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Just before of Onam, a 45-year-old female resident was trembling in the back, losing unconsciousness as relatives rushed her to a specialized clinic.

Merely 48 hours earlier, the woman, who made a living producing drinks in a rural area near Malappuram, had complained of nothing more serious than lightheadedness and hypertension. Doctors prescribed pills and discharged her. But her state worsened with rapid speed: discomfort turned into fever, fever to severe shivers, and on the main festival day, she was dead.

The culprit was Naegleria fowleri – commonly known as the brain-eating amoeba – a condition typically acquired through the nose in natural water sources and so rare that most doctors rarely see a case in their lifelong practice.

Within the state in the current period, above 70 patients were identified and nineteen succumbed from the deadly organism. Cases varied from a baby to a 92-year-old man.

Normally consuming bacteria in warm freshwater, this amoeba leads to a near-fatal condition, called primary amoebic meningoencephalitis (PAM). It enters through the nose during swimming and rapidly attacks brain tissue.

Kerala first recorded cases in recent years, very few a annually, and up until now almost every case were fatal. A new report has shown that merely 488 cases have been reported globally since 1962 – mostly in the United States, South Asia and Oceania. And 95% of the patients have succumbed from the disease.

But in Kerala, survival is enhancing: recently there were thirty-nine infections with a twenty-three percent death rate, and currently, nearly 70 instances have been identified with around a similar fatality. Medical experts say the rise in figures reflects better detection, thanks to advanced laboratories.

"Instances are rising but deaths are dropping. Aggressive testing and timely detection have improved survival – an approach unique to Kerala," noted an expert infectious diseases doctor.

Timely identification allows personalized care: a combination of medications of antibiotics and anti-inflammatories aimed at the pathogen can prevent deaths.

Experts have identified approximately 400 types of free-living amoebae, but just a handful are known to cause disease in individuals – like Naegleria fowleri and Acanthamoeba, each of which can infect the central nervous system. In Kerala, testing centers can now detect the several primary infectious strains, officials confirm.

The southern state's significant dependence on well water and natural water bodies makes it highly susceptible, especially as a lot of ponds and wells are polluted. A group of cases recently, for example, was tied to individuals vaping a substance diluted in non-potable water – a dangerous habit that underscores how polluted sources can become a conduit for transmission.

The state has almost 5.5 million wells and tens of thousands of lakes – and many residents collect their drinking water from wells alone. That pervasiveness renders it unfeasible to manage water sources as basic "dangers" – they are the lifeblood of daily existence in the region.

"Some infections have been reported in people washing in water bodies, some from recreational water, and even through ritual cleansing with untreated water which is a religious ritual," notes a prominent specialist.

Thus public health authorities have attempted to act broadly: in a targeted drive at the end of August, millions of wells were chlorinated.

Authorities have put up warning signs near ponds advising against immersion and used the safety laws to enforce frequent chlorination of pools and storage containers. But despite such steps, ponds cannot feasibly be chemically treated – aquatic life would die – and regulating all village water source in a state of more than millions of people is unworkable.

Experts now focus on education rather than restrictions: households are advised to clean water containers, use treated warm water for ritual rinsing, prevent kids from using irrigation devices and refrain from untreated ponds. Water users are instructed to shield their nasal passages by keeping their heads above water, using equipment and preventing stirring up sediment in standing freshwater.

However, managing risks between alerting the public about potential threats – of using untreated freshwater – and averting fear that could affect daily life is challenging. Many {