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Manipur: Data indicate uncontrolled outbreak, increase in the spread of SARS CoV2 virus

Figure No. 2 Daily reported new cases and death

Interpretation based on the value of the transmission indicators, Manipur is having an uncontrolled outbreak and increase in spreading of SARS CoV2 virus. State surveillance and outbreak response team should be alert of surges in cases by properly maintaining and monitoring the contact tracing database in particular localities.

By Saya Okram

One needs to track numbers to understand how the epidemic unfolds. Timely as well as accurate real-time data is the key to capture the current situation. Due to the dynamic nature of an infectious disease outbreak such as covid 19, a few weeks old data will tell little about the current situation. Data are important to make decisions by policymakers and implementers on what public health interventions are needed to be implemented at which states or districts or locality, to calculate which section of the population is at high risk, are the new cases showing exponentially increasing trends depicting an epidemic?  A well-analyzed and clear numbers are also required by citizens to decide their actions on daily activities depending on the risk of infection and how fast the virus is transmitting at their locality. However, Since the inception of covid 19 pandemic, issues on the drought of data, inaccuracy, and lack of transparency on data sharing have been the major topic of discussion, especially in India. We do not have any government websites with epidemiologically meaningful data and indicators on covid 19. Many data scientists, epidemiologists, and public health experts have been depending on the crowd-sourced database maintained by volunteers for analysis of covid 19 epidemic in India and its different states.

At present, overall epidemic indicators of India are doing good with 7 days moving average Test positivity rate (TPR) of 2.3%, the negative growth rate of -20.8% in last 14 days and effective Reproductive no. (Rt) below 1 (0.93).  There has been a sharp decline in daily new cases for the last 5-6 weeks after experiencing the peak of the second wave during mid of May. However recent trend shows that this sharp fall in new cases has stopped and stable in 42k. This could be due to the positive growth rate of new cases in Northeast India (Manipur, Mizoram, Meghalaya, Arunachal Pradesh, Tripura, and Sikkim) and southern state Kerala while rest of the country have negative growth rate in last one week.

Covid 19 data analysis: Manipur State

How far and fast the virus transmission is happening, are we doing enough testing to detect the epidemic, are our health system responding well are few important questions we need to ask to understand the epidemic situation of covid 19. There are epidemiological indicators that can be computed to respond to the above questions and make policies decisions given that there is accurate and timely available data. Even our state, Manipur is also not an exception when it comes to the drought of essential epidemiologically database on covid 19. Based on the available data on government portals and officially release numbers following indicators are computed to make a better sense of what is really happening with covid 19 epidemic at Manipur.

How far and fast the virus is transmitting?

Indicator1: Effective Reproductive Number (Rt). It is defined as the average number of people infected by a single positive case at a particular time period during an outbreak. It an important indicator to measure the rate of spread of the virus. From the Rt value we can tell the severity of the outbreak, and value below 1 indicates that the outbreak is under control. Rt of Manipur based on data computed till 28th June is 1.11. After maintaining the Rt value below 1 for 23 days (27th May to 18th June), there has been a steady increase in this value as shown in figure No. 1

Indicator2: New daily cases count and growth rate of new cases. The growth rate of daily new cases tell us how many more positive cases occur today compare to last 1 or 2 weeks. Based on 7 days moving average calculation, there was a declining trend in an average of daily new cases for more than 3 weeks during May 31st (875) to 26th June (540). However, trend analysis of growth rate over past two weeks shows the increasing trend of new cases by 27% with a daily average of 697 cases (as on July 8th, Figure No. 2).

Interpretation based on the value of the transmission indicators; Manipur is having an uncontrolled outbreak and increase in spreading of SARS CoV2 virus.

Are we doing enough testing in comparison to the size of the epidemic and rate of transmission?

Indicator1: Daily test done. Over the last 2 weeks daily test has decreased by 3.17%. From figure No. 3, we can highlight the decreasing and plateauing number of tests done daily.

Indicator2: Test positivity rate/TPR. It is defined as number of covid test done that come back with positive result. 7 days moving average TPR of Manipur is 15.3% and trend of TPR is increasing by 3.28 % in last 2 weeks. A detail analysis of data on number of tests done and TPR shows that along with the increasing number of tests, there was sharp decline of TPR. This highlights the importance of the increasing number of testing (Figure No. 3).

