Mumbai: Despite a growing rate of increase in COVID-19 cases and a higher proportion of samples testing positive, on average, since mid-February 2021, central and state governments did not act to impose more restrictions, upgrade health facilities and control the rise in COVID-19 cases, our analysis shows.

On May 1, 2020, the Ministry of Home Affairs (MHA) said that India would track COVID-19 hotspots on the basis of active cases in a district, the time it takes for confirmed cases to double, and testing and surveillance feedback. Starting from February 1, 2021, restrictions on public gatherings were relaxed, according to an order by the MHA, which added that guidelines to track containment zones and maintain social distancing should be enforced by local authorities.

Meanwhile, India’s average doubling time of cases had been increasing since the end of July 2020, and reached a peak of 710 days on February 11, 2021. From then on, the doubling time started shrinking–from 522 days by February 28, 346 days by March 15 and 139 days by March 31, indicating that COVID-19 cases were growing fast.

All this while, states allowed large gatherings such as the Kumbh Mela and did not strictly enforce distancing, mask wearing and other guidelines. As of May 3, COVID-19 cases were doubling in India every 35.7 days. Its case numbers were increasing by over 300,000 and deaths by 3,500, on average, every day even as the media has been saturated with stories of undercounting of deaths and case numbers.

Just like the doubling time, India’s average COVID-19 Test Positivity Ratio (TPR)–the proportion of positive tests in all samples tested for COVID-19 across the country–reached a low of 1.58% on February 11, 2021, after which it has been steadily increasing. The TPR reached 2% by February 28, 3% by March 16 and crossed 5% on March 27.

If a district consistently has a TPR greater than 5% or a TPR that is increasing, it is likely that the virus is spreading and the district is not testing enough people, we had reported in September 2020. The World Health Organization (WHO) says the pandemic is under control if the TPR is under 5% for a period of two weeks. India’s TPR was 21.5% as of May 3, 2021.

Even with an increasing average TPR and falling doubling time, gatherings continued across the country. For instance, even though the doubling time of COVID-19 cases in Uttarakhand decreased from 1,670 days on February 27 to 1,062 days on March 8, the state hosted the Kumbh Mela, a religious gathering, where at least 3.5 million people congregated on April 12, 2021, according to estimates. As of May 3, the doubling time of COVID-19 cases in Uttarakhand was 22 days and its TPR is 17%. Similarly, restrictions in some districts were put in place in Chhattisgarh by Holi on March 28, even though the doubling time of cases had started shrinking consistently by March 4 and had reached 104 days on March 28, down from a peak of 987 on February 14, data show.

Between December 2020 and April 2021, despite the warning signs, dedicated COVID-19 facilities and oxygen-supported beds for severe COVID-19 facilities fell 6%, we reported on April 22.

We analysed the doubling time and TPR of 15 states with the most active COVID-19 as of May 3, 2021. We have also considered two states that saw mass gatherings due to elections (Assam) and government-sponsored events (Uttarakhand) in our analysis. To calculate the doubling time and TPR, we use a seven-day average to smooth daily ebbs and flows in cases and testing. We use data from COVID19.org for the calculations in this story.

To be sure, the doubling time and TPR are not the only measures to track a pandemic and experts point to a number of factors that can help understand the trajectory of cases and take corrective action. “I do not like using doubling time solely as a metric. A comprehensive evaluation of the multiple epidemiologic measures–effective reproduction number [Rt, the number of people infected by one COVID-19 patient, on average], test positivity rate, predictions of infections and deaths in two weeks and healthcare capacity estimates–should have driven policy decisions not just one metric. And in this case, all metrics were pointing to an uptick and the potential for a second surge since February,” said Bhramar Mukherjee, professor of biostatistics and epidemiology at the University of Michigan in the US.

As of May 6, India has 3,573,092 active cases and has reported 230,223 deaths due to COVID-19.

Doubling time in many states fell before India’s average

The doubling time helps understand how quickly the pandemic is spreading in a state. As fewer new cases are reported, the doubling time keeps increasing. As doubling time plateaus, it tells us that the number of new cases is steady, but as this indicator starts reducing, it is an alarm that each day is seeing a surge in new cases.

India’s current doubling time of 35.7 days is “shockingly low” and “at a rate not seen since around the peak of the September wave”, said Maxwell Salvator, who works at the Centre for Precision Health Data Science at the University of Michigan, and is part of Mukherjee’s COVID-19 study group. The doubling time might fluctuate or be unreliable when total case counts are low, but becomes more robust as case counts increase in size, which makes the current reduction in doubling time even more troubling, he added.

On multiple occasions last year, the health ministry announced an increase in the COVID-19 doubling time (see for instance, June 2020 and October 2020) to show that they were successfully dealing with the pandemic. It was only on March 23, 2021 that India’s average doubling time of 202 days was reported publicly, at least 40 days after this number had started dropping, our review of the health ministry’s press releases since February 11 has found.

Also Read: COVID-19: 1,952 Railways employees dead, 1,000 infected daily

Health is a state subject. Even when the central government publicly mentioned that COVID-19 cases were increasing in some states, few additional precautions were instituted in those states by the Centre or by the state governments concerned. On February 27, a week after India’s doubling time had started falling, the health ministry advised eight states to refocus on surveillance and stringent containment in districts that saw a spike in cases. This included West Bengal where elections to its legislative assembly were announced the previous day, followed by massive gatherings at rallies and road shows for the next two months.

Maharashtra was the first state where the doubling time stopped increasing and then started to drop, by the second week of February.

By mid-February, the doubling time of COVID-cases had started falling in Delhi, Haryana and Madhya Pradesh.

By the third week of February, the doubling time started dropping in states such as Telangana, West Bengal, Andhra Pradesh and Assam. In Assam, the doubling time started increasing on March 3, but dropped again within two weeks of declaration of elections, by March 9.

The doubling time has reduced the most in Assam and Andhra Pradesh between January and March. As of May 3, Andhra Pradesh has 17,222 cases daily, on average, 300 times the 55 average cases daily between February 12 and 18. In Assam, average daily cases have increased 400 times from 7.5 between February 10 and 16 to 3,254 as of May 3.

The doubling time in Uttar Pradesh, Rajasthan and Gujarat started reducing gradually towards the end of February while in Karnataka and Tamil Nadu, the doubling time fell in the first week of March.

For the rest of the states, the doubling time started reducing in the beginning of March.

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