SARS-CoV-2 Pandemic, COVID-19 Case Fatality Rates and Deaths per Million Populations in India
Published date: 20-4-2020
SARS-CoV-2 Pandemic, COVID-19 Case Fatality Rates and Deaths per Million Populations in India
Joy Kumar Dey1, and Sanjay Kumar Dey2,3*
1Central Council for Research in Homoeopathy, Ministry of AYUSH, Govt. of India, New Delhi-110058, Delhi, India
2Department of Biochemistry, University of Delhi South Campus, New Delhi-110021, Delhi, India
3Current address: Center for Advanced Biotechnology and Medicine, Rutgers University, New Brunswick-08554, USA
*Corresponding author: Dr. Sanjay Kumar Dey, Department of Biochemistry, University of Delhi South Campus, New Delhi-110021, India, Tel: +91-920 533 7595; E-mail id: firstname.lastname@example.org.
Citation: Dey JK, Dey SK (2020). SARS-CoV-2 Pandemic, COVID-19 Case Fatality Rates and Deaths per Million Population in India. J Bioinf Com Sys Bio 2(1): 110.
As of 3rd April 2020, India had 2547 cases of SARS-CoV-2 infections, with most cases in the states of Tamil Nadu, Kerala, Maharashtra and Delhi. While, foreign-travel-related incidents were the initial source of COVID-19 cases of the current pandemic in India, social transmission emerged rapidly later on. First COVID-19 deaths with foreign travel history and local human to human transmissions were reported respectively on 10th March in Karnataka and on13th March in Delhi. Till3rd April 2020, 66deaths happened in India who was COVID-19 infected. COVID-19 case fatality rates in India is 2.6 which is lower than eight other highest affected countries in the world while higher than two in the top ten countries till now. However, since the number of COVID-19 infected cases in India is very low compared to top ten affected countries in the world, a better estimate was calculated based on the number of infected and dead persons per million population in India which remains lowest compared to as many as top 35 COVID-19 affected countries in the world till 3rd April. Interestingly, comorbid vulnerabilities were similar in all of these countries including India showing increased fatalities in the persons with existing comorbidities, especially like cardiovascular diseases, diabetes, hypertension, kidney failure and breathing troubles, irrespective of age groups. Based on the experience of management of COVID-19 pandemics in USA, Italy, Spain, China, and many other fatally affected countries, it is quintessential for India to adopt strategies to not only increase availability of COVID-19 test kits but also to classify the infected patients with comorbid illness with increased severity, especially for elderly patients. This will improve the chances of survival of COVID-19 cases in India while social-distancing will continue to prevent further spread of the pandemic in the highly populated country like India.
Keywords: SARS-CoV-2; Pandemic; COVID-19; Elderly patients; Foreign travel; CFR; India; Social distancing; Deaths per million
After SARS in 2002-2003 and MERS in 2012, China reported a third corona virus infection in December 2019, with flu-like symptoms and severe respiratory illness originated in the Wuhan city, all started transmitting to humans from bats [1-4]. The virus spread quickly and efficiently, with confirmed cases dramatically increasing within a few weeks. Despite efforts to contain the virus within the city, it quickly spread to other regions of China, and soon to all other countries and continents except Antarctica . In January 2020, the World Health Organization renamed the virus as SARS-CoV-2 and designated the disease COVID-19 .
According to Worldometer (https://www.worldometers.info/coronavirus/), a reference webpage providing real-time world statistics of SARS-CoV-2, there are over 1,116,643 identified cases of COVID-19 in 205 countries and territories worldwide and two international conveyances, namely, the Diamond Princess cruise ship harbored in Yokohama, Japan, and the Holland America's MS Zaandam cruise ship, as of 3rd April 2020 . Based on this ubiquitous and drastic spread of COVID-19 all over the world, World health Organization has declared COVID-19 as a pandemic on 14th March, 2020 [7,8]. Of these 205 countries, India now has the largest outbreak of COVID-19 in South-East Asia [5,9]. In spite of slow spread and low initial death rates due to complete lock down and many other governmental precautionary measures throughout the country, India expects to see a rapid increase in COVID-19 cases and fatalities soon since it is a hotspot of comorbid disorders including cardiovascular disorders (CVDs), hypertension and diabetes especially in elderly people(10-12). Current study has thus evaluated those existing comorbid factors along with case fatality rate of COVID-19 in India and compared the same with top ten COVID-19 affected countries in the world. To understand the risk of fatalities in India, a calculation of deaths or fatalities per million populations in a country was also performed and compared the same with top thirty-five COVID-19 affected countries in the world. Finally, some preventive measures have been highlighted to take necessary actions to stall COVID-19 related deaths of the most vulnerable elderly Indians. The later includes but not limited to increase supply of COVID-19 test kits and bed capacities in hospitals along with sufficient number of ventilation systems.
