From recording its first COVID-19 case on 30 January, India has now crossed 1 lakh cases in a little less than four months.
Four months and three lockdowns down the line, what has India’s journey been so far? And as the nation enters its fourth phase of lockdown with some relaxations, what can we expect in the near future? Through some graphs, we break it down for you.
Journey So Far: Rise in Active Cases
Looking at the outbreak progression in India, the country registered over 1,600 active cases during the month of March. In April, the cases rose by almost 25,000, and by 20 May, India’s active cases had reached 61,149, a spike of almost 36,000 in less than a month.
Even as the country is under lockdown since 24 March, the cases have consistently risen. From 19 to 20 May, in fact, India recorded its highest single-day rise in cases (5,611). Could this be attributed to our expanded testing?
From a week before the lockdown, when India had merely 72 laboratories conducting around 1,400 tests daily, the country has upgraded to 507 labs and over 1,00,000 tests conducted every day, reaching a cumulative total of over 25 lakh tests on 20 May.
But this does not take away from the probability that the rise in cases may simply be due to an increase in the number of infected people (and not just a function of more testing), as Dr Shahid Jameel, Virologist & CEO of Wellcome Trust/DBT India Alliance, tells FIT.
This is not to say that the lockdown did not serve its purpose. While experts are still divided on the extent to which closing down the nation has helped, there is an overall consensus on the fact that it did delay the spread of the virus - which was one of its objectives - in order to allow the states time to build up their health infrastructure. This delay becomes clearer when we look at the doubling rate of the confirmed cases of the virus in the country.
Today, India’s doubling rate is almost 14 days. Before the lockdown, it was only 3.4 days. Even the recovery rate, which is almost 40% today, was only 7.5% on 24 March.
Another positive observation comes into light when we look at the number of days it took for the total coronavirus cases in India to reach the 1 lakh mark from 100. As per this report, India took 64 days, which was longer than the time countries such as the US, Spain, and Italy took (25 days, 30 days and 26 days respectively). Even Germany, France and the UK took under 45 days for the cases to rise from 100 to 1 lakh.
Nevertheless, it is important to note that the cases in India are rising at the fastest pace in Asia.
A relatively more accurate measure of gauging the prevalence of the disease in India would be looking at the positivity rate: the percentage of people testing positive out of the total tested population. In that sense, India’s positivity rate is around 4.2 percent as of 19 May. In the middle of April, it stood at 4.5%. The US and Italy, for instance, report a positivity rate of almost 15%, as per this report.
The measure has also been provided for the states with the highest number of cases in India (in Figure 2). Although the number of cases is expected to rise as the testing expands, in some states such as Rajasthan, Tamil Nadu and Andhra Pradesh, the positivity rate remains low at 2.4, 3.4 and 0.9 percent respectively, despite considerable testing. On the other hand, Telangana with one of the lowest testing rates in the country, reports only a little over 1500 cases.
COVID-19 in India and The World
On 18 May, the Press Information Bureau (PIB) India released a status update for the country, presenting a promising picture compared to some other highly-impacted countries of the world. In India, there are 7.1 cases per lakh population, as opposed to the world average of 60. The number seems to be the highest in Spain, at 494, followed by the United States and the United Kingdom at 431 and 361 respectively (Figure 3).
This data, however, needs to be looked at in the context of testing. Is India testing enough to find these numbers truly encouraging? When compared to the same countries, India’s testing per million people remains at the lowest, followed only by Mexico. The countries with the highest number of cases in Figure 3 also happen to test more, as Figure 4 demonstrates.
Mortality from COVID-19
As India’s testing remains relatively low, people from around the country have been pinning hope on the fewer COVID-19 related deaths in the country than the rest of the world. Here, the case fatality rate, as well as deaths-per-million estimate, appears to be highest in Italy and lowest in China and India, out of the countries compared (Figure 5).
