4. Discussion:
India’s testing rate was on lower-end matched to other countries in a fight against COVID- 19 until 03rd May 2020 but on the other hand % of confirmed cases after testing was lower (3.57%) when compared with Italy (23%), Austria (16.7 %), US (13.5 %) and UK (10 %).[15]. This may indicate that the COVID 19 is still under the Phase 2 stage in India and also highpoint the efforts of the Indian government. Interstate analysis of lockdown 1.0 and 2.0 shows that some states especially West Bengal, Jammu & Kashmir, Punjab and, Haryana have very smaller no. of testing rates, while Tamil Nadu, Maharashtra, Andhra Pradesh, Uttar Pradesh, Rajasthan, Gujarat, and Karnataka have accelerated the testing and data showed a high shift in testing rate in these states during the second phase of lockdown. Impact of social distancing and lockdown can be observed clearly in this study where the total no of cases and % of confirmed cases have declined in states after lockdown 2.0 except Maharashtra. However, the analysis of both the phases 1.0 and 2.0 is quite encouraging, showing positive impact supporting the lockdown initiative of Govt. of India at pan India level. Despite this, the results of the study is a wakeup call for a few states where the testing rate is very less, and % of confirmed cases are high. The testing rate should be accelerated in these states to stop the asymptomatic transmission. Low testing rates may create a panic situation in the future, and undiagnosed cases may lead to community transmission that can create a dangerous situation for populations. Thus it is essentially required, states and central govt. may unite together to build the testing facility and accelerate the testing.
Currently, the mitigation measures adopted by the Indian government had effectively reduced the spread and flattened the now ubiquitous curve to allow health care providers to provide effective care to those in critical need as evidenced by the decrease in % of confirmed cases. But the critical question remains what the future holds because lockdown can’t remain all time, thus during the lockdown, it is essential to test the maximum population in high positive percentage areas so that the symptomatic and asymptomatic cases can be traced and separated. Based on the results obtained in our study, we attempt to answer these questions in a rigorous evidence-based manner. At a fundamental level, epidemics spread over a network where carriers spread diseases with whom they are connected to some degree. These networks or ’links’ can be via person to person interaction, local transport or travel, or via shared spaces/ surfaces. The geographic location of the networks is relevant because there may be different modes of spread that can exist within any region. The mitigation procedures cannot completely break this human to human ’link’ to disconnect the communities, and hence we recommend policymakers and govt. to employ epidemiological studies and serological test cards to screen the asymptomatic cases. Classical epidemiological models are based on serological testing and utilized in past to estimate a reproduction number or R0 (pronounced as R-naught) to describe the intensity of the outbreak and is defined as the average number of infectious. For large scale serological testing, private labs should also be roped in, which will be helpful to accelerate the testing and can screen the COVID-19 asymptomatic cases at a fast track level.
Cross-state comparisons of CFR and RR as important indicators of disease characteristics are critical for national priority setting and recognizing health system performance.[9] In the initial phases of an epidemic, CFR tends to be on the higher side and this overestimation is due to under testing and a time-lag bias, which is more pronounced at the beginning of an outbreak. Although India is in initial phases of COVID-19, estimating CFR and RR are of vital importance as they denote the current status of the pandemic and helps in planning the additional measures to be adopted to tackle the pandemic effectively. Hence, this study was aimed to measure the CFR and RR of different states having at least >100 confirmed cases in India during the ongoing COVID-19 pandemic using recent state-level data after the 1st& 2nd phases of lockdown i.e. 14th April & 03rd May 2020.
Globally, India was in no.32 position in CFR after 1st phase of lockdown and no. 44 position after 2nd phase of lockdown. The improvement in CFR may be attributed to the mitigation measures adopted by the government like complete lockdown, strict social distancing, closure of intra & interstate transport, improvement of testing facilities, awareness programs, self-quarantine and mandatory use of preventive appliances i.e. face mask, hand hygiene, etc., during this period. CFR of eight states has decreased after the completion of the 2nd phase of lockdown compared to 1st phase, indicating the success of mitigation measures adopted by the general public and government. Still, India needs to tackle the menace of low case testing, asymptomatic cases, undetected cases, or delayed case reporting to decrease the CFR on a pan India basis. The study also shows that RR of COVID- 19 has improved in all the analyzed states except West Bengal hinting the strength of clinicians, paramedical staff, and health care workers in the management of this disease with the available medications advised by Indian Council of Medical Research (ICMR). However, limited infrastructure and health care facilities available in India for the 1.3 billion populations (approx.) pose a challenge for the government authorities and policymakers in containing this disease further. Therefore, strategies must be developed including early detection of COVID-19 followed by access to medical care, which may enhance the chances of recovery rates. Besides, case studies with a detailed and accurate medical history, and scoring CFR alongside RR, should be adopted in hospitals which may be helpful in exactly pointing the hotspots of infection. This will, in turn, help the government authorities in identifying the areas with higher infection rates, so that lockdown can be strictly carried out in that parts of the country and necessary medical resources will be mobilized to that areas. Thus, the extended lockdown may provide more time to identify the asymptomatic cases and prevent community transmission at the state level.
5. Conclusion : Indian states have shown a tremendous improvement concerning testing and mitigation measures to fight against COVID- 19 as evidenced by a decrease in % of confirmed cases, CFR, and improvement in RR. Further, employing mass testing and epidemiological studies will strengthen the health care infrastructure and will augment the screening the asymptomatic cases.