The First Three COVID-19 Cases in India Were Reported in Kerala When Indian Students Returned from Wuhan
During 30th January to 2nd February 2020, three Indian students from Kerala who were all studying in Wuhan, China, were repatriated to India and detected with COVID-19 infection . They were quarantined in their homes for 14 days and successfully recovered within few days . Most of the initial COVID-19 cases in India were evolved in the people with prior foreign visits including China, Italy, USA, UK, Iran, Japan, South Korea and so on . Thus, seven most important airports of India (namely, Chennai, Bengaluru, Hyderabad, Cochin, Delhi, Mumbai and Kolkata) carrying maximum international flights were monitored for COVID-19 symptoms, especially by using infra-ray-based body temperature measurements and whomsoever were detected with its symptoms were immediately quarantined in local isolation centers or at their respective homes .
Travel Restrictions and Domestic Containment across the Country
Even with those initial precautions, COVID-19 cases continued to increase in India and social contact-based cases started evolving which resulted in a number of casualties where the victim get the infection from his/her relatives etc. [15-19]. As such, schools, cinema halls, public gatherings were all closed followed by restrictions of all international flights (with few exceptions) from landing on Indian airports since 00 h of 22nd March,2020 . The, containment was further extended by shut down of all domestic flights and trains of the entire country since 25th March 2020 [21,22]. The country goes on complete lock down initially for 14 h on 22ndMarch with Janata Carfew and then continuously for 21 days from 24th March, 2020 [22,23].
21-Day Long Lock Down Made Indians United to Handle Country’s One of The Worst Socio-Economic and Health Challenges Due to COVID-19 Outbreak
Main aim of this lock down was to break the chain of spread of COVID-19 cases in India . This lock down also helped India prepares to get ready for upcoming challenge for the country to manage increased COVID-19 cases in next few weeks. This was initiated with transforming multiple AC coach trains into multi-specialty mobile hospitals containing ventilators and what’s not, in just 24 h . It was an example of not only technological advancements in India but also united working endeavor of multiple ministries, fields of experts and plans of intelligence with a common aim to not transfer patients to a specific physical location of COVID-19 treatment hospital but the mobile hospital instead to reach every remote or urban place across India! Entire health care system, police forces, many NGOs, celebrities and ordinary civilians put their hands together, respectively to provide treatment for the victims, protections and free-foods as well as financial ailments to the needy Indians especially who depends on daily wages, during this essential lock down . This early lock down during India’s lower COVID-19 cases is going to make a huge difference compared to other severely affected countries in the world with immense promise to have slower spread of the infection and faster flattening of the curve . Government also declared multiple economic grants to aid the economic loss during this outbreak [9,25]. This lockdown also decreased the level of pollution to a bearable level .
State and Union Territory-Wise Cases in India
Since the identification of first travel-relatedCOVID-19 cases in Kerala, the number of people confirmed to be infected in India increased slowly till mid of March but now rapidly [9,25,27]. Till 3rd April, 2547 cases are identified in India with 66 deaths occurred (Table 1 and 2) [5,9,25]. Figures 1, 2 and 3 show the Indian states and union territories affected by the pandemic. The country is going to face its greatest health crisis in more than last 70 years. The pandemic depicts how rapidly and easily a new virus can spread through local transmission in an ingenuous population. State and territory-wise existing and new cases of COVID-19 in India are shown in main text table 1 and Supplementary table 1 (Available in PDF), respectively.
Table 1: 2020 SARS-CoV-2 pandemic in India by states and union territories.
State and union territory-wise map of the pandemic COVID-19 cases in India (as of 3rd
April, 2020)(25). Adopted from Night Lantern’s own work based on data obtained from The Times of India and NDTV. CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=86506269
Evolving COVID-19 cases in India (till 3rd
April, 2020). Please right click on the image and play the video
to see date and state/territory-wise increase in COVID-19 cases in India . Adopted from Shanze’sown work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=88600908
Fatalities with Foreign Travel History
Out of current 66 COVID-19 casualties in India, 13 had previous foreign travel histories (Table 2) [5,9,25]. On March 10, a 76-year-old man died in Karnataka who had travel history to Saudi Arabia, and then another man of 64-year age died in Maharashtra on March 17, who had travelled to Dubai, United Arab Emirates recently [15-18,28,29]. On March 19, another man of 72-year age died in Punjab who had travelled to Germany via Italy [30,31]. While, all of them were elderly and vulnerable patients of COVID-19, first surprise came when a middle-aged man of just 38-year-old died in Bihar on March 21, with a travel history to Qatar. Few other deaths with previous foreign travels include 63-year-old male (March 22) died in Maharashtra who traveled from the United Arab Emirates via Ahmedabad, 69-year-old male Tibetan who died (March 23) in Himachal Pradesh traveled from the United States, a 8-year-old female who died (March 23) in Gujarat and traveled to Saudi Arabia, 75-year-old female who died (March 24) in Karnataka and traveled to Mecca, Saudi Arabia, 65-year-old male who died (March 225) in Jammu and Kashmir who came from Malaysia and Indonesia, a 60-year-old male (Yemeni) who died (March 28) in New Delhi and traveled from Yemen, March 28, a 69-year-old male who died in Kerala and traveled from Dubai, United Arab Emirates [32-39]. Later on, COVID-19 cases increased sharply mainly due to local transmissions since all international travels banned on 23rd March onward.
