COVID-19 India: More than 2/3 cases & 75% mortality from just 2.5% geographical area of India.

As on May 27, 2020, total reported COVID-19 cases in India crossed 1,58,000 cases with 4,534 deaths.

Researchers from the Public Health Foundation of India (PHFI) retrieved COVID-19 data from covid19india.org, a crowdsourced platform for COVID-19 data in India. Data for the urban population, population density and population above 60 years was extrapolated for 2020, using the Census of India 2001 and 2011. District level prevalence of diabetes, hypertension, obesity, adult anaemia, in 15-54 years age group and the number of individuals slept in a room in the household were calculated using data from NFHS (2015-16). 

Their interpretation:

1. India has a total of 739 districts. 67.2% of cases and 77.2% mortality of COVID-19 are concentrated in only 20 districts (2.7%) of India which have only 10.5% of the total 1.35 billion population of India. 15 out of these 20 districts have more than 50% urban population.
2. 50.8% cases and 53.2% of deaths of COVID-19 are concentrated in only 5 cities of India: Mumbai, Delhi, Ahmedabad, Chennai and Thane having only 4.4% of the Indian population.
3. All cities having the highest burden of COVID-19 either have an International airport or are major financial/tourist hubs, with a population density of 1,036-28,220 persons per square kilometre in urban areas.
4. Apart from COVID-19 prevalence, death per million (DPM) population is a good indicator to measure health system response, containment measures and overall management of COVID-19. Total 130 countries have DPM more than Indian average. It places India in a good position in comparison of France (437 DPM), Belgium (805 DPM), Italy and UK (545 DPM) and many other countries.
5. India’s DPM is 3.4. DPM in 10 out of top 20 districts is higher than national average & maximum in mega cities like Ahmedabad (87 DPM) and Mumbai (85 DPM), which is more than 25 times of national average.
6. Interesting comparisons are Mumbai having 2640 cases per million with 85 DPM population is worse than Chennai’s 2470 cases per million with 20 DPM in spite of Chennai having more population density. 
7. Analysis by PHFI researchers shows high urban proportion and population density were significantly correlated with the COVID-19 burden in districts having the highest burden of COVID-19. It seems COVID-19 is spreading only in a limited number of large cities with high population density.
8. PHFI researchers make a rational and logical suggestion when they write “declaring an entire district as a Red or Orange zone and locking down the whole district may risk other health services as well as closing all social and economic activities will have major financial burden”.
9. PHFI researchers argue that the availability of more granular data at the ward level in cities and sub-district level in the rural area, together with local policy flexibility at a lower administrative level, might help achieve better control.

This non-peer reviewed article COVID-19 in India: an epidemic in congested cities published in BMJ Global Health Blogs on 28th May 2020  has been written by Dr Ashish Awasthi (Assistant Professor, Biostatistics at Centre for Chronic Conditions and Injuries, Public Health Foundation of India) and Dileep Mavlankar (Head, Indian Institute of Public Health, Gandhinagar as its Director since 2012).

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Dr Divyesh B Mundra is an analytical healthcare management professional.
Masters in Health Administration (MHA) from the most reputed Tata Institute of Social Sciences (TISS), Mumbai.
Since then, he is working for one of India's most innovative healthcare organisations (private hospital chain) based out of Bangalore, Karnataka. He is an avid reader and tweets daily on the Indian healthcare system.
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