|Year : 2022 | Volume
| Issue : 1 | Page : 44-49
COVID-19 pandemic: Probing the dynamics in the North Himalayan state
Priya Sharma1, Saurabh Rattan1, Vikram Katoch1, Gurdarshan Gupta1, Jai P Narain2
1 Department of Health and Family Welfare, Kangra, Himachal Pradesh, India
2 WHO Regional Office for South East Asia Region, New Delhi, India
|Date of Submission||29-Jul-2021|
|Date of Acceptance||11-Jan-2022|
|Date of Web Publication||30-Jun-2022|
Distt Consultant Cum Dakshta Mentor, O/o Chief Medical Officer, Kangra, Dharamshala, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Coronavirus disease or COVID-19 emerged in December 2019 in China and thereafter spread to all regions of the world including India. In the Himalayan state of Himachal Pradesh, India, the first case was identified in the month of March 2020. As the most populous district of the state of Himachal Pradesh, Kangra not only identified the first case in the state but also thereafter suffered disproportionately due to the virus causing severe health and economic disruption. The study was carried out to better understand the pattern and trends of COVID-19 pandemic in the district since its emergence, covering the first and the second wave to use the data to prepare the future course of action.
Materials and Methods: A robust database comprising real-time data in a line list format was created. The observations covered all confirmed COVID-19 cases in the district from March 20, 2020, to June 30, 2021, in terms of disease progression and distribution in time, place, and person, and the possible risk factors for severe disease.
Results: During the study period, 45,871 cases and 1030 deaths were reported in Kangra district, with a case fatality rate of 2.2%. Of the 12 districts of the state, Kangra reported the highest number of cases (22.6%) and deaths (29.7%). Ninety percent of all cases occurred during the second wave. While the first wave peaked in December 2020 with 2596 cases, the highest number of cases occurred in May 2021 when as many as 25,625 cases were reported. The test positivity rate of 15.2% during the second wave which was many times higher than that seen during the previous year. The case fatality rates during the first and second waves were 2.2% and 2.1%, respectively.
Conclusions: The study highlights an explosive surge in COVID-19 cases during the second wave, indicating the highly infectious nature of the virus. While absolute number of deaths was several times greater during the second wave, the case fatality rates did not differ greatly between the two waves.
Keywords: COVID-19 pandemic, epidemiology, India, Kangra, trends
|How to cite this article:|
Sharma P, Rattan S, Katoch V, Gupta G, Narain JP. COVID-19 pandemic: Probing the dynamics in the North Himalayan state. Indian J Community Fam Med 2022;8:44-9
|How to cite this URL:|
Sharma P, Rattan S, Katoch V, Gupta G, Narain JP. COVID-19 pandemic: Probing the dynamics in the North Himalayan state. Indian J Community Fam Med [serial online] 2022 [cited 2022 Aug 17];8:44-9. Available from: https://www.ijcfm.org/text.asp?2022/8/1/44/349387
| Introduction|| |
Coronavirus disease or COVID-19 caused by SARS-CoV-2 emerged in December 2019 in Wuhan city of China and thereafter spread to all regions of the world including India. On January 30, 2020, the World Health Organization (WHO) declared it a public health emergency of international concern and later characterized it as pandemic. As a result, the global community has been living on the edge since the early 2020. The extraordinary impact of the COVID-19 disease has affected all aspects of human race and continues to expose our vulnerability and create uncertainty across economic, social, and medical fronts. It has caused the health system to breakdown. The pandemic response demands action on many fronts, from prevention to testing to treatment. To prevent the devastating health consequences in the future, there is an urgent need for evidence base for deciding how to enhance our preparedness and response capacity if the pandemic continues to evolve and pose a grave threat to the health and development. A well-coordinated approach is necessary to tackle this global crisis.
The early studies have documented that the severe and life-threatening disease occurs more in the elderly as well as those suffering from chronic diseases with concomitant pathologies. However, during the second wave of the pandemic, it was equally seen in the other age groups. The experts generally agree on the magnitude, potential for harm, and potential for the reduction with appropriate COVID-19 precautionary measures to lower the effect of the disease. The exponential growth in the number of coronavirus cases has occurred worldwide. Globally, as on July 12, 2021, there have been 186,638,285 confirmed cases of COVID-19 including 4,035,037 deaths reported to the WHO. During the same period, India reported 30,874,376 cases, with 408,764 confirmed deaths.
