17/04/2020 9:53 AM IST

How Kerala Is Protecting Its Health Workers From Coronavirus

Kerala, which reported India’s first coronavirus case back in January, has only seen two cases of health workers being infected. Both have since recovered.

KK Shailaja
Reshma Mohandas leaving the hospital after recovering from Covid-19.

Thiruvananthapuram, KERALA — Reshma Mohandas can’t wait for her home quarantine period to get over so she can return to duty. The 32-year-old nurse, who tested positive for Covid-19 on 24 March, works at the coronavirus isolation ward at the Government Medical College Hospital in Kottayam.

The oldest Indians so far to recover from the coronavirus—93-year-old Thomas Abraham and 88-year old Mariyamma—were under Mohandas’s care. The elderly couple, who hailed from Ranni village in Pathanamthitta district, had contracted the virus from their son, daughter-in-law and grandson, who returned from Italy in the very beginning of March.

“They were under my personal care since March 12 and I contracted the disease after coming in close contact with them. The couple did not wear masks inside the ward because they found them very uncomfortable. Along with their treatment, I was also like a daughter to them. I never insisted they wear masks,’’ she told HuffPost India over the phone.

Early morning on March 23, when Mohandas developed a throat infection, she immediately alerted the head nurse, who informed the doctors. She was asked to visit the fever clinic at the Medical College and was soon referred to the same isolation facility where she took care of her elderly patients. 

“Other than headache and body pain, I had no complications,” she recalled. On April 3, the same day Thomas and Mariyamma left the ward, Mohandas also headed home to complete her mandatory quarantine period, resolving to get back to work soon.

As countries around the world continue to grapple with the highly infectious novel coronavirus, a major challenge has been maintaining the health and morale of the workers at the frontline of the fight—doctors, nurses, ambulance drivers, hospital workers and para-medical staff. While several states in India are grappling with the shortfall created by quarantined or infected healthcare personnel, Kerala, which reported India’s first coronavirus case back in January, has only seen two cases of health workers being infected. Both have since recovered.

SOPA Images via Getty Images
 People are seen washing their hands as a precaution against the spread of Coronavirus in Kochi. 

How did the state manage this? 

Apart from its investment in a strong public health system, the state has learnt from its experience of dealing with the Nipah virus outbreak in 2018 and 2019. The government prepared ahead to ensure that it would have adequate Personal Protective Equipment (PPE), and has been focusing on safe waste disposal as well as providing counselling to the health workers. 

The Kerala government employs around 15,000 doctors and nurses. Then there is a second line of health workers such as Asha workers, Kudumbasree health volunteers, Anganwadi workers, hospital development committee members, palliative volunteers and other health activists who are in constant touch with people on the ground.

“Many Malayali nurses on duty all over the world have died in recent weeks after contracting the disease. However, the state has ensured full protection to all those working in treatment facilities here. Reshma has fully recovered, and another person who showed symptoms has also been healed. The government has a responsibility to take care of them” said state health minister K.K. Shailaja, who has drawn praise for her scientific temper and level-headed approach to the crisis.

Planning for PPE

Pariyaram Medical College in Kannur is the biggest treatment centre for coronavirus in the state. However, what makes the institute different from others like it around the country is the way it ensures availability of PPE.

“As soon as we started seeing reports of scarcity of PPE in different parts of the world, we started thinking of a way out. We have asked for help from local plastic product manufacturers, textile production units, footwear makers and women self-help groups. We have also made available enough raw materials from Tirupur and Erode in neighbouring Tamil Nadu. Now we are manufacturing the PPE for our requirement through the women’s collective and under the technical help of the local plastic and textile manufacturers. Our doctors are ensuring strict quality control,’’ said Dr Arifa Rahman, who works at Pariyaram Medical College. 

Rahman said that the designs and models of PPE have been evolved taking into consideration the hardships suffered by nurses and health workers.

“Humidity is very high in Kerala at present. So it is uncomfortable and humid inside the PPE. But there is no option,” said K.V. Jomol, a nurse at Pariyaram Medical College. She said the smell of the different kinds of plastic being used for manufacturing the protective gown makes her dizzy. Wearing and removing the suit is a cumbersome process, and requires help from a trained colleague.

“You require a minimum of 30 minutes to wear this plastic protective layer along with two layers of gloves, a mask, goggles and plastic protective cover over footwear,’’ said Dr. Rahman.

While other states have been trying to make up for a shortfall in PPE, authorities in Kerala say they are not worried.

“Across Kerala, we have enough stock of medicines and PPE. We started the purchase in January itself from different sources including China,’’ said Kerala Social Security Mission executive director Dr Mohammed Asheel.

In an earlier interview with HuffPost India, health minister Shailaja had detailed how the state had begun preparing for possible cases from the time news from Wuhan in China began trickling out. The preparation paid off when the first case in India turned out to be a Malayali student who had returned from Wuhan.

“When the first Indian cases of Covid-19 were reported in the state, Kerala Medical Services Corporation Limited (KMSCL) had done enough homework and ensured enough stock to meet any possible emergency. We also have a dozen public sector pharmaceutical companies which can manufacture medicines and PPE at short notice,’’ said Asheel.

The state also has back-up options in place.

“If there is a dearth of PPE, our department needs only raw materials which can be sourced from nearby textile and plastic hubs like Tirupur in Tamil Nadu. Our own staff have got training already to stitch PPE,’’ said Dr S.S. Santhosh Kumar, who heads a 26-member team of doctors who have travelled from Thiruvananthapuram to Kasargod, which has the highest number of Covid-19 patients in the state. 

In Kasargod, he said that more than the supply of PPE, his bigger concern is finding a method for safe disposal of the contaminated waste.

