COVID Management Strategy

COVID-19 surge: Indian government misleading public with recovery rate figures instead of focussing on its new waves

Print edition : October 09, 2020

People waiting to get Rapid Antigen Diagnostic Testing (RADT) done for COVID at a health centre in Visakhapatnam on September 18. RADT results, however, are not conclusive. States have been advised now, a full six months after the outbreak in India, that all negative results of RADT require further validation through Reverse Transcription Polymerase Chain Reaction (RTPCR) if the subject is symptomatic. Photo: K.R. DEEPAK

A health worker prepares to collect a swab sample from a child at a health centre in Secunderabad on September 18. Photo: G. RAMAKRISHNA

Denial is a major component of the Indian government’s COVID management strategy: it focusses on the number of recoveries rather than the surging infections which the public health system seems unable to pre-empt.

The Union Health Ministry has been giving out regular updates on the COVID-19 situation through tweets. A disproportionate focus on recoveries against the daily number of confirmed cases or mortality is characteristic of these messages on social media, which are often followed by press releases. On September 19, the Health Ministry announced that India had crossed another milestone. It had overtaken the United States and become “number one” globally in terms of the number of recoveries (42 lakh to date). India also accounted for 19 per cent of all “global recoveries”. This “global achievement”, it said, was owing to the “Centre-led focussed, calibrated, responsive and effective measures of early identification through high and aggressive testing, prompt surveillance and tracking coupled with standardised high-quality clinical care”.

The unmentioned detail in the press note and tweet was that if there were a large number of cases, there would be a large number of recoveries also, and “world leadership” in recoveries, therefore, was simply a function of world leadership in the spread of the infection. Moreover, the surge in infections in India happened at a time when the curve of the daily number of cases in other countries was on a downward trend since July-August.

A close look at why India’s recoveries exceed those of the only country that has had a larger number of cases reveals some startling facts. On August 1, the U.S. had 47,69,873 (4.77 million) confirmed cases. By September 18, 2,03,171 deaths had been recorded in the U.S. Assuming that all these deaths were of those who were infected before August 1, at least 45,66,702 (4.56 million) of those infected in the U.S. until August 1 had not died until September 18. Yet, the cumulative number of recoveries in the U.S. by September 18 is only 41,91.894 (4.19 million). Did this mean that in the U.S. a large number of COVID-infected patients continued to remain sick for exceptionally long periods without either dying or recovering? It is more likely, instead, that actual recoveries are not being recorded in the U.S. as promptly as is being done in India, where most infected people, according to the statistics, cease to be active within 10 days of testing positive. To give a comparison, on August 1, India had just about 1.75 million cases, but its recoveries by September 18 had reached 4.2 million.

If these figures are to be taken at face value, most of those who have recovered in India were infected after August 1 while almost all of those who have recovered in the U.S. were infected before that date. Clearly, therefore, India’s recoveries being higher than the U.S. is an illusion created by different methods of documentation.

Globally, recovery rates have been estimated at 97 to 99.75 per cent. And none other than Balram Bhargava, Director General of the Indian Council of Medical Research (ICMR), said as early as March in a press conference that 80 per cent of those infected would recover on their own. Therefore, to take “credit” for those recoveries that may have happened without medical intervention was surprising. Secondly, different countries had different mechanisms of declaring “recoveries”. The World Health Organisation (WHO) revised its “discharge from isolation criteria” after consulting governments on the logistical difficulties of establishing two negative RTPCR tests, 24 hours apart. The updated recommendation for discharge (without requiring retesting and discontinuing transmission-based precautions) was published on May 27, regardless of isolation location or COVID-19 severity. The guidelines were revised in the light of limited laboratory supplies, equipment and personnel in areas with extensive transmission, especially in areas outside hospital settings. But the WHO also stated that “countries could use testing as part of their release criteria”, which meant that its earlier recommendation of two negative PCR tests 24 hours apart could be used.

High recoveries in Bihar and U.P.

