An Epidemiological Perspective of COVID-19 in India – Dr. Riddhi Babel (PhDc, MPH, BDS)
It is essential to observe a downward trajectory of cases along with low positivity rate for the successful reopening of the different parts of the country. Investment in the public health system by the government and trust in public health experts is fundamental in India’s fight against this virus, writes Dr Riddhi A. Babel (PhDc, MPH, BDS), Epidemiology PhD candidate at Rutgers School of Public Health.
Coronavirus disease (COVID-19) is an ongoing global pandemic that originated in Wuhan, China in, December 2019. As of June 29, 2020, more, then 10 million individuals have been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and approximately 5,00,000 deaths have been reported worldwide .
Currently, India is the fourth worst-hit country in the world after the United States, Brazil, and Russia with almost 500,000 number of confirmed cases, thereby disproportionately burdened by roughly two-thirds of the load of the South-East Asia region’s cases. A country with a population of 1.3 billion, India had instituted one of the harshest lockdowns by ramping up efforts early on to control the spread of the disease.
The primary reason for this lockdown was to delay the onset of the peak of the disease thus enabling the healthcare facilities to better prepare for the situation in light of the global shortage of essential commodities. However, the alarming spike in the recent number of cases across different regions specifically Mumbai, Delhi, and Gujarat, has been disturbing.
One of the several explanations could be the migrant worker crisis where workers returned to their hometowns on foot or crowded buses and trains which could have been mitigated had the country undergone a planned lockdown. India is particularly vulnerable due to its high population density, a high vulnerability in mega-urban slums, and the major socio-economic divide which pushes up the community transmission rates. Simultaneously, the low death rate could be misrepresentative of the ground reality. The present-day case fatality rate (CFR) of India stands at 3% and this measure conveys the burden or the severity of the disease . However, it does not assign the true risk of mortality since there might be individuals with mild symptoms, along with asymptotic cases as well as cases that have been misdiagnosed. All these factors pose a major challenge to an accurate estimation of CFR.
At present, the testing curve of India is flattening with the number of the average daily tests corresponding to 1 per 100K people . Additionally, the country lacks considerably when it comes to having a centralized death registration system. Besides, the test required to confirm death due to COVID-19 is not easily accessible for everyone. Testing data helps us with the proper interpretation of confirmed cases and deaths. The positivity rate, the number of confirmed cases are the key metrics that would give us an improved understanding of COVID-19 in the country as testing competencies increases.
At this point in time, the positivity rate of India is 8.73% which is another way of determining if the government is testing enough individuals . The positivity rate is a ratio of all positive test to the total tests conducted and is one of the indicators of testing capacities of any territory. Currently, Maharashtra, Delhi and Tamil Nadu have one of the highest positivity rates of roughly about 20% to 25% respectively leading to a fear of a higher number of cases going undetected. Mumbai is considered the epicentre of this epidemic in India.
A high rate indicates that the test coverage is narrow since they are being conducted only among individuals who are seeking medical attention and thus there is an inherent bias. Thus, there is an urgent need to ramp up the testing. According to WHO guidelines, before easing social distancing measures, a positivity rate of less than 5% should be observed for a minimum period of 14 days. It is essential to observe a downward trajectory of cases along with low positivity rate for the successful reopening of the different parts of the country. Therefore, there is a necessity for more robust testing and these tests should be scaled to the size of the outbreak in order to effectively identify new cases and respond to the pandemic through contact tracing, isolation of new cases, and treatment.
The primary mode of transmission of the SARS-CoV-2 that causes COVID-19 is through respiratory droplets between people who are in close contact with each other. Thus, in the absence of any potential treatment, this infectious disease has changed the future course of dentistry due to the specificity of its procedures with dentists facing unique challenges and outlook during this crisis. Dental practices should find a balance between delivering urgent and non-emergent services to patients. The practice of dentistry involves the use of handpieces, ultrasonic scalers, and rotary instruments. Currently, there are no research studies that have been able to assess the risk of virus transmission during dental practice, however, the virus has been shown to persist in the aerosol for hours . This definitely demands additional precautionary measures to be implemented in dental settings.
According to the Centers for Disease Control and Prevention (CDC), dental offices should ensure proper ventilation to promote air circulation along with usage of portable HEPA air filters, prescreening of patients, temperature checks, rubber dam isolation, mouth rinse before dental procedures, use of anti-retraction handpiece and protective gears. In addition, dentists should mandatorily employ four-handed dentistry when using ultrasonic devices, and two-before-and-three-after hand hygiene during this period.
At this time, there have been no known COVID-19 clusters attributed to dental settings anywhere in the country. The current need of the hour is the promotion of teledentistry and simultaneous integration of oral dental records with medical health records as a public healthcare initiative for a sustained coordinated effort to control the virus transmission.
Due to the unprecedented nature of COVID-19, to restrain the continued spread of the disease in India, preventing the spread of misinformation and educating individuals with awareness programs about the calamity of this disease is critical in the absence of any evidence-based intervention. Area-specific closures and patchwork lockdown in conjunction with periodic risk assessments of the rolled-back public health measures, scaled-up testing programs, and identification of hotspots must be undertaken. It is also imperative to make the data easily findable, available along with its detailed descriptions for easy comparison with different countries and on a regular basis.
In conclusion, investment in the public health system by the government and trust in public health experts is fundamental in India’s fight against this deadly virus.
1. WHO. 20200629-COVID-19-sitrep-161. 2020.
2. JohnsHopkinsUniversity & Medicine. Mortality Analyses - Johns Hopkins Coronavirus Resource Center. 2020.
3. JohnsHopkinsUniversity&Medicine. How Does Testing in the U.S. Compare to Other Countries? - Johns Hopkins Coronavirus Resource Center.pdf. 2020.
4. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020;12(1):9.
Dr Riddhi A. Babel, PhDc, MPH, BDS is an Epidemiology PhD candidate at Rutgers School of Public Health. She currently interns at New Jersey Department of Health (NJDOH) as a Health Data Specialist tasked with the development of an HIV epidemiological profile for two counties specifically, in NJ. Besides this, she is also a course instructor over the summer session at Rutgers SPH. She graduated with an MPH from the prestigious Johns Hopkins Bloomberg School of Public Health. Right after, she did an internship with World Health Organization (WHO) in Health Emergency Information and Risk Assessment (HIM) department at the Regional Office for Africa, where she was responsible for media monitoring and analysis, production of risk assessments outputs. Her primary research interest is focused on assessing the regional differences of HIV infection among MSM experiencing stigma and discrimination and to understand the intersectionality of different public health frameworks of multiple social categories.