India on Thursday became the third country in the world, after the US and Brazil, to report more than two million coronavirus disease (Covid-19) cases — the second million coming in exactly three weeks since the country hit a million infections on July 16, with 42% of the new cases coming from Andhra Pradesh, Karnataka, Uttar Pradesh, West Bengal and Bihar.
With a total of 62,088 new cases on Thursday taking the national tally to 2,022,730, the doubling rate — the number of days it takes for number of infections to double — in the country now stands at 22.7 days. This is significantly higher than it was in the US (60.2 days) and Brazil (35.7 days) on the day they crossed two million cases — suggesting that India’s caseload could surpass the tallies in these two countries unless the trend reverses or a vaccine is developed.
If cases in the country continue to grow at the same rate they have till now, which is likely considering how new states such as Andhra Pradesh, Karnataka and Uttar Pradesh have emerged as hot spots, experts estimate that the next million cases may take just a little over two weeks.
The US total now stands at 4,993,508 cases and Brazil is at 2,873,304 million.
With 898 new fatalities reported on Thursday, 41,633 people have died due to the disease in the five months of the outbreak in the country. The silver lining is that the country’s case fatality rate (CFR) is 2.06% — not only better than the global average of 3.75%, but also significantly better than the CFR in the US (5.72%) and Brazil (3.81%) when these countries had the same number of cases.
Experts say the focus of the battle against Sars-Cov-2 – the virus that causes Covid-19 – now needs to shift to the hinterland and the peninsula, both high population density regions with, in the case of the former, significant rural populations and relatively inadequate health care systems.
On July 16, when the country touched a million cases, nearly 56% of all cases could be traced to the three regions that were the original hot spots of the disease in India – Maharashtra, Tamil Nadu and Delhi. In the last three weeks, however, this trend has shifted.
Delhi, which was responsible for nearly 12% cases in the first million, has reported less than 3% of the new cases in the second million.
The gains from the reduction in cases in Delhi, however, were undone with the outbreak spreading to new regions. States such as Andhra Pradesh, Karnataka, Uttar Pradesh, West Bengal and Bihar, which together reported less than 19% of cases in the first million, reported nearly 42% of new cases since July 16.
“There are reports of cases coming from rural areas but the advantage that we have there is that population density is low because of which cases can be identified, isolated and treated early. In these areas surveillance can be far better and also compliance, and that is instrumental in controlling spread of the disease effectively,” says Dr VK Paul, member, Niti Aayog, who also chairs one of the National Task Forces on Covid-19 management.
Health secretary Rajesh Bhushan said during a briefing on Tuesday that even though infections had spread to newer areas, there was no cause for concern because almost 82% of the caseload was limited to 10 states. “Fifty districts account for about 66% of the current caseload, therefore, there’s no need to panic as the disease spread is limited,” he said.
India’s journey to two million cases took 158 days, with at least 90% of these cases coming after the lifting of the hard nationwide lockdown that was announced at the end of March — a strategy that officials and experts said bought the country precious time to set up isolation centres, add hospital beds, and strengthen testing infrastructure. With crippling economic costs piling up, the country began unlocking in June, when the outbreak was on a sharp upward trajectory.
On Thursday, during a virtual meeting of the regional director of World Health Organization (WHO) for South-East Asia with ministers of health of the member nations, Union health minister Harsh Vardhan said that the lockdown was “effective in slowing down the rate of growth of cases and gave the government time to augment health infrastructure and testing facilities”.
“From one lab (for Covid-19 testing) in January, India has 1,370 laboratories at present. Indians anywhere can access a lab within three hours travel time and 33 of the 36 states and UTs exceed WHO’s recommendation of testing 140 people per million per day,” he said.
“India’s proactive and graded multilevel institutional response to Covid-19 made it possible to have very low cases per million and deaths per million in spite of having a high population density and low fractional GDP spending and per capita doctor and hospital bed availability as compared to other developed countries,” he was quoted as saying in a statement from the health ministry.
Doctors also say that the number of severely ill patients is low, and most of those needing hospitalisation are recovering faster.
“Most positive cases do not require hospitalisation, and those needing intensive care is actually a minuscule number. Most people in hospitals have moderate disease with good chances of recovery. The need is to take care of our old and vulnerable population with co-morbidities that is at high risk of developing severe illness,” says Dr Rommel Tickoo, senior consultant, department of internal medicine, Max Healthcare.
In the last week, India has added an average of 53,955 cases a day — up from 30,076 a day in the week when it crossed a million cases. This increase in daily cases has been consistent with the rate at which testing has been ramped up across the country. In the last week, 565,000 samples on average were tested for Covid-19 every day, against 292,000 a day for the week ending July 16.
At least some of the testing gains can be attributed to a decision by several states to rely on antigen tests instead of the Reverse Transcription Polymerase Chain Reaction, or RT-PCR test, which is considered by scientists to be the gold standard. An antigen test, also known as a rapid test, has become popular with many governments as it offers tests within the hour as opposed to the RT-PCR tests whose results reach the subject 24 to 48 hours. Since the former can possibly lead to false negatives, several cases can slide under the radar. But experts say it can be used in small areas of hot spots to test every resident and quickly isolate as many patients as possible. In contrast, the RT-PCR test is the most definitive test currently available and experts say it should be used as often as possible.
India’s average weekly test positive (or positivity) rate has risen from 6.5% in early June to 10% at present, but the aggregate level statistics mask sharp differences in testing performance across the country. Maharashtra, the state with the highest number of infections, at 479,779, has a test positive rate of 17% in the last week, while for Uttar Pradesh, this number is less than 5%.
The WHO identifies 8-12% as the ideal range for test positive rate in a country with an active outbreak. A number too low or too high implies that volume as well as targeting of Covid-19 testing is inadequate to accurately detect the spread of the disease.
“The Covid situation is quite dynamic and the numbers change on a daily basis, and same goes for the positivity rate. However, if you look at the overall trend, India’s current positivity rate is on the lower side, even in comparison with other countries. Same goes for the case fatality rate which is probably one of the lowest in the world. We have been able to manage the disease quite effectively so far,” says Dr GC Khilnani, former head, pulmonology department, All India Institute of Medical Sciences, Delhi.
The number of people who have recovered from Covid-19 in India touched 1,375,797 on Thursday, bringing the proportion of recoveries to68.01%,against the global average of 64.2% of all cases recovered. To be sure, India’s recovery rate is expected to eventually soar to over 90% — since current trends indicate the final fatality rate could lie between 2-3% — once the outbreak nears its end.
This also means that a total of 605,300cases (29.91% of total infections) in the country remain active. The number of active cases has been steadily increasing in the country, which may be a cause of concern for officials. It was 96,970 at the start of June, and 227,298 on July 1. Active cases — those still under treatment — is a crucial metric because it directly reflects the pressure on the health care system in any region.