Late January, a medical student fleeing from Wuhan became the first confirmed cases of SARS-Cov-2 in India.1 Couple of her classmates also contracted the virus and India made its initial entry into a leader board no country wants to lead. The three students largely remained asymptomatic and recovered with a month, ending India’s first tryst with the virus.
The second wave started at the end of February. By now, SARS-Cov-2 had spread to 64 countries / regions across the world, with South Korea and Italy reporting over 1,000 confirmed cases. But it is quite possible there were cases in India long before that. It was only in in May that we found that the virus had already reached France in late December itself.2 It is quite possible that the virus had reached India from Europe long before we started screening the flights coming from Europe.
Nevertheless, as confirmed cases started gradually increasing in India, the Central Government took a bold step in locking the country down for three weeks to prevent the spread of the virus. Many countries were opting for lockdown to tackle the virus, but the step by India was a bold one for two reasons:
- Lockdown is a strategy for the rich. It meant many will have to live off their savings and those who can’t will have to be protected by the government. US alone has provided for over 3 million via unemployment benefits.3 India, with perhaps the largest number of poor people in the world, would have struggled to provide for those getting unemployed due to lockdown.
- It would have taken a phenomenal effort to enforce the lockdown given the size of the country and population density in certain parts. The only comparable country is China, which can rely on heavier surveillance than India could enforce.
By 14th April, Goa, the North East and East India excluding West Bengal were largely unaffected by the virus and had limited the number of cases to less than 100. States like Haryana, Karnataka and Kerala had managed to control the spread as well and showcasing more than one-fourth recoveries.
But it was already evident by then that many places in the country where the infection had reached the community.
Though India officially denied community reach of the virus, on 10th April, Indian Council of Medical Research (ICMR), which was coordinating India’s Covid19 response (Which in itself was odd since there was already another organization fitted for it – Integrated Diseases Surveillance Programme (IDSP) 4) had recommended 36 districts be prioritized to target Covid-19 containment activities. This was based on the Sentinel Surveillance study done till 2nd April.5
By 3rd April, India recorded a little over 3,000 cases of SARS-Cov-2. This was spread across 255 districts in 30 states and union territories. Incidentally, only 66 districts had reported more than 10 SARS-Cov-2 cases then.
And ICMR was recommending stricter containment in 36 districts.
As the economic cost of the lockdown became more apparent, India went on a period of staggered release of lockdown after 14th April. But as expected from a country with community transmission of a virus, India showed a consistent increase in cases as norms got relaxed. What was 104 districts on 24th March, when lockdown started, it became 379 on 14th April, 489 on 4th May, 564 on 17th May and with the last release on 31st May – 654 districts have seen confirmed cases of SARS-Cov-2 across the country.
The Road Ahead
Image 1 – Italy
Image 2 – India
After a long three month struggle, Europe is finally starting to hope they can move beyond Covid. While most of the European countries peaked in cases late March, they have seen a gradual decline in cases over two months.
This long tail foreshadows what we may see in India. But for that, we have to reach the peak first. So, we can expect considerable pain, both from Covid and the economy, for at least the next two months before things start to get better.
The 66 districts that saw more than 10 cases on 3rd April, now account for 66% of the SARS-Cov-2 cases in the country.
As cases increase, hospitals get stressed and treatment gets delayed. This leads to an increase in fatality rate. While India is doing remarkably well with around 7,500 dead from 267,000 SARS-Cov-2 cases (2.8%), there are over 100 districts with a fatality rate of 3.7% and above. The ones to watch out for over the coming weeks:
Jalgaon (Maharashtra), Dhule (Maharashtra), Kolkata (West Bengal), Solapur (Maharashtra), Aligarh (Uttar Pradesh), Meerut (Uttar Pradesh), Dewas (Madhya Pradesh), Patan (Gujarat), Khargone (Madhya Pradesh), Amravati (Maharashtra), Nashik (Maharashtra), Mathura (Uttar Pradesh), Gorakhpur (Uttar Pradesh), Sagar (Madhya Pradesh) and North 24 Parganas (West Bengal).
All these districts have shown consistent growth the past week and has high fatality rate. With more testing, it may be possible to weed out the SARS-Cov-2 carriers and catch patients early, although districts like Kolkata and Nashik may already be stressed, given the high number of cases there.
Ujjain (Madhya Pradesh), Anand (Gujarat) and Panchmahal (Gujarat) have seen low growth in cases recently, but has an overall high fatality rate. Increasing testing in such places may reveal the extent of the spread, since high fatality rate may be due to late stage discovery of the disease.
On a positive note, there are 48 districts that show a high growth rate in cases with a less than 1% fatality rate. This would indicate better testing and good potential to keep a check on the virus. These include Chennai (Tamil Nadu), Chengalpattu (Tamil Nadu) and Gurugram (Haryana). All of the three districts have recorded over 1,000 SARS-Cov-2 cases
Among the 25 districts that have over 1,000 cases, Indore (Madhya Pradesh) and Jaipur (Rajasthan) have shown the slowest growth rate the past week, indicating a positive road ahead.
Late March, George Gao of the Chinese Center for Disease Control spoke to Science Magazine about the road ahead with SARS-Cov-2 – Trace all SARS-Cov-2 carriers with mass testing, Isolate the carriers and trace out their close contacts, Quarantine and isolate the close contacts.6 As we officially start to slowly unlock our economy in June, despite the numbers on the rise, it will be a difficult road ahead for all of us in India.
A century ago, the Indian subcontinent was the biggest graveyard for the Spanish flu virus. In all probability, we are again headed there and the only way to have some form of control is to trace the infected early by mass testing and ensuring strict quarantine of the infected and their contacts. We also need a workable serological test7 to determine who have already been infected (and not initially traced) so that they can get back to work.
By Ranjith Kollanur
Bout the Author
Ranjith Kollanur is the Managing Parter with the Unseen Ink,
2 https://www.bbc.com/news/world-europe-52526554
4https://idsp.nic.in/index1.php?lang=1&level=1&sublinkid=5778&lid=3707
7https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html