Cover Story

The geographic spread of COVID-19 in India

Print edition : July 31, 2020

Rajesh Bhushan, Officer on Special Duty with the Health Ministry, addressing a media briefing on the COVID-19 situation in New Delhi on July 9. Photo: PIB

Union Health Minister Dr Harsh Vardhan in New Delhi on July 10. Photo: PIB

Disinfection in Thiruvananthapuram in the wake of a spurt in COVID-19 cases, on July 3. Photo: S. Mahinsha

At a 'fever clinic' in Chennai on June 29. Photo: B. Jothi Ramalingam

Despite the government’s unfounded optimism, the southward movement of the virus and the growing absolute numbers imply that India has quite a distance to cover before it can breathe easy in the ongoing fight against the pandemic.

ON July 9, when COVID-19 monitoring sites showed a single-day spike of 25,790 cases in India, the biggest so far, the government continued to maintain that there was no “community transmission”.

On the same day, at a Group of Ministers meeting chaired by Union Health Minister Harsh Vardhan, members were told that India had one of the lowest number of cases and deaths per million when compared with the five worst-affected countries. However, no comparisons were drawn with the world’s most populous nation, China, which had controlled the spread of the virus rather effectively.

“It would perhaps be not fair to compare India to other countries. In terms of absolute numbers, India had 195.5 cases per million population,” the government said in a press release.

However, a Health Ministry official, quoting the World Health Organisation’s (WHO) situation report, told the media that there were 538 cases per million in the country.

At the press briefing on July 9, held almost a month after the previous one, Ministry officials presented a picture of optimism. India, they said, was not in the community transmission stage, and added that there were localised outbreaks in some areas. This was borne out by the data that showed that only 49 of the country’s 733 districts had reported cases.

The officials also said that it was possible to trace and track contacts of active cases within 72 hours and, therefore, it was erroneous to talk of community transmission. They added that the WHO had not issued any standardised definition of local or community transmission.

Unfounded optimism

Senior Health Ministry officials appeared optimistic that despite being the second most populous country in the world, India’s management of the COVID-19 situation was satisfactory and that it had done “relatively well”.

The number of cases per million population as per the WHO situation report was 538, which a Health Ministry official said was among the lowest in the world. The cases to population ratio from the Americas and Europe was much higher and, in some countries, it was 16-17 times the Indian ratio.

The death rate in India was only 15 per million of the population, whereas the rate in some countries was several times that figure.

The officials said that as of July 9, 4,76,000 patients had recovered and there were 2,69,789 active cases. The low caseload had prevented the public health systems and infrastructure from getting unduly burdened, they added.

The rate of recovery was 1.75 times that of active cases of infection. The recovery rate rise was appreciable, said Rajesh Bhushan, Secretary in the Health Ministry, and shared a graph that showed the recovery percentage as 62 per cent now. However, there was no reference to the single-day spike of more than 25,000 cases that day.

Chasing the infection

The daily testing rate in India, 2.67 lakh on an average, had definitely gone up. But it had increased in the process of chasing a growing spread of the infection. The increase in the present testing capacity had made it possible to confirms a growing number of cases. This is hardly an achievement.

Instead of a rapid ramping up of testing in order to get ahead of the infection by quickly identifying the infected and isolating them, which should have been done when the country was under lockdown, the country’s strategy was to chase the infection, and not pre-empting it.

The strategy pre-empting infection adopted by countries such as South Korea succeeded in controlling the spread. A faster rate of testing in the initial stages of the outbreak in that country meant that fewer tests were required. In contrast, a slow rate of testing in India allowed the infection to spread and go out of control.

Within India, eight States— Maharashtra, Tamil Nadu, Delhi, Karnataka, Telangana, Andhra Pradesh, Uttar Pradesh and Gujarat—accounted for 90 per cent of the active caseload, while six States—Maharashtra, Delhi, Gujarat, Tamil Nadu, Uttar Pradesh and West Bengal—accounted for 86 per cent of the COVID-19 deaths. Some 32 districts accounted for 80 per cent of the deaths.

