COVID-19 Update

COVID-19 scaling new peaks in India

Print edition : October 23, 2020

A health worker screens a resident of Dharavi, Mumbai, for symptoms of COVID-19 on September 4. Photo: Rafiq Maqbool/AP

As India continues to be second in the global ranking of total COVID-19 cases, and the number of deaths continues to increase, questions remain about the reliability of the number of cases being captured by tests in India.

For the Central government, handling the COVID-19 pandemic has been more a case of optics than anything else. It has tried relentlessly to convince the public and the media that the situation has been under control from day one, is under control now and will be so in the future as well. According to spokespersons of the Ministry of Health and members of the top scientific establishments, the lockdown was a huge success, the government proceeded with scientific tools right from the beginning, and all that people had to do was to maintain a two-metre distance from each other and wear masks.

Daily tally highest in the world

The other feature of the government’s way of portraying the reality has been to highlight the number and rate of recoveries unmindful of the fact that India continues to be second in the global ranking of total COVID-19 cases, and crossed the 4-million, 5-million and 6-million mark in September. Also downplayed was the fact that throughout September, the daily tally of cases remained far higher than in any other country. There was a similar situation with regard to deaths, with over 33,000 deaths being recorded in September.

While the overall positivity ratio of tests over the entire span of the pandemic in India, based on data published by the Indian Council of Medical Research (ICMR) and the Ministry of Health, is 8.4 per cent, the seven-day average of the daily positivity rate has fluctuated in recent times. After having climbed steadily over May, June and July, this average declined in August, then stabilised for a period of time, before another phase of upward movement in September, which was again reversed towards the end of the month. Through all these fluctuations, the positivity rate has remained above 7.5 per cent, far higher than it was at the beginning of May (under 4 per cent).

According to the Johns Hopkins Coronavirus Resource Centre’s data comparing international test per capita and positivity rates, as of September 30, in more than 60 countries, including the United States (4.5 per cent) and the United Kingdom (2.66 per cent), the positivity rate was less than India’s. In 30 countries, the positivity rate was more than India’s. The testing comparison page says that a country’s testing programme should be scaled to the size of the epidemic, not to the size of the population. According to the World Health Organisation, governments ought to relax social distancing measures only if the positivity rate is 5 per cent or below in the previous 14 days. The Indian government, however, continues to ease restrictions despite a positivity rate much beyond that threshold, and has now decided to open up cinema halls and multiplexes in October.

A high positivity rate is usually treated as an indication that not enough testing is being done. Yet the government has maintained that its “Five T strategy” of “test, track, trace, treat, technology” has yielded good results. As evidence, the government cited the results of the second sero-survey which were announced on September 29, although the self-congratulatory note of the first sero-survey was absent this time. When releasing the results of the first survey, conducted between May 11 and June 4, the Ministry of Health prided itself on the fact that this was the largest sero-survey to be conducted anywhere in the world.

According to a release by the Ministry of Health, the second survey was conducted in the same 70 districts and 700 villages/wards covered in the first survey in order to assess the extent of the infection among the general population. The period of the survey was between August 17 and September 22, and blood samples were collected from 29,092 individuals. This time, two sets of data were presented; one that examined prevalence among those aged 10 years and above, and the second among adults 18 years and above. According to the survey results, the prevalence of infection was 6.6 per cent in the above-10 age group, while it was 7.1 per cent among adults, implying that one in 15 individuals has been infected. Urban slums were the most vulnerable, followed by non-slum areas and rural areas. A 15.6 per cent prevalence rate was observed in slum areas as compared to 8.2 per cent in non-slum areas, while it was 4.4 per cent in rural areas.

The irony is that the Central agencies had little to say about taking concrete steps to ameliorate the living and health conditions of urban slum dwellers, given their high susceptibility to the virus. If anything, the declaration that urban slums contribute more to the virus load will definitely have an adverse impact on how the rest of society views slum dwellers.

The sero-survey done in Mumbai earlier also showed a significant difference in prevalence between slum and non-slum populations in the city. Surveys in cities such as Delhi, Chennai, Mumbai, Ahmedabad and Puducherry also showed much higher prevalence rates than the overall India figure in the ICMR’s all-India survey, thereby confirming that urban populations with higher density were more affected than rural ones. This, in fact, indicates that the prevalence in India, with its large share of rural population, should be actually lower than more urbanised countries. However, this does not seem to be the case. The results of the U.S. and Brazil with samples of similar size as India’s (28,503 in the U.S. and 31,128 in Brazil to India’s 29, 082) despite their lower populations, was 9.3 per cent and 2.8 per cent respectively. Brazil conducted two rounds; in the first round, conducted between May 14 and 21, the seroprevalence was 1.6 per cent, which increased to 2.8 per cent in the survey conducted between June 4 and 7. The seroprevalence in Spain, conducted in April-May, which involved taking samples from a much larger population cohort (51,958 samples), was 4.6 per cent, substantially less than the prevalence ratio of India. So, barring the U.S., which showed a higher percentage of an infected population, and Iran, where it was reportedly 22 per cent, India’s infected numbers were still on the higher side.

The 7.1 per cent prevalence of COVID-19 exposure in the adult population recorded by the second sero-survey was substantially more than the 0.73 per cent prevalence shown in the first. In other words, the estimated number of infected adult Indians had gone up from 6.4 million to 62.25 million between the two surveys. The “achievement” being claimed in this was that the number of people testing positive had gone up more than proportionately, implying thereby that testing was capturing a larger number of those infected than at the time of the first survey. Thus it was claimed that by August 2020, there were only 26 to 32 infections per reported case as compared to 81 to 130 in May 2020. However, the claim that this was the effect of the scaled-up testing, tracking and treating strategy does not sit well with the increase in the positivity ratio that also occurred in between. It needs to be also kept in mind that there have been reports in the media on controversies about some data being excluded.

Fluctuations in testing rates

Even with regard to testing numbers, there have been issues. On the one hand, there have been large fluctuations in the daily test numbers reported by the ICMR. These were as high as 14.92 lakh on September 24, but dropped to less than 7.09 lakh just three days later. There was no cogent explanation for that, especially as testing capacities had proven that up to 15 lakh tests could be conducted every day. The Health Secretary, while briefing the media on September 29, sought to attribute it to fluctuating infection rates that were responsible for the lower figures. Responding to a question on testing rates in States such as Bihar and Uttar Pradesh, the Health Secretary explained that testing rates were very good in both States but there were problems regarding the false negatives from the Rapid Antigen Diagnostic Test (RADT) results, which needed to be reconfirmed with the more reliable Reverse Transcription Polymerase Chain Reaction (RTPCR) test. Even though the testing numbers had increased overall, the proportion of RADT tests (meant only for containment zones) was rather high as a proportion of the total samples tested.

Another issue has been of discrepancies between the ICMR figures for daily testing numbers and those emerging from the State COVID-19 bulletins issued every day. All this means that questions still remain about the reliability of the number of cases being captured by tests in India.

The flip side of the claim that the government’s strategy helped contain the prevalence of COVID-19 (apart from the fact that 62 million and counting is hardly a small number) was that the ICMR had to admit that a large proportion of the population was still vulnerable to the infection. There was no chance that those who were not infected had developed immunity, while the overall prevalence is not enough to generate “herd” immunity either. In other words, the very large numbers of daily cases and deaths in India have considerable scope to increase, even as one does not know what effect the onset of winter will have on the numbers.

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Editor, Frontline

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