The revised guidelines for symptomatic and asymptomatic persons were introduced primarily because of the burden felt on the health system and not because they were epidemiologically or clinically sound. India also revised its discharge guidelines subsequently, as the revised guidelines were more convenient. Interestingly, Bihar, with its poor health infrastructure, was one of the States in India with a recovery rate of 91.6 per cent, far higher than the national average and much more than Tamil Nadu’s 89.6 per cent or Kerala’s 71.3 per cent. Whether this recovery rate has anything to do with the impending Assembly elections there is anybody’s guess. Bihar’s testing rates were equally startling. It has tested 54 lakh persons to date while Uttar Pradesh, another State with a high “recovery” rate at 78.8 per cent, has tested more than 82 lakh. What kind of testing method and recovery criteria were used in Uttar Pradesh or Bihar could, again, only be second-guessed.

With no disaggregated data of what proportion of active cases had recorded recovery in clinical care or hospital settings and home care or how many of the active cases were still in hospital in various States, it can be concluded that people had mostly recovered on their own. While “recoveries” are disproportionately highlighted in the Ministry’s tweets and press releases, the death toll is seldom mentioned. Likewise, there was little explanation for the faltering and varying daily testing rates, which corresponded and impacted the outcome of confirmed cases the following day. On its part, the Health Ministry has consistently striven to convey a picture of optimism. Yet, some of its own efforts convey a different picture. Consider the following. On September 18, it tweeted that 60 per cent of the active cases were concentrated in “only five” most affected States. There were 13 States and Union Territories that had fewer than 5,000 active cases.

The tweet was followed by another one that highlighted how the Centre was supporting the States and Union Territories with high caseloads and how Central teams had been deputed for supporting State governments. The previous day the ministry tweeted that the gap between the number of active cases (10.5 lakh) and recoveries was growing, and that active cases constituted one fifth of the total number of confirmed cases. A day prior to that, the press was told that testing had been scaled up in all States, using both the Reverse Transcription Polymerase Chain Reaction (RTPCR) and Rapid Antigen Diagnostic Testing (RADT). States had been advised now, a full six months after the outbreak in India, that all symptomatic negatives of RADT should be mandatorily subjected to RTPCR. On an average, more than 9.5 lakh samples were being tested in government laboratories and close to 1.2 lakh in private labs, the government has claimed.

The total of these figures came close to 11 lakh. However, while the daily testing figure has hardly ever significantly exceeded 11 lakh in September, there were several days on which the figures fell well short of that number, including as low as 7.2 lakh on one occasion. This had an effect on the number of confirmed cases on those days. But then, of the total samples tested, nearly 40 per cent were by the RADT method. It was known that in some States like Delhi, only around 11,000 RTPCR tests were being conducted daily as against 45,000 by the RADT method— which would put the percentage of the latter at much more than 40 per cent of the samples tested. On the other hand, States like Tamil Nadu do not use RADT at all. The ratio of RTPCR to RADT is not known in several other States, for example Uttar Pradesh, whose COVID bulletin itself was not easily accessible.

The situation on the ground was far from optimistic, as a recent missive from the Home Secretary, Government of India, showed. Following reports of disruptions in oxygen supply, on September 18, Home Secretary Ajay Bhalla wrote to the Chief Secretaries of States and Union Territories, asking them to ensure smooth supply of medical oxygen which was critical for moderate and severe cases of COVID. He wrote: “With increasing number of active cases of COVID-19 the consumption of oxygen is also expected to increase.” All States and Union Territories were required to “continuously monitor the availability of medical oxygen in their respective jurisdictions”, he said.

No uniformity in data details

There were no uniform guidelines on what kind of information State bulletins ought to be giving. For instance, each State bulletin ought to have had information of the break-up of RADT, RTPCR and other tests for COVID and also of those deceased persons who had co-morbidities and those without co-morbidities. Data were required on how many of the active cases were in hospital or were being treated at home, and on shortfalls of health staff and equipment, given the fresh surge in cases. Now, as per the guidelines, all false negatives from RADT were to be retested with RTPCR. There was little information on how many of these tests had actually taken place and how many tested positive after that. It was not surprising, then, that the sero-surveillance done in Delhi showed a sero-prevalence positivity ratio of 33 per cent in Delhi, that is, almost one in three persons in Delhi have had exposure to the infection.

