After its fourth phase, the lockdown was lifted as of May 31 in most parts of the country except for the containment zones, where it will continue until June 30.
On the basis of the guidelines issued by the Ministry of Home Affairs vide its circular dated May 30, States will ease restrictions in a phased manner beginning from June 8. All manner of activities and the movement of goods and personnel, including movement across State borders, will now be unrestricted. However, passenger trains and Shramik Specials, domestic air travel, movement of Indian nationals stranded abroad, travel of specified individuals abroad and evacuation of foreign nationals will continue to be regulated.
The government did not offer the public or the scientific community any rationale—scientific, medical or otherwise—for continuing with the lockdown beyond the second phase, and the lifting of the lockdown seems equally arbitrary. The 10-week period of lockdown seems to have been influenced by a statement the editor-in-chief of the leading medical journal The Lancet made on an Indian TV channel without explaining how he arrived at that conclusion.
One can give the government the benefit of the doubt for the first two phases of the lockdown. They may have been necessary for the government to get its act together on medical infrastructure from primary to tertiary care, including building up stocks of personal protective equipment (PPE) for the public and for health care workers, and to ensure that it had the necessary equipment and reagents for high rates of testing of people. But, even today the country is not fully prepared on that front.
One continues to hear reports about the inadequate supplies of PPE to health care workers and the shortage of doctors. As per the Indian Council Medical Research (ICMR), the current testing rate is around 1,40,000 per day. This is about 3,300 tests for a million population, which is a low figure. This level of testing should have been in place in February-March itself and subsequently ramped up to much higher rates.
Faced with a burgeoning caseload and the apparent shortage of testing kits, particularly in States, the ICMR is still procuring antibody (IgG) ELISA (enzyme-linked immunosorbent assay) test kits. After the early fiasco of the poor performance of the rapid antibody kits from China, the government began to import kits from the United States.
In parallel, the ICMR initiated the indigenous development of a kit called Kavach through the National Institute of Virology, Pune, an institute under its wing. As of date, only three makes of the kit, two from the U.S. and Kavach, have been validated for field use, including sero-surveys of asymptomatic individuals. This initiative of domestic development and manufacture, as the virologist T. Jacob John pointed out in an earlier Frontline article (“Lockdown and after”, May 8, 2020), should have started in January-February so that kits would now be ready for widespread countrywide antibody ELISA testing of the population.
Although this indigenous technology was transferred for licensed production to seven pharma companies, the ICMR has so far only approved the one manufactured by the Ahmedabad-based Zydus Cadila Healthcare Ltd. Also, it is not clear why IgM (or for that matter even IgA) testing kits are not being deployed. While it is true that the immune system produces IgG antibodies in large quantities, IgM antibodies are the first to be produced after a viral attack.
In fact, a recent release of the ICMR itself said: “IgG antibodies generally start appearing after two weeks of onset of infection, once the individual has recovered after infection and last for several months. Therefore, the IgG test is not useful for detecting acute infection but indicates episode of SARS-CoV-2 infection in the past.” So, if you are tracking asymptomatic individuals as well, an IgM antibody test would be more efficacious than an IgG antibody test. IgGs are found in blood and fluid samples only after about 7-10 days, while IgAs, though produced in smaller quantities, are found in the respiratory tract and saliva as well.
As the country’s count of confirmed cases continues to be in the exponential phase (Fig. 1), deception is in evidence from the manner in which the government is putting out the infection data in its press releases and public statements.
The focus of the releases of the Union Ministry of Health and Family Welfare (MoHFW) has now totally shifted towards the recovery rate of COVID-19 patients and the case fatality rate; they no longer talk of the epidemiological causes of the increasing caseload, for instance, the impact of the return of migrant workers to their respective home States.
Although the data on the share of positive cases among the returnees in the total caseload of States should be readily available with all the States—because all the people returning are being quarantined and their health status is being checked at every entry point—this data are not being made public except by a few States, including Tamil Nadu, Telangana and Andhra Pradesh. And there have been news reports on this issue on States such as Bihar and Uttar Pradesh based on statements made by the State governments.
Migrant workers not the source of primary infection
Of course, while there has been a spurt in the number of confirmed cases with the influx of returnee migrant workers—including in Kerala, which had brought the infection spread totally under control during the lockdowns—one can say on the basis of the meagre data that is available that the general positivity rate among the returning migrant workers appears to be low, except perhaps in the case of Bihar. Bihar has claimed that the caseload among migrants coming into the State is much higher than what Delhi claimed was the caseload at departure.
