Covid-19 Update

Andhra Pradesh & Telangana: Relentless rise

Print edition : September 25, 2020

At a COVID testing centre in Vijayawada, Andhra Pradesh, on August 24. The State has ramped up testing in the wake of the growing number of coronavirus cases. Photo: V. Raju

A flower vendor in Vijayawada on August 18. Photo: V. Raju

Migrant workers and their families returning from Uttar Pradesh, in Hyderabad, Telangana, on August 29. Photo: Nagara Gopal

While Andhra Pradesh becomes the second State, after Maharashtra, to have the largest number of COVID cases, Telangana pays the price for its government’s flawed initial strategy.

Visiting the town of Kurnool, Andhra Pradesh’s judicial capital, on August 20 to take part in Rajiv Gandhi’s birth anniversary, Sake Sailajanath, president of the Andhra Pradesh Congress Committee, was surprised to see a senior party functionary standing aloof even when he beckoned the man over. A piqued Sailajanath sought to know why. The man’s reply shocked him: “Sir, I have tested positive for COVID-19.” Expressing grave concern, Sailajanath, who is himself a doctor, told Frontline that this was the state of play in Andhra Pradesh: people had become lackadaisical, exhibiting an attitude that a face covering or mask was all they needed to be safe from COVID-19. Patients who had tested positive were not following the State’s protocol on isolating themselves, either at home or in hospitals. Said COVID-19 Task Force Committee Chairman M.T. Krishna Babu: “Awareness about the pandemic is there, but the feeling among most people is, ‘we may not get the virus’. Overcrowding and a lack of social distancing is evident at wine shops and in markets.”

Not surprisingly, on August 30, Andhra Pradesh climbed a peak it hardly wanted to. Having reported over 10,000 cases of COVID-19 every day for the fifth straight day then, it became the second State behind Maharashtra to have more than 1,00,000 active COVID cases. With 4,45,139 cumulative positive cases, Andhra Pradesh crossed Tamil Nadu’s tally (433,969 positive cases) and is, again, behind only Maharashtra (792,541 cases).

Alarming statistics

There are even more chilling statistics. As of September 1, eight of the State’s 13 districts figured among the 25 most infected districts in the country; all 13 districts are already among the 50 most affected districts. In Andhra Pradesh, 8,524.1 people out of every million of the population have tested positive for the coronavirus. The all-India confirmed per million average is 2,806.3.

Again, in Andhra Pradesh, the infection positivity rate, which is the indication of the spread of the virus in the community, has in recent weeks gone way above the national average. The national average, after rising steadily over three months, touched a peak of 9.01 per cent on August 9. It has since then come down and hovers around 8.72 per cent. Cumulatively the positivity rate in Andhra Pradesh is 11.76 per cent (in Tamil Nadu it is 8.93 per cent).

But what is worrying is that in the last few weeks Andhra Pradesh has seen a massive spike in its positivity rate. For example, on August 18, the State conducted 56,090 COVID tests, of which 9,652 turned out to be positive, that is 17.20 per cent. Again, on August 30, as many as 10,603 of the 63,077 people tested were positive (16.80 per cent).

A declining positivity rate is an indication that fewer people in the community are getting infected for the same number of tests being conducted. In such a situation, while the number of new positive cases would rise with an increase in testing, the spread of the disease would be seen as slowing down or even stymied. Officials, both from the Health Department and from the Task Force, aver that the high positivity rate clearly indicates community spread of the disease. And this is what needs to be slowed down.

The starkly unsettling figures are reflected on the ground. Andhra Pradesh is one of the four States (Maharashtra, Uttar Pradesh and Karnataka being the others) with the largest caseloads in India and are primarily the cause of the surge of cases in the country. Cumulatively, of Andhra Pradesh’s 13 districts, East Godavari with 60,661 positive cases leads the way followed by Kurnool (45,558), Anantapur (41,584), West Godavari (38,054), Guntur (36,378), Visakhapatnam (37,519), Chittoor (37,717), Nellore (31,739) and Kadapa (27,113).

Officials from the State Health Department had anticipated peaking of COVID-19 cases in August. But in many of the districts, such as Kurnool, Guntur, East Godavari and West Godavari, caseloads have been at their peak for almost the entire month of August. In Chittoor, Kadapa and Nellore, and in recent weeks in Prakasam, with 18 to 20 per cent caseloads, there are no signs of the virus retreating.

But the silver lining is the State’s case fatality rate (CFR), the proportion of deaths among those who test positive for the infection. At 0.93 per cent it is one of the lowest in India (the national CFR is 1.80 per cent) and is much lower than the global average of 3.34 per cent. (Maharashtra has a CFR of 3.1 per cent, Delhi 2.6 per cent, West Bengal 2 per cent, Tamil Nadu 1.7 per cent and Karnataka 1.7 per cent.) In all, there have been 4,053 COVID-19 deaths in the State.

Andhra Pradesh has also led the way in testing, having conducted over 3.782 million tests over the past five months since April. This translates to 72,437 tests per million of the States’ 52.22 million population. Only three States, Uttar Pradesh (5.62 million), Tamil Nadu (4.81 million) and Maharashtra (4.21 million), have done more tests. Andhra Pradesh is currently doing over 60,000 tests a day.

The large number of cases has not fazed officials like K.S. Jawahar Reddy, Special Chief Secretary, Health, Medical and Family Welfare. Said Jawahar Reddy: “We will not reduce testing to show a lower number of positive cases. Nor are we afraid or bothered about becoming the State with the largest number of positive cases, just so long as the mortality [CFR] continues to be low. Yes, we were shaken when we started recording over 10,000 positive cases every day. But the number has stabilised and we have continued our efforts to test, trace and isolate/quarantine those infected, either at the 100 plus government hospitals/COVID care centres, with an availability of 38,500 beds, or at the nearly 130 COVID-19 notified private institutions, which have 35,000 beds. Besides, our efforts are specifically designed to reduce fatalities and increase the survival rate.”

