Maharashtra: Case in cities decline, rural areas a concern

Till a week ago, five districts were contributing the greatest number of cases to Maharashtra’s daily infection and death tally: Mumbai, Pune, Nashik, Nagpur and Thane

Till a week ago, five districts were contributing the greatest number of cases to Maharashtra’s daily infection and death tally: Mumbai, Pune, Nashik, Nagpur and Thane. By April end, two of these districts – Mumbai and Pune -- have begun to record a decline in the numbers, though experts said it is still too early to see this as cause for cheer, as the state’s surge now seems to be driven from rural parts of the state and smaller districts with poorer health care infrastructure.

HT Image

Since mid-March, Maharashtra has seen a sharp uptick in the number of Covid-19 cases. In the week ending April 8, the daily average of new cases reported from Maharashtra was 51,469. In the week ending April 29 the average daily new cases were 63,652. According to Union health ministry figures, Maharashtra also led the surge in deaths reported over a 14-day period: 45.2% between February 18 to March 3; 42.7% in the first fortnight of April. Though it is no longer leading the surge in latter metric anymore, it continues to remain the most affected state in the country.

“During the first wave, the virus spread from big cities to smaller ones and then to the peripheral/rural areas. This time it may not be exactly same this time, we expect the curve to tread on similar lines. The districts or the cities with weak health infrastructure and weaker tracking-testing fail to contain the spread effectively. In some districts like Sangli and Amravati which border neighbouring states, the spread become difficult to contain because of the inter-state mobility,” an official from state health department said on condition of anonymity.

The surge is no longer coming from densely populated urbanized districts like Mumbai, Thane and Pune, but from smaller ones like Nashik, Ahmednagar, Hingoli and Yavatmal among others, where the tertiary infrastructure is not well developed.

“Smaller districts like Hingoli, Parbhani, Ratnagiri do not have tertiary care facility. We have asked these district administrations to ramp up the infrastructure so that they can take on the extra load of cases and arrest the spread,” state health minister Rajesh Tope said.

The numbers bear this out. In the week between April 22 and 29, Mumbai’s active cases dropped from 82,616 to 67,255; Thane’s dropped from 80,743 to 56,973; and Pune’s from 117,337 to 104,529. In the same time period, Nashik saw a spike from 46,706 to 52,954; Sangli from 9,600 to 13,095; Chandrapur from 18,388 to 26613; and Amaravati from 6,280 to 7,243. As on April 28, 23 districts reported more growth rate than state’s rate of 1.55%, while in districts like Yavatmal, Chandrapur, Ratnagiri, it was more than 3%.

The weekly test positivity rate (TPR) of these districts was high too. Nashik, Ahmednagar, Osmanabad, Hingoli reported more than 34% positivity rate against state’s rate of 25.38%. Simply put, TPR rises when most of the people who are getting tested are positive anddeclines when most samples tested return negative. But this rate, experts say, has to be correlated to the number of tests. Trends across the pandemic show that when tests declined, TPR went up.

Nagpur district has reported 50,000 cases and 638 deaths in the week between April 24 and 30. Of these, 19,002 cases and 239 deaths were recorded in rural areas of the district.

The district continues to face an acute shortage of beds and oxygen, along with anti-viral drugs, like Remdesivir. Dr Pinak Dande of Dande Multi-Speciality Hospital said, “We are virtually helpless as we cannot provide beds to new patients as several infected persons are on the waiting list. Moreover, it’s very difficult to cope with the existing patients despite doing our best because of inadequate oxygen supply and life-saving drugs.”

On Friday, Nagpur added 6461 new cases while Nasik added 4,696; by comparison, Mumbai added 3,888 and Pune 10,019 new cases to the state’s tally of 62919 new infections. The state now has a total of 4.6 million cases, and the death toll rose to 68813 after the addition of 828 fresh deaths on Friday. The recovery rate in the state is now 84.06%.

Experts pointed out that the surge indicated that these districts are yet to reach the peak, which will continue to drive up the state figures.

Falling numbers, TPR

In the first week of April, Mumbai’s daily case average stood at 9737. In the following week, the daily average dropped slightly to 8879 and to 8074 in the third week. In the ongoing fourth week of the month, the daily case average has further declined to 5628. On the other hand, the number of deaths has shown a rise. There has been a steady downward trend in testing in the city: starting April 22, the number of tests has ranged from 41,826 to 30,428 (April 27).

However, Mumbai’s daily Covid-19 test positivity rate – the percentage of tests that are positive, or TPR – has been on a steady decline, data shows. From 30% on April 4, when the city recorded the highest single-day surge of 11,206 cases, the test positivity rate came down to 10.79% on April 29, with cases dropping to 4,174.

Maharashtra continued to report a daily caseload of more than 60,000 cases, by reporting 62,919 fresh cases on Friday taking the tally to 4,602,472 and the death toll to 68,813 after the addition of 828 fresh deaths. Mumbai saw a further drop in cases as there was an addition of 3888 new cases, pushing the tally to 648,471 and toll to 13,125 after the addition of 89 deaths.

Pune district topped the chart of new cases with 10,019 cases, including 4,365 in Pune city. The district also logged the highest, 150 deaths on Friday, while it continues to have the highest, 106,019 active cases. State’s second capital Nagpur and Nashik district reported 7,170 and 4,696 cases and 44 and 34 deaths respectively.

69,710 patients recovered against 62919 new infections on Friday resulting in an improvement in the recovery rate which stands at 84.06%. This also helped to reduce the number of active patients to 662,640.

State’s daily test positivity rate dropped to 21.68% after conducting 290207 tests in the last 24 hours.

“It is very difficult to predict virus behaviour, but I think, what Mumbai and MMR helped in reducing the number is curbs on local train travel. Major chunk of office too has been shut down helping in reducing the crowding. But in rural areas all activities at marketplaces, wedding ceremonies continue as usual making it difficult to bring cases under control. But I believe that these areas are reaching their peak and are likely to stabilise in next few days. It would help bringing down the overall state cases,” Dr Rahul Pandit, member of state-appointed task force said.

Dr Kapil Aher, district health officer of Nashik said, “The spread of virus in Nashik is rapid because of the urbanisation and mobility due to the commercial, agricultural activities. The cases in the district have started stabilising though the downward trend may take a couple of weeks to begin.”

Officials said that tracking-tracing and testing in smaller districts and rural areas have been poor. “Many of our backward districts are lagging in the tracing, which needs to be more than 20 people per infection, besides the low testing. Secondly the poor health infrastructure also causes rapid spread as the infected people are not properly isolated,” the official quoted above said.

The case fatality rate (CFR) is high across the state: the weekly CFR rose to 0.94%, in the week ended on April 25, from less than 0.5% a month ago. In districts like Sindhudurg and Nanded, it is 3.66% and 3.46% respectively.

Dr Avinash Supe, head of the death audit committee appointed by the state government said they expect the CFR to start dropping in next few weeks. “The rise of CFR always lags behind the rise in cases by 2-3 weeks and similarly its fall comes two weeks after the cases start falling. Secondly, the percentage of mortality is not as high as it was in the first wave, when it had crossed 6-7%. Yes, in numbers the deaths are more, but we have been doing our best to bring it down. We have been interacting with rural, district level doctors virtually on individual cases helping them in clinical and ICU management and medical protocol to reduce the mortality,” he said.

“The police authorities have been told to pull all strings to ensure that strict implementation of the lockdown SOPs. The administrations have been directed to ramp up tracing and testing which will help them in reducing the cases,” another official from the health department said.

(With inputs from Pradip Maitra)