Categories: CoronavirusIndia's

Is India’s coronavirus death ‘paradox vanishing?

Travel for this story was supported by the Pulitzer Center.

Science‘s COVID-19 reporting is supported by the Heising-Simons Foundation.

A team of researchers in rural Maharashtra state visits houses to track the spread of COVID-19 in India.

PHOTO: RAJA SENGUPTA

At a tiny rural hospital about 1 hour’s drive northeast of Pune, India, in early April, workers loaded an SUV with coolers, syringes, vials, thermometers, and electronic tablets. They drove 20 minutes to the village of Karandi, slowing to pass caravans of migrant sugarcane cutters in ox carts. They spent more than an hour taking blood samples at a cluster of houses shared by three generations of one family. Later, the team would scour the blood for antibodies that indicate past run-ins with COVID-19.

Girish Dayma, who helps oversee this research program run by a satellite of King Edward Memorial (KEM) Hospital in Pune, says the team’s surveys show that up to 40% of these villagers have antibodies for SARS-CoV-2. “It was thought that the rural area was not much affected,” Dayma says. “The data are very much important to convince the policymakers that we need interventions in rural areas.”

Studies like KEM’s are also crucial to determining whether, as some researchers believe, India’s horrific death toll is actually lower than expected from the rate of infections. Good data are scarce. Last week, hundreds of Indian researchers appealed to the government to release what it has and collect more. “[O]ur inability to adequately manage the spread of infections has, to a large extent, resulted from epidemiological data not being systematically collected and released in a timely manner,” they wrote.

The current surge in COVID-19 cases has humbled those who thought the country had bested the disease. In early February, with cases dropping below 10,000 per day, restrictions were dropped, political leaders staged massive rallies, and masks became rare in many crowded locales. But the devastating surge starting in late March gave the lie to the suggestion that India might be approaching herd immunity; 10,000 cases hit Pune alone the day the KEM team visited Karandi. A few weeks later, India topped 400,000 cases in a single day.

Debate has swirled over whether new variants or waning immunity are at work, just how many people have become infected, and—most contentious—how many have died. Official figures suggest that, compared with other countries, India has recorded relatively few deaths given its count of COVID-19 cases. “We have been trying to find explanations for the low number of deaths in India since last year,” says a signatory of the appeal, microbiologist Gagandeep Kang from the Christian Medical College, Vellore.

“The ‘Indian paradox’ really is quite puzzling,” says Prabhat Jha, an epidemiologist at the University of Toronto. Explanations include underestimates of deaths, demographic effects, and environmental factors like abundant vitamin D from the Indian climate. But now, with hospitals struggling to find enough oxygen for their COVID-19 patients, crematoria overwhelmed, and media reports of intentional undercounting of deaths to make the current deluge look less dire, the seeming paradox may be disappearing.

In India’s first wave, which ran from June through November 2020, cases never went above 100,000 per day. Hospitals struggled—the KEM intensive care unit in Pune for a time relied on raincoats instead of proper gowns—but few reached capacity with severely ill patients.

Even then, it was hard to nail down the magnitude of infections and death. “We rely on reporting of positive cases, which obviously leaves big gaps because a large percentage of people are asymptomatic, and a lot of people don’t have access to testing,” says Soumya Swaminathan, chief scientist at the World Health Organization and a native of India. For mortality, she notes that only 20% of death certificates list a cause.

The notion of an Indian paradox surfaced as early as April 2020 and remains largely speculative despite frequent references by the health minister. One convincing study looked at 450,000 people who sought COVID-19 tests between June and the end of 2020 in 12 of the most populous Indian cities, including New Delhi, Mumbai, Pune, Kolkata, and Chennai. Led by Jha, it found that seropositivity over time jumped from about 17.8% to 41.4%, implying a huge increase in cases. Yet even after factoring in 30% underreporting of COVID-19 deaths—the worldwide average—the team calculated about 41 deaths from COVID-19 per 100,000 population, they reported in March on medRxiv. That mortality rate is less than half the corresponding U.S. figure.

Other studies, however, suggest the demographics of the outbreak could explain the anomaly. One thorough study looked at reported COVID-19 cases and deaths last spring and summer in two southern Indian states, Andhra Pradesh and Tamil Nadu, that are home to about 10% of the country’s population. The researchers reported that older adults—the group at greatest risk of dying—accounted for relatively few of India’s infections (Science, 6 November 2020, p. 691). Only 17.9% of the deaths in the study were in people age 75 or older, compared with 58.1% in that age bracket in the United States.

One reason is that India’s population skews young. In 2011, the most recent census year, 45% of the population was 19 years or younger, and only 4.8% was 65 or older. And infection rates in the old were unusually low, perhaps because those who survive to old age in India are often wealthier and better able to socially distance, the researchers argue.

The results don’t mean COVID-19 is any less deadly in India, notes the paper’s first author, Ramanan Laxminarayan, an economist and epidemiologist who founded the Center for Disease Dynamics, Economics & Policy in Washington, D.C., and New Delhi. Unsurprisingly, increasing age was accompanied by a steady climb in the COVID-19 death rate, peaking at 16.6% in those 85 and older. “If you have 65% of your population in an age group where mortality rates are extremely low, then obviously, you’re going to see an overall

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