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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 10
| Issue : 3 | Page : 150-157 |
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Andhra Pradesh's COVID-19 pandemic case fatality rate
Venkata Adapa Suresh Babu1, Smitha Sree Adapa2, Hanumanth Narni3
1 Department of Physiology, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Marikavalasa, Visakhapatnam, Andhra Pradesh, India
2 Department of Obstetrics and Gynaecology, Krishna Hospital, Maharani Peta, Visakhapatnam, Andhra Pradesh, India
3 Department of Community Medicine, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Marikavalasa,Visakhapatnam, Andhra Pradesh, India
| Date of Submission | 19-Aug-2020 |
| Date of Decision | 27-May-2021 |
| Date of Acceptance | 21-Jun-2021 |
| Date of Web Publication | 17-Mar-2022 |
Correspondence Address:
Dr. Venkata Adapa Suresh Babu
Department of Physiology, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Marikavalasa, Visakhapatnam, Andhra Pradesh - 530048
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdrntruhs.jdrntruhs_135_20
Background: The first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified in Wuhan, China, in late 2019, the epicenter of the COVID-19 outbreak. In India on January 30, 2020 and in Andhra Pradesh on March 12, 2020 first case was reported. The case fatality rate (CFR) among diagnosed cases is generally about 2%–3% but varies by country.
Aim: To estimate the CFR in Andhra Pradesh during the pandemic in different phases.
Methods: All the secondary data were collected either from the covid19india website or github website or Indian government websites or Andhra Pradesh State government website or media quoting the government announcements January 30, 2020 to August 8, 2020. The CFR was estimated as per the Methods for Estimating the Case Fatality Ratio for a Novel, Emerging Infectious Disease.
Results: In the pre-lockdown phase, the CFR of Andhra Pradesh was 0.00%, Uttarandhra, Central Andhra & Rayalaseema was Nil, and South Andhra it was ranging from Nil-0.00%, In lockdown phase, the CFR Andhra Pradesh was ranging from 1.34 to 42.31%, Uttarandhra - Nil -5.56%, Central Andhra - Nil-100.00%, South Andhra - 0.00-66.67%, and Rayalaseema - Nil-100.00%. In post-lockdown phase, the CFR Andhra Pradesh was ranging from 0.99 to 2.50%, Uttarandhra - 0.59 to 4.55%, Central Andhra - 0.82 to 14.33%, South Andhra - 1.05 to 2.30%, and Rayalaseema - 0.37-8.07%.
Conclusions: The CFR of confirmed cases of COVID-19 in Andhra Pradesh and its districts was a downward trend except Prakasam district.
Keywords: Andhra Pradesh, CFR, COVID-19, districts
How to cite this article:
Suresh Babu VA, Adapa SS, Narni H. Andhra Pradesh's COVID-19 pandemic case fatality rate. J NTR Univ Health Sci 2021;10:150-7 |
| Introduction | |  |
Coronaviruses (CoVs) are a large group of enveloped, positive-sense, single-stranded, highly diverse RNA viruses infecting mammals and birds and producing a wide variety of diseases.[1],[2],[3] They have been divided into four genera, two of which contain viruses infecting humans.[2] Pathogen is a betacoronavirus, similar to the agents of SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome).[4] All human coronaviruses (HCoVs) are primarily respiratory pathogens. During the winter of 2002–2003, an alarming new disease appeared: SARS, which was quickly attributed to a new CoV, the SARS-CoV.[2] More recently, in June 2012, a related but different CoV producing severe respiratory disease has emerged, the Middle East respiratory syndrome coronavirus (MERS-CoV).[2]
The first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified in Wuhan, China, in late 2019, the epicenter of the COVID-19 outbreak. COVID-19 (coronavirus disease-2019) is a respiratory tract infection that is caused due to a novel coronavirus, SARS-CoV-2 (initially called 2019-nCOV).[5] The International Committee on Taxonomy of Viruses (ICTV) announced “SARS-CoV-2” as the name of the new virus on February 11, 2020.[6] The World Health Organization (WHO) announced “COVID-19” as the name of this new disease on February 11, 2020.[7] The virus quickly spread across China and the globe, until the WHO declared COVID-19 a pandemic on March 11, 2020.[7]
The WHO announced that Wuhan's case fatality rate (CFR), China, which is considered the epicenter of the outbreak, is between 2% and 4%.[3] In China, as of February 20, 2020, the CFR was 3.8% nationwide, 5.8% in Wuhan, and 0.7% in other areas.[8] The CFR was 3.4% estimated by the WHO as of March 3, 2020.[9] The mortality rate among diagnosed cases (CFR) is generally about 2%–3% but varies by country; the correct overall mortality rate is uncertain. The total number of cases, including undiagnosed persons with milder illness, is unknown.[10] Knowledge of this disease is incomplete and evolving; moreover, CoVs are known to mutate and often recombine, presenting an ongoing challenge to our understanding and clinical management.