As for testing numbers, the weekly average number of daily tests (Monday to Friday) in the week beginning August 31 was 10.86 lakh. This figure rose a little to 11.28 lakh in the next week starting from September 7. However, despite confirmed cases rising, the number dipped in the week starting on September 14 to 10.43 lakh. There has also been a pattern of testing numbers dropping significantly on weekends. Each time a dip in the testing figures has been accompanied with a dip in the number of confirmed cases. The reduction in confirmed cases on a few days was not because of “high recoveries” but because of low testing on the previous day. There has been little explanation for the dip in testing on those few days even though the government claimed that it would soon overtake the U.S. in the number of of daily tests.

Chasing the virus

The number of daily tests had increased as an integral part of “chase the virus strategy”, stated the Health Secretary at a press briefing. In fact, more than anything, that has been the main problem in the strategy—that India is chasing the virus and not getting ahead of it. The “chasing the virus” strategy actually meant that the virus had gone out of control and the government was merely following the infections and responding to them rather than pre-empting the surge. When asked why testing was not ramped up early on in March-April, the reply was that it was a new virus and that it was a learning process even for people within the government.

Despite the seriousness of the situation, government officials have been at pains to convey that things were getting better. On September 18, the government rushed a high-level Central team to Jammu, where the confirmed cases had reportedly doubled within the span of a week. A Central team had earlier visited Srinagar, too, following similar escalation in confirmed cases.

The claim in the government tweet that India would soon overtake the U.S. in terms of the number of people tested was also a bit of sleight of hand given India’s population size and the large number of infections. In terms of tests per million population, 111 out of 213 countries in the world are ahead of India, but the number with higher cases per million is only 81, and countries with higher deaths per million number are only 77. Balram Bhargava, at a recent press conference by the Health Ministry, said that India had “distributed the curve” in such a way that there were not a large number of deaths, unlike the U.S. or other European countries where a large number of deaths occurred at the peak of the pandemic. India was able to avoid the peak because of the “effective lockdown” in March, April and May. This kind of comparison with countries that have been least successful in dealing with the pandemic has been the standard tactic adopted by the government. India’s performance relative to its Asian and even South Asian neighbourhood has become progressively worse, whether one looks at cases or deaths, despite one of the most severe lockdowns (see table). But this is ignored. The danger now is that the onset of winter may further aggravate the situation.

From being way below the global chart of confirmed cases in May and June, even below China, India has inched slowly upwards. Despite the resurgence of fresh cases in parts of Europe, the overall numbers of fresh cases in Europe were still far below the levels in India despite much higher testing. Indeed, if one compares some major Indian States with countries in Europe with similar population sizes—Maharashtra with Russia, Tamil Nadu with Germany, Karnataka with United Kingdom, Andhra Pradesh with Italy, Telangana with Poland or Delhi with Netherlands—it generally appears unfavourable for the Indian States. The number of tests is significantly higher in the European countries, while the number of confirmed cases is higher in India.

The government continues to be in a denial mode. In the United Kingdom, by contrast, the Mayor of London admitted candidly that testing capacities were not enough. According to a Reuters report that Jeremy Hunt, the chairman of the British Parliament’s health committee, said “testing capacity would have to be sufficiently boosted so that everybody could have a test”. In India, however, testing at a much lower level is being touted as a great achievement.

There is also nothing unique about India’s supposed recovery and fatality rates. Many countries with similar age demography and socio-economic conditions have had similar or better experiences. For instance, among South Asian countries, both Sri Lanka and Nepal have had a lower case fatality ratio (CFR) than India’s. The real point is that the number of additional cases being added each day in India are by far the highest in the world, and this also means per capita cases and deaths in India are also rising fast. Even if the CFR is kept low, even a low fatality rate would translate into huge numbers given the size of India’s population. It is also likely that all COVID-1related deaths are not reported, which means the official CFR is lower than it should have been, as many experts have argued.

A senior NITI Aayog member had declared early in the pandemic that the infection would peak in mid May in India and then the curve would bend downwards. Union Health Minister Harsh Vardhan said on August 31 that COVID-19 would come “under control by Deepawali this year”. While the first prediction was proved wrong, it might require nothing less than an act of God for the second prediction to prove right.