As India Extends Lockdown, Health Experts Question Lack of Village-Level Data

Mumbai: As the Indian government extended the nationwide lockdown beyond May 4 for two more weeks, some crucial data are missing: How are the country’s villages doing? Are there too many unexplained deaths? The answer to those questions are crucial as chief ministers queue up to seek extension of lockdown backed with scant or no data whatsoever, health experts tell IndiaSpend.

As of 5 p.m. on May 1, 2020, India has reported 35,365 cases of COVID-19 and 1,152 deaths, according to HealthCheck’s Coronavirus Monitor. Globally there are over 3.2 million confirmed cases and over 233,000 deaths, according to the Johns Hopkins Coronavirus Research Center, due to the infectious virus to which there is no known cure or vaccination.

On May 1, 2020, the Indian government extended the nationwide lockdown beyond May 4, 2020, but promised some relaxation in the orange and green zones.

“Any epidemic of any type is not a national phenomenon, it is a collection of local and regional epidemics with vast intervening areas of no or low disease,” said Dileep Mavalankar, director, Indian Institute of Public Health, Gandhinagar. “The emphasis on district-level data is wrong. We need to have sub-district level data to understand if the cases are only in one corner of a district.”

The key data missing are whether there are patients with symptoms of severe acute respiratory infections dying in large numbers in the villages, as COVID-19 affects the patient’s lungs the most.

The government does release district-wise data on COVID-19 from time to time, but not on where the cases are within a district. Some large cities such as Mumbai--also a COVID-19 hotspot with more than 7,000 cases--do release ward-wise data but not others. 

The World Health Organization (WHO) has repeated that the end of the pandemic needs countries to ‘test, isolate and care’ for those affected. A lockdown that is backed by fear, and not data, could be hardest on the poor and increase mortality rates among those affected, said experts. Lockdown works by delaying the peak of the virus and buys health systems more time.

If India’s villages and the majority of its districts are faring well, there is no reason to keep them under lockdown. “We need to identify major hotspots like Delhi or Mumbai and shut those areas out,” said K Sujatha Rao, former health secretary of India. “Rest of the economy can certainly be allowed to continue.”

According to Rao, putting an entire country under lockdown makes surveillance and management of the virus less efficient as the resources and manpower are stretched thin.

Gaps in testing capacity continue

On April 26, 2020, a journalist in Telangana, DVL Padma Priya, tweeted about being denied a COVID-19 test despite showing symptoms including fever, body ache, dry cough, shortness of breath and the disappearance of sense of smell and taste. A government hospital denied her a test since she had no travel history - India suspended international flights on March 22 and domestic flights on March 25, over 30 days back. Most Indians coming to hospitals now are unlikely to have travel history. 

India expanded its testing criteria on March 20, 2020, to include all patients hospitalised with Severe Acute Respiratory Illness and close contacts of confirmed cases. On April 9, 2020, the guidelines were expanded further to include all patients with COVID-19 symptoms.

After Priya’s tweet garnered attention, the state health department called her and offered to have her undergo a test.

Priya’s daughter has now been sent to her grandparents to stay safe. Her experience highlighted the difficulties in getting a test even for those eligible, and how the real gap is of a rigid policy out of step with a raging virus about which information is constantly evolving.

“The epidemic is more widespread. That is my hypothesis and I would like to see it tested,” said Jay Bhattacharya in an interview on April 24, 2020. The professor of medicine at Stanford University also looks at the intersection between health and economics. Since more than 80% of COVID-19 patients display few or no symptoms, it would be impossible to test 1.3 billion Indians, Bhattacharya said, recommending that a few thousand antibody tests be conducted across cities to find out the extent of the spread of the virus. (When attacked by a foreign object such as a virus, our body’s immune system kicks in and responds by producing antibodies--a type of protein--that take down the virus. The presence of these antibodies in the blood indicates whether or not a person has had COVID-19, even if they have shown no symptoms. The WHO has warned that while it is an indicator of infection, it does not mean the individual could not be re-infected with COVID-19.)  

Lives lost on both sides of lockdown

India’s lockdown is one of the most extreme in the world. Even at the peak of the COVID-19 infection that killed over 83,000 in China, the country never shut down the entire economy but only the Hubei province that was most affected. New Zealand has said the virus is “currently eliminated” and there is no evidence of community transmission--the kind of transmission where the source of the virus is not known. South Korea contained the spread by rapidly expanding testing and providing it free of cost to anyone who might need it.

Bhattacharya stressed that there are deaths on both sides of the lockdown policy--either due to COVID-19 or due to livelihood loss and starvation. “India’s numbers would be higher if the lockdown would not have happened, absolutely, but we have not made any effort to measure the costs.”

Because the outbreaks happen in various localities and regions, there is no single “Indian epidemic curve to flatten”, said Mavalankar. “Instead we have about 300-500 individual epidemic curves in various cities and towns to flatten.” This, according to him, makes the COVID-19 pandemic manageable and we need to use the data to zero in on these clusters and lock them down instead of the entire country.

So what is the way forward?

“The Kerala model of phased easing of the lockdown is a good example of how this can be achieved using specific public health criteria--these include the number of new cases occurring in a district in a specific period, number of persons under home surveillance, and number of hotspots in the district,” said V Ramana Dhara, professor at the Indian Institute of Public Health, Hyderabad. “In the event of a resurgence, a lockdown can be implemented again.” 

