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India’s Covid-19 Crisis: Data Analysis

Cases and deaths surge on the subcontinent, with current trajectories and virus variants of particular concern.



India's infections per million still lead regionally, but Nepal is rapidly closing that gap given the much steeper rate of infection. (Courtesy of COV-IND-19 Study Group)

Cases and deaths continue to rise dramatically in India, with about 1 million new cases every three days. Yesterday’s data compiled by Covid-19 India shows 324,390 new cases and 2,585 deaths. The recent surge has overloaded both the nation’s healthcare system and crematoriums. It has also led to variants that appear to evade the AstraZeneca vaccine, which the country stopped exporting in late March, due to shortages.

In a livestream organized by the U.S. Chamber of Commerce Foundation on Tuesday, Professor Ali Mokdad cast doubt on the ability for some vaccines to help combat these variants.

“We don’t think AstraZeneca, unfortunately, is going to help India that much simply because of the variants that are circulating,” said Mokdad, who holds a doctorate in Quantitative Epidemiology. He said the efficacy rate to prevent infection against two strains circulating in India, P.1 and B.1.351, is 10%, based on clinical trials in South Africa.

Mokdad, a professor of health metrics sciences at the Institute for Health Metrics and Evaluation and chief strategy officer for population health at the University of Washington, also predicted 1 million deaths in India by August 1.

The U.S. government announced on Monday that it would be shipping 60 million AstraZeneca Covid-19 doses globally. India expects to receive the “biggest share” of those doses, according to Reuters.

Direct Relief has committed $5 million to respond to the Covid-19 crisis in India, and will be shipping oxygen concentrators and other requested supplies to partners working in India.

On the Chamber of Commerce livestream, which also featured representatives from the White House, USAID, US-India Business Council, and nonprofits, the most pressing needs included building more makeshift hospitals and expanding bed capacity, especially in smaller cities. More oxygen tanks and a strengthening of the supply chain, as well as ventilators were also noted as critical needs. The most requested medications include Dexamethazone, Remdesivir, and Tocilizumab.

Analysis: Subcontinent and Surrounding Region

Andrew Schroeder, Direct Relief’s VP of Research and Analysis, shared his interpretation and contextualization of analysis originally conducted by Bhramar Mukherjee,  chairperson of biostatistics at the University of Michigan’s School of Public Health and a professor of epidemiology. Schroeder cautioned that all numbers related to the pandemic in India, similar to other countries, should be understood as imperfect and based on many assumptions, since cases counts rely on testing, which is unevenly distributed, and Covid-19 deaths are conditional on a positive test. He pointed out that undercounts in the two metrics are, thus, related to one another.

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

From Schroeder:

Looking across the region we still see the same general trends, with India by far being the area of greatest concern in terms of infections per million but with Nepal rapidly closing that gap given the much steeper rate of infection. Afghanistan is also heading in the wrong direction relatively quickly, and Pakistan is not making significant progress.

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

Death rates are headed in the wrong direction throughout the region, although here, too, Bangladesh appears to be making progress.

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

These figures continue a worsening trajectory that occurred over last weekend. Here is where things stood as of April 26.

(Coutresy of Cov-
(Courtesy of COV-IND-19 Study Group)

First there’s the observed data on cases and recoveries, which continues a trend from last week. Cases continue to diverge quickly from recoveries, which indicates that the rate of infections is significantly outstripping capacity to treat Covid-19 cases. Back in February and early March, cases and recovered were almost equal daily. As of now, new cases daily are over 1.5 times the number of recoveries.

An analysis of case numbers by state shows broad-based increases, with the most alarming rates of increase coming in a few states in particular. Maharashtra state is the clear upper outlier, but very steep rates of increase can be seen in Bihar, Chhattisgarh, Delhi, Gujarat, Karnataka, Kerala, Madhya Pradesh, Punjab, Rajasthan, Tamil Nadu, Uttar Pradesh, and West Bengal. Again, everywhere is increasing in concerning ways — even as those states have the most concerning rates of increase.

