COVID Strategy

Maze of numbers

Print edition : July 03, 2020

A queue for COVID-19 screening at a coronavirus designated hospital in New Delhi on June 10. Photo: Manish Swarup/AP

A health worker conducts a survey in a red zone in Ongole, Andhra Pradesh, on April 30. Photo: Kommuri Srinivas

In terms of COVID statistics, governments, both at the Centre and in the States, seem keen to hide more than what the numbers could otherwise reveal.

On June 18, 10 days after the Central government’s decision to “Unlock” India in phases, a Union Health Ministry release stated that there were 1,60,384 active COVID-19 cases under medical supervision across the country from 62,49,668 samples collected until then. Giving bare details, it further stated that the recovery rate was 52.96 per cent and that there were 953 laboratories (699 in the government sector and 254 in the private sector) in the country. Significantly, there was no mention of the fact that each day anywhere between 10,000 and 11,000 cases were being added to the overall tally.

The same day, Union Health Minister Harsh Vardhan launched India’s first mobile Infectious Disease Diagnostic Lab to promote last-mile testing in remote and inaccessible areas. According to a government release, the mobile laboratory could conduct 25 RT-PCR (Reverse transcription-polymerase chain reaction) tests a day, 300 ELISA tests, and additional tests for tuberculosis and HIV at Central Government Health Scheme (CGHS) rates. The laboratory’s launch was in some sense an admission of the fact that the infection had spread to rural pockets too. Not a surprise, considering the large-scale migration of workers from cities to their villages in March through May. The exodus was spurred by the government’s abrupt decision to impose a lockdown without a contingency plan for the migrant worker population engaged mainly in the informal sectors of the economy.

Sero survey

Despite the wide geographical spread of the infection, the government has consistently maintained silence on possible community transmission. On June 11, the government released the results of the first serological survey conducted in the country that gave an indication of the spread of the infection in the general population. The briefing began with a statistical presentation that showed India in a favourable position vis-a-vis the worst faring countries. The number of cases and deaths per lakh population in India was lower than that in Mexico, Turkey, Iran, Germany, France, Brazil, Russia, Italy, the United Kingdom, Spain, the United States, Peru and Chile. It glossed over the fact that India had the highest number of cases and deaths among East and South Asian countries.

Next in the press briefing were the results of the first part of the serological survey conducted in the third week of May in 83 districts to monitor the transmission trend of SARS-CoV-2 infection. Blood samples were collected from 26,400 individuals to test for antibodies. The second part of the survey was being done in containment zones of hotspot cities to ascertain what section of the population had been infected with SARS-CoV-2, the results of which are awaited.

The survey results presented by a panel comprising Dr Balram Bhargava, Director General, Indian Council of Medical Research (ICMR), and Dr Vinod Paul, Member, NITI Aayog and chairperson of the National Task Force (NTF) on COVID-19 stated that only 0.73 per cent of the general population had been infected. The infection fatality rate (IFR) was also low, at 0.08 per cent. The summary of the results were full of contradictions. While 0.73 per cent of the population surveyed had shown past evidence of being infected, the lockdown and containment had been successful in preventing the rapid spread, the presentation said. A large proportion of the population was still susceptible, the survey said, and the risk was 1.09 and 1.89 times higher in urban and urban slums respectively compared with rural areas.

If the 0.73 per cent infection rate is extrapolated to the 1.37 billion population of the country, it would be around 99 lakh, which is by no means a small figure. The districts for the sero survey were selected on the basis of the incidence of reported COVID cases as on April 25. The survey was done in the third week of May to ascertain the prevalence of antibodies in the population as a result of contracting the infection in April end.

The conclusions of the survey were as follows: One, a “large proportion of the population is still susceptible and infection can spread”; two, “non-pharmacological interventions like physical distancing, face mask, hand hygiene, cough etiquette must be followed strictly”; three, “urban slums were highly vulnerable for the spread of infection”; four, “local lockdown measures need to continue as advised by the Government of India”; five, high-risk groups like the elderly, those with co-morbidities, pregnant women and children under 10 need to be protected; six, “States cannot lower their guard and [should] keep on implementing effective surveillance and containment strategies”; and seven, “efforts to limit the scale and spread of the disease will have to be continued by strong implementation of containment strategies by the States”.

