On Tuesday, India reported more than 68,000 Covid-19 cases over 24 hours. The scale of the pandemic has been steadily rising in the country, with 3.7 million cases and 65,288 deaths so far. The country is currently third in the world in terms of number of cases and is set to overtake Brazil soon.
In the past few months, the virus has actively spread from urban hotspots such as Delhi and Mumbai to rural areas where the health infrastructure is even less prepared to cope with the high volume of Covid-19 cases.
Dr Ramanan Laxminarayan, epidemiologist and founder of the Center for Disease Dynamics, Economics & Policy, in Washington, D.C. said in an email interview with HuffPost India that the transmission of Covid in rural India will be not as rapid as in urban India, but will persist for much longer because of the size of population.
He said that India was approaching a “state of a high-plateau” where cases will continue to remain high before gradually decreasing.
In the interview, Laxminarayan also spoke about how testing in India is still low compared with other countries, how rapid antigen tests are bringing down actual numbers and why testing should now be targeted at the elderly and people with comorbidities.
Edited excerpts from the interview:
You had said in June that India may have tens of millions cases by September. While the number is still high, there is a significant difference from that forecast. What does this indicate?
India is testing a lot of samples, but the rate of testing per capita is still quite low compared to other countries. Serology surveys that are able to indicate the true number of infections show that we are only counting a small fraction of the vast numbers of infections occurring each day. The under count can be by a factor of 50 to 150.
You had called for an “exponential” ramping up of coronavirus testing in April. Do you think India is testing enough now?
India is testing a lot more but most of these are low-sensitivity antigen tests. Overall, the testing increase is welcome but it has come a bit late. We had a window of opportunity in March and April to use testing to identify cases and to use isolation and containment to bend the epidemic curve. That window was lost by restricting testing just to a few government labs. At this point, testing should be targeted to the elderly and those with comorbidities to bring them in early for critical care and to reduce the number of deaths.
“The guidelines say that anyone who is negative on a rapid antigen test should get an RT-PCR test but my understanding is that very few are getting this follow-on test.”
Most states in India are relying on rapid antigen testing. Can you explain why there is a problem with this?
Rapid antigen tests are only about 50-60% sensitive, far less than the standard RT-PCR tests that are themselves only 70% sensitive. Sensitivity is a function not just of the test but also of the operator skill in taking a swab, ambient temperature and other factors. So if we are missing roughly half of infected people when we do an antigen test, that means that the other half are out there transmitting the virus because of the false notion that they are uninfected. The guidelines say that anyone who is negative on a rapid antigen test should get an RT-PCR test but my understanding is that very few are getting this follow-on test.
Covid spread in India was expected to peak in July. Do you think we have gone past that?
Peaks are a function of lockdowns and human behavior. They are not exogenous events like the monsoon over which we have no control. The continued lockdowns have pushed out the peaks in many states and overall, India has been able to significantly slow down but not stop the virus.
You had also said that India won’t have one single peak. Can you explain why?
Different states have started their Covid epidemics at different times and so we should expect them to also peak at different times. We are approaching a state of a high-plateau when cases will continue to be high for a period of time before they gradually start coming down.
Hotspots are now emerging across rural India, in some of the poorest areas in the country. What does this mean for the spread of Covid-19 in the next few months?
It was inevitable that the disease would eventually spread widely in rural India which has both fewer testing facilities and less access to treatment. Disease transmission in rural India will not be as rapid as in urban India but rural India is larger and so it will persist for much longer because of the size of population. Also, it is likely that mortality rates will appear to decline because many rural deaths are unreported and even when they are, the medical cause of death is not recorded.
“Although COVID-19 is exacting a significant health and economic impact on the country, it offers an opportunity to rethink India’s approach to public health.”
India is seeing a record number of cases each day. By when do you expect the numbers to dip?
It’s going to be a while and we are going to be on a high plateau for a while. The numbers may appear to dip after a while once the disease is mostly in states with weak health capacity but a real decline may take longer.
Several states in India will experience winter in a few months. Will this affect the course of the disease in any way?
Respiratory illnesses tend to worsen in the winter months but it is not clear how the novel coronavirus will behave. If there is a seasonality, as is the case with influenza, it would be more likely to be in the northern states where there is a stronger temperature gradient.
What are the steps the government needs to take at this stage to cope with the spread of Covid?
The central government response to date has been primarily through the lockdowns and other law-and-order measures. States have responded with testing, tracking and containment in line with their capabilities and ironically, it is the better-equipped states that are reporting a larger Covid burden—simply because they have the capacity to detect these cases and deaths. There is likely a much larger burden in northern states with weaker health systems but this is not being reported.
What are the lessons that you hope India will learn from this pandemic to improve its public healthcare system?
Although COVID-19 is exacting a significant health and economic impact on the country, it offers an opportunity to rethink India’s approach to public health. If done correctly, the legacy of COVID-19 could be a much needed public investment in health, a well-equipped workforce to respond to future pandemics, and system capacity for surveillance, contact tracing, research, disease modeling, and response.
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