The first COVID-19 case was reported in India on January 30, 2020 in Kerala state, an imported one. The first local COVID-19 case was reported on March 4, 2020 in Uttar Pradesh state; the source of infection was in contact with the confirmed imported case, belong to their family.[11],[12],[13],[14],[15],[16]
The first COVID-19 case was reported in Andhra Pradesh on March 12, 2020 in S.P.S. Nellore District, an imported one. The first local COVID-19 case was reported on March 19, 2020 in Visakhapatnam district; the source of infection was in contact with the confirmed imported case, belong to their family.[11],[12],[13],[14],[15],[16]
The first COVID-19 case of death in India occurred on March 10, 2020. However, it was reported on late March 12, 2020 and updated on March 13, 2020 in Karnataka state, an imported one. The first local COVID-19 case death was reported on March 12, 2020 in Delhi, source of infection was contact with son, who was an imported confirmed case.[11],[12],[13],[14],[15],[16]
The first COVID-19 case of death in Andhra Pradesh occurred on March 30, 2020. However, it was reported on April 3, 2020 in Krishna district; source of infection was contact with son, who has travel history to Delhi and his diagnosis was confirmed on March 31, 2020.[11],[12],[13],[14],[15],[16]
As on August 15, 2020, India recorded 26,47,304 total confirmed cases, 6,77,677 active cases, 19, 18, 076 recovered cases, 51,045 deaths, and 3,00,41,400 tested population. [11,12]
As on August 15, 2020, Andhra Pradesh recorded 2,89,829 total confirmed cases, 85,945 active cases, 2,01,234 recovered cases, 2,650 deaths, and 28,60,943 tested population.[11],[12],[13],[14],[15]
There different versions of the COVID-19 CFR and RR were reported through various platforms.
The cumulative CFR of COVID-19 confirmed cases was 2.59% on August 15, 2020 in India. The cumulative CFR of COVID-19 confirmed cases was 1.32% on August 15, 2020 in Andhra Pradesh as per the methods for estimating the CFR for a novel, emerging infectious disease––Ghani et al., American Journal of Epidemiology.[16]
Hence, this study aimed to estimate the CFR in Andhra Pradesh during the pandemic in different phases.
The objectives of this study were as follows:
- To estimate the CFR and pattern of COVID-19 confirmed cases in Andhra Pradesh, district wise and phase-wise.
- To estimate the cumulative CFR of COVID-19 confirmed cases in Andhra Pradesh and its districts up to August 15, 2020.
- To classify districts based on the magnitude of CFR in Phase-7 and cumulative CFR up to August 15, 2020.
| Material and Methods | | |
A retrospective study was conducted at Gayatri Vidya Parishad Institute of Health Care & Medical Technology, Marikavalasa, Visakhapatnam, from March to August 2020. All the secondary data were collected either from the covid19india website or github website or Indian government websites (MOHFW) or Andhra Pradesh State government website or media quoting the government announcements. Institutional ethics committee approved the research proposal on 01-08-2020.
Inclusion criteria
All the districts reported >1000 confirmed cases in the seventh phase up to August 15, 2020.
Exclusion criteria
All the confirmed cases of foreigners and the other states origin were excluded.