The authorities have not given any official epidemiological explanation for these trends. Rather, the government continues to adopt the same self-congratulatory demeanour, which has characterised its approach from the beginning of the outbreak.

There was no epidemiologist or senior scientist at the press briefing of July 9, which was surprising given the high count of cases every day and it’s the southward movement of the pandemic.

Worst yet to come

Jacob John, Professor of Community Medicine and Epidemiology at the Christian Medical College, Vellore, told Frontline that the reporting of the cases depended on the quantum and appropriateness of testing and the phase of the pandemic.

“The patterns that are visible need not reflect the reality. We are still early in the exponential phase of the pandemic in our country and the south being more connected is seeing now the second level of spread after the metros,” he said, adding that the worst was yet to come.

(In the context of the United States, top infectious diseases expert Dr Anthony Fauci has warned the U.S. President against having a false sense of complacency over low death rates.)

Despite the bluster of optimism, it was clear that deep down the Union government was aware that the numbers indicated something more serious. Hence, its directions to continue with strict containment measures, surveillance, demarcation of containment zones, strict perimeter control, intensive contact tracing, house-to-house search/surveillance and identification of buffer zones to identify new cases.

Steady trends

India’s position as a country with the third largest number of confirmed COVID-19 cases in the world and the largest number of cases and deaths in Asia has been marked by a combination of remarkably steady trends that are not always seen in other parts of the world.

The proportion of active or currently infected cases to the cumulative total of confirmed cases has been coming down over time in India. Since the fatality rate was not high, this decline reflected primarily the growing numbers of those who have recovered. Their numbers now far exceed the number of active cases—4,95,512 recovered versus 2,76,685 active cases and 21,604 deaths as per official data on July 10.

Some 15 per cent of COVID-related deaths were in the 14-44 years age group; 32 per cent of the deaths were in the 45-59 years age group (15 per cent of the population); 39 per cent of deaths were in the 60-74 years age group (8 per cent of the population).

People aged 75 years and above, who belong to the age group that comprised 2 per cent of the population, accounted for 14 per cent of all COVID-19 deaths.

Absolute numbers still high

Viewed in isolation, high absolute numbers would be considered a good sign because the pandemic is deemed to be have come to an end, when there are no longer any active cases and all those infected have either died or recovered.

With the proportion of active cases now having come down to around 35 per cent from the near 100 per cent level it was at the beginning of the pandemic, and deaths still being under 3 per cent of all cases, it seemed that the country was approaching the end without having paid a very heavy price in terms of lives lost to the COVID-19 infection.

Yet, the absolute numbers of the active cases have been increasing day by day and the curve has not yet started moving downwards indicating that the pandemic is coming to to end. The absolute numbers are relevant because they determine the extent of the caseload on the health system, a load the government claimed it has prevented.

In this regard, India’s experience has not only been different from that of countries of the European Union and east Asia, where the downward movement began several months ago, but also from other countries that had a large number of cases, like Russia, where the number of active cases began declining mid-June. India is still climbing the hill and is far from being over it.

Mixed picture

The growth in the number of new infections every day presents a mixed picture. Over the course of the epidemic, there has been a downward trend in the rate of growth of confirmed cases per day, as a result of which an increasing trend in the doubling time has also been visible.

This has been the main reason for the decline in the proportion of active cases, since the active cases on any day are mainly those added to the total tally relatively recently, typically those that tested positive in the previous two weeks or so.

This, again, would appear to be a good sign as the end of the epidemic requires this daily growth rate to become zero or near zero. In India, the daily growth rate is currently around 3.5 per cent, compared with the 8-10 per cent level seen in mid-April, when the first three-week lockdown ended.

Despite this, however, the absolute number of new cases reported every day has also steadily increased day by day and has kept hitting a new high every second or third day. For the pandemic to end, the absolute number of cases must decline for several days successively. But that has not happened.

There is no evidence that India is past the peak. The decline in the daily rate of growth was not fast enough to achieve it; also, the rate does not show any further reduction.

India’s situation was not even like the U.S, where a decline in the number of daily cases was under way; things took a turn for the worse only when the country opened up and started easing restrictions.

