Over the last few weeks of Unlock, the daily number of new cases has gone up from just above 10000 to more than 25000. However, as Graph 1 shows, the rate of spread is not uniform and there is great heterogeneity in the paths of the pandemic across India. As of now, among those states and territories with a substantial case load, it is only in Delhi that the pandemic has shown some signs of relenting.
Graph 1: Total Cases and Daily Cases ( 5-Day Moving Average) as on 8 July
However, when we look at more disaggregated data—at the city/district levels—it is seen that many of the initial hotspot cities have been able to bring down the number of new infections (Graph 2), controlling the exponential spread of infection considerably. Indeed, the pandemic has shifted to new hotspots, and is spreading rapidly, predominantly in urban areas.
Graph 2: The Path of the Pandemic in Chennai, Ahmedabad and Indore
Given this context, this article closely explores data from Delhi and Mumbai to analyse both morbidity as well as mortality trends over the last five weeks of Unlock. Surprisingly, a look at the weekly new case load (Graph 3) reveals that notwithstanding the public perception to the contrary, Mumbai has managed to keep the numbers almost constant across five weeks. Although Mumbai did not take proactive steps to curb the spread of the virus soon enough, it seems that strict containment measures and infection management post the initial spike—as has been seen in Dharavi—have helped control further spread of the virus in high-density and low income urban residential areas. Despite a worrying rise in cases in the first half of the Unlock period, which caused administrative panic, Delhi was also able to bring down the level of new infections considerably through well-coordinated efforts between the Delhi government, the Central government, and the Municipal Corporation of Delhi (MCD).
Given the weak surveillance systems, it is important to verify any perceived decline of recorded cases with mortality data because deaths are harder to miss. Particularly in democracies like India, any spurts in undocumented deaths will be noticed, as was seen in the initial phase of the pandemic. A look at death data (Graph 4) shows that after the nightmarish week of 10-17 June, the number of deaths have certainly come down in both Mumbai and Delhi.
Despite the improvement in the overall situation, some major concerns remain in Mumbai, particularly with regards to testing. As is clear from Graph 5, while testing numbers in Delhi have seen substantial improvement over the Unlock period, testing in Mumbai seems to have stagnated, and is, in fact, going down. Aggressive testing combined with active case finding, isolation of patients, and tracing of contacts has helped Delhi bring down the weekly burden of new recorded cases (Graph 5), but the extremely low number of tests in Mumbai certainly keeps alive the possibility of a silent spread gaining momentum, and triggering a subsequent surge in recorded cases, and deaths. It needs to be added that while both Delhi and Mumbai have started conduction rapid antigen tests along with RT-PCR tests, the proportion of the former in Delhi is more than half of the total tests. Rapid antigen tests are bound to be less accurate than the RT-PCR tests, are known to return a higher proportion of false negatives.
To examine the sufficiency of testing in Mumbai and Delhi, it is important to look at trends of test positivity rates. Graph 6 looks at COVID-19 test positivity rates for the two cities over the first five weeks of Unlock. It is clear that aggressive testing and contact tracing have helped Delhi bring down the positivity rate, and the spread of the virus itself, even if possible false negatives may have exaggerated the fall. However, it is of great concern that the stagnation in testing numbers in Mumbai is paralleled by a rapidly increasing test positivity rate, currently nearing 38%, which means that Mumbai is still finding one positive case for every three tests done. This points towards the possibility of a possibly subterranean spread, which may soon become a major problem, even though the lower number of deaths now gives the impression that the virus is under control.
While Delhi is on the path to recovery, at least from the first wave, the citizens and the administration need to be very alert, since the success of infection control during the Unlock phase will depend mainly on people’s voluntary compliance regarding physical distancing measures and mobility control. If infection is not actively kept under control, the green shoots of any economic revival that we see now will be severely undermined by strict lockdowns, which may become inevitable in view of rising morbidity and mortality. In that sense, while there is relief, the administration will need to balance the need to allay panic with the need to avoid complacency.
For Mumbai, while deaths have come down, there is an urgent need for tests in the city to be ramped up so that positivity rates are kept within the limits of 5%. Delhi seems to be on the way towards achieving this, despite a relatively high case load. With Unlock, the movement of workers from satellite cities to Mumbai and back has seen an increase, and this has resulted in case numbers increasing in Thane and Pune, adding another layer to Mumbai’s existing challenges.
In the initial phase of the pandemic, there was a time when panic could kill more people than the virus itself. Even as India emerges from that phase relatively better than many had anticipated, we are entering another phase where complacency may kill many more than panic. With voluntary RT-PCR without a doctor’s prescription being allowed in Mumbai, it is expected that the number of tests in Mumbai will go up. However, as the financial nerve-centre of the country, Mumbai’s administration should pump in more resources into testing more aggressively.
Reportedly, many health workers supporting COVID-19 management efforts in Mumbai are returning to their home states, possibly pushing down the effective number of beds, risking a reversal of the improvements in mortality rates. Mumbai showed the world, through its efforts in Dharavi, that even against impossible odds, it is possible to screen and test aggressively to bring daily case load to single digits. Given this context, in many similar high risk pockets of Mumbai, where containment of the infection was achieved, there is the danger of these gains getting lost unless test positivity rates are brought down, and voluntary physical distancing is promoted.
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Oommen C. Kurian is Senior Fellow and Head of Health Initiative at ORF. He studies Indias health sector reforms within the broad context of the ...Read More +