Andhra Pradesh consists of 13 districts. To better understand, avoid overcrowding of the data, and better visualize, Andhra Pradesh was divided into the following regions: Uttarandhra, Central Andhra, South Andhra, and Rayalaseema.
CFR: The CFR is defined as
where k = 100. The period of time covered depends on the nature of the disease and it may cover for several years for endemic disease. This proportion covers the number of deaths as an indicator of the seriousness of a disease. This is often used as a measure of showing the effectiveness of various treatment methods.[17]
To estimate the CFR during the pandemic, Ghani et al.,[16] mentioned two simple estimators in the American Journal of Epidemiology in the September 2005 issue article: “Methods for Estimating the Case Fatality Ratio for a Novel, Emerging Infectious Disease.” in the following manner:
Two simple estimators can be obtained for the case fatality ratio from aggregate case reports. If, at any given time point s, D(s), R(s), and C(s) denote the cumulative number of deaths, recoveries, and cases, respectively, then these estimators are (1) by dividing D(s)/by C(s),(2) by dividing D(s)/by D(s)+R(s)}
e1(s) = D(s)/C(s)
e2(s) = D(s)/{D(s)+R(s)}
The first estimator ignores the censoring that arises when patients remain ill in the hospital. The second implicitly assumes that the case fatality ratio for those who remain in the hospital will be similar to that for those whose outcome is known. Furthermore, for the second estimator to work reasonably well, the hazards of death and recovery at any time t measured from admission to the hospital, conditional on an event occurring at time t, should be proportional.[16]
The estimated CFR of SARS, obtained by dividing D (t) by C (t), was 3%–5% in the first few weeks of the global outbreak. However, when researchers used the appropriate statistical techniques and accounted for the discrepancy between the cohorts of D (t) and C (t), the estimated CFR jumped to 6%–8%. Today, long after the outbreak ended, we know that SARS's final death rate was 9.55% (774 of the 8098 people who had the infection died). Such a shift in the estimates has nothing to do with the severity of the disease.[18]
In this study, the second estimator was used, as mentioned above, for estimating the CFR for COVID-19 in Andhra Pradesh. The study period starts from the first COVID-19 case reported in Andhra Pradesh, i.e., on March 12, 2020 to the middle of the Unlock-3, i.e., on August 15, 2020. The total duration was divided into eight phases.
The CFRs were estimated for COVID-19 in Andhra Pradesh, and its districts where >1000 confirmed cases were reported in Phase-7(Unlock-3) up to August 15, 2020. All the confirmed cases of Foreigners and Other States origin reported in the Andhra Pradesh were excluded.
Statistical analysis
Data were entered and analyzed using SPSS V24. Descriptive statistics were represented with percentages, mean with SD. K-means clustering analysis was applied to make the classification of Andhra Pradesh Districts based on the magnitude of CFR. Standardized scores were obtained for CFR. The Elbow method was employed and determined two clusters. QGIS 3.14.1 software was used to make India map. The results were represented in the form of tables and graphs as per the grouping mentioned above.
| Results | | |
During the Phase-0 CFR of the whole of India was 20.37% and it was 0.00% in Andhra Pradesh. The CFR in Uttarandhra, Central Andhra & Rayalaseema was Nil, and South Andhra it was ranging from Nil-0.00%,
During the Phase-1 CFR of the whole of India was 22.51% and it was 42.31% in Andhra Pradesh. The CFR in Uttarandhra & South Andhra was ranging from Nil-0.00%, Central Andhra & Rayalaseema it was ranging from Nil-0.00%.
During the Phase-2 CFR of the whole of India was 9.31% and it was 4.45% in Andhra Pradesh. The CFR in Uttarandhra was ranging from Nil-0.00%, Central Andhra ranging from 0.00-8.70%, South Andhra ranging from 0.00 to 2.00%, and Rayalaseema ranging from 0.00 to 7.69%, During the Phase-3 CFR of the whole of India was 5.87% and it was 1.73% in Andhra Pradesh. The CFR in Uttarandhra was ranging from Nil-5.56%, Central Andhra ranging from 0.00 to 3.13%, South Andhra -0.00%, and Rayalaseema ranging from 0.00 to. 53%.
