Monday, June 24, 2024

A fresh COVID-19 data interpretation approach

There is a fresh spike in COVID-19 cases in India, a surge that is attributable to at least three reasons. One, the XBB.1.16 recombinant variant which has higher transmissibility in comparison to other circulating variants. Two, the recent viral flu surge (H1N1 and H3N2 sub-types) which resulted in health-care providers recommending higher COVID-19 testing. Three, the availability of COVID-19 testing at low cost and the COVID-19 surge that is nudging people who have a cough and cold to get themselves voluntarily tested. This has sparked off discussion that a fresh wave is imminent in India. In fact, since the last and third national COVID-19 wave in January 2022, there have been a few spikes every now and then, with each episode triggering fears of a fresh wave (fortunately, these fears did not come true).

Impact of ill-informed discourse

In the last three years, there has been another development that has been cause for concern. A few groups have emerged which continue to, and very vocally, argue that COVID-19 is very dangerous and has not gone. These groups, or the ‘Covid-forevers’, bearing an uncanny similarity with two century-old anti-vaccination groups, invoke ‘post-COVID’ and ‘long COVID’ as arguments to say that even though infections are mild, COVID-19 continues to be a serious disease. Their signature mark is they do not want to discuss anything else other than COVID-19. Based largely in the West, the ‘membership’ of these groups is expanding in India.

Also read: Explained | Should India worry about rising COVID-19 cases?

There is every epidemiological evidence to show that COVID-19 has become endemic in India. However, a disease becoming endemic does not mean zero cases or no seasonal surge. The last pandemic before COVID-19 was that of the swine flu (H1N1) pandemic, of 2009-10. It was caused by influenza A virus new subtype H1N1. It was a pandemic that got over in 2010. Since then, the H1N1 subtype is causing a seasonal rise in flu cases, and is the most commonly circulating influenza A virus subtype. In the past two months in India, there has been a lot of news about the H3N2 flu, but the other and more commonly circulating subtype of flu has been that of H1N1. However, and rightly, we have not responded to H1N1 like the way we did in 2009-10. And this should be our response as well to the variants of SARS-CoV-2.

We need to be mindful that public discourse on fresh waves is not completely innocuous. Though the medical impact has been blunted, any discussion about a fresh surge has a social impact in terms of creating panic and fear, apprehensions in parents about sending their children to school (thus, causing learning loss) and on livelihoods. The burden of these indirect impacts is borne disproportionately by the poor, the disadvantaged and those whose voices rarely matter.

Drop the old parameters to track disease

One of the reasons for a fresh discourse on a wave is a new sub-variant XBB.1.16 (which essentially is a recombinant of the Omicron variant). It is one of 100-plus recombinant variants and one of 700-plus SARS-CoV-2 variants which have been reported in the last three years. It is not a variant of concern as Alpha, Beta, Gamma, Delta and Omicron were. In the last three years, on average, around four to five new variants of SARS-CoV-2 have been detected every week. Variants will continue to emerge, and thus we should embrace the rise and fall in COVID-19 cases.

For a country with a population of 1.4 billion and with SARS-CoV-2 around, a certain number of cases will be reported on a sustained basis. Let us understand this using the example of tuberculosis (TB), another respiratory disease. Every day, an estimated 7,000 new TB cases happen in India. The bacterium for TB is far more stable while SARS-CoV-2 is prone to mutations and variants. Therefore, one of the first steps in India for the experts is to arrive at a consensus on the number of COVID-19 cases which are expected even when the disease is endemic. This could be in terms of absolute numbers or new cases per 1,00,000 people per week or month.

Another key reason why every spike in cases fuels talk about a fresh wave is the continued use of older parameters of daily new COVID-19 cases. However, there is a clear dissociation between infection and disease since the emergence of the Omicron variant.

Editorial | No cause for alarm: On the Omicron recombinant XBB.1.16 in India

In the last eight weeks, though the number of daily new COVID-19 cases has gone up by nearly 55-fold, from a very low base, the number of hospitalisations and deaths has changed only marginally. This is why focus on daily new cases has only very limited public health relevance, if any, now.

There is a need for a more objective approach to define parameters to track COVID-19 situations. In public health, the approach should be to collect information to intervene. With targeted and voluntary testing, daily COVID-19 cases and test positivity rates are a very weak parameter as well as a flawed approach — it is influenced by prescriber and citizen care-seeking behaviour. Therefore, a better parameter would be to focus on and track moderate to severe illnesses and hospitalisation.

This needs to be made even more granular by further desegregation of data by those who were admitted after COVID-19 infections, and those who were already in hospitals and incidentally tested positive. At this stage when COVID-19 is endemic in India, the dashboard parameters of cumulative cases, cumulative hospitalisation and cumulative deaths are also not relevant.

It is time we start tracking, comparing and analysing COVID-19 data on a monthly and weekly basis for the calendar year. New dashboard indicators should begin tracking for the year 2023 onwards, which will give us an idea of trends — these were obliterated by cumulative data for the last three years.

Various forms of surveillance (genomic, wastewater, influenza-like illness and Severe Acute Respiratory illness) are going to be integral tools for response in the long term. However, some of these datasets should be linked to clinical outcomes. The multiple agencies working in these systems should work with clinicians, data, and public health experts to make real time inferences. The government should also put out this data in the public domain so that independent researchers and academicians can analyse and support the response process.

COVID-19 has become endemic in India and the medical impact of the disease is low. But the virus is ubiquitous.

At this stage, India’s response has to be calm and evidence guided. Governments should focus on the public health aspects of rolling out new parameters to track the disease, develop strategies to fight misinformation and ‘COVID-forevers’, and launch sustained health communication messages about preventing all respiratory illnesses. There is no role of any specific targeted intervention for COVID-19 only. For citizens, it is important not to panic with every spike, not be influenced by unverified social media messages, and to learn to conduct individual self-assessment of risk and take preventive measures according to the health risk.

ECG approach for COVID-19 data response

Looking ahead, the response to the evolving COVID-19 situation needs to be determined by a holistic assessment of the situation through careful examination and interpretation of ECG data: Epidemiological (trend in moderate to severe cases); Clinical (change in symptoms, hospitalisation and outcome), and Genomic and other surveillance (variants, etc.) data. Most importantly, our selection of data for decision making needs to be objective, factoring in the evolving epidemiology of COVID-19 and being solution oriented.

Dr. Chandrakant Lahariya is a consultant physician and epidemiologist. He is the founder-director of the Foundation for People-Centric Health Systems, New Delhi

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