COVID-19 Update

Fears of a surge in COVID-19 infections in the country

Print edition : December 04, 2020

Diwali shoppers throng a market in old Delhi on November 10. Photo: Adnan Abidi/REUTERS

Photographs of people who died of COVID-19 between September 22 and September 28 in various cities in India displayed by their relatives. India hit its peak level of daily COVID-19 cases in the third week of September, and continues to have the highest number of daily deaths in Asia in November. Photo: REUTERS

Several States saw an increase in the number of COVID-19 cases in the first fortnight of November even as others reported a slight decrease, but governments both at the Centre and in the States would do well to remain alert to the possibility of an increase in cases similar to what Europe and the U.S. are reporting now.

Almost eight months into the COVID-19 pandemic and with infections still far from under control, there is little clarity on the trajectory of the virus and its spread in India. The fortnightly briefings by the Ministry of Health and Family Welfare (MoHFW) give a superficial indication of the reasons and the extent of the spread, with presentations by MoHFW officials tending to focus less on the shortcomings and more on the achievements of the health care establishment. On November 10, the day of the most recent official briefing, mediapersons were informed that a record 12 crore tests had been conducted, that the recovery rate was 92 per cent, and that active cases comprised only six per cent of the total number of confirmed cases while the cumulative positivity rate (share of positive cases in the total samples tested) was 7.18 per cent.

However, the Health Secretary stated that the daily positivity rate had been 4.2 per cent over the first week of November and that this was because of the high testing figures of 11 lakh tests every day in the same period. What was not explained was why only 11 lakh tests were conducted each day when the testing capacity of laboratories put together was close to 15 lakh.

If the Central government is to be believed, the situation in India appears to be under control in the face of a global resurgence of COVID-19 cases. But the reality is that India continues to rank second only to the United States in the number of COVID-positive cases and has the third largest number of deaths after the U.S. and Brazil.
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A closer look at individual States while comparing the weekly change in the number of cases since the peak in mid September does not offer much promise. In Asia, India continues to lead with the highest number of cases, highest number of daily cases, as well as the highest number of deaths and daily deaths. As of November 12, India accounts for almost 50 per cent of the total number of new cases in Asia (source: Worldometer), almost 50 per cent of the total number of deaths and less than 50 per cent of the total number of new deaths in Asia. After reaching the peak in mid September, cases began to decline but from October 24 onwards, the decline in the number of cases plateaued.

Another oft-repeated assertion by MoHFW officials is that the cases per million (6,270 cases per million) in India were among the lowest in the world. This does not tally with the information posted on credible global data sources. Of 219 countries, there are at least 35 countries, including Bangladesh, Pakistan, Sri Lanka (in South Asia), where cases per million population are much less than that of India (source: Worldometer). In some of the countries in East Asia, the number of confirmed cases was found to be less than a hundred per million. For example, it was 55 per million in Thailand; 13 in Vietnam; 18 in Cambodia; 3 in Laos and 60 in China.

As compared to the rest of East Asia, the testing rates in India have been far less. While the manner in which the spread of the virus was controlled in the region is commendable, the same cannot be said of India. Of 49 countries in Asia, there were at least 20 that had conducted more tests than India per million population. Of 48 countries in Europe, all but three had conducted a greater number of tests than India per million population.
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It has also been reiterated by the health care establishment that the deaths per million are among the lowest (India: 92 deaths per million; world average: 160 deaths per million) in the world. Again, if this assertion is compared with East Asia, the figures for India are much higher. There were 101 out of 219 countries where the deaths per million population were lower than India’s; in some cases, the numbers were in single digits. Out of 49 countries in Asia, only in 15 countries the deaths per million rate exceeded India’s, while the others reported a death rate much less than India’s. Even as a surge has been reported from Europe, there are apprehensions of a similar surge happening in India as well.

Spike in Delhi

Delhi has witnessed an unprecedented spike over the last fortnight. It reported an average of 7,000 cases on November 6, 8 and 10. On November 10, Delhi reported 7,830 new cases; on November 11, it reported 8,593 cases, thus becoming the State to record the highest tally in the country on those days. The number of deaths reported in Delhi was 83 on November 10 and 85 on November 11, which was also the highest in the country.

