COVID-19 Strategy

Wilful denial of the increase in COVID-19 cases and deaths

Print edition : August 14, 2020
The daily number of COVID-19 cases and deaths hit new highs in July but the government continues to remain in self-congratulatory mode, blind to the possibility of community transmission.

On July 23, the Ministry of Health and Family Welfare issued a press release celebrating the fact that for the second consecutive day, “recoveries in a single day continued to post a significant rise”. The release also said that in the previous 24 hours, 30,000 persons had recovered, which was the highest number in a single day recorded until then. There was an appreciable growth in the recovery rate (63.18 per cent), reflective of the increasing gap between the number of active and recovered patients, it added. “This accomplishment can be attributed to the Union Government-led COVID-19 management strategies,” it claimed.

However, the note glossed over the fact that the country had also recorded the largest single-day spike in deaths (1,129) and the number of confirmed cases (45,720) over the previous 24 hours.

The number of confirmed cases reported every day steadily rose from below 20,000 in the beginning of July to more than double the number by the third week of the month. The note also glossed over the detail that many State governments were implementing “weekend lockdowns” or 15-day lockdowns following a spurt in cases.

There was no cogent explanation for either the acceleration in the growth of fresh cases in States other than those that had contributed to the maximum caseload or the spurt in newer areas within States. Whilst the note presented a glowing picture of the curent situation, the fact remains that the pandemic is far from being contained.

Govt assertions

According to what was said at an earlier media briefing, 86 per cent of the active cases were in 10 States, Maharashtra and Tamil Nadu together accounting for 50 per cent and Karnataka, Delhi, Assam, Andhra Pradesh, Uttar Pradesh, Telangana, West Bengal and Gujarat for the rest. “It was not growing at the same pace everywhere,” a senior Health Ministry official said at the briefing. While this was true, it was also true that infections had now spread to the rest of the country.

On that day, some 29,000 fresh infections were reported from across the country, but Health Ministry officials suggested that one ought not to “just look at absolute numbers”. A senior official said that there was a “progressive decline in the daily growth of numbers”.

On the criticism that the goverment was not testing enough people, a panel of health experts and Health Ministry officials told the media on July 21 that the “test, track and treat” strategy “led by the Centre” and followed by the States and Union Territories (UTs) had ensured that the national average testing rate had gone up to 180 tests a day per million population.

This was more than the World Health Organisation’s (WHO) recommended rate of an average of 140 tests a day per million population, they added. The officials also said 19 States/UTs were testing more than the WHO standard, with Goa topping the list with 1,333 tests a day per million. The Health Ministry officials referred to a WHO document titled “Public Health Criteria to Adjust Public Health and Social Measures (PHSM) in the context of COVID-19”, which was an interim guidance measure issued on April 16 when the pandemic was at a much earlier stage of development. A series of annexes were subsequently issued to help countries with their public health and social measures and to manage the risk of resurgence of cases. An annexe dated May 12 was specifically prepared for countries where large-scalepublic health and social measures had been introduced, India being one of them.

It mentioned various measures relating to epidemiology, health system and surveillance based on which the public health and social measures could be adjusted.

For instance, if the effective Reproduction Number was less than one for at least two weeks (R one, the effective number of secondary cases per infectious case in a population) and where less than 5 per cent of samples test positive for COVID-19, it would indicate that the epidemic was under control. At present India’s positive rate was 8.07 per cent, according to the Ministry officials.

The officials also said that there were 30 States with positivity rates less than the national average. A graphic prepared by the Ministry and shared with the media listed only eight States that had low positive confirmation rates. Among these States, fresh cases have actually seen big spikes in July in at least three: Karnataka, Madhya Pradesh and Uttar Pradesh. Some of them have also been compelled to introduce partial to full lockdowns to check the transmission.

The percentage of positive samples, according to the WHO’s guidance measure, could be “interpreted only with comprehensive surveillance and testing of suspect cases in the order of one per thousand population per week”. If 80 per cent of cases were from contact lists and could be linked to known clusters, it indicated that transmission chains had been identified. A decline in the number of deaths over the past three weeks, a decline in hospitalisations and ICU admissions over the last two weeks, and so on also indicated that the epidemic was under control.

Positivity rate

In one of its earliest bulletins, the WHO noted that largescale testing was one of the reasons for the flattening of the epidemic curve of new infections based on the experience of the Italian town of Vo, and countries such as South Korea, Iceland and Norway.

According to Statista.com, India stood 25th among the 30 most impacted countries ranked according to their level of testing per million population. Countries with a higher level of testing include Brazil, the United States, South Africa, Iran, China, Spain, Russia, Qatar, Kazakhstan and all major West European nations.

Considering that India is now in the third place among all countries after the U.S. and Brazil in the number of confirmed cases, the testing rate is clearly lower than required. The significance of the test positivity rate is that it indicates how successful a country has been in using testing to reduce the chain of further transmission. A high positive rate would indicate that a country was not testing enough for that purpose. A low positive rate, on the other hand, would indicate that a country had tested, treated and isolated infected persons efficiently.