The experience of the U.S. and other countries that have managed to control the pandemic suggested that even after the peak was crossed, it would take a long time to reach the point where it was possible to rest assured that things are not going to get out of hand again. Controlling the COVID-19 pandemic still remains a long haul for India.

India’s tryst with the coronavirus can thus be described as being marked by a peculiar combination. On one hand, there is sustained failure to control the pandemic, even three and a half months after the first round of drastic containment measures were initiated. On the other, there are signs that at no stage did India experience the kind of sudden explosion of the epidemic as seen in some other countries.

Shifting geography

Lurking behind this big picture is perhaps a story of the shifting geography of the infection marked by an increase in the spread of potential hotspots, reflecting a moderation in some part of the country being accompanied by acceleration elsewhere. And complete control has not ben achieved.

From the beginning of Lockdown 1.0 till date, 75-80 per cent of the total number of confirmed cases were accounted for by a cluster of nine States in western, southern and central India: Maharashtra, Kerala, Tamil Nadu, Andhra Pradesh, Telangana, Gujarat, Madhya Pradesh, Rajasthan and Delhi. However, the timing and extent of their contribution to the growth in the national totals has been far from uniform.

At the beginning of the epidemic, Maharashtra and Kerala laccounted for the bulk of the confirmed cases . However, these States quickly moved in completely different directions: while Maharashtra saw an explosion in numbers and became the epicentre of the growth of the infection in the country, Kerala succeeded in in taming the infection to a large extent.

Several other States soon crossed Kerala in the number of cases, and the number of active cases in that State was as low as 16 in early May, when the return of expatriates began.

Kerala saw a surge in imported cases after that, which has continued since, but the State still accounts for less than 1 per cent of the total number of confirmed cases in India.

In contrast, Maharashtra’s share in the nation’s tally of fresh cases every day remains the highest despite the fact that the average growth of daily cases in the State has slowed down considerably and has been lower than the rate in the rest of the country since the end of May. This is chiefly because of the lasting effects of the earlier surge.

Surge post-June

Cases surged in Delhi and Tamil Nadu early on during Lockdown 1.0, a surge that was attributed mainly to the Tablighi Jamaat event in Nizamuddin in Delhi. However, this specific surge soon subsided and Gujarat, Rajasthan and Madhya Pradesh replaced these two States to drive up the country’s infection rate for most of April.

In May, however, there was another switching of positions between these two groups of States as Delhi and Tamil Nadu saw a fresh surge while Gujarat, Rajasthan and Madhya Pradesh saw an easing despite the lifting of lockdown restrictions.

This surge in Delhi and Tamil Nadu got intensified from the end of May when both States eased lockdown restrictions. During June, the combined share of these two States in the country’s total number of confirmed cases climbed rapidly to match that of Maharashtra, whose numbers had been slowly declining over the same period.

The surge in Delhi was also reflected in neighbouring regions, most notably Haryana, which earlier appeared to have brought the infection under control.

A rise in numbers in the east after the return of migrant workers added to the overall growth. This region, except West Bengal, had seen very few cases until then.

Andhra Pradesh, Telangana and Karnataka appeared to have things under control and along with Kerala. Their combined share in the total number of confirmed cases began to steadily decline and stay below 5 per cent until the last week of June, when they started experiencing an acceleration of the infection. While Tamil Nadu’s daily numbers were higher because of the base created by the past growth, the rate of increase in these three States has been far higher.

States such as Gujarat, Madhya Pradesh and Rajasthan continue to add to the increasing numbers although their share in the overall growth of numbers has been coming down.

This leads to the question: Could the objective of taming the epidemic in India have been better achieved and with much less pain by a strategy of more targeted lockdowns spaced out in time, combined with a “trace and test” procedure?

The government’s strategy to impose a nationwide lockdown, when the number of cases and the regional spread was low, might have been counter-productive and played a role in creating conditions that accelerated the spread.

The Centre’s twin steps of overuse of the drastic containment measure, casting the net wide, and enhancing testing and ramping up the public health system capacity right at the beginning is probably flawed. It has resulted in a situation where both these steps are more difficult and expensive at a time when they are needed the most, given the country’s limited resources.

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