Figure it out, Delhi

* The average number of cases an infected person is likely to cause has dropped from an estimated high of 4.2 recorded in the early days of the pandemic to 0.62

* The mortality rate is similar to that of many other lower respiratory tract viral infections, but what makes Covid-19 different is that right now it is difficult to predict who — apart from the elderly, diabetic or those with high blood pressure — are the most vulnerable

* Delhi recently launched a plasma bank at the Institute of Liver and Biliary Sciences (ILBS) Hospital to treat Covid-19 patients

First, the good news. The worst seems to be over for Delhi, if the Capital can hold on to what it has achieved so far. With over 1 lakh cases and more than 3,000 deaths, the Covid-19 situation in Delhi may be within the reach of control.

But now for the bad news: Experts are taking the Delhi government’s Covid-19 data with a pinch of salt.

Delhi is one of the cities most affected by the novel coronavirus that has swept across India and the world. If, however, the numbers are accurate, there is hope. In the first week of July, every five infected people in Delhi further infected only three on an average. In other words, the average number of cases an infected person is likely to cause has dropped from an estimated high of 4.2 recorded in the early days of the pandemic to 0.62.

“Assuming that the Delhi government has not under-reported the number of deaths among the detected Covid-19 cases (a scenario which has been questioned in recent times), Delhi most likely will be able to cope with the demand on its healthcare for the month of July,” says Tanmay Mitra, a physicist-turned-systems immunologist at the Helmholtz Centre for Infection Research in Braunschweig, Germany.

If the present trend continues, the cumulative number of reported Covid-19 infections in Delhi is likely to remain in the range of 1,25,000-1,34,000 by July 20, he says. “The cumulative number of reported deaths will remain in the 4,000-4,700 range if the current trend persists,” Mitra adds, while also stressing that any long-term prediction is likely to differ, to an extent, from real-time data.

Mitra is part of a research team that is tracking various aspects of the Covid-19 pandemic in the world. The team has been developing mathematical models to forecast numbers of infected people, the future of the outbreak and pressures on the healthcare system in many Indian states, including Delhi. Their analysis for Germany was gainfully used by that country to keep Covid-19 mortality low as compared to that in other major European countries.

The number game

The future of Delhi, however, is greatly dependent on the data being revealed, and many experts are wondering if Delhi is testing enough numbers. The team in Germany points out that its analysis shows Delhi tested (in June and in the beginning of July) around six people for each reported case. Yet, when stricter rules were in place in the April-May lockdown period, it was testing 10-15 people.

“When we need more tests to be conducted because of higher contacts among people during phases of ‘unlock’, the authorities in Delhi are failing to ramp up sufficient tests,” Mitra says.

The present reproduction number may actually be higher than 0.62, as the proportion of undetected cases is likely to be more than what was initially recorded. Doctors agree that there is a need for greater clarity on the number of fresh tests conducted and how many of them turn out to be Covid-19 positive.

Srinath Reddy, president of the New Delhi-based Public Health Foundation of India (PHFI), a non-governmental advocacy group, points out that currently there is information only about the total number of tests conducted on a daily basis.

“If the test positivity rate is indeed coming down, while the number of tests being conducted is going up, as claimed by (Delhi chief minister) Arvind Kejriwal, it is a good sign,” Reddy says. “But the question of course is, what is the number of new tests performed and the number of people who come up as positive. There is a need for excluding repeat tests carried out on those already tested (and recovered after the treatment),” he says. Patients have to get a Covid-19 negative test result twice before being declared cured, and these tests, it is feared, are being included in the total number of tests.

Vikas Jha, a socio-political researcher who has been collating data on Covid-19 patients, also points out discrepancies in the government data. The total number of patients — in hospitals, at home, or recovering — does not add up, he says. In the coming days, there may be a dip in the number of recovered patients, he warns.

Questions are also being raised on the kind of test being conducted. The antigen testing method involves looking for antibodies; if a person has antibodies related with coronavirus, it means the person is either Covid-19 positive or has recovered. Though cheaper and faster, antigen tests have higher false-negative rates — that is, they may show an infected person as infection-free.

Another test is called the real time Reverse Transcription-Polymerase chain reaction (real time RT-PCR), which is considered the gold standard in detecting the SAR-CoV2 virus that causes Covid-19. The RT-PCR has a success rate of 60-70 per cent while it is 50-60 per cent for the antigen test.

“Without revealing all these numbers, it’s like the dance of the seven veils,” Reddy says, referring to the dance form where a performer removes a veil — only to expose another under that.

