What’s increasing India’s 100,000 Covid-19 deaths?

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That is alarming, Dr Ravi said, because it is contrary to what’s happening all over the world and in India as a whole – widespread testing and improved knowledge of treatment options is bringing down case fatality rates.

Dr Ravi said she believed Maharashtra and Punjab were both showing symptoms of a bigger malaise – limited testing, leading to higher positive rates. Lower testing could leader to a rise in death rates, she said, because authorities catch the infection only when it’s too late.

Is testing the problem?

Punjab’s positive rate – at 6.2% – is significantly lower than that of Maharashtra – 24%. But it’s also much higher than Bihar (2.5%) or Jharkhand (3.7%) – states that are doing about the same number of tests per million as Punjab – 60,000. And yet their positive rates are far lower.

“If you test less and your positive rate is still high, it means the infection is way ahead. You are catching cases too late,” Dr Ravi said.

Her argument was backed up by the picture in Maharashtra, she said – a state that has consistently reported high positivity rates, high deaths, but has not ramped up testing significantly.

Positive rate and case fatality rate in selected states

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Positive rate and case fatality rate in selected states

Not everyone is convinced of the correlation between the two. “I don’t know of any direct relationship,” said Dr Gautam Menon, a professor and researcher on models of infectious diseases. “You’re not testing enough means you’re missing a ton of cases. But what fraction of those cases lead to deaths is hard to say.”

Dr Ghose said he thought there could be a more roundabout link – that lesser awareness and ability to get tested – which results in limited testing – could also lead to later hospitalisations, increasing the chances of death.

A recent study in the states of Andhra Pradesh and Tamil Nadu found that the median time from hospitalisation to death among Covid-19 patients was 13 days, leading researchers to conclude that “a substantial proportion of patients” in the two states were likely diagnosed late.

And yet Tamil Nadu is a state that has been consistently testing at high rates, and also has a low case fatality rate. In absolute numbers, it has reported more than 9,000 deaths, the second-highest in the country, but daily deaths have been falling since July.

But Dr Jacob John, an epidemiologist, said that was because diagnosing the infection early was not always going to affect a patient’s treatment plan because in many cases, doctors follow that plan even without a diagnosis.

“For poor testing to have poor outcomes, one has to assume that testing will change the way a patient is managed,” Dr John said.

Instead, a higher case fatality rate is the result of a poor health delivery system, he said, and the same system also delivers limited testing and treatment once someone ends up in a hospital.

Urban districts are reporting higher deaths

 

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