Some key questions on Covid-19 numbers

The Indianhealth management system has never been known to be good at recording numbers,with an unstated bias towards underreporting cases, over the years and for arange of diseases. There are indicators that this flaw continues in the midstof the Covid-19 pandemic. In Telangana, for example, six doctors organised as”Doctors for Sewa” have come out in writing on how Covid-19 deaths are notreported in the total State’s tally. This is one illustration of the looseprotocols on reporting Covid-19 related deaths. There have been concerns abouthow the Centre itself records these numbers, given that the official narrativeis that the epidemic curve will now be headed downward. The weekend of April24, the government Empowered Committee on Medical Management predicted the endof the epidemic by May end. Further, for some unknown reason, the governmentannounced on Tuesday (May 05) that Covid-19 numbers would be updated on theMinistry of Health & Family Welfare website only once a day instead oftwice a day. “All concerned may please note,” it said, without offering anyreasons. This comes alongside some carefully crafted political positioning andsometimes one-upmanship (as seen in Maharashtra and West Bengal) playing itsown role in the fight against the pandemic. The Air Force display, droppingflowers on hospitals on Sunday, May 3, was an unwanted digression from the coreand burning issues of the day. Such deliberate digressions have occurred morethan once previously.

An importantconcern that needs an open and frank discussion is the number of Covid-19 casesand the puzzle they represent. On the one hand, we have a reported death tollthat is low relative to India’s population. This can lead to the argument that,even if under reported, the death toll cannot be way off the mark and thatIndia is therefore doing well in adjusting its systems to the pandemic. We arenot as bad as some of the developed nations, it might appear, for reasons wedon’t know or understand. Could it be some protection acquired from theuniversal BCG vaccination? One advantage that may play a part is that a faryounger demography weathers the virus better than other nations with moresenior citizens.

   

On the otherhand, consider that India’s doubling rate at this stage might appear to befaster than what was reported in Italy. The numbers tell us this simple tale.India increased its number of infections from 257 on March 24 to 34,863 onApril 30 – the period from before the lockdown began to the end of the lastmonth. This represents a doubling of seven times. Italy increased its numbersfrom 1,694 on March 1 to 205,463 on April 30, a doubling of about seven times.

In short,Italy had seven doubling steps in eight weeks; India had seven doubling stepsin five weeks. India was under lockdown from 25 March. The growth rates ofepidemic in Italy and India were more or less the same but India is a bitfaster. This observation would indicate that we are sitting ducks and will beswamped as the numbers rise.

Which bringsus to another part of the puzzle of numbers reported in India. On May 04, theUnion Health Minister Dr. Harsh Vardhan noted that “Outcome ratio (recoveredvs. death) for all closed cases, which indicates the clinical management statusin the hospitals, has improved. He said data analysed since 17 April showedthat “there is an improvement in the country compared to that prior to 17 April2020 (outcome ratio was 80:20) while as of today it is 90:10.” This mightindicate a significant improvement within a fortnight or so, and needs furtherscrutiny. What precisely has changed, if anything? We don’t know.

Looked atfrom another perspective, the picture looks very different. According to theWHO, data for COVID-19 to date suggests that 80% of infections are mild orasymptomatic, 15% are severe infection, requiring oxygen and 5% are criticalinfections, requiring ventilation. These fractions of severe and criticalinfection would be higher than what is observed for influenza. WHO points outthat while the true mortality of COVID-19 will take some time to fullyunderstand, data so far indicates that the crude mortality ratio (the number ofreported deaths divided by the reported cases) is between 3% and 4%.  India’s death toll stands at 1,568 as of May5.  When counting backward, it meansthese patients took some three weeks to reach the stage when they passed away –say a week for the incubation, a week for the symptoms to take hold and a weekin hospital as conditions worsened and death followed. So, if 1,568 is 4% ofcases, the total should be 39,200 (1,568 X 25). But three weeks ago, which is April 14, we had only 11,487 reportedcases, which is only 30% of 39,200. How then do the numbers add up? If the reportedcases were correct, then the mortality figure for India would be alarminglyhigh at 14 per cent (i.e. 1568/11487).

Clearly,there is something amiss somewhere in the way the numbers are coming through.This is alarming, not merely because the toll would be incorrectly reported butthe epidemiological response will be impacted if we do not count the correctnumbers or have an open discussion on what the numbers are telling us. This isnot to suggest that there is a deliberate attempt at a cover up, althoughbiased counting cannot be ruled out either. It could be fragile systemcrumbling under pressure and failing to carry reports cleanly, mixed up with aresource crunch, stress and anxiety and confusing signals from officialcirculars on what the hospitals should do and what they should avoid.

A simplerule would be to encourage State governments to openly, freely, frankly reportnumbers. Those who report more can call for more help, more support, even morefunds rather than be pulled up, stigmatised or shown in poor light,irrespective of party affiliation. Let the floodgates to honest, transparentdata open up. That’ll help us fight the pandemic better. For example, there isa circular highlighted by “Doctors for Sewa” of 20 April 2020 that asked doctorsnot to test samples from those who have died with clinical Covid-19 symptoms.They were previously not tested and died in hospital. That means those deathswill be reported under some other classification and the Covid-19 numbers willbe lower, but why? The consequence will be the spread of the infection becauseall those that the patient came into contact with, including doctors, nurses,family members, associates, will not be tested or quarantined and will notreceive early alerts to seek medical advice. There has to be a clearunderstanding that a pandemic is no time to twiddle with numbers – let us treatthe disease and let the numbers reflect the true nature of the disease. That’sthe best way forward.

(Rattanani is a journalist and faculty member at SPJIMR.  Dr. John is retired Professor of Clinical Virology, CMC Vellore, and past President of the Indian Academy of Pediatrics. Numbers quoted are from PubMed and local media reports)

(Syndicate: The Billion Press, editor@thebillionpress.org)

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