Future tense

Questions are also being raised on how the Capital will fare in August. Randeep Guleria, director of the All India Institute of Medical Sciences (Aiims), has been reported as saying that if the situation remains the same, Covid-19 cases in the city will peak in August, before it slumps.

But doctors on the front line of the coronavirus fight say that it’s not clear how Delhi will deal with the virus in the coming weeks. “At this stage nothing can be predicted. With the relaxation in the lockdown in the national capital, there is a possibility that there might be an increase in the number of cases,” says Sayan Nath, senior resident, department of critical care and anaesthesia, Aiims.

The mortality rate is similar to that of many other lower respiratory tract viral infections, but what makes Covid-19 different is that right now it is difficult to predict who — apart from the elderly, diabetic or those with high blood pressure — are the most vulnerable. Since the disease is still to be fully understood, concrete solutions or effective treatments are still to be found, Nath says.

“For common illnesses such as hypertension or diabetes, one can refer to textbooks any time but whenever there is a new infectious disease such as Covid-19, not much is known about it in the initial phases. Also, in a pandemic-like situation, it is difficult to conduct a study on a large scale,” he says, pointing out that all these factors make it difficult for experts to predict which sections are likely to be adversely affected. “We have identified some symptoms, but as the pandemic evolves, these symptoms might not be enough,” Nath observes.

On the prevention and treatment front, too, there is confusion. Last week, Delhi announced a five-step strategy to contain the pandemic — increasing the number of beds, testing and isolation, providing patients in home isolation with pulse oximeters (to check oxygen levels), use of plasma therapy (transfusion of plasma from recovered patients into those seriously ill) and screening and surveys.

Delhi recently launched a plasma bank at the Institute of Liver and Biliary Sciences (ILBS) Hospital to treat Covid-19 patients. It urged recovered Covid-19 patients to donate plasma to help others recover. A donor can donate plasma every 10 days without any ill-effects. There are, however, eligibility guidelines and criteria on who can donate.

How prepared is the government when it comes to health facilities? Not much, contends Harjit Singh Bhatti, the national president of the Progressive Medicos and Scientists Forum (PMSF), an association representing doctors, academics, and scientists from across the country.

The government is trying to bring in some changes but nothing significant has happened as patients are still struggling to get beds in health centres, he says. Steps are being taken to increase the availability of beds by converting rail coaches into quarantine facilities, but there is little information on where these bogies are situated. Hotel rooms have been earmarked for Covid-19 patients, but not everybody can afford to pay (roughly ₹4,000 a day), he adds.

Emergency measures: Despite the government converting banquet halls and hotel rooms into care centres, many are still facing difficulties in finding beds

The Delhi government announced recently that it would facilitate video conferencing between patients and family members to help them stay in touch. “New announcements are being made every day by the Delhi government. These things come up very quickly on social media, but when it comes to actually implementing them, the reality seems far away,” Bhatti says.

Way ahead

Bhatti fears an increase in the number of cases in July. The Delhi government, he says, should conduct door-to-door surveys in the containment zones to identify Covid-19 positive cases.

“There is also a need for active intervention by the government. Right now, the government waits for patients to come on their own to hospitals but this will not help in controlling the infection,” he warns.

Reddy believes that Delhi should have started household surveillances in the initial phase of the pandemic itself. The Aam Aadmi Party (AAP) has members in every ward and they should have been drawn into the campaign for citizen engagement — that is, getting citizens to maintain a regimen that would have helped contain the infection or help people seek treatment.

“If the government didn’t want to involve political workers, it could have used cadets of the National Cadet Corps or National Social Scheme volunteers for citizen engagement. After training, they could have been posted as liaison contacts with the health department. If such an arrangement is there, people can get in touch with them if a test or hospital admission is required,” Reddy says. “With every citizen being on his own and having to run to 10 different hospitals, it can only create chaos,” he adds.

Sending police personnel in search of patients will not be of much help, he argues. “It is better to engage citizen-volunteers for this. Otherwise the stigma and fear will drive the infection underground,” the PHFI president says. Even mohalla clinics — small health centres set up by the AAP government — can play a more proactive role, he says.

A Delhi government official, however, stresses that personnel at these clinics, which provide basic medical care for common illnesses, have been trying to contain the pandemic. “Mohalla clinics have played a crucial role in creating awareness about this crisis, while also giving basic treatment to other patients and ensuring that the hospitals are not over-crowded,” the official states.

The Delhi government has been doing what it can, the official holds. “We have focused equally on treatment and prevention. Through videos we have tried to make people aware of why prevention is important. Containment has also been a part of prevention,” he says. “The Delhi government is doing everything that is possible,” the official adds.