Himachal Pradesh with a population of 6.85 million is situated in the northern part of India in the foothills of Himalayas, and Kangra is the most populous among its 12 districts [Figure 1]. We describe here the epidemiological features of COVID-19 in the district including the disease pattern and trends over time.
| Material and Methods|| |
A case of COVID-19 was defined as a person with laboratory confirmation of COVID-19 infection by RT-PCR or a rapid antigen test, irrespective of clinical signs and symptoms. To capture the data on all cases and deaths in the district, a robust database comprising comprehensively collected data in a line list format was created by the district health authorities. The study participants were included based on the testing done at flu clinics across various subcenters, primary health centers (PHCs), community health centers, civil hospitals, and zonal hospitals and at medical colleges. Positives from both polymerase chain reaction and rapid antigen tests were taken into account which included testing for primary contacts, for symptomatic individuals from various organizations (tourism, banking sector, education, transport, and hoteliers), and further for other purposes such as travel and new appointments. The basic demographic and illness-related data were entered into Microsoft Excel 2010 and sorted and cleaned for errors. Results comprising descriptive data were obtained and expressed to compare in frequencies and percentages.
| Results|| |
Between March 20, 2020, and June 30, 2021, Himachal Pradesh reported 202,123 cases with 3463 deaths. The first case in the state was a 63-year-old woman, a resident of Kangra district who tested positive on March 20, 2020, and had recently returned from Dubai. Since then, and as of June 30, 2021, a total of 45,871 cases and 1030 deaths were reported in the district of Kangra with a case fatality rate of 2.2%. This represented 22.6% of cases and 29.7% of all deaths reported in the state of Himachal Pradesh. Since facilities for gene sequencing are not available at Kangra, the existence or extent of contribution by various variants in driving the pandemic surge was not possible.
The pandemic however occurred in two waves [Figure 2]. The first wave began in March when the first case was diagnosed. Following a period of low occurrence, the cases began to rapidly increase in beginning of September 2020 and continued till it peaked in December. Thereafter, it showed a downward trend which lasted till the end of March 2021. During this period, the pandemic had accounted for 9578 cases and 225 deaths.
|Figure 2: Distribution of COVID-19 cases from March 19, 2020, to June 30, 2021, Kangra district, Himachal Pradesh|
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Following a short period of lull, the cases again began to increase from April onward signaling the heralding of the second wave. Thereafter, the cases increased quickly and in large numbers, with as many as 1605 cases being reported on a single day, on May 7, 2021. During a short period of 8 weeks, 36,293 cases and 805 deaths were reported during the second wave, which peaked in May, wherein the district witnessed a record number of cases and deaths (25,625 and 559) respectively. Nearly 90% of the total cases recorded in this pandemic period were during the second wave. While there was a three-fold increase in the absolute number of cases and deaths during the second wave, the case fatality rates were not significantly different between first and second wave (2.3% vs. 2.2%) [Table 1].
|Table 1: Some key epidemiological indicators as observed during the first wave (March 2020-March 2021) and second wave (April 2021–June 2021)|
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During the pandemic period, 298,884 samples were tested up to March 31, 2021, out of which 9578 were reported positive with a test positivity rate of 3.2%. Of 237,750 samples tested during April to June 2021, 36,293 (15.2%) showed positive results. While the number of samples collected was lesser than those collected in the past 1 year, the positivity shown was much higher. The test positivity rates started to increase from July 2020 peaking in September at 7% and thereafter started to decline which can be attributed to initiation of rapid antigen testing randomly among the population as well as primary contacts of confirmed cases of COVID-19. In February 2021, the rate was 0.74%. From March 2021, the test positivity rate shot up at an unprecedented rapid pace peaking at 27.8% in the Mid May 2021 and then began to decline sharply to 2.6% on June 30, 2021. The trend indicated that the test positivity rate preceded actual increase in cases at least by a few weeks, thereby providing a useful alert to health authorities of the impending increase in cases that may follow.
Of the cases, 56.6% were male and 43.4% were female, with a female: male ratio of 1:1.3. The difference in gender distribution was statistically significant, with P = 0.006 [Table 2]. Most (41.2%) cases among males were in the age group of 30–49 years, followed by 50–64 years (19.50%) and 18–29 years (19.26%).
|Table 2: Age and sex distribution of COVID-19 cases reported from March 2020 to June 2021, Kangra district, Himachal Pradesh|
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In the peak days of both the waves, it was revealed that highest occurrence of cases was seen in males and in the age group of 30–49 years [Table 3]. In terms of clinical presentation, [Figure 3] reveals 37,167 (81%) persons who tested positive did not present with any symptoms or were asymptomatic, 1199 (3%) had mild illness, while 1872 (4%) had moderate illness, and 5633 (12%) were severely ill requiring medical attention in a hospital. The asymptomatic patients were managed at home and the ones who had issues such as inadequate space for isolation and mild illnesses were isolated in a dedicated COVID care center. Moderately ill patients were treated at hospitals notified as designated COVID hospitals, and the patients who were severely ill were managed at Medical College, Tanda, located about 15 km from the Kangra town. Pneumonia and acute respiratory distress syndrome were the most common complications associated with severe COVID cases; four cases of mucormycosis have been diagnosed so far in the district.
