The fall and rise of COVID numbers

The number of cases begins to rise again after weeks of showing a declining trend, confirming that the COVID challenge is not over yet.

Health-care staff attending to a complicated case in a COVID-19 ICU on August 6 at Government Medical College in Malappuram in Kerala. The State has been aggressively testing and vaccinating and undercounting of COVID deaths is reportedly minimal.

The 1st of August 2021 was a significant date in two different senses from the point of view of the trajectory of the COVID-19 pandemic in India. Assuming February 8 as the starting date of the second wave, August 1 marked the completion of 175 days of it. The number of daily cases hit their maximum on May 6, which was exactly in the middle of the period between February 8 and August 1. Both the phases of the wave on either side of the peak were of 87 days’ duration each. Remarkably, the cumulative number of confirmed cases reported in each of these 87-day periods was also almost identical—10.24 million before the peak and 10.20 million after. However, while only 78,395 cases were reported in the first week of the wave between February 8 and February 14, the week ending on August 1 saw 2,84,696 confirmed cases across the country, over three and a half times the number in the first week.

The week between July 26 and August 1 was also the first one after May 6 which saw a total that was higher than the one reported in the previous week. Before this week, the reported numbers declined consistently in every successive week. With the week ending on August 1, however, this declining trend of the second wave appears to have halted, long before the numbers reverted to the levels seen at the start of the wave. Does this mean that the second wave is already over and a third wave has started? Or is this a temporary deviation from a trend? Only time will tell. Either way, the development confirms that the COVID-19 challenge is far from over.

Kerala: What is the real story?

The official briefing of the Union Health Ministry on August 3 made it a point to emphasise that almost half the cases in the country were reported from Kerala and suggested that the country’s overall COVID situation continued to improve. Yet, the estimates of the effective reproductive number (Rt) across the States presented in the same briefing revealed a different picture. The effective reproductive number (Rt) is a measure of the number of secondary cases that any one infectious case gives rise to in a population: a value greater than 1 indicates that the number of cases will increase; a value of 1 implies that the disease is endemic; a value less than 1 indicates that cases are declining.

Estimates of the effective reproductive number at the end of July showed that it was above 1 and increasing in eight States; most of these States showed an effective reproductive number greater than Kerala’s. These States included other southern States such as Karnataka and Tamil Nadu but also northern States like Himachal Pradesh. For seven other States, including Haryana, Delhi, Jharkhand and West Bengal, the effective reproductive number was 1 and stable. At least three north-eastern States—Mizoram, Nagaland and Meghalaya—also fell in either of these two categories, as did Puducherry and Goa. So in several parts of the country that are geographically distant from each other the pandemic was not showing signs of receding. A similar picture emerges if the weekly total of confirmed cases in the two weeks ending on July 25 and August 1 are compared. The later week saw an increase or stability in the number of reported cases in several States where the effective reproductive number was above 1 or equal to 1. While the absolute numbers in them may be still small, even populous States like Uttar Pradesh and Madhya Pradesh saw an increase in the number of confirmed cases between these two weeks.

This is actually not the first time that Kerala has accounted for half or more of the reported cases in the country. Indeed, exactly the same situation existed when the second wave began in February. As other States saw a surge in cases when Kerala’s numbers were declining, the State’s share in the nationwide total dropped to below 3 per cent by the first week of April. Thereafter, the numbers rose in Kerala and its share in the nation’s total cases started rising slowly again. As the number of daily cases started declining across the country after the peak of May 6, Kerala also experienced a declining trend until the third week of June, after which its numbers started rising slowly even as the rest of the country continued to show a decline. Such a juxtaposition of rising numbers in Kerala with a declining nationwide total was also seen during the first wave between mid September and October. In other words, fluctuations in Kerala’s share in the nationwide total have always reflected the fact that the trajectory of the pandemic in the State does not always follow that of the rest of the country.

The real reason for Kerala being in focus today is the State’s success, by no means perfect but significantly greater than other States’, in controlling and managing the pandemic. The spread of the infection in the State’s population has been much less when compared with the spread in other parts of the country. The Indian Council of Medical Research’s (ICMR) fourth (June-July 2021) seroprevalence survey of the proportion of the population carrying COVID-19 antibodies corroborates this. In the figures issued for 21 major States, Kerala not only showed the lowest seroprevalence at 44.4 per cent, way below the all-India average of 67.6 per cent, it was also behind most other States by some distance. Indeed, eight of the remaining States showed a seroprevalence of over 70 per cent, while another 10 showed between 60 and 70 per cent. The remaining two States, Maharashtra and Assam, were at 58 per cent and 50.3 per cent respectively.

