'Concerned over how quickly COVID-19 cases are rising in India'

Harvard Global Health Institute Director Dr Ashish Jha has expressed concern over how quickly the new coronavirus cases are rising in India and said when populous states like Bihar and Uttar Pradesh get hit hard, the country could see a "large increase” in virus infections and deaths.

India on Sunday saw a record single-day spike of 15,413 new COVID-19 cases, taking the country's infection tally over the 4 lakh-mark, while the death toll rose to 13,254 with 306 new fatalities.

“Right now I'm concerned by how quickly the number of new cases are rising. India's density may be contributing to this and we've seen high rates of spread in some of the larger metro areas like Mumbai, Delhi and also Chennai,” Jha said.

"But what concerns me most is major population areas -- such as in Bihar and UP -- that have not yet gotten hit very hard. When they do get hit we will likely see a large increase in the numbers of cases and deaths, which we need to prepare for,” he said.

Jha stressed that the “trajectory” of cases is “very concerning” in India, which jumped into the top five countries in the world in terms of numbers of new cases.

“For six days in a row, India has seen over 10,000 new cases, and given the lag between infection, onset of symptoms and death, I expect numbers to continue to rise in the coming weeks and months,” he said in an email interview.

The renowned health expert noted that the number of cases in India may be higher than what the data suggests because while testing has been improving, it has not been rolled out in a way that will capture all low-symptomatic patients.

Jha said since several factors come into play, it is hard to predict how COVID-19 will pan out across India.

Jha referred to the ‘Youyang Gu COVID-19' model, which forecasts infections and deaths from the virus around the world, for an estimate of a probable COVID-19 death toll in India.

The Gu model suggests that there could be 1,36,056 projected total deaths and 27,333,589 total infected people in India by October 1, 2020.

Noting that while the number is only an estimate, Jha stressed, “What we do know is that we are not as far along in the trajectory of the disease as we hoped; this may be a 12 month fight or more.”

Responding to a question on India's response in dealing with the outbreak so far, Jha said he has supported the national lockdown implemented in March and thinks “it was the right thing to do” but may not be sustainable.

“I also recognise the cost of this measure for people across the country. While it may have been the right approach, it's not sustainable. Lockdowns are meant to buy time, so the real question is -- How did we use the time that the lockdown gave us?

"What is not clear to me is if this period was adequately leveraged to set a strong foundation for getting the disease under control. It is imperative that when lockdowns are employed, they are used well,” he said.

Jha noted that in line with leveraging the lockdown, testing capacity has increased somewhat over the past two months but said that it is “still far too low.”

India is testing approximately 4.2 people per 1,000, which he said is “one of the lowest testing rates” in the world. It is the lowest of highly-infected countries, compared to the US (72/1000), UK (59/1000), Russia (106/1000).

Jha pointed out that while the development of the contact tracing app ‘Aarogya Setu' was a "step in the right direction”, widespread privacy concerns may plague its effectiveness.

On what should be done by India to control the infection rate, Jha said a lockdown is never a long-term strategy.

“If COVID-19 is going to be the reality for the next 12 months, India requires a detailed plan for how to control this virus moving forward,” he said.

He stressed that testing needs to be ramped up significantly and broadened to include more people who are not acutely ill. Further, this testing strategy needs to be paired with comprehensive tracing and isolation efforts, particularly given what is now known about the potential for asymptomatic, or pre-symptomatic spread.

There is also a need for real support for states that do not currently have the infrastructure required to meet an increase in cases.

“What it comes down to is India's response needs to be driven by science and data as much as possible; keeping an eye on the number of cases, number of deaths and overall mortality due to the disease. Without the data that widespread testing and contact tracing provides, the government cannot make informed, evidence-based decisions to guide an effective COVID response,” he said.

Further, with the majority of India's workforce in the informal sector with limited or no basic labour assurances, Jha said workers are “highly susceptible to stresses in the system such as a lockdown, which is particularly painful, and in some cases, deadly.”

He asserted that he disagrees with the view that there are only two options -- lockdown completely or engage in high-risk work.

“There's a third option: with widespread testing, tracing and isolating, we carefully reopen, in a way that's responsive to risk, making sure that people who do need to work are as safe as possible -- taking time off if they contract the disease.

"But this requires sustained and country-wide commitment to testing workers regularly, tracing their contacts and safe and supportive isolation for the infected,” he said.