐old man—were some of the first to get COVID‐19 in Kerala. They contracted the virus through contact with an infected family member who had arrived from Italy. With good medical care, the couple recovered from COVID‐19, even though they, especially the man, had other very serious medical ailments. ³

Kerala witnessed a spurt in COVID‐19 cases after the report of the first case on 2 February 2020. The nationwide lockdown, which began at midnight on 24 March, restricted the entry of people from outside the state. Subsequently, in Kerala, the COVID‐19 curve flattened by the third week of April, and new cases dropped to near zero by the first week of May, with no evidence of community spread. This approach to dealing with COVID‐19 was described by experts and the media as the ‘Kerala Model’.

Although the lockdown limited the spread of COVID‐19, it resulted in an economic crisis and a public outcry, particularly regarding the untold miseries that it has caused among the working class. However, there has been minimal discussion about the psychological impact of the lockdown measures, including on the elderly population not ill with COVID‐19. People aged above 65 were strictly advised to stay at home during the lockdown period. Volunteer forces looked after the needs of those confined to their homes, but social distancing created a challenging situation for the mental health of the elderly. A major cause of loneliness was reverse quarantine, wherein the elderly remained separate from the rest of their household to avoid contracting the infection from them. Measures taken by the state government and local organizations worked to ensure social connectedness for the elderly. For example, Kudumbashree (meaning ‘prosperity of the family’), which was founded in Kerala and is one of the world's largest women’s empowerment organizations, launched an outreach programme for the elderly during the COVID‐19 lockdown. The programme used information, education and communication approach to introduce confidence‐building measures that aimed to support the elderly in abiding by the extra precautions. ⁴ Also, the Kerala Police Department introduced Prasanthi (meaning ‘highest peace’), a scheme run by the department’s Janamaithri Suraksha Project (meaning ‘people friendly’) to provide to support to the elderly. ⁵ This scheme delivered essential medicines, food, other provisions, and treatment to elderly individuals in need. It also offered counselling services through call centres staffed by specially trained female police officers providing round‐the‐clock help.

The measures taken by Kerala may not sound extraordinary, but meticulous, timely planning and cautious execution are evident in the strategies. The success of the ‘Kerala Model’ can be partially attributed to the state government's preparedness: the Department of Health and Family Welfare of Kerala issued detailed guidelines addressing COVID‐19 on 5 January 2020, weeks before the first case was detected in India. The government’s strict implementation of measures such as efficient contact tracing, aggressive testing, and effective quarantine of infected persons was a key factor in the management of COVID‐19 during the initial phase of the disease. Critical cases of COVID‐19 were treated with prescribed antiviral and antibiotic medicines, and ventilators were used as and when required. The use of immune‐boosting traditional medicines was encouraged, as Kerala is the land of Ayurveda.

As the extended lockdown was slowly lifted, the first repatriation flight arrived in Kerala on 7 May. As of June 2020, all returnees must still quarantine for 14 days in specialized facilities, but senior citizens aged 70 years and older, quarantine only in their own homes. The state government maintains strict surveillance of the returnees and uses testing to limit the spread of the disease. There are now 10–25 new COVID‐19 cases per day, but this rate is likely to increase in the coming days. However, Kerala’s head start in preventing the spread of COVID‐19 in the initial phase may help the state in dealing with the next wave of the disease.

Disclosure

The authors have no conflicts of interest to declare.