1 million Covid-19 infections in India, toll nears 25,600

India on Thursday became only the third country in the world — after the United States and Brazil — to hit a million Covid-19 infections, with 36,247 new cases taking the country’s tally to 1,004,652, and 690 new fatalities putting the disease death toll in the four-and-a-half months of the outbreak at 25,594.

Experts estimate the next million to take less than a month — the doubling rate stands at 20.6 days — and say the focus now needs to shift to rural parts of the country that traditionally have been beyond the reach of adequate health care mechanisms, and where new hot spots are now feared to pop up.

On Thursday, India had 343,268 active cases and the case fatality rate (CFR) — the proportion of people who succumbed to the illness from among known infections — was 2.5%. The US, which has 3,648,250 cases and 140,518 deaths, has a fatality rate of 3.9%; and Brazil, with 1,978,236 cases and 75,697 infections, is at 3.8%.

India’s journey to a million cases took 137 days, and half of these were in a hard nationwide lockdown announced in the early days of the outbreak — a strategy that officials and experts said bought the country precious time to set up isolation centres, add hospital beds and beef up testing infrastructure. With crippling economic costs piling up, the country began unlocking in June, when the outbreak was on a sharp upward trajectory.

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In the last week, however, India has added an average of 30,076 cases a day, up from 23,895 a day in the seven-day period before that. At least two states, Bihar and Assam, announced they will be reimposing lockdowns while Uttar Pradesh — the state with the highest population — said it will follow a weekend shutdown.

At this rate, Covid-19 infections are on track this year to surpass the roughly 2.4 million tuberculosis infections recorded in India in the 12 months of 2019, and lead to a comparable number of deaths. TB, widely regarded as the deadliest infectious disease in India, led to the deaths of around 79,000 people, according to the Union government’s India TB Report 2020, although the World Health Organization (WHO) estimates this number to be over 400,000.

“With nearly 400,000 active Covid-19 cases, we will never be able to have a long enough lockdown to get the cases to 100s,” said Bhramar Mukherjee, the head of biostatistics at University of Michigan, among a team of academics from three American universities that predicted India would hit 1 million cases by July 15 after the lockdown began to lift.

Mukherjee stressed on the need to step up testing and closely analyse real-time data in order to head off the outbreak. “It is important to identify states and metros at nascent stages of growth and impose strong measures, including punctuated modulated lockdown. This cannot be done when infections are already leading to large case-counts. What you are seeing today happened two weeks ago,” she added.

A second expert said that increasing testing in places where coverage has been limited will now be crucial. “There’s no doubt that the disease is widespread, with even community transmission obvious in certain states. The way ahead is to test as many people as possible, to be able to track and isolate those people who are infected so that the disease spread is contained. If you isolate them in time then the spread in the community will be curtailed,” said Dr Jacob John, former head, virology department, Christian Medical College, Vellore.

India’s average weekly test positive rate has risen from 7.7% in mid-June to 10.1% at present, but the aggregate level statistics mask sharp differences in testing performance across the country. Maharashtra, the state with the highest number of infections at 284,281, has a test positive rate close to 20%, while for Uttar Pradesh, this number is less than 4%.

WHO identifies 8-12% as the ideal range for test positive rate in a country with an active outbreak. A number too low or too high implies that volume as well as targeting of Covid-19 testing is inadequate to accurately detect the spread of the disease. Three states have a test positive rate in this range. Tamil Nadu and Gujarat have a positive rate of 8.7% and 9% but experts have expressed scepticism on the numbers due to the other parameters reported from these region. Tamil Nadu has a CFR of 1.4% while for Gujarat, this number is 4.7%.

Delhi is the only other region with a test positive rate of 8.1%, as well as the highest per population testing numbers across the country. The national capital has recorded a sustained decrease in new cases for the last six days at least, and a dashboard by Mukherjee and her team estimates that the rate of transmission in the Capital is now below 1 — a threshold below which an outbreak can potentially be halted.

“Only two states, Maharashtra and Tamil Nadu, constitute 48.15% of country’s total active case load. Of the total 36 states and UTs, only 10 states constitute 84.62% of the total active case load,” the Union health ministry said in a statement on Thursday, adding that “targeted measures have contributed to a steady decline in the number of active cases”.