The assertion in the press conference that the “lockdown was successful” had little basis according to the conclusions arrived at by the sero survey that large sections of the population were still susceptible and that containment strategies would continue.

Data deficit

Apart from the basic details given in the government’s press releases, there was no break-up of the asymptomatic and symptomatic cases. If the number of active cases under medical supervision were symptomatic, could it be assumed that all the remaining infections were asymptomatic and not likely to develop complications but still had the potential of infecting others? On June 17, when the number of confirmed cases and deaths were added retrospectively, as part of a “data reconciliation exercise”, it stirred up questions on whether States were reporting correctly.

On June 15, the Press Information Bureau (PIB) declared as fake a news agency report that claimed to have sourced its information from an ICMR study. The agency report was published in a few newspapers. Citing an ICMR study, the report said that the peak of COVID-19 had shifted to November and that there would be a paucity of ICU beds and ventilators. The PIB Fact Check on Twitter, however, stated that the report was misleading and that the ICMR had not carried out the study.

Frontline accessed a copy of the multi-author study under dispute titled “A Model based analysis for COVID-19 pandemic in India: Implications for Health Systems and Policy for Low and Middle Income countries”. The academic paper did not appear to have been peer reviewed but was funded by the ICMR. An ICMR researcher and the chair of the Operations Research Group of the NTF were two of its seven authors. The study “gratefully acknowledged” the inputs on research methods by the members of the Operations Research Group of the NTF and of a member of ICMR’s Global Health Policy Research Cell.

The study aimed at comparing and predicting health outcomes under (i) an unmitigated scenario with only air travel restrictions, and (ii) the current scenario with air travel restrictions and an eight-week lockdown. It was a model-based study among several others that were being done nationally and globally. There could be disagreement with the findings of the study, but to declare it as “fake” was an extreme reaction on the part of the government, more so when the ICMR had funded it.

The model also explored the effectiveness of the eight-week lockdown along with the intensified public health measures at varying levels of effectiveness. It ascertained the need for augmenting infrastructure and costs of COVID-19 management. The authors reiterated what many others had already said: that lockdown measures tended to delay the onset of the peak and give enough time for health systems to prepare; that strengthening the public health system response in terms of testing, isolation, treatment of cases and contact tracing would lead to significant gains in meeting caseload and health system needs. This had to be the mainstay of reducing the impact of the pandemic until a vaccine was available.

The study also said that an eight-week lockdown would shift the peak by 34-76 days and an effective lockdown would reduce the caseload by 69-97 per cent at the end of eight weeks. If public health surveillance measures were intensified by 60 per cent, they would result in a reduction of cases at the peak by 70 per cent and cumulative number of infections by 26.6 per cent, it said. Intensified public health measures could reduce by 83 per cent the requirement of ICU beds and ventilators, it said. However, intensified public health measures would raise the cost of management of COVID-19 to 6.2 per cent of the gross domestic product (GDP). At the moment, India was spending far less on overall health and on COVID-19 management in particular.

The model-based study also projected that the current dedicated resources such as ICU beds, isolation beds and ventilators would last until September 3, beyond which there would be an unmet need for about 3.3 months for isolation beds and 2.9 months for ventilators. The authors were candid enough to admit that the study had data limitations as it was based on epidemiological evidence drawn from countries that had already experienced the epidemic. Future research should focus on generating more epidemiological evidences and carrying out model-based analysis at the State level to inform local policies, it said.

In all fairness, the authors had merely underscored the need for preparedness. The reasons for the government’s discomfort regarding the findings were unclear. It did not seem to want to associate the ICMR with the study, but in the PIB Fact Checker it suppressed the fact that the ICMR had funded the study. A complete dissociation was therefore not possible.

