COVID-19

COVID-19 and the danger of complacency

Print edition : November 06, 2020

Dr Harsh Vardhan, Union Minister for Health and Family Welfare, holds a videoconference on Jan Andolan and COVID-appropriate behaviour with the heads of all the All India Institutes of Medical Sciences and Central government hospitals, on October 14. Photo: PIB/PTI

A health worker takes COVID waste for disposal, at the Rajiv Gandhi Government General Hospital in Chennai. In addition to the fatigue that must have set in among health workers charged with implementing the test-trace-isolate strategy, the increase in testing capacities have not kept pace with the growth of the infection. Photo: B. Velankanni Raj

Amid a downward trend in new cases and deaths, the government is shifting its focus on to COVID-appropriate social behaviour, but it must not be lax in fully utilising the testing capacity since a second or even a third wave may be likely.

The next two and a half months are going to be crucial in our fight against coronavirus because of the oncoming festival season and winter; till the time a vaccine is available, follow the social vaccine,” Union Health and Family Welfare Minister Harsh Vardhan said on October 8. His statement coincided with the launch of a Jan Andolan, or people’s movement, by Prime Minister Narendra Modi aimed at taking behavioural messages relating to COVID-19 to the people. Both his statement and the declaration of a national awareness campaign were reflective of the government’s own shift in strategy: from one of aggressive testing to focussing on behavioural change as an antidote to check the transmission of the virus.

At the fortnightly press briefing on October 15, the Information and Broadcasting Secretary, who was also present, said the campaign would continue until March. “The economy is opening up,” he said and advised people to “adjust to the new normal”. A new slogan, “Jab tak dawai nahi, dhilai nahi”, has been coined for the campaign, which effectively means that there should not be any relaxation in precautionary norms until a vaccine is available. This also means that now people have to deal with the virus pretty much on their own.

Also read: COVID-19 Update | Maharashtra: Pandemic fatigue?

There has been little reason for the government to feel jubilant or optimistic about the COVID-19 numbers, in terms of the daily number of cases or deaths since India continues to occupy second place close behind the United States. Interestingly, at a time when the heads of all medical institutions ought to take the lead in encouraging the ramping up of tests, which peaked at 14 lakh on two occasions in mid September, the Health Minister now wants them to be the “frontrunners” in showcasing the importance of the “social vaccine”—a euphemism for COVID-appropriate behaviour—to break the chain of transmission.

Cumulative positivity rate still high

The only recommended way of breaking the chain of transmission is through more testing, tracing and treating and not merely through socially appropriate behaviour. The share of tests that returned a positive result (positivity ratio) is an indicator of how much countries are testing. The World Health Organisation (WHO) recommends a positivity rate lower than 10 per cent, ideally 3 per cent, to assess whether countries are testing adequately. At slightly over 8 per cent, India’s cumulative positivity rate is still high, with individual States having far higher positivity ratios.

Also read: COVID-19 Update | Tamil Nadu: Curious statistics

At the regular fortnightly briefings by the Health Ministry, officials congratulated themselves on India having the highest recovery rate in the world and the lowest case fatality rate (CFR). While it may be true that India’s recovery rate is among the highest, there still are many countries with a lower CFR. What was also not disclosed at the latest briefing was that India had retained its number two position in the total number of confirmed cases for the third consecutive month, behind the U.S. India was also among the largest contributors to the daily average number of cases and deaths globally.

Doubling time

The Ministry officials also claimed that the doubling time of confirmed cases had increased from 25.5 days in August to 73.4 days in October. While this trend was indeed the case, it was also a fact that more than a hundred countries had a greater doubling time than India. According to Our World in Data’s global comparison of doubling time, while Zimbabwe and Burkina Faso had the same doubling time as India, countries such as Brazil (77 days), Mexico (77), Vietnam (75), U.S. (85), Ecuador (87), Bangladesh (92), Sri Lanka (88), Iran (95), South Korea (114), Pakistan (119), Germany (156), Italy (176), New Zealand (196) and China (246) had a similar or far higher doubling time.

At 70-lakh-plus cases as of mid October, and with a doubling rate of 73 days, it could be expected that the total number of confirmed cases in India would reach 1.5 crore by the end of the year. India recorded its highest number of confirmed cases in a single day, 97,570, on September 16, and the trends since then would certainly be consistent with the country having crossed a peak of the pandemic.

Also read: COVID-19 Update | Kerala: In a vulnerable position

A clear downward trend has been observed in the countrywide number of confirmed cases reported daily and even in the number of active cases and of daily deaths. There has also been a decline in the seven-day average of new cases confirmed each day, although this phenomenon has been a recent one.

Countries that have experienced a similar decline include Brazil, Iraq, Mexico and Indonesia, while an upward trend has been noticed in European countries and the U.S., leading to speculation of a second wave in the coming months with the onset of winter. Countries where the seven-day average figure of daily cases has shown an upward trend include the U.S., France, Russia, the United Kingdom, Spain, Argentina, the Netherlands, Iran, Colombia, Poland, Ukraine, Germany, Italy, Belgium and the Czech Republic.