|Figure 3: Clinical profile of Covid-19 cases. Data source: Available from District Database of Kangra. *Data also include cases reported from neighboring states/districts who have tested positive within the jurisdiction of District Kangra|
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| Discussion|| |
Our data from district Kangra show that the COVID-19 pandemic consisted of two distinct peaks representing two different waves. There was an initial upsurge in cases beginning from September 2020 attributed to the rapid influx of Himachal citizens returning to their home state, leading to establisment of human to human transmission in the community. The health department took the lead in the establishment of quarantine centers on borders and COVID control rooms along with the effort of the district administration, which eventually helped in containing the spread of virus to large extent. Subsequently, surge of cases was seen in the 1st week of December 2020 marking as the peak of first wave in the district which corresponds to the mixing of people during social gatherings and to the exhaustive screening following the tourist influx in the winter season at all the major borders of the district and for that matter of the state.
While cases during early part of the pandemic coincided with the cases having travel outside of the state, the subsequent surge of cases or the peak can be attributed to the fact that September to December has the largest number of cultural and religious gatherings. Further comparing the results to the data of Spanish flu 1918–1919, we can very well compare the peaks as the Spanish flu had the same trend in which the first peak had a fewer number of cases as compared to the second wave. The same has been the case with the number of deaths also. Both the surges had peak of 10 days with gradual tapering off. Further, after the 10-day peak period in both the waves, the incidence reduced while the prevalence remained high.
With the remarkable decline in cases, at present, it appears that the worst is over as the number of cases and test positivity rates continue to decline in Kangra as well as across all districts of Himachal Pradesh [Figure 4]. However, the overall positivity rate has declined to less than 5% which were close to 40% between May 3 and 16. Nevertheless, keeping in mind the emergence of new variants such as delta plus, we must remain prepared for the next wave may seem likely, given the prevailing situation. However, we noticed that the increase in test positivity often preceded increase in actual cases, indicating that monitoring test positivity can help in providing a warning signal of impending increase in cases. Such a finding can help the health authorities with time to prepare themselves to respond effectively to a surge in cases that is likely to follow.
|Figure 4: Test positivity rates over pandemic period (March 19, 2020, to June 30, 2021). Source: District database of Kangra, HP|
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Interestingly, the Kangra district data also shows that the death rate was slightly higher in the 1st year of the disease in comparison to the 2-month analysis although positivity was much higher in the second wave, indicating that the second wave was driven primarily by new variant of the virus, which was at least 60% more transmissible than the original Wuhan virus. Sporadic distribution of other laboratory-confirmed strains of virus such as the UK and Delta has come to notice.
Further, the COVID-19 pandemic shows striking similarities to the Spanish flu pandemic of 1918 as well as H1N1 flu of 2009 in many ways. All three had viral origin, the etiology of them remains unknown till date although subsequent association to animals has been made but the causation still remains questionable, the clinical profile of the affected individuals shows similarity, the exceptional similarity in pathogenicity during second waves is some of the most striking similarity. In addition to that, it is a common finding that when one wave ends the level of disease spread falls to some extent which gives an immediate “at ease signal,” which is generally premature which is followed by high positivity rate.,,
The one overriding lesson from the pandemic is that it is exposed the stresses and weaknesses of our health systems. This highlighted the need for a strong and robust health system to tackle such health emergencies. As the government tries to instill the belief in testing, tracing, and treatment strategy, general masses have distanced themselves from undergoing repeated tests. It has become challenging for the health personnel in the current times to undertake testing in the field robustly as the general population still struggles to overcome the barriers such as stigma associated with the disease. COVID-19 has exposed major gaps in the healthcare systems of even the advanced countries of the world. This requires a strong communication campaign to instill in general population, especial youth to practice COVID-19 appropriate behavior. Experience shows that behavior change is best achieved through interpersonal communication by involving the community-based organizations and social media.
The pandemic gives us an insight into the sectoral crisis where urgent and immediate action is needed. It is important to ponder on highlighted facts and develop baseline methods to assess the gaps and lacunae in the system and to timely devise strategies to overcome them.
| Conclusion|| |
The need to develop a decentralized system to achieve health security and sufficient infrastructure to save lives cannot not be underestimated. Investment in public health and primary prevention can deliver significant health and economic dividends. It is important to provide opportunities to youth involved in public health to bring high-quality and specialized care to previously underserved populations and nurture their use to disease. The health facilities at the grass root level such as subcentres, health-care workers, and PHCs need to be strengthened to keep up with the issues that can be dealt with so that tertiary care facilities can be available for the patients needing dire and urgent care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Bedi P, Dhiman S, Gole P, Gupta N, Jindal V. Prediction of COVID-19 trend in India and its four worst-affected states using modified SEIRD and LSTM models. SN Computer Sci 2021;2:1-24.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]