Even though India’s testing had gone up in recent weeks, the positive ratio of 8-10 per cent in July indicated that there was a long way to go before the positive ratio came down to one, as was the case in Australia, South Korea and Uruguay. The WHO said a positive rate of 3-12 per cent was the general benchmark of adequate testing. At a level of almost 13 per cent on July 23, India’s daily positive rate was at the higher end of the benchmark.

According to ourworldindata.org, a portal tracking testing rates globally, India tested fewer than seven persons per thousand population for most of June. This went up to 10.42 tests per thousand on July 21 or 10,421 per million. Even Brazil was testing more than India, while countries such as Russia (176.14), the U.S. (142.67), Australia (136.33) and Colombia (24) were far ahead.

The WHO identified four transmission scenarios in the third week of March. The first one was where there were “No Cases”; the second was “Sporadic Cases” where one or more cases were detected, either imported or local; the third included countries where clusters were detected; and the fourth was a scenario of community transmission where larger outbreaks were detected or there was sustained and pervasive local transmission.

Despite the emergence of fresh cases on a daily basis and a steadily rising daily toll, the government claims that there is no community transmission in the country.

The rate at which the total number of confirmed cases were rising daily in India, averaging around 3.5 per cent throughout July, was significantly higher than that of the U.S. (1.9) or Brazil (2.1) or the world average of 1.7 per cent. Despite these trends, the government justifies its denial of community transmission by arguing that the WHO had allowed governments the freedom to use such nomenclature depending on their individual situations. Therefore, the only reason why India does not have community transmission is because the Central government says so.

According to ourworldindata.org, the high positive rate of tests indicates that the true number of infections might be much more than the number of confirmed cases. The data portal said that while the WHO had suggested a positive rate below 10 per cent as a benchmark of adequate testing, the ideal rate was below 3 per cent. A handful of countries had achieved successes in bending the curve in this way. Data for Thailand, Germany, Slovakia, New Zealand and South Korea showed that they monitored the outbreak and caught up with it, as a result of which they were able to get ahead of the infection and effectively contain its spread.

These countries brought down the daily number of positive cases by rapidly increasing the number of tests relative to the number of confirmed cases. On the other hand, countries such as India, Brazil, the U.S., Mexico, Panama, Nigeria, Pakistan and South Africa were not able to achieve such a rise in testing even as daily case counts spiralled.

Thus, starting from a similar place, some countries caught up with the virus with their testing and got ahead of the infection, while others increased testing only in the process of chasing a growing spread.

At a July 14 briefing, Health Ministry officials maintained that if the country was testing 140 persons a day per million population, that could be described as “comprehensive.” There are more than 1,400 laboratories in the country where tests are done using either the gold standard “reverse transcription polymerase chain reaction” technique or the rapid antigen method. For a population of 1.3 billion, the number of laboratories is woefully low.

Community transmission

The persistent denial that India was in the community transmission stage has been part of the officialese put out on a regular basis. The Indian Medical Association (IMA) was even reportedly forced to retract the statement by the Chairman of the IMA’s Hospital Board to a leading news agency that India was in the stage of community transmission. Within two days of that observation, the IMA issued a clarification on its stand on community transmission.

The text of the clarification itself showed that there was some pressure to issue such a statement. Curiously titled “IMA’s stand on Community Transmission of COVID”, the note stated that “the purported statement” was not from the IMA headquarters.

The note issued by Rajan Sharma, the IMA’s national president, and R.V. Asokan, general secretary, clarified that “it was for the official agencies to ascertain this stage in the natural history of the epidemic; crowdsourcing data cannot replace authentic data. All presumptions in this regard should be considered a matter of personal opinion.” The IMA officials stated that the IMA was confident that the public health authorities and the medical fraternity were fully engaged in and prepared for containing the fallout. According to them, data showed that “the clusters are in urban metros and not in the countryside where open spaces are the rule”. This brief statement was shared with the media by Health Ministry officials. The observations aimed at discrediting crowdsourced data were strange, given that data aggregator sources, nationally and globally, rely on data issued by Central and State governments. Also, data from crowdsourcing agencies have not been significantly different from data put out by government sources.

The data thrown up by the recently conducted sero-surveillance in Delhi showed that nearly 24 per cent of the population in Delhi had been exposed to the infection at some point, much higher than the all-India prevalence of 0.73 per cent that the previous national sero survey in 22 districts had shown.

The study was conducted during the June 27-July 10 period by the National Centre for Disease Control in collaboration with the Delhi government using the antibody test method, or the Enzyme Linked Immunosorbent Assay (ELISA) method.

The method basically shows past infection due to SARS CoV-2 in individuals who tested positive. A total of 21,387 samples were collected, and, on an average, antibodies were found in 23.48 per cent of the persons tested.

This meant that one in every four persons in Delhi, or almost five million people, were infected. Such a high proportion of infections is likely to have been also reflected in several parts of the country that are recording a large number of confirmed cases.

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