During the Phase-4 CFR of the whole of India was 4.15% and it was 1.34% in Andhra Pradesh. The CFR in Uttarandhra was 0.00%, Central Andhra ranging from 0.00-16.67%, South Andhra ranging from 0.00-1.16%, and Rayalaseema ranging from 0.00-4.35%.
During Phase-5(Unlock-1) CFR of the whole of India was 4.01 and it was 2.50% in Andhra Pradesh. The CFR in Uttarandhra was ranging from 0.82 to 4.55%, Central Andhra ranging from 1.66 to 14.33%, South Andhra ranging from 1.05-1.28%, and Rayalaseema ranging from 0.37 to 8.07%.
During Phase-6(Unlock-2) CFR of the whole of India was 2.50% and it was 1.99% in Andhra Pradesh. The CFR in Uttarandhra was ranging from 1.81 to 3.78%, Central Andhra ranging from 1.26 to 2.33%, South Andhra ranging from 1.65-2.26%, and Rayalaseema ranging from 1.17 to 1.89%.
During the Phase-7(Unlock-3) CFR of the whole of India was 1.74% and it was 0.99% in Andhra Pradesh. The CFR in Uttarandhra was ranging from 0.59- to 1.65%, Central Andhra ranging from 0.82 to 1.53%, South Andhra ranging from 1.09 to 2.30%, and Rayalaseema ranging from 0.56 to 1.47% [Table 1]. | Table 1: Phase-Wise Case Fatality Rate (CFR) of COVID-19 Confirmed Cases in Andhra Pradesh and its Districts
Click here to view |
The overall pattern of the CFR during the 6 months in Andhra Pradesh, starting from the pre-lockdown phase to the lockdown phase, and then to post-lockdown phase (unlocking phase) of India were as follows:
The CFR was high in the Pre-lockdown Phase in the whole of India and high in the Phase-1 of Lockdown Phase in Andhra Pradesh. Initially, the CFR was very high in the Pre-lockdown Phase in some states and during Phase-1 of Lockdown Phase in Andhra Pradesh, because the case was diagnosed as a confirmed case after the death. Because of that, some districts it was as high as 100.00% [Graph 1]. The CFR decreased from the pre-lockdown phase to the lockdown phase, and the future decreased to the post-lockdown phase in India and Andhra Pradesh also except during Phase-5 and Phase-6 [Graph 1].
In Uttarandhra in Srikakulam and Vizianagaram districts, the CFR was highest in Phase-5 of post-lockdown phase and decreasing consistently from that phase. In Visakhapatnam district, the CFR was highest in Phase-3 of lockdown phase, then seesaw pattern during the lockdown phase and post-lockdown phase, again decreased in the Phase-7 [Graph 1].
In Central Andhra in East Godavari district the CFR was highest in Phase-4 of lockdown phase and decreasing consistently from that phase. In West Godavari district, the CFR was highest in Phase-5 of post-lockdown phase and decreasing consistently from that phase. In Krishna and Guntur districts, the CFR was highest in Phase-1 of lockdown phase, then seesaw pattern during the lockdown phase and to post-lockdown phase, again decreasing consistently from Phase-5. The only difference between these two was in Guntur district it was same during Phase-3 and Phase-4 [Graph 1].
In South Andhra in Prakasam district the CFR was highest in Phase-7 of post-lockdown phase and increasing consistently from Phase-5. In S.P.S. Nellore district, the CFR was highest in Phase-1 of lockdown phase, then decreased, again seesaw pattern during next phases and decreased in the Phase-7 [Graph 1].
In Rayalaseema in Kurnool district the CFR was highest in Phase-1 of lockdown phase, then seesaw pattern during the lockdown phase and to post-lockdown phase, again decreasing consistently from Phase-5. In Y.S.R. Kadapa district, the CFR was highest in Phase-6 of post-lockdown phase, seesaw pattern during the same phase and decreased in the Phase-7. In Anantapur district, the CFR was highest in Phase-1 of lockdown phase, decreasing consistently from that phase and maintained same during Phase-3 and Phase-4, then seesaw pattern during next phases and decreased in the Phase-7. In Chittoor district, the CFR was highest in Phase-5&6 of post-lockdown phase and decreased in the Phase-7 [Graph 1].
