COVID19- India’s Progression

The next few days are crucial for India in terms of COVID19. Where will we go?

*********Update (27th March): This article was originally written on 23rd March. Just two days after it, coincidentally but not surprisingly, the Indian government announced complete shutdown for 21 days. Probably the best decision taken in recent time. Here is how the number looks as of today (Confirmed: 764 Death: 20 Recovered: 71). India hasn’t seen the exponential growth yet, which is a piece of good news. I am optimistic that this number will not grow to the level of Italy or Iran if the shutdown is adhered to by the people. Fingers crossed*******

This article provides an avenue to discuss where India stands with respect to the outbreak of the novel Coronavirus and the government’s plan to tackle the pandemic in the near future. With the data currently available to us, we will evaluate two possibilities: will India be like South Korea and manage with scratches or will it be similar to total war-like situation in Italy.

The seriousness of the situation and the value of life is paramount and in no way, the article and the statistics are undermining the gravity of the situation. This article is to help us understand the outbreak more clearly. For the latest information please visit WHO.int or CDC.gov

It will also suggest why India should change its internal travel plan to complete lockdown if it wants to contain the pandemic.

Here is the data as of the 21st of March, 2020.

Dated for three countries as of 21st March (JHU)

Here is the progression over time. Please note that all the three charts are on different timelines as depicted by Y-axis.

Case Progression: India vs Italy

Correlation with Italy

If you glance through the news, it is most likely that you would have heard that India is the next hotspot of the COVID19 pandemic. Europe is the next candidate for this. The similarity between the two? Population.

There are multiple reasons why reporters, medical professionals, experts, and common people are making this prediction. Reasons behind this kind of forecast can be classified into either one or more of the below. Walking through each of the points, we see the (obvious) rationale for making such claims.

1. Population

India’s population is 1,380,004,385. That is upwards of a billion people. In comparison, Italy’s population is 60,461,826, which is 1/22 as compared to India. To put things in perspective, for every Italian, we have 22 Indians. South Korea is 1/26 times of India.

It makes a lot of sense to see why this number is of value. If Italy, having 1/22nd fraction of the population can face such a level of havoc, why won’t India?

The population of the countries

2. Quality of living and Healthcare System

India is not known for its healthcare system. Italy ranks 2nd after France in terms of healthcare delivery system worldwide, while India is not even among the top 100 (I cannot find the exact position, but holds little relevance for the current discussion). Most of the Indian population is poverty-stricken and has little to no access to basis sanitization and decent healthcare benefits.

3. Comparison with other countries in terms of timeline

This is perhaps the most important of all points. Italy, China, Iran, etc. saw very high exponential growth in less time. It is no question that COVID19 is a pandemic and we are seeing unprecedented growth. This makes it obvious, and in a way good, to compare India to these countries. We have nothing to lose by overestimating rather than underestimating, but we have to realize that not every country will see the level at the same level, and it will depend on multiple factors.

4. Lack of any more data to conclude otherwise

In the recent past, this is the first time something has hit us so hard. SARS, MERS, Ebola, although much more fatal (in terms of confirmed cases vs death cases), were relatively limited in terms of overall confirmed case count. The numbers below show the details.

As we can see, COVID19 is way beyond the fence in terms of total confirmed count, but considerably low when we take the fatality rate.

Are there any other factors that we should consider?

There are other factors that we should be considering if you want to predict with reasonable clarity. No two countries are the same and it will never be possible to accurately predict the progression of any pandemic in one country based on some other country data. There are so many factors, it becomes impossible to deal with such a complex system. The best way to do is, stop predicting and start acting (on the line of Nassim Nicholas Taleb).

But we still should be looking at the following important factors and critical data points to better understand how we can contain the situation.

If you glance through the factor below, they indicate India seems much closer to South Korean outcome rather than the Italian. Only time will tell.

1. Age

2. Gender

3. Smoking Habit and existing medical conditions

4. Comparing India with other countries

1. Age

Age is one of the primary indicators of fatality. As per the data published by the worldometer, WHO and CDC, here is how it affects the fatality percentage. The below table and chart show how likely is a person to die of COVID19 if they are in a certain age group.

Fatality by age for COVID19

Fatality rate over age group

It is very much evident that if the patient is 50+ years of age, the likelihood of death is far higher as compared to other age brackets. If you are below 10 years of age, it is 0%.

Below is the 60+ age demographic of Italy, India and South Korea.

Take away: In terms of age demography, India has much less elderly people as we have a relatively younger population. This can act to our advantage, but can also wreak havoc because our total elderly population is upwards of 4 times to that of Italy’s. That said, it is not evident that all or any of these elderly people will suffer from COVID19.

This means that our effort should be directed towards the isolation and treatment of people of this age group.

