As India records rising COVID cases, key lies in reducing mortality rates

As COVID-19 continues to rage in India, many wonder if India has entered the second wave of the pandemic. But that, probably, is a misconception. India does not face a single homogenous epidemic wave. The pandemic in India is in different stages in different parts of the country, but the response has been driven by a single, centralised, overarching strategy instead of being decentralised and owned locally. This strategy might be counterproductive.

While India reported the first 1 million cases in 170 days, the latest 1 million took only 17 days (quicker than even in the USA). India’s public health infrastructure was already failing its citizens and its frontline staff. Now, amid the COVID-19 crisis, evidence indicates that the delivery of health services is only worsening.

As of September 1, 80% of cases have been reported from just 80 districts of India! Over 66% of the new cases are from rural districts.

In the current juncture, when a bulk of the cases are coming from rural districts with weak health infrastructure, the possibility of containing the pandemic is extremely limited. Lockdowns are also not a good option given the tremendous opportunity cost. The way forward should include a number of measures that could help reduce the mortality rate and facilitate a quicker exit from the pandemic.

Early testing of high-risk individuals should be prioritised, says an editorial titled ‘India’s Battle against COVID-19: Progress and Challenges’ in The American Society of Tropical Medicine and Hygiene. Authored by Ramanan Laxminarayan, Shahid Jameel and Swarup Sarkar, it says the current national guidelines does not do this and, therefore, this could be a missed opportunity for averting deaths in vulnerable populations of the elderly and those with comorbid conditions.

The editorial also says a transparent data-driven and locally owned approach to pandemic management is the need of the hour to fight the pandemic. Even in a state like Tamil Nadu, the data on tests done is not publicly available, making it difficult to get an idea of the true nature of the infection across geographies. The fact that data collection is still centralised only obstructs the flow of information, causing confusion among the public on the need to comply with COVID guidelines, including ensuring personal protection and social distancing.

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Besides transparent data, there is also a need for greater participation of NGOs and civil society groups at the present juncture to help mitigate the continued effects of the lockdown and also help in providing the marginalised and the vulnerable, especially in rural areas, access to healthcare facilities. In the initial stage of the shutdown, many volunteers and NGOs came out to help migrant workers who were walking back on the highways to their village. Their participation after those initial stages has not been the same, say the authors.

According to the editorial, India should be extra careful as in a couple of weeks, monsoon would taper down across many geographies and usher in the annual ‘flu season’, when other diseases like dengue and malaria are common. The symptoms of these ailments are similar to that of COVID-19. To prevent any further strain on the existing health infrastructure, there is an urgent need for a specific clinical and testing strategy to enable distinction between the diseases and the treatment required for them, the editorial points out.

According to the authors, there is still confusion about how best to care for patients at home with asymptomatic infection, in hospitals with mild-to-moderate disease and also with the serious cases, although the ministry of health and family welfare (MoHFW) had issued national guidelines on clinical protocol in April. Health workers say that the confusion is caused by the lack of clear guidelines for clinical protocols for patient management. Global examples show that these protocols change rapidly as more clinical data is released.  In India, there is an urgent need for communication of these protocols to practitioners and frontline health workers.

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The article says there is a need for publicly available histopathology data to combat the pandemic and such crisis in future effectively. Currently, in India, many deaths are being recorded without a COVID-19 test. The number of officially reported deaths likely underestimates the actual numbers, the authors say. Identification of these and analysis of publicly available histopathology data offer a tremendous opportunity to learn about the disease and, thereby, prevent future cases and deaths. India currently lacks a mortality surveillance system for COVID-19. This needs to be put in place as soon as possible, says the article.

The authors say testing in India is still low despite the increase in the past few months. On India’s testing conundrum, they write, “India was slow to provide testing despite the significant capacity for reverse transcription-polymerase chain reaction (RT-PCR) testing in both public and private laboratories.”

