Note that views expressed in this opinion article are the writer’s personal views and not necessarily those of TrialSite.
by Juan J Chaime
The SARS-CoV-2 pandemic, fueled by the highly transmissible Delta variant, raged in India between April and May 2021 with a period of intense mainstream media coverage. Numerous broadcasts and articles depicted hospitals with no beds available, crematoriums at full capacity, and a large unsatisfied oxygen demand. Literally a month later and India contained its CV-19 outbreak. However, the media offered few reports of the vigorous recovery generally—no systematic effort to explain how the world’s second most populous nation turned this crisis around in so little time. Why so little interest in such an important, historic reversal of such an intense, massive crisis? Rather as conditions dramatically improved in June most cameras and subsequent stories faded away to other pandemic hot spots. But what did Indian health authorities in fact accomplish should have been front and center news for the entire world.
India’s strategy is not a secret. In fact, at least part of the protocol of turnaround became a public facing document in the form of a new national treatment protocol. Publicized in late April 2021 by the Minister of Health and other health authorities the guidelines can still be observed via the Minister of Health website. India’s latest protocol comprises the use of ivermectin and inhaled budesonide as early treatment. Most states embraced the new protocol, with a few opting for other approaches. 
A successful case
Leading the dramatic turnaround from the Delta variant-driven CV-19 surge was the state of Uttar Pradesh, India’s most populous with approximately 220 million people. An independent media tracking the pandemic praised this state’s pandemic management. The brilliance of the public health-led initiatives in Uttar Pradesh didn’t escape notice of the world’s health agency. The World Health Organization (WHO) acknowledged the Uttar Pradesh public health effort twice.  Its program comprised 141,610 teams distributed in 97,941 villages. Organized to proactively detect and treat cases, teams of two went from house to house in a direct, orchestrated effort to contain the pathogen’s transmission. Upon virus detection, early onset treatment commenced immediately. Along with each case the Uttar Pradesh outreach teams identified at least 15 contacts per patient. A population-wide effort, health units usually in pairs were instructed to test all household contacts and proactively treat all contacts testing positive.
Uttar Pradesh introduced ivermectin early in the second wave. Since then, ivermectin become the primary treatment and prophylactic medicine in the state. In April 2021, to treat the Delta variant, the protocol comprises seven medicines: Ivermectin, azithromycin, doxycycline, paracetamol, vitamin D3, aspirin and zinc. By July 2021, Uttar Pradesh’s results were excellent, but they kept the program and the outstanding results progressed ongoing. When comparing Uttar Pradesh with regions or countries with similar populations, the difference is striking.
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Most Indian states implemented early treatment approaches, but the state of Kerala decided against such a move—perhaps due to oppositional special interests such as unfortunately the WHO itself. Until this day, this state opts against treating asymptomatic and mild cases. Early in the pandemic, the United Nations recognized Kerala’s health minister for her successful handling of the pandemic. Yet, since June 2021, the data indicates a far different outcome. Kerala has become the exception in India’s overall success story. With a population of approximately 36 million, Kerala represents one of India’s wealthiest, boasting the highest human development index in the nation of 1.4 billion people.
Kerala CV-19’s protocol
On April 25, 2021, Kerala’s government modified their CV-19 treatment guidelines. The document recommended ivermectin to treat (late) patients with shortness of breath or comorbidities. The guide also introduced budesonide to treat patients if symptoms persist for over 5 days. Kerala’s government changed the protocol again on August 6. The document dropped ivermectin and introduced monoclonal antibodies to treat high-risk patients. But until now no systematic review of the results was available.
Correlation between actions and results
- By 5/17/21, imposing control measures that reduced mobility preceded a large decrease in daily cases detected.
- By 6/23/21, the relaxation of control measures during weekdays preceded the halt in the decrease in cases. Driven by the new permissive measures, cases increased.
- By 8/3/21, a central government audit criticized the protocol used, as well as the poor detection of contacts and the low control in quarantines.
- Between 8/12/21 and 8/21/21, there was a substantial increase in the number of cases days after the most important festival in Kerala.
- By 9/3/21, CV-19 cases started a new the decline. The decline began when Kerala’s government issued stricter quarantine controls. The drop happened despite returning to pre-pandemic mobility levels.
The measures taken in Kerala in September have resulted in a continuous improvement in the number of cases. But this is a feeble progress. From early September through early December, the positivity rate went from 19% to 8%. The positivity rate at the national level is 0.8%, 10 times lower than Kerala. Why was Kerala’s progress so much more diluted than Uttar Pradesh, a far more populous state, and others?
Kerala’s lack of early treatment strategy proved a failure in controlling the outbreak. With only 3% of the total population of India, Kerala has contributed 59% of all CV-19 cases and 66% of fatalities. And as for the positivity rate in the same period, while Kerala was 13%, in India excluding Kerala, the figure equaled under 1%.
Nonetheless, Kerala’s health minister remains steadfast, touting the state’s successful strategy. Since her swearing-in during May 2021, Veena George directs the state’s population to CV-19 vaccination ongoing.   However, the data speak loud and clear. Kerala’s results are dreadful. While much of the rest of the population continues to accept early treatment approaches, Kerala mimics approaches in the West. They depend completely on mass vaccination, augmented with investigational products such as monoclonal antibodies– not designed for early onset, home use. Of course, antivirals such as Merck’s molnupiravir will soon be available, while Remdesivir and other expensive pharmaceuticals such as Roche’s tocilizumab were available in hospitals. However, the strikingly successful early care programs common in places such as Uttar Pradesh—and again praised by WHO, weren’t acknowledged by much of the rest of the health care world.