Fatalities from Local Transmissions
First social transmission related COVID-19 casualties in India was reported on March 13 2020 when a 68-year-old woman was confirmed to be infected from her son as a carrier of COVID-19 who had a travel history to Japan, Switzerland and Italy [17,19]. Then, on March 22, a 63-year-old male died in Maharashtra , a 67-year-old male died in Gujarat [41,42], on March 23, a 55-year-old male died in West Bengal , on March 24, a 65-year-old woman died in Maharashtra , on March 25, a 54-year-old male died in Tamilnadu and a 64-year-old woman died in Madhya Pradesh [45,46], on March 26, a 65-year-old woman died in Maharashtra, all of them had no previous foreign travel history [47,48]. Casualties due to local transmissions continues in higher rates since 27th march and are beyond the scope of describing here in texts, rather all of them are tabulated in Table 2, below.
Early-Stage Disease-Wise COVID-19 Fatality Rates in India by Underlying Health Conditions
Like every other country Indian COVID-19 pandemic did not leave a specific age group from its fatal effects (Table 2). However, with increased chances of comorbid disorders in the elderly people, COVID-19 could severely affect the aged person mostly resulting in as many as 45 deaths among total 66 COVID-19 deaths till 3rd April, 2020 (Table 2). A disease-wise fatality rate (DFR) of COVID-19 was calculated based on the corresponding comorbid disorder present in COVID-19 fatalities by dividing the total number of COVID-19 deaths carrying a particular comorbid disease by the number of confirmed COVID-19 deaths in India (till 3rd April, 2020) multiplied by 100. The result indicates that diabetes (26 out of 66 deaths, 39.4%), cardiovascular ailments (22 out of 66 deaths, 33.3%), hypertension (17 out of 66 deaths, 25.8%), respiratory ailments (10 out of 66 deaths, 15.2%)and kidney diseases (7 out of 66 deaths, 10.6%) remained the highest causes of COVID-19 related DFR in India which was expected since India is known as a hotspot for both kidney and heart diseases along with many cities which are highly polluted (Figure 4) [10-12,91]. While, as much as 31.8% (21 out of 66) deaths reported without any health issues which may actually be due to non-conductance of proper diagnosis of the COVID-19 infected died person for his/her underlying health conditions, if any. Nevertheless, this high % of fatalities in healthy Indians also signifies the high infecting abilities of SARS-CoV-2 irrespective of comorbid conditions. Thus, not only elderly people or weak people of the country, everyone should maintain social distancing and avoid contacts with any COVID-19 infected patient to minimize the risk of transmission of infection.
Table 2: Details of COVID-19 deaths in India. *M = Male; W = Woman.
Figure 4: Corona virus early stage disease-wise fatality rates (DFR) by underlying health conditions in India (as of 3rd April, 2020). Early-phase outbreak of COVID-19 in India indicates that the chances of infection increases with presence of comorbid disorders.Values indicate % DFR calculated as the ratio of total COVID-19 deaths carrying a particular comorbid disorder divided by total COVID-19 deaths in India (as shown in table 2) multiplied by 100using data obtained from [5,9,25,27,92,93]. Parentheses indicate the ratio of absolute numbers of COVID-19deaths carrying each comorbid disorder divided by total COVID-19 deaths in India as of 3rd April, 2020.
Comparison of COVID-19 Case Fatality Rates between India and Top Ten Affected Countries in the World
COVID-19 case fatality rates (CFR) for India and other top ten countries, namely USA, Italy, Spain, Germany, China, France, Iran, UK, Turkey, Switzerland were calculated based on the corresponding country’s ratio of number of total COVID-19 deaths divided by the total number of COVID-19 confirmed cases (till 3rd April, 2020) taking data available from Worldometer and “https://ourworldindata.org” sites as well as from the “Global Covid-19 Case Fatality Rates” of the Oxford University site(5, 92, 93). Figure 5 is showing the COVID-19 CFR of India and other ten countries as well as average CFR of the whole world. It is imperative that although current number of cases and fatalities are far less in India, CFR is higher than Turkey and Germany and almost similar to USA indicating that India is also expecting a boom of COVID-19 cases soon while keeping a low CFR near 2.6 to 3.0. However, CFR is a poor measure of mortality risk of a country due to COVID-19 since every country has different numbers of population density and thus say for example, a high CFR in a country with low population density poses a risk of only lower number of total mortalities compared to a lower CFR in a highly populated country like India.
