Prof K Srinath Reddy, president, Public Health Foundation of India, is Member of ICMR’s Covid-19 Task Force, and of the Executive Group of the International Steering Committee of WHO’s Covid-19 Solidarity Trial. In this first edition of E-Xplained last week, he explained a range of issues related to India’s battle against Covid-19 to a large Zoom audience from across the country. Prof Reddy was in conversation with Abantika Ghosh and Monojit Majumdar of The Indian Express. Edited excerpts:
How have we fared in the battle so far?
Let’s look at some of the statistics that have been projected. Firstly, if you look at deaths as an absolute number and start counting the number of deaths, day by day, or week by week, you do get some impression that things are actually worsening. Certainly, we want to prevent every single death if possible, but let’s look at the death rates. We always have to look at a rate, which has the numerator and a denominator.
Let me just read out a few figures. Deaths per million in India is 1.3 at the moment. In the US, it is 226 per million, in the UK it is 449 per million, in Belgium it is 726 per million. To repeat, we are at 1.3 per million, so from that point of view, it appears that in terms of loss of life, we are managing to contain that problem.
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Of course, we’ll have more cases, particularly when we are doing more tests per day. Again we’ll have to look at what are the new cases occurring as a percentage of the new tests per day. Now, when you look at the curve, unfortunately the curve is a combination of old cases and new cases and when you’re looking at how that curve is going up, that doesn’t give me too much of information. On the other hand, if I want to track progress, I am going to look at four areas. Firstly, I am looking at the number of new cases out of the number of new tests as a percentage. Second is, using influenza-like illness symptoms for symptom-based syndromic surveillance per week through home visits by primary health teams wherever available, or even telephonic surveillance. Third, I’d like to look at what are the Covid positive cases of serious acute respiratory infection (SARI) getting admitted in the hospital, how many cases of such serious respiratory infection are there and what percentage are Covid, and on a weekly basis how is it changing. And lastly, what are the deaths per week. Again, I’d like to track that, but again, overall, I’d like to keep deaths per million as an important indicator and see whether that is changing. So unless we get this kind of a picture, we’ll not be able to say, how well we are controlling. But at the moment based on most of these, I believe we are actually doing reasonably well. But that doesn’t mean that we can be complacent; we need to follow up and see what’s happening.
There is this criticism that we are not testing enough. Is it possible deaths are happening that are being missed because those tests aren’t being done?
Well, deaths that are happening in hospitals would almost always be tested if they are being admitted with serious acute respiratory infection. It is only deaths out of hospital, which could possibly be missed. There could be a certain amount of mis-classification, but still you’re not going to have such a disparity.
But the lockdown has also caused hospital visits to go down…
Yes, it is a possibility. But then we need to look at what the deaths are, overall in hospital and out of hospital, and then see whether the deaths particularly compared to the previous year, or the previous two years’ average, have shown a spurt, but taking out the road traffic accidents. Because during the lockdown, the road traffic accidents would have come down markedly, so remove that element, and then see whether the total deaths Covid and non-Covid combined, all-cause, have gone up quite a lot. If they have, then you can ascribe it to Covid as an additional element. That’s one way of looking at the data.
How reliable is doubling time as a metric?
Essentially, doubling time is a metric they decided upon because they thought this was an exponential curve. Now, the problem with this kind of a measurement is that it is also dependent upon the number of tests that you are doing… But again, I would not like to take a count, where I am adding all the old cases and adding the new cases. I’d rather look at the number of new cases in the numerator and new tests in the denominator, and calculate that percentage. But certainly, even taking this particular thing into account, if by doing more tests you’re finding out more cases, still the doubling time is lengthening, that’s a good sign. Read K Srinath Reddy’s earlier interview here
In the number of cases, from about May 1, there has been a spurt. A part of it, I am sure, is a function of increased testing. But could it also be that towards the final days of the earlier phase of lockdown, there was a degree of fatigue and it wasn’t being implemented that harshly?
Well, I would say that there have been some slippages and the slippages could have contributed, and certainly slackening of the lockdown… and lowering of inspections and also unplanned violations that took place. But let us also accept the fact that the virus… is still moving around. It is a question of how much we can slow down that spread, that is important. It is not as though we have actually locked it up permanently or we are planning to lock it up. There will be new cases; we have to make sure that we are protecting the most vulnerable people while that spread is happening.
One of the things about India is the stigma that’s been associated with it. Is this something unique to India?