The Director General of the Indian Council of Medical Research (ICMR) attributed the spike to the festival season, pollution, wedding season, social gatherings and the greater movement of persons in and out the city. But Delhi is not alone in reporting a higher daily incidence of cases. The spike in Delhi has been accompanied by a fresh spike in neighbouring Haryana and western Uttar Pradesh. The U.P. government has also embarked on an aggressive testing drive following a surge in the National Capital Region (NCR) adjoining Delhi.

According to MoHFW data, 54 per cent of new cases were reported from the six States of Delhi, West Bengal, Kerala, Maharashtra, Haryana and Tamil Nadu. Significantly, 62 per cent of the new deaths were reported from Delhi, Maharashtra, Uttar Pradesh, West Bengal, Kerala and Punjab.

Break in downward trend

In the first week of November, the weekly total of confirmed cases exceeded that of the previous week for the first time since India hit its highest level of confirmed daily COVID-19 cases on September 17. While the increase was just a little under 5,000 cases (or a little over 700 every day), it broke the downward trend that had lasted for over one-and-a-half months.

The weekly total (November 1-8) of 3,24,344 cases was less than half the 6,40,000-odd cases seen in the week during the daily peak (on September 16) and the week before. The number, however, still remains high and any stabilisation at this level instead of a continuation of the decline would only increase the prospects of another surge. So far, the downward trend since the peak has been almost a mirror image of the rising graph between end July and mid September. While this pattern suggests that at least four more months are needed to return to the pre-lockdown situation, a stabilisation or another surge would only lengthen this period. One needs to wait and watch, though, to confirm if the latest week under discussion was an aberration or if it actually marks the end of the declining trend.
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A vast majority of States saw an increase in confirmed COVID-19 cases over the two weeks under consideration. In Delhi, Haryana, Himachal Pradesh, Punjab, Uttarakhand, Telangana and several States in the north-eastern region, the jump from the previous week was significant. Other States such as Gujarat, Jammu and Kashmir, Madhya Pradesh, Rajasthan and U.P. have shown modest increases. In Assam, Bihar, Jharkhand, West Bengal and Chhattisgarh, there has not been much change from the previous week and the number of cases has only decreased marginally.

The case of Bihar sustaining a low number of infections despite all the election-related activity in recent times, of course, adds to the mystery. What has, however, prevented the nationwide figure from climbing is that some of the States which earlier had extremely high numbers, such as Andhra Pradesh, Kerala, Maharashtra, Tamil Nadu and Odisha, continue to report a decrease in numbers.

The first week of November also saw over 4,000 COVID-19-related deaths nationwide, again an increase from the previous week. The case fatality rate (CFR) also appears to have stabilised and resistant to any further decline. Earlier, the number of fatalities had not grown as rapidly as those of confirmed cases because the CFR had progressively come down. In the event of a surge now, though, the number of deaths could rise proportionately. Unfortunately, testing capacity does not appear to have increased and neither is the existing capacity being fully utilised. Testing numbers in the last two weeks have not only been below peak levels, but also lower than the levels seen more than a month ago. What has also gone unnoticed in the briefings is the spread reported in the hill States in the North.

The Union Health Secretary appeared irritated when a journalist raised a question about the low rates of testing as compared with other countries. He said that one could verify from global data sources if there were doubts about the claims of high testing and low cases per million made by the Ministry.

The method of testing has always been a questionable one as the majority of samples have been tested using the less reliable rapid antigen test (RAT) method as opposed to the gold standard reverse transcriptase polymerase chain reaction test (RT-PCR). Only 46 per cent of the samples were tested by the RT-PCR method while 49 per cent were tested by the RAT method. The Health Secretary also said that in Bihar, only 12 per cent of the tests on samples were by RT-PCR. The rest were by RAT. There was no method to ascertain what percentage of symptomatic samples tested by the RAT method had reported negative and were followed up by an RT-PCR test as recommended by the World Health Organisation and the ICMR.
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For now, India’s position appears to be relatively better than that in Europe and the U.S., which are seeing record numbers of cases in absolute as well as per capita terms. While Europe and the U.S. are likely to have first access to any vaccine that become available and have better infrastructure to reach large sections of their population, India is more unfavourably positioned and therefore has to avoid being hit by a second surge. No amount of effort and vigilance can therefore be considered enough. It, however, appears that even the government is suffering from COVID-19 fatigue in India.