Coronavirus: is India the next global hotspot?

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The coronavirus installed slowly in India, but six months after its first confirmed infection, it has passed Russia to register the third highest number of cases in the world.

With the second largest population in the world, much of which lives in cities, the country may have always been destined to become a global hotspot.

But the data behind its number of cases is questionable, as India does not test enough and an abnormally low mortality rate has baffled scientists.

Here are five things we know about the spread of coronavirus in India.

1. Indian cases are increasing rapidly

India recently experienced a series of record peaks, adding tens of thousands of cases daily. He registered most of his confirmed cases in June, a few weeks after it reopened after a hard lock.

As of July 8, India had 742,417 confirmed cases.

But the real extent of infection rates in the population is unclear, according to virologist Shahid Jameel.

The government randomly sampled 26,000 Indians in May, which showed that 0.73% had the virus. Some experts have reservations about the sample size, but others, like Dr. Jameel, say it is the only national indicator they have to work with.

“If we extrapolate this to the entire population, we would have had 10 million infections by mid-May,” said Dr. Jameel.

Since confirmed cases in India have doubled every 20 days, this would bring the current total to between 30 and 40 million.

The gap between confirmed cases and actual infections exists in all countries, but to varying degrees. The test is the only way to fill it. “If you test more, you will find more,” said Dr. Jameel.

This has happened in India in recent weeks – as the government stepped up testing, the number of cases suddenly increased.

India has performed more than 10 million tests since March 13, but more than half of these tests took place after June 1.

2. India does not test enough

India’s official workload is high in absolute terms, but it is relatively low in terms of population. The world, on average, has three times as many cases as India per capita – a fact recently highlighted by the government.

But, according to Dr. Jameel, the workload per capita in India is low simply because it tests so little.

Compare India to countries that have a high per capita workload and you will find that these countries test much more.

India’s workload is almost invisible on this scale because its test rate is so low.

But it’s not just how much you test, it’s also who you test.

India’s emphasis on screening and screening from the start has limited the pool of people tested to high-risk cases and their contacts – and prevented it from spreading to the general population.

Tests and traces are insufficient once the infection begins to spread quickly, said Himanshu Tyagi and Aditya Gopalan, mathematicians who have studied Covid-19’s testing strategies. It helps contain, but it does not discover new cases that have emerged undetected in the community, said Mr. Tyagi and Mr. Gopalan.

India has to test a wide range of people for this to happen. But how do you know who is testing India? It is difficult to compare the number of tests between countries, as some count the number of people they test, while others count the number of tests they perform. India does the latter and this number is slightly exaggerated since most people get tested more than once.

Instead, scientists prefer to calculate the number of tests needed to find a single confirmed case. The more tests you need, the more you throw your net. Here, India is doing badly compared to countries that have successfully controlled the spread of the virus.

And the more you test widely, the lower your positive rate – that’s why New Zealand and Taiwan have rates well below 1%.

India’s positive rate fell from 3.8% in April to 6.4% in July. If it continues to increase, it is because the tests are still limited to a small group of high-risk people and their contacts.

3. The recovery figures in India are promising

Evidence suggests that those in India who have been diagnosed with the virus recover faster than they die.

This is crucial, said Dr. Jameel, because it puts pressure on the health system. Currently, deaths are increasing more slowly than confirmed cases or recoveries – but if that rate increases, it would increase pressure on hospitals, possibly leading to an increase in deaths.

The caveat is that low screening rates mean fewer new cases are registered, and at a slower rate. This will speed up the recovery rate compared to that of confirmed cases.

Globally, India’s recovery curve seems steeper than in other severely affected countries – in this case, a steeper curve is a good thing. This means that Covid-19 patients in India recover faster than those in the United States or Brazil.

India’s share of recoveries – that is, the percentage of total confirmed cases in a given country that have fully recovered – is also higher. With nearly 60%, it is far ahead of the United States, where it is 27%.

However, when it comes to recovery, the data is patchy and the definition varies.

India defines as recovered anyone who tested positive for the virus and then, weeks later, tested negative. Some countries only count hospitalized cases that recover fully.

What is important is that, regardless of the number of people recovering in each of these countries, the share of recoveries from India is higher.

And that’s because the reported deaths in India are lower.

4. The death rate in India is very low

India has so far recorded around 20,160 deaths from Covid-19. In absolute numbers, it is the eighth highest total in the world. But for a million inhabitants, it is low.

“It’s a fraction of what you see in Western Europe,” said Shamika Ravi, economist and senior researcher at the Brookings Institution.

There have been many questions about the figures for the death of Covid-19 in India, and most experts agree that they are probably underreported.

But Dr. Ravi said that does not explain the significant difference in death rates between India and Europe.

“If we did have high mortality rates, no amount of data could have hidden this – that’s 20 to 40 times more deaths,” she said.

The low death rate in India is also similar to that of other countries in the region, such as Pakistan and Indonesia.

Theories range from a higher prevalence of infections in the region to a less virulent strain of the virus circulating in these countries to younger populations on average than in western countries, since Covid-19 mainly kills the elderly .

“Not every country can rig their data,” said Dr. Jameel. “Perhaps the innate immunity in these populations is higher due to a high burden of other infections. But we really don’t know yet why their death rates are so low.

5. Each Indian State Tells Us a Different Story

As in the United States or the European Union, statistics on coronaviruses vary considerably from one Indian state to another. Three states – Delhi, Maharashtra and Tamil Nadu – currently account for around 60% of the country’s workload.

And as the number of cases has decreased in some regions, it has increased in others. The latest wave occurred in Karnataka and Telangana in the south. Another southern state, Andhra Pradesh, also experiences constant and intense peaks.

India’s response to the virus has so far been centralized, and that is part of what needs to change, experts said.

India will have to be “divided into districts” to implement an effective strategy against the coronavirus, said Dr Jameel, “because another national lock-up may be even less effective than the previous one”.

And rather than state-level snapshots, authorities would need granular and localized data, according to Dr. Ravi. “At each block, we need to know if you have symptoms,” she said.

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