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

In terms of cases per 100,000, this is what the map looks like right now at the state level:

And this is what the map looks like at one admin unit down from the state level.

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

If we look at the key metrics by state we can pick up some additional areas of concern. In particular I’d like to call attention to the calculation here of the R(0) (reproduction rate) value by state – which I’ll remind is the number of people that will be infected by a single infected individual. In general, anything over one is bad news and means that infections will tend to increase given the rate of spread between individual contacts. Over two, however, is an extremely serious emergency.

Right now, there are four states with a R(0) greater than 2: Bihar, Kerala, Odisha, and Assam. I should note that on the observed case totals data Odisha and Assam didn’t register on a linear scale because the size of their cumulative case totals is relatively low compared to places like Maharashtra and Delhi.

However, the R(0) value illustrates that there is extremely rapid spread happening in these areas. Also, note that every state has a R(0) above 1, which bears out that the entire country is a significant issue at the moment.

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

Here’s that same data in rank format:

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

In order to see roughly what that means let’s look at the forecast for Assam. Right now there are 235,587 observed cases in Assam. Based on the current rate of change, absent significant new countermeasures, that number is expected to grow by nearly 3x in the next month. And in the worst case scenario of entirely uncontrolled spread it could grow by nearly 10x.

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

Here’s the same forecast for the entire country, which of course has a lower R(0) value than Assam – You’re looking at a projected increase of about 32 million cases in the next month – which at the present national Case Fatality Rate of .011 would translate to an additional 352,000 deaths. Of course, all effective counter-measures taken during this time would serve to reduce those numbers.

(Courtesy of COV-IND-19 Study Group)
(Courtesy of COV-IND-19 Study Group)

Analysis: Nepal Focus

Schroeder also added analysis from Nepal, which is, by some measures, deteriorating even faster than India. What follows are confirmed cases, confirmed deaths, the reproduction rate, and the test positivity rate. Data from Pakistan and Bangladesh are also included for regional context. Confirmed cases and confirmed death graphs are a 7-day average on log scale to make the y-axis easier to view.

Confirmed cases: India is a significantly higher in terms of overall new cases than everywhere else, but the slope of the increase in Nepal is steeper. Interesting, although potentially independent, they started their current ascent around the same time. Bangladesh also started a similar ascent around the same time, but has actually relatively quickly turned the situation around, on or about April 9. Pakistan remains an area of concern but is a slower growth rate.

(Courtesy of Johns Hopkins University)

Confirmed Deaths: Once again the death rate in India is highest overall, but Nepal is, in some respects, moving faster in terms of increasing deaths as well as cases. Bangladesh and Pakistan are also continuing to increase, which is not unusual given typical lags between case and death increases. This lag effect also however likely means that the eventual death rate in India and Nepal may get much higher than currently anticipated. It’s also the case that there is considerable debate ongoing about the accuracy of the mortality statistics, particularly in India but likely for other countries as well.

(Courtesy of Johns Hopkins University)

Reproduction Rate:  When we look at the reproduction rate, we can really start to see major differences in transmission at the country scale. Whereas India remains high – well above the key threshold of one – there is evidence that the rate is already flattening or declining, which is likely accounted for primarily by new movement restrictions and declining R(0) in some of the most heavily populated areas like Maharashtra. Similarly, Bangladesh’s declining case count is echoed in the declining reproduction rate, and Pakistan is similarly showing clear signs of epidemic containment. On the other hand, Nepal is very far into critical territory. A nation R(0) value over two is a huge concern, especially given the overall fragility of the Nepalese health system.

(Courtesy of Arroyo-Marioli F., Bullano F., Kucinskas S., Rondon-Moreno, C.)

Test Positivity Rate: Just as with the reproduction rate, the share of positive tests is running far higher in Nepal than in any of the neighboring countries. India is not far behind. Pakistan is clearly not out of the woods on this measure. And Bangladesh once again is showing strong signs of epidemic containment.

(Courtesy of Our World in Data)

Additional reporting contributed by Chris Alleway.

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