The presence of antibodies in the population can come either through vaccination or infection. As of July 1, Kerala had given at least one dose of the vaccine to 32.3 per cent of its population and fully vaccinated over 10 per cent; by August 4, these figures had become 42.4 and 17.7 per cent respectively. These figures were higher than those of all the other States in the ICMR seroprevalence list, except the small hill States of Uttarakhand and Himachal Pradesh. At the other end, Madhya Pradesh showed a seroprevalence level of 79 per cent even though barely 23 per cent of its population had received at least one dose of the vaccine by July 1. (See Table 1.)

So how did the State with the highest level of vaccination, and also the highest number of cases per lakh of its population, end up with the lowest level of seroprevalence? The obvious answer is lower incidence of the infection combined with more efficient testing. Kerala may be one of only a couple of States where vaccination rather than infection accounts for the presence of antibodies in most of the people who have them. This also accounts for Kerala’s higher numbers at present—lower seroprevalence means a larger population is vulnerable to the infection. The highly infectious Delta variant could also be playing a role in Kerala.

Kerala’s greater success in controlling the pandemic has been is attributed to the fact that it ensured that its public health system is not overwhelmed by COVID, in contrast to many States during the second wave. The case fatality ratio has consistently remained remarkably low in Kerala. Of course, the CFR is based on the official death count. Several reports have, however, confirmed, by comparing the official toll with death registration figures, that undercounting of deaths has been minimal in Kerala, significantly lower than in other States.

Kerala, therefore, offers very important lessons for the country’s pandemic response. It also shows up, by contrast, the Narendra Modi government’s larger failure in pandemic-control strategy. For that reason, running down Kerala’s success in controlling the pandemic, as opposed to simply emphasising the need for further improvement and optimising efforts to control the high numbers at present has a political value for the Modi regime. Yet it should be remembered that even if the absolute numbers in Kerala appear to be greater than those in most other States, the trend in several other parts of the country are worrying. Most of these regions may not have the wherewithal Kerala possesses to capture either the true numbers or to ensure availability of medical care. The government would be well advised therefore to eschew political one-upmanship and extend full support to all States’ efforts to check any danger of another surge.

Political calculations

Unfortunately, narrow political calculations and concerns about image still seem to dog the Central government’s approach. In a release titled “COVID-19 Mortality—Myths Vs. Facts” issued on August 4, the government has yet again tried to debunk reports of a significant undercounting of COVID-19 deaths in India. It has termed as “speculative” reports of “excess deaths” from all causes pointing to higher COVID fatalities than the numbers recorded officially, and asserted that any inferences from such exercises would be erroneous. The report is carefully worded and avoids a blanket denial of the fact that the number of COVID-19 deaths may have been much larger than reported; but its silences are telling. The government has defended the ‘robustness’ of both the country’s Civil Registration System (CRS) of births and deaths and the system of counting and reporting COVID-19 deaths. Yet it has failed to explain why there are such large discrepancies in the death numbers put out by the two systems. It has thus left to speculation why there are such large numbers of excess deaths from all causes in several States.

Meanwhile, the Modi government continues to make exaggerated claims on the achievements of India’s COVID-19 vaccination programme. Yet, the fundamental difficulty facing India in this situation is that the country that was supposed to be the world’s largest vaccine manufacturer simply has not been able to expand its vaccine production capacity to meet its own requirements, let alone meet the demand from other countries which were relying on it for supplies. The fourth monthly update on the worldwide production of COVID-19 vaccinations of the Global Commission for Post Pandemic Policy shows that while the production of COVID vaccines in India did increase in July to 136.1 million from the 120.5 million doses produced in the previous month, India remains the true laggard among the four major regions that account for the bulk of the global production. Table 2 shows that while India is among the four major global manufacturing regions for COVID vaccines, it is the only one contributing to the global pool of vaccines a share that is smaller than its share in the world population. India’s vaccination programme, therefore, might eventually need imports from the other producers as their own vaccination programmes approach completeness. The prospect of India supplying vaccines to the rest of the world appears remote.

India’s COVID management has been highly centralised. Yet, there are wide variations in the health delivery systems among States, which has impacted testing and vaccine delivery. The lack of uniformity in these areas is a matter of concern, apart from the large exposure to COVID as shown by the fourth sero survey. Placing the onus on behavioural changes by people to halt the spread is not adequate.