Coronavirus in India: Are people safe or should they worry? | Analysis
Are there undiagnosed novel coronavirus (Covid-19) cases in India? That’s the question everyone is asking as a surge in new cases across the world nudged the World Health Organization (WHO) to raise the global risk assessment to “very high”, which is the same category as China, the epicentre of the emerging pandemic that has affected around 60 countries and territories since December. Countries outside China now account for more than two-thirds of new cases, with 15 countries reporting local transmission of infection till Saturday, according to WHO.
Microsoft founder and Bill and Melinda Gates Foundation co-chair Bill Gates has called the coronavirus a “once-in-a-century pandemic” in an op-ed in the New England Journal of Medicine and urged countries to both “solve the immediate problem and keep it from happening again” even as global markets are on course for their worst week since the 2008 financial crisis. The US intelligence agencies monitoring the global spread on Friday raised concern about India’s inability to prevent or control an outbreak because of its high population density, according to a Reuters report.
“There’s need for perspective, not panic. Surat had 52 suspected plague-related deaths in 1994, which led to economic losses of upto US $2 billion because of panic, mass migration, and trade embargoes on exports. Deaths from tuberculosis, which is also a droplet infection like Covid-19, are 100 times more every year,” said Dr Dileep Mavalankar, director, Indian Institute of Public Health, Gandhinagar.
More testing, higher cases
“It appears that the “increase” in numbers affected is directly related to screenings. While the infected cases are increasing, the fatality rate is decreasing because the denominators (i.e. person infected) is also increasing, which in turn is related to screening. The key first step is initiate screening at the earliest, targeting strategic areas – travel patterns, concentration of elderly, denser location etc,” said Dr Subu V Subramanian, professor of Population Health and Geography, Harvard University, Cambridge, Massachusetts.
The global fear is disproportionately high against the case fatality rate of Covid-19, which is less than 2% outside China, according to Dr Mavalankar. “Chinkungunya and encephalitis outbreaks kill more people every year! Covid-19 usually causes mild illness, with few cases in children and young adults. Most deaths are in older people and those with pre-existing medical conditions (such as cardiovascular disease, chronic respiratory disease or diabetes),” he said.
India so far has managed to contain the infection, with three students from Wuhan diagnosed with Covid-19 in Kerala leaving quarantine after being cured. Since the last case was diagnosed 26 days ago in India, none of the close contacts have developed Covid-19, which has an incubation period— the time taken to develop symptoms after getting infected – of up to 14 days (outliers up to 28 days), but its high population density and mobility within states makes it one of the world’s hotspots for emerging zoonosis.
Adding to the global screening and surveillance challenge are reported cases of infection in people who have not travelled to China or had no known exposure to an infected person, of infected people with no symptoms spreading disease, and infection resurfacing in people cured of Covid-19. This, along with India’s patchy and overburdened public healthcare infrastructure, may make containment tough in states like Uttar Pradesh and Bihar, where health infrastructure and outcomes are two-and-a-half times lower than in Kerala, according to NITI Aayog’s State Health Index 2019.
The outcomes of poor public health infrastructure are starkly evident when outbreak occurs. For example, while Kerala clinically controlled a potential outbreak of the Covid-19 and highly-fatal Nipah virus disease, Bihar is still struggling to prevent deaths from annual acute encephalitis syndrome over the past 40 years.
Scientists say it’s uncertain whether warm weather will affect transmission and lower cases, so the focus must remain on infection control practices. “We don’t know enough about Covid-19 virus behaviour to make predictions, but going by other infections, it’s unlikely that the heat will have much effect on transmission. Seasonal flu and cold affect people throughout the year in India, and other Middle East respiratory syndrome (MERS) caused outbreak in the middle-east, where the weather is hot and dry,” said Dr G Arunkumar, director, Manipal Institute of Virology, Karnataka.
“I guess thus far the only sensible advice is ‘101 public health’ – basic hygiene of washing hands and when symptoms are developed quarantining oneself. It’s time not to panic or sensationalize but simply be objective and common sensical about handling this,” said Dr Subramanian.
“Once community transmission starts, people will build herd immunity against the novel coronavirus, as they have against H1N1, which has become one of the many seasonal flu viruses,” said Dr Mavalankar.