As of date, according to news reports, the positivity rates at departure from Maharashtra, Gujarat and Delhi—the main States from where migrant workers are returning—are reported to be 15 per cent, 8 per cent and 9 per cent respectively. These numbers would, of course, be distributed across the many States that are home to these returnees, and at entry points of these home States, the percentage share of positive cases among them to the overall caseload of the States seems to be low as is evident from the data available from a few States.
This is not surprising because, as K. Srinath Reddy, president of the Public Health Foundation of India, said, and which was quoted in a June 4 news report in The Indian Express , migrant workers, given the nature of their occupation and places of dwelling, never posed a threat as they would have had a very low exposure to the virus. The source of infection has primarily been foreign travellers, and their contacts secondarily helped its spread to others. Both belong largely to the upper-middle and upper classes. “Their [migrant workers] likelihood of having the virus by March 25,” he said, “was very remote. If they had been assisted with being sent back, we would not have seen this problem. But having kept them in urban hotspots… for almost eight weeks, there was a danger they might have actually carried the virus. However, compared to others, their exposure rates would [still] have been much less.” Of course, as has been said a zillion times before, this situation caused untold misery to these lakhs of workers and their families across the country. They faced not only exposure to the virus but also loss of livelihood, lack of access to food and water that led to hunger and death, lack of shelter and lack of basic civic amenities, all of which continues to this day.
Thus, it is clear that the returning migrant labour force is not the chief cause of the surge of cases that is seen today. The surge is due to the clusters of cases in urban regions and the community transmission that had already set in in many districts across the country, notwithstanding the MoHFW’s continued denial of that fact. But there is tacit acceptance of community transmission as is evident from the ICMR release of May 30 on the detailed guidelines for the use of rapid IgG antibody test kits where it says: “[For] sero-surveys to understand the proportion of population exposed to infection including asymptomatic individuals. Depending upon the level of sero-prevalence of infection, matching public health interventions can be implemented for prevention and control of the disease. Periodic sero-surveys are useful to guide the policymakers.”
For perhaps the first time, there is acknowledgement of the need to trace asymptomatic individuals, which can be a random survey in the 170 hotspot districts the government has identified across the country. Indeed, belatedly, the ICMR has initiated (according to a May 12 release) a community-based random sero-survey using IgG antibody tests. “[This will be] a household level cross-sectional survey that will cover 24,000 adults distributed equally across four strata of districts categorised on the basis of reported cases of COVID-19. Overall, the survey will be conducted in randomly selected 69 districts from 21 States. The survey will involve collection of venous blood samples from 400 randomly selected individuals (one per household) from 10 clusters in each district,” the release said.
Besides, it has also advised sero-surveys among the following cohort groups in different settings: immunocompromised people (such as those with severe acute respiratory infections, chronic obstructive pulmonary disease or TB); individuals in containment zones; health care workers; security, police, paramilitary and civil defence personnel and volunteers; press corps; rural and tribal populations (after the reverse migration); industrial workers or labour force; farmers and vendors visiting large markets; staff in municipal bodies; drivers; employees of banks, post offices, courier services, telecom offices and shops; air travel-related staff; staff of international operations; and people in congregate settings and prisons.
These measures should have been in place by March at least, which would have given the government a better insight into the prevalence of COVID-19 in varied settings across the country, and appropriate non-pharmaceutical interventions could have been taken to curb the spread of infection instead of the sledgehammer approach of arbitrary lockdowns.
If the government had realised early on that migrant workers were not the spreaders of infection, which would have been the case if only it had listened to epidemiologists and other experts in the country, it could have given these workers gainful employment (with appropriate PPE, of course), wages and shelter during the lockdown, both in urban and rural areas, instead of letting them suffer for want of money, shelter and food. In urban areas, particularly in cities and big towns, the period of lockdowns could have been used to execute work on civic amenities, which are in a dismal state across the country, such as the repairing and relaying of roads, the laying of pedestrian-friendly footpaths, increasing green cover and maintaining public parks, getting street lights and traffic signals in working condition, marking road signs, painting street signboards, clearing and cleaning up of garbage dumps, cleaning up public toilets and public spaces and preparing urban areas for the upcoming monsoon season.
After the lockdown is lifted, the public will again be travelling on the same potholed roads that people have become so familiar with that they know when the next pothole is coming, hitting the same invisible vehicle-breaking speed breakers, walking on inhospitable footpaths with open manholes, jumping across stagnant pools of water and walking past the stench from public toilets and garbage bins, which are themselves pieces of garbage.