2. Gender

Gender is also a good indicator if we look at the data provided by WHO and CDC. The gender split in COVID-19 cases worldwide is about 50–50, but there are gender differences in survival. Emerging evidence suggests that more men than women are dying, potentially due to sex-based immunological or gendered differences, such as patterns and prevalence of smoking.

Since we don’t have the gender data for India COVID19 cases, it is difficult to evaluate this criterion. Nonetheless, if we see South Korea, 62% of their cases were reported in women. And as the data shows, women have less chance (5 in 10 men, 3 in 10 women, this is a big difference) to die compared to men. We don’t have gender data for Italy as well.

Take away: India should publish the gender split of the confirmed cases to better evaluate this criterion. We cannot make any guess without that number for India, but we do know that if the confirmed cases split is heavier towards women, we might have fewer fatalities.

3. Smoking Habit and other Health Conditions

Not surprisingly, smoking habit plays a vital role in survival with COVID19 (as it does with any major illness). “Active smoking increases your risk of respiratory tract infection,” says Professor Tom Wilkinson, NHS consultant physician and researcher at the University of Southampton.

Percent of Population smoking

If we look at the data above, India has far fewer people who are active smokers (11% vs 24% or 27% compared to Italy or South Korea). Hence even if the number of confirmed cases might be significantly higher, we expect to see less of it converted to actual fatality.

On the other hand, India has a higher number of individuals with Cardiovascular diseases compared to. According to the stats, 146 out of 1000 people in India due

If we see the below table, India tops in all the categories for which we have information. I can make a reasonable assumption that for the category that we don’t have information (CVD, CRD, Hypertension), India will be higher compared to other countries.

Take away: India has an advantage when it comes to the population with smoking habits, but that is overturned by the population in India suffering from major pre-conditions. For these pre-conditions, the fatality rate is much higher and hence we might see situations worsening for these people. The advice for such patients (especially with Cardiovascular diseases, is to stay as much isolated as they can).

4. Comparing India with other countries

One of the most striking observation is how and why India has such a smaller number of reported cases. As per the below table, although India started seeing cases during the same time Italy and South Korea did, we did not see a significant rise in the number of cases.

The below visualization makes it more clear between India and Italy. As we see, both countries started seeing the cases around the same time, but Italy saw a sudden rise in the confirmed and the fatality, which India remained relatively stable.

There can be many reasons for this:

1. India is not testing enough people. This is true. For every 1 million people, India is performing tests on only 3. Compare this to Italy, which is testing 1420 people per 1 million. The less we test, the less number we have.

2. Patient One: The first person to be testing positive was a 38-year-old man who had attended three dinners, played soccer and ran with a team while he was still contagious. By the time he was diagnosed, patient One has harmed, meeting more than 100 people. We are not sure if we had such a situation in India. All personnel who were tested positive during the initial phase have traveled abroad or got in contact with someone who did. Once contained and traced, it was much easier to avert the patient One scenario here.

3. India is under-reporting the fatalities: This can be true as well and can go in conjunction with point 1. But even if this is true, I am not sure how can India under-report such a high number. The current death toll (2/22) is 7 people. I can understand India is under-reporting maybe 70–80 people. But I don’t know how can we underreport 1000+ death cases.

The fact that the population of India is so high makes any pandemic the worst-case scenario. India should strategies in divide and break. All states should go into complete lockdown and behave as smaller clusters so as to minimize the damage.

In conclusion:

1. Population’s age demography is on India’s side.
2. We don’t know about the gender distribution of confirmed cases in India. If there are more women who have coronavirus cases, the overall fatality count might be less.
3. India’s smoking population is drastically low and hence can be assumed to have better resistance to respiratory-related problems.
4. India’s CVD and diabetics are higher compared to Italy and South Korea and that might affect the total count of fatality.
5. India has somehow managed to be under the radar until now which is a very good sign. Italy started at the same time and has 5000+ deaths. India has 7.
6. Overall population count will be the biggest burden India faces and can negate all the advantages. The solution is to isolate the individual states and impose strict travel restrictions.

Ref
https://www.worldometers.info/world-population/population-by-country/
https://worldpopulationreview.com/countries/best-healthcare-in-the-world/
https://www.worldlifeexpectancy.com/cause-of-death/coronary-heart-disease/by-country/
https://www.isglobal.org/en/ebola
https://www.thejournal.ie/quit-smoking-coronavirus-5047328-Mar2020/
https://www.indexmundi.com/facts/indicators/SH.STA.DIAB.ZS/rankings
https://www.indexmundi.com/facts/indicators/SH.DYN.NCOM.ZS/rankings
https://caravanmagazine.in/health/lack-testing-kits-understaffed-hospitals-covid-exposes-india-crumbling-healthcare-system

**All images are created using TIBCO Spotfire.**