Jawahar Reddy said it was learnt that COVID patients who got a fever for a second time were in great danger, it being an almost sure indication of a cytokine storm. (Cytokine storm is a phenomenon that occurs when the body’s immune system suddenly causes an uncontrolled, abundant, and even excessive release of pro-inflammatory signalling molecules called cytokines, which in turn triggers a deranged immune response to an infection.)

He said: “We have estimated that on an average, doctors need at least a week to test, identify, stabilise and save COVID-19-infected patients. Currently, the average hospitalisation, even in cases where the patient has succumbed, is for 4.5 days. Our aim is to make this seven days. We are actively isolating and ensuring the hospitalisation of severe cases where the oxygen level falls to below 94. It boils down to how each hospital handles a patient.”

When the pandemic struck Andhra Pradesh, which has no major metropolitan city, it had to start almost from scratch. Today all the 13 districts are self-sufficient in testing and hospitalisation, say officials like Jawahar Reddy. The pandemic, according to him, has acted as a catalyst to prompt the Y.S. Jaganmohan Reddy-led government to ramp up health facilities: it is proposed to start seven super speciality hospitals in tribal areas and 16 medical colleges (in addition to the existing 11) with attached institutions, 550 urban health centres and 10,000 village health clinics at every village secretariat. Required land, consultants, and designs for most of these medical colleges and village health centres, according to officials, have been finalised. With Jaganmohan Reddy determined to implement his controversial decision to carve out 12 new districts (in addition to the existing 13), each district will have at least two medical colleges.

Officials hope that by September end, Andhra Pradesh will be past the worst of it. They estimate that by then 20 to 25 per cent of the State’s population will have been infected with the coronavirus.

Unsure in Telangana

In Telangana, the Kalvakuntla Chandrashekar Rao (KCR) government’s response to the virus continues to be befuddled and ham-handed. Much of the blame for this is attributed to the Chief Minister’s dictatorial attitude. Not prepared to brook dissent or a different opinion, KCR has tied his officials up in knots as the State lurches precariously from one crisis to another. KCR has himself hardly made any public appearances in recent weeks.

Senior Ministers confessed to Frontline that the State was helpless in fighting COVID-19 and it was up to the people to take responsibility. In some congested areas like the Greater Hyderabad Municipal Corporation, the government has all but thrown its hands up. A study published in The Lancet in July, assessing the vulnerabilities of Indian States to COVID-19, ranked Telangana as the third most vulnerable State to the effects of the pandemic.

With positive cases and fatalities mounting in the State, there are many voices alleging that the KCR government has been fudging, even suppressing, figures of COVID-19 deaths. A former Congress legislator said, “COVID-19 infected people are dying like birds during a drought. But the government is keeping the real figures under wraps. They have declared that only some 800 have died [as of September 1, as per the Telangana government webssite 846 people had died of COVID-19]. How is that ever possible?”

Syed Ali Murtaza Rizvi, Secretary, Health and Family Welfare Department, refuted this charge: “We are reporting facts. No COVID-19-related deaths are hidden.”

At the start of the pandemic, the Telangana government’s strategy and response, though publicly unstated, was to keep testing at a minimum, hope that those infected with the virus would develop antibodies, and aim for herd immunity. But by July it became obvious that the strategy had failed. Intermittent lockdowns and sealing of the State’s borders had only a limited effect. Admittedly, the return of migrants working in Gujarat and Maharashtra only pushed up the number of COVID positive cases, especially in the State capital, Hyderabad.

By July testing was sought to be ramped up and by the end of that month, Telangana was conducting nearly 20,000 tests every day; this figure reached 50,000 by the end of August. So far the State has conducted nearly 1.42 million tests, which translates into 38,351 tests per million population. As of September 1, as many as 1,30,589 people had tested positive for COVID.

A recent sample study by the Telangana Health Department highlighted the importance and sheer necessity of testing for early detection, isolation, treatment and containment. Of 61,148 people tested, 59 per cent constituted primary and secondary contacts (27,516 primary and 8,560 secondary) and did not show any symptoms. Only 41 per cent had symptoms such as fever, influenza-like illness (ILI) or Severe Acute Respiratory Infection (SARI). Close contacts of patients, including family members, too tested positive for the virus though many of them were asymptomatic. As many as 69 per cent of those who tested positive did not have any symptoms, while the remaining 31 per cent had symptoms.

Telangana, according to Minister for Medical, Health and Family Welfare Etela Rajender, had now geared up to fight the virus. Said Rajender: “Besides ramping up testing to 65,000-70,000 a day, we are taking a number of preventive measures, including providing patients who have been recommended home quarantine with a medical kit that has a wallet of medicines, supplements to boost immunity as prescribed by the ICMR [Indian Council of Medical Research] protocol, and a pamphlet of the dos and don’ts.”

He also said that testing was now available at over 2,100 centres, from mobile collection centres to primary health centres and government and private hospitals. For patients requiring further intervention, Rajender said there were 18,015 beds at the 30 government and 187 designated private hospitals, besides 8,686 beds at 90 COVID care centres.

According to Rizvi, the focus was now on testing, contact tracing and field surveys to identify people suffering from SARI and having them counselled by doctors and providing treatment as close to the patient as possible. Said Rizvi: “It is a dynamic, constantly changing and challenging situation. We are following ICMR guidelines.”