What do these numbers tell us about the testing?  Compare to the scale of the epidemic happening at the state, the testing level at Manipur is not enough and we are not doing proper surveillance of the community to detect any localized surge of cases. This data highlights that contact tracing is limited to people with high risk only leading to the missing of the new chain of transmission in the community. One drawback in the calculation of TPR is the non-availability of data on daily test done for each district in Manipur which further restricts the calculation of district-wise TPR. It a key indicator to assess the epidemic situation geographically at the state and to allocate the inadequate health care resources based on the severity of the outbreak and for effective management of covid 19 situations.

How well our health care system is responding?

Indicator 1: Case fatality rate/CFR: It is defined as no. of death out of total positive cases. And CFR of Manipur state is 1.81%. On average we have 697 new cases in a week and out of these, 11 death cases occurred which is 7th highest CFR all over the country.  Trend analysis of CRF for last 2 weeks shows fluctuation in value within + – .5.

Indicator 2: Vaccination coverage. Based on latest data available (July 5th), 22.06% of the population has received one dose of the vaccine and as for completed doses/ 2 doses, only 2.51% of the population are inoculated with complete doses (Figure No. 4). Though there has been an increasing number of doses inoculated over past weeks, Manipur rank 3th among the 10 states with the lowest vaccination coverage (completed doses) all over India. These indicators show the lacunae in implementation of care cascade such as triaging of cases and clinical management of covid 19 cases at the state and our health system still needs to strengthen its response to the epidemic. Apart from these above-mentioned indicators, for effective health system response, state also should give importance to collecting and preparing database on hospitalization, bed occupancy, the need of oxygen support, ICU beds, separate contact tracing data. Such data should be made available at the public domain for rigorous data analysis and inputs by public health professions outside the government health system.  

Way forward

Strengthening the implementation of already available cost-effective and comprehensive public health interventions and social measures (which works for all kinds of variants of SARS CoV2) such as active surveillance of influenza-like illness, being serious in spending time, money and energy in test, trace, isolate and treat strategy, use of appropriate and effective mask, managing 3C’s- crowded places, close-contact settings, confined and enclosed spaces, more focus on ventilation & natural airflow and scaling up vaccination coverage are ways to be out of this pandemic.  Studies have reported ‘over dispersed’, as an epidemiological characteristic of SARS CoV2 transmission which means that this virus tends to spread in cluster/super spreader rather than steady manner.

Therefore, health authorities of the state should focus on doing backward contact tracing means searching for answers to the question ‘who infected this person and how?’. This answer will help the pandemic decision-makers and epidemic investigators in identifying the nature of transmission which is being dominantly prevalent in the state, the reason behind clustering of cases in a particular locality, in knowing which activities (family members or gathering at the locality, social mixing, workplace, market areas, cultural or religious events), which environments setting (close or open spaces) attributes to cluster burst outbreak in a district. Based on the findings of such rapid case study we can prioritize the epidemic control activities to prevent further spread.

The epidemic response is all about timely and rapid response, therefore state surveillance and outbreak response team should be alert of surges in cases in the particular locality by properly maintaining and monitoring the contact tracing database. We need to have a consistent policy in place guided by data and timely analysis to lower the risk of exposure in everyday life as prolong lockdown and restriction is definitely not one of the public health tools to contain the virus in long run. Shifting the burden of handling this confusing crisis of covid 19 to the shoulder of citizens completely without any sustainable public health interventions and social support and blaming the behaviors of victims without effective communication and information would be epidemiologically very stupid on the part of government health authorities. As a Japanese epidemiologist said about Japan’s approach to overdispersion of covid 19 “Looking at the forest and trying to find the clusters, not the trees”. I hope, pandemic decision-makers of the state understand that Covid 19 is still a public health crisis rather than an individual health problem that cannot be treated by very individualistic medical intervention only though Covid 19 has become all sort of possible political, economic and social crises in the world lately.

Source of data and graphs:  (Analysis done with data available till 08/07/2021)

(Dr Saya Okram is an epidemiologist and public health research consultant)  

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