Figure 5: Comparison of COVID-19 CFR of India with world’s most affected top ten countries. Values indicate % COVID-19 CFR calculated as the ratio of total COVDI-19deaths divided by its total infected cases in the corresponding country/world multiplied by 100 using data obtained from [5,9,25,27,92,93]. Parentheses indicate the ratio of absolute numberofdeaths and cases of COVID-19 in a correspondingcountry/world as of 3rd April, 2020.
Comparison of COVID-19 Deaths per Million Populations of India and That with Top Thirty-Five Affected Countries in the World
A comparison of COVID-19 deaths per million population of a country can give more realistic estimation of rates of mortalities in a highly populated country like India. As such, this calculation was made using data available from Worldometer, European CDC and “https://ourworldindata.org” sites for India and its superseding 35 countries in the list with highest number of COVID-19 cases in order [5,9,25,27,92,93]. For example, calculation of deaths per million population in India was made by dividing 66 total COVID-19 deaths in India with its population in million (~1300 million) resulting in a value of 0.05 (Figure 6) [5,93]. The combined data for all 35 countries along with India as shown in figure 6 below indicates that India has a very low COVID-19 deaths per million population which is far better than all its preceding 35 countries in terms of higher number of COVID-19 cases [5,45]. This also suggests that India should expect lower number of deaths per million population due to COVID-19 cases in future since in spite of first detected case in the country was on 30th January and even after spending 62 additional days, the rate remains equally low as of 3rd April, 2020. However, since India has a very large population of 1.3 billion, thus total number of deaths might increase dramatically even though the deaths per million people remain say for example as low as just 10 which will still result in 13,000 COVID-19 deaths in India.
Figure 6: Comparison of number of COVID-19 deaths per million population (in a country) in India with world’s most affected top thirty-five countries as of 3rd April, 2020.Calculation of deaths per million population in India/top 35 countries/world was made by dividing total number of COVID-19 deaths (as of 3rd April, 2020) in the corresponding country/world divided by its population in million taking data available from [5,9,25,27,92,93]. India’s early COVID-19 deaths per million populations are very low indicating a lower mortality rate is expected during further spread of the pandemic in the country.
As mortality and severity of illness are correlated to both age and comorbidities in general in India, having strategies to safeguard these high-risk groups will provide adequate protection from COVID-19 infections. Moreover, till now India has completed only 47,951 tests (or 35 tests per million population of India) for the COVID-19 infection which is far less than expected to do for a highly populated country like India and thus needs to increase the test number rapidly to identify, isolate and provide treatment of more number of upcoming patients. Early access to medical care including ventilation facilities is the need of the hour on which the government needs to increase the speed of work to improve chances of survival. Additionally, rigorous medical history taking, diagnosis and scoring for comorbid disorders which are currently not done properly as discussed above may identify the high-risk groups faster. Although age/age-group of every COVID-19 fatalities are well documented in India, unlike most of the developed countries currently India lacks a similar age-group database for every COVID-19 infected cases in the country which is otherwise a must to identify most vulnerable age-groups to design better strategies to manage the current as well future corona virus pandemics. A high COVID-19 fatality of 21 Indians (out of 66 total) who did not had any detected health issues (Figure 4) and casualties in younger COVID-19 cases (Table 2) prompted us to suggest every Indian to follow social distancing, proper hygiene and washing hands or body surfaces frequently irrespective of their health history or age-groups, respectively to reduce the risk of infection and possible casualties. Point of care-based treatment will also help to flatten the COVID-19 infection curve earlier and with a smaller number of casualties. An exponential increase in the COVID-19 cases is expected in India soon which will certainly result in severe socio-economic loss in the country unless necessary steps are taken. These must include but not limited to ensuring availabilities of essentials goods including drinking water, essential foods, medicines and financial arrangements for the needy people especially who are dependent on daily wages.
Authors thank the colleagues and faculties of the Department of Biochemistry, UDSC for various scientific discussions related to COVID-19 pandemic in India.JKD thanks the Central Council for Research in Homoeopathy, New Delhi for providing fellowship.SKD thanks UGC for providing CSIR-UGC NET fellowship and Prof. Eddy Arnold, Rutgers University, USA for providing post-doctoral associateship. JKD thanks Dr. Bindu Sharma, Scientist-4, Central Council for Research in Homoeopathy, New Delhi for her continuous encouragement for drafting this manuscript. This work was supported by the Dey Health Care and Research Foundation, West Bengal, India (http://dhcrf.org/).
Conflict of Interests
Authors declare no conflict of interest.
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