But none of this happened because there was no thinking or planning before imposing the lockdown, which was implemented as a law-and-order measure rather than a health-related measure necessary during an outbreak as dictated by medical science and epidemiology. Instead, migrant workers were left in the lurch for over two months and allowed to return to their homes after perhaps many of them had picked up the virus while moving around in urban areas in search of food, water and shelter.
In rural areas, without any clarity on the continuation of Mahatma Gandhi National Rural Employment Guarantee Act-related work during the lockdown, most States had suspended MGNREGA schemes and projects, which resulted in the loss of earnings of households of rural families and farmers with small holdings during this non-harvest period.
By the time the government announced that MGNREGA work could start from April 21, the lockdown made the logistics of getting any project revived or started extremely difficult. A report in theWire.in said that, according to government data, only 20 per cent of the number of people who were engaged in work in April 2019 got work in April 2020, with two States (Andhra Pradesh and Chhattisgarh) accounting for 57 per cent of the work generated. As a result, rural unemployment rose from 8.49 per cent at the end of March to 22.67 per cent on April 29. So, the opportunity that the lockdown period offered has been squandered across all States, with the poor having to bear the major burden of the economic downturn. If the health infrastructure has been ramped, as the government claims now after four phases of lockdown, it tells very poorly on its planning and governance. The time available during the first phases should have been more than sufficient.
Besides data on the prevalence of infection among the returning migrant workers, the other data that have never been shared is the age distribution of the confirmed cases. While vague statements are made about 80-90 per cent of the cases being asymptomatic or with mild symptoms, the age distribution of the caseload would have, on the one hand, given one an idea about the nature of virus virulence and, on the other, would have provided the basis for continuing with the lockdown or opening up. From global data, it is clear that younger people get cured of infection, while the elderly (over the age of 65 or so) are impacted severely by the disease. If the age distribution of infection in India was such that a large percentage of cases were among the younger age groups, then that could have been a rationale for lifting the lockdown much earlier; the younger lot could go about their work and earn their livelihood because even if a small fraction of them get infected, they would come out of it in a fortnight or so. As the well-known epidemiologist Jayaprakash Muliyil, formerly of the Christian Medical College, Vellore, observed in an earlier Frontline article, this would have also had the positive effective of building up herd immunity in the population. The economy too would have suffered much less than it has now as a result of the extensive and irrational lockdowns.
CFR and IFR
As mentioned earlier, the government is practising data deception in presenting data on the ongoing epidemic by highlighting the recovery rate and case fatality rate (or CFR, which is the ratio of the number of deaths to the number of confirmed positive cases. Because the testing rate is low, the number of positive cases will be much lower than the real number of positive cases or the true infection load). As the testing rate goes up, as has happened of late, given that the major share of cases are either asymptomatic or mildly symptomatic, from which people recover quickly, it is obvious that the recovery rate will increase and the CFR will come down.
If, as the government says, the CFR is about 3 per cent, the recovery rate will move closer to 97 per cent, much higher than the 48 per cent that the government is tom-tomming about at present. In fact, as was pointed out in an earlier article (“Data discrepancy”, Frontline , May 8), the global average infection fatality rate (or IFR, which is the ratio of the number of deaths to the true number of infections) is a little over 1 per cent; the study discussed in that article had calculated the IFR for India to be 0.41 per cent only. So, with increased testing, as the confirmed caseload approaches the true infection load, the recovery rate will, in fact, approach 99 per cent.
Now deceptive public information and the increased testing rate are being touted as the success of the lockdown.
On May 21, the MoHFW claimed the following in press releases: “The period of the lockdown has been gainfully utilised to ramp up the health infrastructure in the country. As on date, 45,299 people have been cured, taking our recovery rate to 40.32%.... The recovery rate is improving continuously…. Of the active cases, only approx. 2.94% of the cases are in ICU. The case mortality rate in India is 3.06%, which is much lesser [ sic ] in comparison to the global case mortality rate of 6.65%.
This brings into focus our efforts towards timely case identification and proper clinical management of the cases…. As on 21.05.2020, 26,15,920 samples have been tested and 1,03,532 samples have been tested in the last 24 hours through 555 testing labs (391 in the government sector and 164 private labs).”
There is no mention of the spurt in cases that is evident in different parts of the country or the epidemiological cause for it, the nature of clusters and the 170 hotspots nor what trend in cases the Ministry expects to see on the basis of sound scientific reasoning in the days or months to come after the lockdown is lifted. The only accidental piece of information that came out in one of these releases was the age distribution of deaths, which is along expected lines given the global data: Of the total number of COVID-19 deaths in India, 64 per cent were males and 36 per cent were females. In terms of age distribution, 0.5 per cent of the deaths were in the age group of less than 15 years, 2.5 per cent in the 15-30 years age group, 11.4 per cent in the 30-45 years age group, 35.1 per cent in the 45-60 years age group and 50.5 per cent in the above-60 years age group. Further, according to the release, 73 per cent of the death cases had underlying co-morbidities.