“We arranged a ward with 200 beds for coronavirus treatment in a single day. Finding a permanent system for waste management was strenuous for us as we had no previous experience in that area. But we achieved that too in three days with support of the local community. Now a proper scientific waste management system is in place in this new treatment facility,’’ he said.

Other measures

The state has been devising ways to act on the innovative measures developed by in-house professionals. On April 12, Kerala’s famous poverty eradication mission Kudumbashree, comprising women neighbourhood groups, began mass production of the TMC shield, a protective gear for medical staff deputed to treat COVID-19 cases. TMC is a special mask developed by post-graduate doctors from the Thiruvananthapuram medical college. According to Kudumbasree mission director S. Harikishore, the shield will prevent the N-95 mask and goggles worn by doctors and medical staff from becoming carriers of the virus through droplets. The disposable shield is priced at Rs 10 per unit. The raw materials are being sourced easily from plastic and textile manufacturers in the state, he said.

Medical staff collect samples from people at newly set upped Walk-In Sample Kiosk (WISK) to test for the COVID 19 coronavirus at Ernakulam Medical College in Kerala on April 6, 2020.

The state has also established Walk-in Sample Kiosks (WISK) to help health workers collect throat swabs without using PPE. These kiosks,  developed by the Ernakulam Government Medical College Hospital in consultation with the district administration, have been modelled after the sample collection method adopted by South Korea. The kiosk, fitted with ultraviolet light, gloves and exhaust fan, can itself function as a personal protection kit, according to Dr Ganesh Mohan of Ernakulam Medical College.

“The health worker will remain in the kiosk and collect the throat swab using the gloves attached to it. The gloves would be sanitised after each use,’’ he said. The inspiration for developing the model was a photo seen on social media of a similar sample collection method in South Korea.

Apart from cost-effectiveness, WISK is also helpful in sample collection during mass collection drives. Health department staff can easily transport it to any place for initiating mass sample collection drive. 

The production cost of a WISK is around Rs 40,000 and this amount can be lower in the case of mass production, said Ernakulam district collector S. Suhas. 

The government-run Kerala State Drugs and Pharmaceuticals Limited (KSDPL) has begun preparations to revive production of anti-malaria drug hydroxychloroquine (HCQ) after an interval of more than a decade. The drug, touted most famously by US President Donald Trump as a possible cure for Covid-19 (though this is yet to be proved), has been recommended by Indian Council for Medical Research (ICMR) for health workers. 

“If the union government can ensure supply of raw materials from states like Gujarat, we can supply this drug even to other states,’’ said C.B. Chandrababu, chairman of KSDPL.

Speaking to HuffPost India, state nodal officer for health emergencies Dr Amar Fettle said one of the biggest gains for the state so far was its ability to protect the health professionals from the disease. “Infrastructure-wise, we have the topmost corona care wards in the country. Better facilities and timely supply of PPE and medicines are easing the tension of health workers. For us in the health sector, Lini Puthussery is not just a fond memory but also the inspiration to ensure complete protection for our frontline warriors,’’ he said.

Puthussery was a 28-year-old nurse who died in 2018 after contracting the Nipah virus from a patient. Her name was recalled by many of the health workers who spoke to HuffPost India.

Keeping spirits high

The state is also taking care of the mental wellbeing of health professionals by providing them with access to psychological counselling. 30-year-old nurse Veena Damodaran, who is now in home quarantine after treating a dozen COVID-19 positive cases at an isolation ward at Government Medical College Hospital at Pariyaram in Kannur, has reason to believe that a negative attitude is more deadly than coronavirus. 

“In all those 14 days which I spent in the ward, the major task was finding ways to prevent negativity creeping into the minds of patients. As negativity is contagious, I had to defend myself against it in all those days,’’ she said. Mental health experts, said Damodaran, are doing a great service in all corona care centres by imparting confidence to both health professionals and patients.

What makes Veena happiest about her first experiment with a pandemic during her ten years of service is the complete recovery made by a 21-year-old pregnant woman just before her scheduled delivery. The patient, who was just 21 years old, had contracted the infection from her husband, who had returned to Kasargod from Dubai and was stressed out.

“In the initial days in the isolation ward, she was and hesitant even to have food and water. It was a great struggle to infuse confidence in her mind and to impart scientific knowledge about the virus to her. She delivered a baby boy exactly two days after her complete recovery. Another challenge was handling a two-year-old boy who tested positive. In keeping him engaged for two weeks, I virtually turned into a close family member for him,’’ said Veena, who also hopes to return to the fight against the pandemic with renewed vigour after the statutory quarantine.

An ambulance driver (R) of Ernakulam medical college puts on gears up with protective apparel as he prepares before going to pick a suspected virus patient, in Kochi on February 4, 2020.

HuffPost India spoke to around 12 nurses who work in the corona care wards of Kerala and almost all of them said that Puthussery was a source of inspiration.

For male nurse Josi Jose, who has been working in Pariyaram for the last 13 years, the biggest loss was the death of a 71-year-old patient from Mahe in Puducherry, who was under his care. “He was under treatment for some other diseases at a private hospital in Kannur before shifting here at the last minute after confirmation of Covid-19 positive. His condition was very serious while being admitted here. If there was an early diagnosis at the private hospital and he was shifted here in time, he might have been saved. But my satisfaction is that sixteen others who were under my care had turned negative and returned to their homes,’’ he said with pride.

Health minister Shailaja said that more than 70 nurses and other medical professionals from the private sector in the state have also contacted her, expressing their willingness to work free of cost in the corona care wards of government medical colleges. 

“They all are aware of the risks involved. But the state feels blessed because of their readiness to treat the affected without considering the possible risks,’’ she said.