Key Questions India Must Confront In Its Fight Against Coronavirus 

Infectious disease experts’ take on some of the key issues with regards to Covid-19 and what the nation must do.

A sign illustrates the proper way to wear a protective mask at an elementary school. (Photographer: Adam Glanzman/Bloomberg)
A sign illustrates the proper way to wear a protective mask at an elementary school. (Photographer: Adam Glanzman/Bloomberg)

The Covid-19 virus is spreading in India at the fastest pace in the world with the highest single-day infections and deaths. The second-most populous nation will soon eclipse the outbreak in the U.S. Yet, the Indian government defends its handling of the pandemic citing low mortality rate and recoveries. Infectious disease experts call that a flawed way of looking at things, warning that it’s too early to think that the nation has controlled the outbreak.

India added 97,894 fresh cases in the last 24 hours, taking the total case count to 51,18,253 in Asia’s third-largest economy, according to the Health Ministry’s update on Sept. 17. This includes 40,25,079 patients who’ve recovered.

At 83,198, India now has the third-highest fatalities trailing the U.S. and Brazil. The nation is recording most deaths daily anywhere in the world.

BloombergQuint spoke to infectious disease experts on what it means and what the nation must do.

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Low Mortality Rate—False Relief

India’s mortality rate at 1.6% is among the lowest in the world even as it’s recording most deaths every day. The country recorded more than 1,100 deaths daily for the last 15 days. That compares with the daily average of 700 for the U.S. and Brazil in the last one week.

There could be many explanations for that, according to Dr. Abdul Ghafur, infectious disease expert with Apollo Hospitals, Chennai. India’s young population, he said, could be one of the reasons for a lower mortality rate. More than 65% of 130 crore Indians are below the age of 35.

And it will be too early to take relief in low fatality rate, given the country’s large population base and the pace of the outbreak—more than 90,000 cases a day.

Besides, the mortality rate does seem to be lower across many countries, not just in India, Raman Laxminarayan, founder and director of the Center for Disease Dynamics, Economics & Policy in Washington, DC, said in an emailed response to BloombergQuint. The case fatality rate as calculated in public figures isn’t meaningful since many deaths are being missed, Laxminarayan said.

Dr. Faheem Younus, chief of infectious diseases at University of Maryland Upper Chesapeake, in an emailed response, said low testing can also be a factor with some people succumbing to Covid but mislabeled as stroke or heart disease.

India is testing 42,000 people per million population. That the lowest among countries with large outbreaks and compares with 2.62 lakh in the U.S. and 2.4 lakh in the U.K.

Moreover, an average death count of 1,100 a day is tragic.

Allowing this virus to run its natural course will have heavy consequences in the form of morbidity and mortality, Dr. Younus said.

“For the sake of argument, let’s reckon that just less than 10% of India’s population or about 100 million people get infected. Even if the mortality is 0.5%, that would be 500,000 deaths. Even if 3% require a hospitalisation, that would be three million people. India doesn’t have that sort of capacity
Dr. Faheem Younus, chief of infectious diseases at University of Maryland Upper Chesapeake

According to Prabhat Jha, professor of global health and epidemiology at Dalla Lana School of Public Health, University of Toronto, India is not flattening the mortality curve, the most important and useful indicator. Moreover, he said, 80% of deaths in India occur in rural areas and mostly without medical attention, the causes of death are not known.

Recovery Rate—Meaningless

India has seen most people getting cured of the coronavirus than anywhere in the world, with a recovery rate of 78.5%. Experts said the recovery rate statistic should be discarded.

A high recovery, professor Jha said, is a useless statistic and should not be used.

Laxminarayan agreed. It’s meaningless from an epidemiological standpoint, he said, adding high recovery rate is not at all unusual for a disease where most people will recover on their own without any medical intervention. “Eventually, we should hope that 98% of people will recover from the disease.”

Dr. Younus said higher recovery rate may also be because of many variables such as a younger population, lean population, and genetic determinants or cross immunity from previous seasonal viral infections.

Is The Pandemic Under Control?

No, said health experts.

“I’m afraid but this was always to be expected given India’s weak public health system,” Laxminarayan said, adding the virus is pretty much out of control and there is no possibility of reversing the extent of its spread across the country.

The consequence of a pandemic is not just in mortality, but also the number of people sick or hospitalised, Laxminarayan said. “By those criteria, we are not in good shape.”

According to Dr. Younus, it’s hard to take the position the pandemic is under control in India. “We have more than 5 million cases identified with rather modest testing. On Sept. 13, the World Health Organization reported the most number of cases ever recorded in one day and India was one of the countries where those cases came from.”

Professor Jha, too, said there is no clear evidence that India has been able to manage its cases properly. The death rates among the seriously sick, hospitalised, ventilated are high in India, he said.

What India Must Do

The biggest challenge, according to health experts, is lack of public data. To start with, India needs to fix that.

For example, the nation had reported 1.9 lakh cases by May-end. But a sero survey conducted to assess the spread of disease and immunity in a population suggested more than 60 lakh people were infected earlier that month. Officially, India crossed 50 lakh only on Sept. 16.

Dr. Jayaprakash Muliyil, one of India's leading epidemiologists and chairman of the scientific committee of the National Institute of Epidemiology, said whatever numbers that are being reported is just tip of the iceberg. “The overall tally is much larger than that,” he said. It’s in the sero-survey that gives the true picture of the virus.”

Since most of the data are not in public domain, as they are in other countries, it is difficult to understand the trend, Laxminarayan said.

“The reports put out by the government tend to focus on aspects like recovery rate, which is quite meaningless,” Laxminarayan said. “The meaningful metric that we should have access to is the proportion of hospitalised Covid-19 cases who survive. Unfortunately, that data is not being shared at this time.”

According to professor Jha, India must ask all municipalities to release weekly total death counts for 2018-19, and for the completed weeks of 2020. This is a simple way of seeing if the total mortality curve went up or is coming down.

The government, Jha said, must take steps to know any big increase in deaths in rural areas after migrant workers, mostly young, went back home. The government must ask mobile phone companies to give meta data on where migration occurred from the big cities and in those rural areas, he said.

These workers went back to their villages taking infection with them. In the village, under lockdown situation, infection would be mostly confined to the home, so if there is a big increase in deaths within homes in rural areas, the government must take steps to know this.
Prabhat Jha, professor of global health and epidemiology at Dalla Lana School of Public Health, University of Toronto

India saw a mass exodus of migrant labors to their villages as the world’s biggest lockdown to contain the pandemic left them stranded in cities with no jobs. While the government said nearly one crore returned to their native states, it didn’t have any data if migrants died during the lockdown.

India, according to Jha, needs to rapidly scale up, offer free or very low-cost home tests, and increase funding to support those who are infected but have to work to earn daily wages.

Dr. Younus said India and other developing nations have an opportunity to do precise and honest messaging.

“It’s important to fight the infodemic along with the pandemic. It neither requires a new infrastructure nor a billion dollars,” he said. “A simple message repeated enough times is one of the most effective strategies against this pandemic while we wait for a vaccine.”

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