In March, before the shutdown was announced, about 1.5 million people had entered into the country through airports. Poor control and tracing methods and the deluded belief that a shutdown would lead to the disappearance of the virus had led to extremely low testing then. More importantly, testing for the Cov2 virus in the early days of the pandemic was restricted to just a few government labs. Private laboratories and diagnostic centres, which typically provide the bulk of pathology services, were not allowed to test at all. The restriction possibly could have been to maintain quality but presumably also to control the flow of information.

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“Testing for COVID-19 in India continues to rank among the lowest in the world on a per-capita basis. Testing rose from 3,000 tests per day on March 24, 2020, (approximately 2 per million population) to more than 1 million tests per day as of  August 31, although much of this increase was due to the introduction of rapid antigen tests that have far lower sensitivity than RT-PCR. At the current time, India has conducted approximately 18,000 tests per million population, a rate that is a third that of South Africa, about 60% that of Nepal, and among the lowest of any large country,” they note in the paper.

As the pandemic spreads to rural districts, it offers an opportunity to rethink our approach to public health. If done correctly and effectively, this adversity caused by the Cov2 virus could be the ‘excuse’ for a much-needed massive public spending in healthcare. This would help us build a well-equipped and trained workforce in our healthcare delivery not only for the present pandemic but also for response to any future pandemics. We must invest heavily in public health infrastructure. Such a move is also likely to create the much-needed economic multipliers that the country facing an unprecedented economic contraction needs now in the form of jobs and an increase in consumption.

Currently, in the sixth month of the pandemic in India, there is still a massive demand for health workers and essential supplies like PPE, ventilators, testing kits, etc. The pandemic initially affected metros and cities, which arguably have better infrastructure than rural areas, where the situation is now worsening, especially in 116 districts of the six larger states of the country.

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To limit the spread further, it is important to streng­then tracking, testing, and treating positive cases even at the district levels. But, according to some observers, India is still nowhere near a peak.

“What is happening in the hinterland is just anybody’s guess, because we don’t have the data,” says Texas-based scientist and entrepreneur Dr Navaneetha Rao, who has been tracking the pandemic closely. “Talking about a single peak for India is meaningless. It is going to be a series of rolling peaks across the country and across the calendar period,” he says. “Even in places like Chennai, where cases seem to be flattening now, the situation will not remain the same. The virus will spread as the population flows in and out, as interactions between people increase. The  question of flattening the curve truly does not make sense and that is one of the issues here.”

Serology surveys show testing is lagging

Many sero surveys have indicated that testing does not provide a correct picture about the scale of the pandemic in India.

The government has been conducting ‘sero surveys’ through various agencies. According to a serological study based on 21,387 samples by India’s National CDC from June 27 to July 10, 23% of the population in Delhi had been infected with the coronavirus.

The number of seropositive — roughly 4.7 million — was approximately 40x the reported cumulative number of infections in Delhi, indicating that a large number of infections were likely missed by the testing process.

Another sero survey undertaken by TIFR in Mumbai in early July indicated that 57% of those living in slums had antibodies for SARS-CoV-2, compared with 16% in other parts of the city. Unpublished data from the Indian Council of Medical Research indicated that 10 million people (0.7% of the Indian population) were infected by early May, at a time when fewer than 50,000 cumulative infections had been reported. Epidemiologists, after comparing seroprevalence data with reported infection data, believe India could have undercounts by a factor of 40x–200x.

Data released by Thyrocare, a private diagnostic testing firm, in the third week of August indicated that nearly 1 in 4 Indians could have already been exposed to the SARS-Cov2 virus. “I am not surprised by these results, which only confirm ICMR serological data and show that reported cases are a small fraction of true infections, which are likely in excess of 200 million at this stage,” epidemiologist and health economist Ramanan Laxminarayan told The Federal.

Based on the above data, one can conclude that India is moving towards a kind of ‘involuntary herd immunity’ in metros like Mumbai, Delhi, Chennai, etc. This might not have been an intended strategy, but, currently, it is what it is!