Regarding the stigma, I think it is an extremely unfortunate thing… I believe that the kind of language we have used in media, even from politicians, that this is a “huge killer epidemic”, frightened people and the feeling that other people can infect you and you can just drop dead, that risk has been exaggerated. We’ll end up probably with far less than 1% mortality when all things are done and all cases are properly counted. Therefore, the fact that we are a young population, we are a rural population, many factors that are likely to reduce the mortality in our case, is something of a message that has to be given… But we have to ensure that the stigma that is directed at other infected people or against healthcare providers, or against even some of the people from the Northeast, who are again stigmatised because of their appearance, I think that whole thing has to be done away with…
I think particularly when we are likely to come out of the lockdown, we need a lot more of community engagement. When you have a community-partnered public health, when you have elected local bodies, or community-based organisations, women’s self-help groups, other NGOs working in the field, they are the ones that can actually convey the message to the people. But if you are only having one-way communication between the techno-bureaucracy through the media and you are getting saturated with messages on TV channels, about how many people are dropping dead in the US, or Europe or China or anywhere else, naturally the fear factor builds up.
Coming to some specific states, what is your assessment of what is happening in Maharashtra or Gujarat? Maharashtra has a positivity rate of 18% against the national average of 3-4%.
Definitely, they are problem areas, it is clear that the virus has spread more and we are also seeing more severe cases. Now, we are particularly worried, of course, about slums… I understand now they are taking action. Apart from trying to do syndromic surveillance in the slums, they are also trying to take the people who are in the high-risk group, that is the elderly people and people with co-morbidities, taking them out of the slums and housing them elsewhere until they feel the situation is under control. Obviously, they cannot evacuate the entire slum. Similarly, we will have to see, in some of these hotspots, even while trying to do the containment methods, how best we can protect the most vulnerable.
To extend that to deaths, five states — Maharashtra, Gujarat, Tamil Nadu, Delhi and Rajasthan — account for 70% of all cases as well as 70% of all deaths. If you include Madhya Pradesh and West Bengal, which are not in the top five in terms of cases, the deaths are really high. How would you explain that?
Firstly, I think the problem is that if you are not doing a large number of tests, your denominator is going to be on the lower side, because you have deaths in the numerator and the diagnosed cases in the denominator. That is one reason. So if you do a large number of tests, automatically the so-called case fatality rate comes down… Second, of course, is that we do not know what is happening to the treatment protocols, how quickly people are being hospitalised, and how they are actually being treated. So there are two elements to this; both need to be examined.
After the lockdown, what is the way forward?
Well I don’t think we can live in permanent imprisonment of a lockdown, we have to go mobile but also ensuring that schools reopen for children and so on. There are a lot of social elements also that need to be restored. But we have to do it with care. See, you’ll not be able to test every person on the street… but we have to depend upon physical distancing, masks in public places, as well as hand hygiene as important elements for a long time to come if we have to slow down the transmission and also ensure that the deaths are contained and not a surge. To ensure that we contain the transmission as well, as much as possible, I would particularly emphasise, containment between urban and rural areas. Our rural areas are much better protected now, we must continue to protect them by ensuring only essential travel needs and transport of essential goods.
Secondly, I would also say that we must ensure that some of the non-essential travel is cut down and some of the work that can be done without necessarily going to the office, non-manufacturing activities for example, as far as possible, we should try and keep that level of social distancing even in employment. So if we continue to do that, at least over the next one year, we will be able to slow down the epidemic and we may be able to get the virus to change its pattern. Because it is well known that if you can actually make sure that the virus does not have a large human host which it can move around in, it can actually mutate to a less virulent form… So I believe we need to resume life, but with great caution.
Out of people, drugs, material and data, which emphasise improvement, which one would you do in the Indian context?
… I believe, drugs will come up later on. Material, of course, in terms of personal protection equipment and even testing kits, is going to be important, and data will automatically flow when you actually start gathering data. But I think people are the most important… particularly how do you actually ensure that you are doing contact tracing, how are you doing isolation at home, how are you doing health education? And people who are in the medical profession, how are they doing testing, how are they doing the treatment, how are they doing the isolation? It is our health workforce that has been unfortunately been very weak because of a number of years of neglect of our health system; we have not adequately financed and built up our health system, and we are paying the price for that.
Mumbai has around 9,000 cases, Ahmedabad around 4,500 cases, Delhi around 5,000. How can you say that community transmission has not taken place?
Well, that’s for the government to explain why it is not using that particular term. But I don’t think we should be shy of it, because every single country has had a phase of community transmission. How well they contained it is the important element. But one of the reasons why we are seeing the three areas you mention as being particularly vulnerable, is because of the large inflow of foreign travellers… So, they are calling it local transmission, but that’s a matter of semantics. I am not going to start disputing those words, but certainly let’s not be shy that every country has had community transmission…
—Transcribed by Mehr Gill
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