But what has been most disappointing in the Indian scenario of the ongoing COVID-19 epidemic is the Indian scientific community not speaking up.
Silent scientists
While one can understand that the in-service scientists in government laboratories and institutions kept silent fearing retribution, one wonders what happened to the entire community of retired scientific researchers, academics and professionals. Hardly any voice of criticism has been raised through media writings or academic publications. One, of course, privately hears that if anyone tries to give advice that does not toe the government line, it is taken as criticism and, therefore, shunned. Even within the government set-up, as reported earlier, the expert groups set up for COVID-19 were rarely consulted or in any way involved in the decision-making on lockdowns, and so on. There was hardly any outcry when the task force set up specifically to look into drugs and vaccines for COVID-19, which was headed by the Principal Scientific Adviser, was disbanded without any explanation.
A somewhat muted remark was made in a joint statement issued on May 25 by the Indian Public Health Association, the Indian Association of Preventive and Social Medicine and the Indian Association of Epidemiologists that said: “Open and transparent data sharing with scientists, public health professionals and indeed the public at large, which is conspicuous by its absence till date, should be ensured at the earliest.”
It went on to say: “India’s nationwide ‘lockdown’ from March 25, 2020 till May 31, 2020 has been one of the most stringent; and yet COVID-19 cases have increased exponentially through this phase, from 606 cases on March 25 to 138,845 on May 24 [i.e. > 229 times]. This draconian lockdown is presumably in response to a modeling exercise from an influential institution which [presented] a ‘worst-case simulation’. The model had come up with an estimated 2.2 million deaths globally. Subsequent events have proved that the predictions of this model were way off the mark. Had the Government of India consulted epidemiologists who had a better grasp of disease transmission dynamics compared to modelers, it would have perhaps been better served…. Policymakers apparently relied overwhelmingly on general administrative bureaucrats. The engagement with expert technocrats in the areas of epidemiology, public health, preventive medicine and social scientists was limited.
“India is paying a heavy price, both in terms of humanitarian crisis and disease spread. The incoherent and often rapidly shifting strategies and policies, especially at the national level, are more a reflection of ‘afterthought’ and ‘catching up’ phenomenon on part of the policymakers rather than a well thought [out] cogent strategy with an epidemiologic basis.”
As of June 4, the total number of confirmed cases, deaths and cured cases stand at 2,26,770 (with 1,10, 960 active cases), 6,348 and 1,09,462 respectively. In Figure 1, the graph of increase in the number of cases against the total number of cases (plotted in a log-log scale as a moving average over six days) is still closely aligned with the reference straight line representing exponential growth, which means that the growth in the number of infections is still in the exponential phase.
Figure 2a is a similar graph at the State level, showing only those States with more than 150 cases. One sees that the trajectories of many States, even those that had steered off the exponential phase, now seem to be roughly aligned with the reference straight line just like the national-level data, with about half a dozen States of concern driving the national trend.
reversal of trend
As the restrictions began to be eased and with the inter-State movement of people, the airlifting of Indians stranded abroad, regulated domestic air travel and Shramik trains carrying migrant workers to their home States, and with people coming into States from outside (both from within the country and abroad) by all means of travel, a surge in the number of cases has occurred in most States. States, such as Kerala, that had fallen off the exponential phase are seeing a reversal of that trend, with growth approaching the exponential. Figure 2b, which shows the specific cases of Karnataka, Kerala and Maharashtra, illustrates this.
While Maharashtra remains closest to exponential growth, which it has been all along, both Kerala and Karnataka are moving towards the straight line. Until March 26, the trajectories of all the three States were roughly along the straight line.
The graph of Kerala then began to deviate from the straight line and fall off the exponential growth phase. Barring some fluctuations in mid April, this trend continued until about May 6 when the graph plummeted almost to the minimum. After that date, it has begun to increase again. Karnataka, too, had begun to deviate on April 8, but since May 5 the increase is evident. With their limited resources (financial and otherwise); a short supply of doctors and other skilled health care workers, diagnostic test equipment and PPE; and, above all, less than optimal health infrastructure at their disposal, how well States cope with this resurgence of cases should become evident over the next 30-45 days.
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