(Shetty is an IndiaSpend reporting fellow.)

Mumbai: As the Indian government extended the nationwide lockdown beyond May 4 for two more weeks, some crucial data are missing: How are the country’s villages doing? Are there too many unexplained deaths? The answer to those questions are crucial as chief ministers queue up to seek extension of lockdown backed with scant or no data whatsoever, health experts tell IndiaSpend.

As of 5 p.m. on May 1, 2020, India has reported 35,365 cases of COVID-19 and 1,152 deaths, according to HealthCheck’s Coronavirus Monitor. Globally there are over 3.2 million confirmed cases and over 233,000 deaths, according to the Johns Hopkins Coronavirus Research Center, due to the infectious virus to which there is no known cure or vaccination.

On May 1, 2020, the Indian government extended the nationwide lockdown beyond May 4, 2020, but promised some relaxation in the orange and green zones.

“Any epidemic of any type is not a national phenomenon, it is a collection of local and regional epidemics with vast intervening areas of no or low disease,” said Dileep Mavalankar, director, Indian Institute of Public Health, Gandhinagar. “The emphasis on district-level data is wrong. We need to have sub-district level data to understand if the cases are only in one corner of a district.”

The key data missing are whether there are patients with symptoms of severe acute respiratory infections dying in large numbers in the villages, as COVID-19 affects the patient’s lungs the most.

The government does release district-wise data on COVID-19 from time to time, but not on where the cases are within a district. Some large cities such as Mumbai--also a COVID-19 hotspot with more than 7,000 cases--do release ward-wise data but not others. 

The World Health Organization (WHO) has repeated that the end of the pandemic needs countries to ‘test, isolate and care’ for those affected. A lockdown that is backed by fear, and not data, could be hardest on the poor and increase mortality rates among those affected, said experts. Lockdown works by delaying the peak of the virus and buys health systems more time.

If India’s villages and the majority of its districts are faring well, there is no reason to keep them under lockdown. “We need to identify major hotspots like Delhi or Mumbai and shut those areas out,” said K Sujatha Rao, former health secretary of India. “Rest of the economy can certainly be allowed to continue.”

According to Rao, putting an entire country under lockdown makes surveillance and management of the virus less efficient as the resources and manpower are stretched thin.

Gaps in testing capacity continue

On April 26, 2020, a journalist in Telangana, DVL Padma Priya, tweeted about being denied a COVID-19 test despite showing symptoms including fever, body ache, dry cough, shortness of breath and the disappearance of sense of smell and taste. A government hospital denied her a test since she had no travel history - India suspended international flights on March 22 and domestic flights on March 25, over 30 days back. Most Indians coming to hospitals now are unlikely to have travel history. 

India expanded its testing criteria on March 20, 2020, to include all patients hospitalised with Severe Acute Respiratory Illness and close contacts of confirmed cases. On April 9, 2020, the guidelines were expanded further to include all patients with COVID-19 symptoms.

After Priya’s tweet garnered attention, the state health department called her and offered to have her undergo a test.

Priya’s daughter has now been sent to her grandparents to stay safe. Her experience highlighted the difficulties in getting a test even for those eligible, and how the real gap is of a rigid policy out of step with a raging virus about which information is constantly evolving.

“The epidemic is more widespread. That is my hypothesis and I would like to see it tested,” said Jay Bhattacharya in an interview on April 24, 2020. The professor of medicine at Stanford University also looks at the intersection between health and economics. Since more than 80% of COVID-19 patients display few or no symptoms, it would be impossible to test 1.3 billion Indians, Bhattacharya said, recommending that a few thousand antibody tests be conducted across cities to find out the extent of the spread of the virus. (When attacked by a foreign object such as a virus, our body’s immune system kicks in and responds by producing antibodies--a type of protein--that take down the virus. The presence of these antibodies in the blood indicates whether or not a person has had COVID-19, even if they have shown no symptoms. The WHO has warned that while it is an indicator of infection, it does not mean the individual could not be re-infected with COVID-19.)  

Lives lost on both sides of lockdown

India’s lockdown is one of the most extreme in the world. Even at the peak of the COVID-19 infection that killed over 83,000 in China, the country never shut down the entire economy but only the Hubei province that was most affected. New Zealand has said the virus is “currently eliminated” and there is no evidence of community transmission--the kind of transmission where the source of the virus is not known. South Korea contained the spread by rapidly expanding testing and providing it free of cost to anyone who might need it.

Bhattacharya stressed that there are deaths on both sides of the lockdown policy--either due to COVID-19 or due to livelihood loss and starvation. “India’s numbers would be higher if the lockdown would not have happened, absolutely, but we have not made any effort to measure the costs.”

Because the outbreaks happen in various localities and regions, there is no single “Indian epidemic curve to flatten”, said Mavalankar. “Instead we have about 300-500 individual epidemic curves in various cities and towns to flatten.” This, according to him, makes the COVID-19 pandemic manageable and we need to use the data to zero in on these clusters and lock them down instead of the entire country.

So what is the way forward?

“The Kerala model of phased easing of the lockdown is a good example of how this can be achieved using specific public health criteria--these include the number of new cases occurring in a district in a specific period, number of persons under home surveillance, and number of hotspots in the district,” said V Ramana Dhara, professor at the Indian Institute of Public Health, Hyderabad. “In the event of a resurgence, a lockdown can be implemented again.” 

(Shetty is an IndiaSpend reporting fellow.)


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