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Coronavirus in South Asia: Is low testing hiding scale of the outbreak?

August 17, 2020
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Cases in Pakistan are on a downward trend
Cases in Pakistan are on a downward trend

India has the third largest number of coronavirus cases in the world after the US and Brazil with more than 2.6 million infections reported so far.

That’s not surprising given its huge population, but what is the scale of the epidemic in neighbouring countries?

Is the outbreak growing in South Asia?

With cases doubling every 24 days, India’s numbers have been rising fast after it relaxed a strict lockdown, imposed in the last week of March.

It’s seen record numbers of daily cases, as it continues to ramp up its testing, currently conducting over 700,000 tests each day.

Can India test a million people a day?

Chart showing cases in S Asian countries- UpdatedChart showing cases in S Asian countries- Updated
Chart showing cases in S Asian countries- Updated

However, other countries in South Asia seem to be on a different trajectory, with confirmed infections showing what seems to be a downward trend, after steep increases in May and June.

In Pakistan, with the second-highest number of total cases in the region, there is cautious optimism after cases fell from a peak in mid-June of almost 6,000 new infections each day, to less than 1,000 by August.

And Bangladesh, which had a total of 279,144 cases as of 17 August, saw its daily cases peak between mid-June before they dropped in the last week of July and beginning of August.

There were concerns about a possible rise in infections after Eid celebrations in Pakistan and Bangladesh at the end of July.

While there seems to be one happening in Bangladesh, Pakistan’s infections have continued to decline.

Boy in Afghanistan gets his temperature checkBoy in Afghanistan gets his temperature check
Boy in Afghanistan gets his temperature check

Afghanistan’s numbers have been falling after a spike in mid-June, although there are questions about the reliability of its official figures.

A recent survey conducted by their health ministry showed that more than a third of the country’s population could have been infected.

In Nepal, the government imposed a lockdown which went on for 100 days, during which time most cases were in areas bordering India. It’s imposed new local restrictions in several provinces, as infections have been going up in some densely-populated urban areas.

Sri Lanka has much lower levels of infection. It has had spikes in cases since April, but has had relatively low numbers. It has implemented a tight lockdown, traced contacts of positive cases and imposed strict quarantine rules.

Sri Lanka imposed tough restrictions on movement across the islandSri Lanka imposed tough restrictions on movement across the island
Sri Lanka imposed tough restrictions on movement across the island

“A thorough contact-tracing system was in place using public health officers, local police, intelligence officials and local administrative officials,” says BBC Sinhala’s Saroj Pathirana.

How much testing is done in South Asia?

South Asia has about a quarter of the world population, but only 15% of total recorded infections are from this region.

“Total number of cases per million in India and the rest of South Asia are low, but so is the number of tests per million,” says virologist Dr Shahid Jameel.

He says that while total numbers of tests in these countries seem high, they are not when you factor in population sizes.

India has has so far conducted 30 million tests. Pakistan has carried out more than 2.2 million.

Bar chart comparing different countries on testing- UpdatedBar chart comparing different countries on testing- Updated
Bar chart comparing different countries on testing- Updated

But per capita tests in these countries are far lower than in other countries.

And in Pakistan and Bangladesh, testing levels have fallen, which will have had an impact on the number of positive cases recorded.

Pakistan conducted over 31,000 tests per day in June. And on 27 July, a record 41,666 tests were conducted – the highest number ever done in Pakistan.

But the numbers of tests fell sharply over the following days, declining to a low of 10,759 on 3rd August, before rising again.

A government survey conducted in July around the Pakistani capital, Islamabad, suggested that nearly 300,000 people may have been infected by the virus there alone, a majority of them asymptomatic.

Bangladesh’s testing numbers have also gone down after the government introduced a high testing fee in July. There’s also been a scandal around the sale of fake negative test certificates.

In Nepal, a total of 517,907 tests had been conducted as of 16 August, with just over 10,000 tests a day.

Bar chart showing countries rate of testing per confirmed case - UpdatedBar chart showing countries rate of testing per confirmed case - Updated
Bar chart showing countries rate of testing per confirmed case – Updated

Testing data for Afghanistan is not available and the Red Crescent has expressed concern that the actual number of cases could be much higher than officially announced.

The World Health Organization (WHO) has set a benchmark range for adequate testing of between 10 and 30 per confirmed case in a country or region.

South Asian countries fare poorly on this measure.

Russia and Japan, which have populations similar to Bangladesh, are testing far more widely finding a positive case for every 53 and 19 tests respectively. But Bangladesh is identifying one positive case for every five tests carried out – well below the WHO benchmark.

Nepal was finding a positive case for every 20 tests until August 16, down from 25 tests as of June 14.

What about the death rate in South Asia?

Deaths recorded in these countries are far lower than in western countries, whether we look at absolute numbers or per head of population.

Click here to see the BBC interactive

This appears to be an encouraging sign, but there are questions about the reliability of data in a region with relatively low levels of public health spending.

“Many deaths are not reported within the vital registration system and the causes of deaths are incorrectly classified,” said Professor Kamran Siddiqi, a public health expert at the University of York.

But Dr Shahid Jameel says even if the deaths are under-reported, the difference from other areas of the world is “quite stark”.

“The most plausible explanation is that the populations in South Asia are made up of far younger people than say in Europe and the US,” Prof Siddiqi says.

Additional research by Waliur Rahman Miraj in Dhaka and Rama Parajuli in Kathmandu

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