There is no doubt that there has been a decline in the number of active cases, which crossed 10 lakh by September 17 but is now slightly over 8 lakh. The number of daily deaths touched 1,200 in September, but over eight successive days in the first week of October that number was below 1,000 and falling. A government release on October 15 declared with unconcealed pride that the number of active cases was below the 9-lakh mark for a week and the 680 fatalities reported were below the 1,000 mark for the previous 12 days. At the press briefing itself on the same day, Health Secretary Rajesh Bhushan remarked that this was a “consistent trend”. According to him, as the number of tests was going up, the positivity rate was declining, although there was little explanation for the fluctuating figures of testing. Interestingly, it was Balram Bhargava, Director General of the Indian Council of Medical Research (ICMR), who pointed out that even though the daily testing capacity had touched 15 lakh, the testing numbers had gone down.

Also read: COVID-19 Update | Karnataka: Fearing the worst

Sero-survey

V.K. Paul, NITI Aayog member and chairperson of the expert committee on COVID, cautioned that there could be a resurgence of respiratory viruses in winter. According to the latest sero-survey, large sections of the population were still susceptible to the virus. There was no reason therefore to reduce testing unless the government expected people to acquire herd immunity in the coming months. The WHO recently declared that the “herd immunity” approach was unethical and problematic.

The high rates of recovery claimed by the government should bring cheer to a country that has recorded the second largest number of COVID-19 cases in the world and the third largest number of deaths. The peak also took a long time in coming—six months after major restrictions, including the lockdown, were first introduced. Yet, it might still be too early to conclude that India is past the worst and the future will only be better. There are several reasons for this.

The course of the epidemic in several countries that succeeded in bringing numbers down long before India’s peak shows that a second or even third wave is likely once controls and restrictions are eased. Several countries in Europe are struggling with such a second wave now. Even Russia is experiencing a big second surge with daily cases now more than the earlier peak. The U.S., on the other hand, is heading towards its presidential election on the back of a third phase of upward movement in the number of infections. Only countries in Asia that have effectively extinguished the virus from their midst are limited to dealing with sporadic localised outbreaks. India has certainly not reached that point yet, and its daily number of cases is still the highest in the world, averaging well above 60,000. In the 28 days since the peak was crossed, India still added over 2.1 million cases to its tally.

Also read: COVID-19 Update | West Bengal: Puja in the time of pandemic

It is also not clear what precisely are the causal factors behind the curve heading downwards after such a prolonged climb. One explanation that was put forward said that this was possibly a natural decline because a large proportion of the population had already been infected. This was based on a projection from the results of the first nationwide sero-survey (done in May) using the growth in the number of confirmed cases since then as an indicator of the rate of spread.

However, the second sero-survey results, which came soon after, presented a different picture: over 90 per cent of the population was still vulnerable to the virus and India was nowhere even remotely close to achieving herd-immunity naturally. If that is the case, the scope for another upsurge cannot be ruled out given that the carriers of the virus within the population who can infect others are at least a few million in number.

The government, of course, claims that this downswing was a result of its effective containment strategy. However, that could be considered as having some validity if something really new had emerged in the run-up to the peak from the strategy that was in place for the months when the curve was steadily climbing. However, restrictions were being continuously eased and lockdowns had long been discarded as a viable option.

Also read: COVID-19 Update | Telangana: Doubts about data

Of course, the testing numbers rose and, therefore, an increase in testing capacities could perhaps be considered as having increased the effectiveness of the test-trace-isolate-treat strategy. However, in addition to the fatigue that must have set in among health workers charged with implementing it, the increase in testing capacities had not kept pace with the growth of the infection. Indeed, in the run-up to the peak, the test-positivity ratio in India had been climbing. This upward movement had also ended a brief phase of decline in the ratio after months of a steady climb but which still kept the ratio much higher than in May-June. It was only after the number of cases started coming down that the test-positivity ratio moved downwards.

Numbers mismatch

Discussing the test-positivity ratio and its daily movements is fraught with difficulty because of a mismatch between the number of tests reported by the ICMR and those reported by State bulletins together. Not only is there a difference in number, the ICMR numbers show much more extreme day-to-day fluctuations. However, both sets of figures indicate that the average number of daily tests in India since the mid-September peak in daily cases has plateaued at a level below that in mid September. This leads to the question, why is testing not being used more effectively to suppress the virus more decisively?

Also read: COVID-19 Update | Andhra Pradesh: ‘Past the peak’

We may not know the exact reason why the curve has turned downwards, but we do know that it means that India has been presented with an opportunity to use the testing capacity created in a more aggressive way to contain and not just to count the rising numbers. Are we letting the opportunity slip by and thus making a second wave more likely?

The nationwide peak in mid September also does not mean that it is the same story everywhere, although almost everywhere a declining trend has emerged. In a few States, such as Maharashtra and Andhra Pradesh, where the numbers were very high around or just before the nationwide peak, there have been very large drops since. However, in several states such as Karnataka, Kerala, Tamil Nadu, Chhattisgarh, Gujarat, Madhya Pradesh and Rajasthan, the daily average numbers are still not too far away from where they were in mid September. Even Delhi and Goa are still throwing up significant numbers every day. Some of these have also already seen their second wave.

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