The CFR of COVID-19 in Andhra Pradesh has a downward trend similar to the overall India CFR trend except in few phases.
The cumulative CFR of COVID-19 confirmed cases in Andhra Pradesh on August 15, 2020 was 1.32% and its districts ranged from 0.95%-2.52%. The highest cumulative CFR was in Krishna district and lowest was in Anantapur district [Table 2].  | Table 2: Cumulative Case Fatality Rate (CFR) of COVID-19 Confirmed Cases in Andhra Pradesh and its Districts
Click here to view |
The Cluster analysis of the COVID-19 confirmed cases CFR in Districts of Andhra Pradesh during the Phase-7 and cumulative CFR up to August 15, 2020 divided the Districts into 2 clusters basing on the magnitude of CFR.
During Phase-7
Cluster I, consisting of 10 Districts with lower magnitude CFR. Cluster II, consisting of 3 Districts with higher magnitude CFR.
Cluster I Srikakulam, Visakhapatnam, East Godavari, West Godavari, Guntur, S.P.S. Nellore, Kurnool, Y.S.R. Kadapa, Anantapur, and Chittoor [Map 1].
Cluster II Vizianagaram, Krishna, and Prakasam [Map 1].
In Cluster I, the CFR of the COVID-19 confirmed cases ranged from 0.95 to 1.73%, Mean was 1.24%, and the standard deviation was 0.29%. In Cluster II, the CFR of the COVID-19 confirmed cases ranged from 1.95-2.52%, Mean was 2.24%, and the standard deviation was 0.29%. The overall CFR of the COVID-19 confirmed cases ranged from 0.95-2.52%, Mean was 1.47%, and the standard deviation was 0.52% [Table 3].
The cumulative case fatality rate
Cluster I, consisting of 7 Districts with lower magnitude CFR. Cluster II, consisting of 6 Districts with higher magnitude CFR.
Cluster I Visakhapatnam, East Godavari, West Godavari, S.P.S. Nellore, Kurnool, Y.S.R. Kadapa, and Anantapur [Map 2].
Cluster II Srikakulam Vizianagaram, Krishna, Guntur, Prakasam, and Chittoor [Map 2].
In Cluster I, the CFR of the COVID-19 confirmed cases ranged from 0.56-1.09%, Mean was 0.78%, and the standard deviation was 0.19%. In Cluster II, the CFR of the COVID-19 confirmed cases ranged from 1.47-2.30%, Mean was 1.66%, and the standard deviation was 0.32%. The overall CFR of the COVID-19 confirmed cases ranged from 0.56-2.30%, Mean was 1.18%, and the standard deviation was 0.52% [Table 2].
| Discussion | | |
The cumulative CFR of confirmed cases of coronavirus disease 2019 (COVID-19) in India and Andhra Pradesh during the pandemic was less- 2.59% and 1.32% respectively compared to the other HCoVs diseases. The CFR of SARS during 2002–2003 SARS epidemic -11%,[19] MERS during MERS 2012 epidemic- 36.11%,[20] as of now coronavirus disease 2019 (COVID-19) in India was-2.59% and Andhra Pradesh- 1.32%.
| Conclusions | | |
The CFR of confirmed cases of COVID-19 in Andhra Pradesh and its districts was a downward trend except Prakasam district. The CFR was 0.99% during middle of Phase-7(Unlock-3) and on August 15, 2020, and the cumulative was 1.32%. In all the districts of Andhra Pradesh, the CFR of confirmed cases of COVID-19 was a downward trend except Prakasam district. The cumulative CFR of confirmed cases of COVID-19 during the pandemic in the Indian subcontinent, Andhra Pradesh and its districts as on August 15, 2020 was low compared to the other CoV diseases SARS, and MERS.
Limitations
This study limited to the CFR of confirmed cases of COVID-19 of India, Andhra Pradesh and its districts. There were no similar studies in the phased manner. The methodology of estimation of the CFR also was different.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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