Lack of transparency

Lack of transparency has been an issue for some time. According to Venkatesh Nayak, head of the Access to Information Programme at the Commonwealth Human Rights Initiative, to date there has been no centralised form of information in the public domain on COVID hospitals and treatment centres in the country. He filed a formal request on April 17 under the Right To Information Act seeking information on district-wise details of COVID hospitals, their postal addresses and telephone numbers but received no response. He then filed a complaint with the Central Information Commission (CIC). On June 5, the CIC issued an advisory to the Union Health Ministry to fill the information gap. The CIC also observed that it was “appalled to learn that this basic information pertaining to district-wise designated COVID treatment centres could not be provided to the information seeker by any of the respondents”.

A random survey of COVID-related websites and web pages of 21 State governments and two Union Territories Nayak did concluded that there was an urgent need to develop templates for information disclosure across the country. There was no uniformity in terms of details given in State government bulletins across India as Frontline had pointed out earlier. Some State bulletins like that of Uttar Pradesh needed a login id to access basic information on the daily count of infections and deaths as well as COVID hospital details. Likewise, there was scarce information regarding the implementation of regulations in the private health care sector where reports of overcharging and denial of treatments were being reported consistently by the media.

In a recent article titled “Pandemic and Beyond: Regulating private healthcare” in policycorps.org, an online portal, Shweta Marathe, a Pune-based health researcher, says that private hospitals that accounted for two-thirds of hospital beds in the country, 80 per cent of ventilators and employed 90 per cent of doctors were handling less than 10 per cent of the critical load. There was no monitoring mechanism to ensure that hospitals were not overcharging and denying health care, the article says.

Inward spread

On June 18, Union Minister for Information and Broadcasting Prakash Javadekar lauded the efforts of the Bharatiya Janata Party-led government in Madhya Pradesh in effectively controlling the spread of COVID. But, according to Amulya Nidhi, a public health activist based in Bhopal and associated with the People’s Health Movement, this claim was contrary to the situation on the ground. By the second week of June, COVID-19 cases had spread in all the 52 districts of Madhya Pradesh, he said. The number of positive cases had crossed 11,000 and the death toll was 476. The number of testing laboratories had gone up to 59, but as of June 15 as many as 4,180 test results were still pending.

“In the last two months there have been issues related to pending samples, missing samples and missing test reports, and civil society and the media have raised allegations of misreporting of the number of COVID cases in the State,” he said. “According to Indore’s health bulletin of June 14, of 1,058 test reports that day, 1,006 reports were negative and only six were found to be positive. When the media raised the issue of the missing 46 test reports, the authorities clarified that out of the 46 reports, two were repeated positive and 44 were [classified as] Sample Insufficient for the Process [SIP]. This was a new classification introduced in the bulletin, unheard of earlier,” Amulya Nidhi told Frontline.

The Jan Swasthya Abhiyan (JSA), he said, had been raising since early May the issue of inappropriate handling of samples and had taken up the matter with the ICMR. On investigation, the ICMR also found that there were multiple gaps in the managing of test samples. It had written to the State government way back in April highlighting multiple violations such as leaked and missing samples and incomplete documentation. As many as 5,059 samples were “rejected”, with Indore alone accounting for 529 samples.

Said Amulya Nidhi: “The State government had stopped providing the status of testing kits and other supply-related information to citizens since early May 2020. Similarly, there is no information on how many various categories of hospitals and health centres exist in the State and the infrastructure development that was carried out in the last two months in the State. The lockdown was intended to slow down the infection curve and buy time to strengthen the public health system. As per the State government’s COVID management plan of May 28, even though the fatality rate has gone down from 4.7 to 4.3 per cent over 10 days from May end, the rate of deaths [seven-day Compound Annual Growth Rate] during the same period had increased from 2 to 2.4 per cent. This report also confirmed that the peak was expected in July, but the administration has been sending a general message that things are in control. A large segment of the political leadership is now busy with campaigns for the upcoming byelections for 24 seats which determined the change of government in March, just when the pandemic was making headway in the State.”

He also expressed concern that instead of drawing out plans to ensure regular treatment of people with non-COVID conditions through the public health-care system, the government had issued an order for short-term empanelment of private hospitals under Ayushman Bharat.

A letter from the Editor


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Editor, Frontline

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