According to the data analysis by Statista, however, the number of days it took for the deaths from the novel coronavirus to double in the most-affected countries worldwide as of 17 May, India’s 13 days is only more than Brazil’s 12 (out of the countries shown in Fig.5). For Italy, it took 42 days, for the US, 26 days and for China, 86 days.
Moreover, as FIT had earlier reported, this low death rate in India could be attributed to a host of factors, including India's historically abysmal death reporting - only 22% deaths here are medically certified. Shiva Ayyar, Head of Critical Care at Bharati Hospital, Bharatiya Vidyapeeth Medical College, Pune told FIT, “The mortality rate in India should be understood to be deceptive. Deaths are significantly underreported here. Due to abysmally low levels of testing the denominator number of diagnosed cases is also low. Suspected cases leading to death are not counted, again contributing to low deaths. The number of cases in India does appear to be low now but this may change over time as the lockdown is lifted.”
FIT also reached out to Dr Shahid Jameel, who says, “Deaths can be measured with more certainty than infected cases. But, we are underestimating deaths because a lot of deaths are not counted as COVID-19 deaths or they may be dying at home. World over, the deaths are either underestimated or overestimated. The cumulative figure that we have today for deaths is for infections that happened on an average of 15-20 days ago.”
Making Sense of the Lockdown: Has it Helped?
In the past few days, India has consistently seen a rise of 4500-5000 cases, with the highest spike being from 19 to 20 May, of 5,611 cases. How do we make sense of these numbers, and what do they imply for a post-lockdown situation?
Dr Jameel explains, “All through the lockdown, things were stable till around mid-April. After that, it started taking off. Particularly in May, the curve of daily additional cases has become steeper. So we are as much in the woods now as we were 2 months back.”
Responding to the optimistic pictures being presented for India as against the rest of the world, Dr Jameel says, “It really depends on who you are comparing yourself to.”
Saudi Arabia, with over almost 60,000 cases, has a death rate below one percent. Similarly, Malaysia’s is only around 1.6%. “Now even if you argue these are smaller countries, look at China. They have a huge population, but we have clearly surpassed them in the total number of cases, even though our death rate, so far, is lesser.”
Asymptomatic Cases - Good or Bad News?
The testing criterion will have to be expanded, to better assess the situation for a disease which remains mild or asymptomatic in 80 percent of those infected, as worldwide estimates have shown. These cases, when left undiagnosed, become carriers of the disease, and could indelibly infect many others as life resumes to ‘normal’. Interacting with FIT, Dr Sumit Ray, a critical care specialist in Delhi, had said, “We cannot 100% stop the transmission because of asymptomatic cases, but that is the reason why you need to wash your hands, keep social distancing as far as possible, wear a mask in public and also clean surfaces that are commonly touched and used.”
What Does the Future Look Like?
Dr Jayaprakash Muliyil, India's leading epidemiologist, tells FIT that India is nowhere near the finish line. “We need to be ready for an acceleration of transmission as the lockdown is lifted. We don’t have drugs or a vaccine, so cases will definitely rise.”
But a prolonged lockdown is not the answer, he stresses. “You see, the lockdown has destroyed lives and caused harm to all kinds of people from across age groups, even obstructing their regular health care and hospital visits. The virus, on the other hand, affects mostly the elderly.”
This is the way a viral epidemic work, he adds. A virus doesn’t understand lockdowns, it only knows how to travel, and the only way that can stop is when the people create those barriers by following all precautions and staying away from crowds.
He also believes that India’s focus should be on helping and supporting its hospitals in order to save more lives. “The only concern right now is the people dying due to the virus. We need to stop that by focusing our resources on our hospitals.”
This also becomes worrying when we look at reports of overflowing hospitals in Maharashtra, and possibly other cities in the coming days as the virus spreads further and infects the vulnerable.
With the World Health Organisation also giving out warnings about the possibility of the virus never going away, or the chances of not having a vaccine any soon, the only way forward would be to practice social distancing and to wear masks for at least six months to a year. Dr Jameel also says. “There is no getting away from it. We have to start living differently.”