key: cord-0952611-jrim0m9b
authors: Shukla, Durgesh; Bhadoria, Sumit Singh; Bansal, Manoj; Changulani, Richa
title: Evolution of the pandemic: Analysis of demographic characteristics of COVID-19-infected patients during its two waves in Gwalior district of central India
date: 2022-03-18
journal: J Family Med Prim Care
DOI: 10.4103/jfmpc.jfmpc_1189_21
sha: 98344d96cbf2e7a3a87dbd0f18b8e6d6bb017fc8
doc_id: 952611
cord_uid: jrim0m9b

BACKGROUND: Studies of pandemics in past centuries have suggested that the second wave was always more lethal and devastating as compared to the first wave. Regarding coronavirus disease (COVID) pandemic also, various speculations were made that during the second wave virus changes its nature either for age structure, gender or rural–urban differential. Present study was aimed to compare the demographic and mortality profile of COVID-19 patients during the two waves. MATERIALS AND METHODS: A total of 51,425 individuals with 16,538 cases from first wave and 34,887 cases from the second wave were included in the study. Frequency, percentage, case fatality rate (CFR) and OR (95% CI) were calculated. Level of significance was considered at 5%. RESULTS: Maximum cases were observed in the age group 21–30 years (23.7%). During the first wave, 29.5% females were infected while during the second wave 38.5% females were infected. Infection in rural areas increased to 5.7% as compared to 4.8% in the first wave. Among the females, CFR increased to 37% in second wave which was 25.2% in the first wave. Disease load was at its peak in the month of April 2021. CONCLUSION: During the second wave, infection rate and mortality were higher in females and patients residing in rural areas showing extension of community spread. Patients with age above 50 years succumbed more. Occurrence of more than two-fifth of the cases in a single month (April 2021) shows a need for better planning for the supposed third wave to tackle any unwanted situation.

Introduction pre-COVID era. Experts kept on warning about the risk of second wave, about the mutation of virus, about continuation of precaution and COVID appropriate behaviour. The communication from the government and of experts seems to go unheard. Daily cases began increasing by March 2021, "which marked the beginning of second wave." [6] Association of Schools of Public Health in the European Region defined second wave as a resurgence of the incidence rate during a pandemic, which cumulatively presents an exponential increase in the number of cases of the disease in a given time period and specific territorial zone. This exponential increase follows from the disappearance or near disappearance of cases of the disease and may be influenced by a new behavioural characteristic of the infectious agent or a modified characteristic from another already known. [7] Within few weeks daily case and fatalities grew exponentially and crossed previous peak by many folds. By April end as daily case crossed 400,000 per day, India broke world records of both daily cases and fatalities reported in any nation ever. [8] The entire health system collapsed. The scenes of shortage of oxygen, hospital beds, medicines and even cremation spaces would continue to haunt the nation's consciousness for decades to come. These scenarios clearly show that the second wave was much larger in magnitude, as compared to the first wave but very little information exist about the demographic characteristics like age, sex and rural-urban differential. For a country like India, primary care physicians are the backbone of its health system; their role in pandemic has been significant which involved screening of suspected COVID-19 patients, specimen collection, maintenance of fever outpatient services, treatment and follow-up of mild or moderate COVID-19 cases in a hospital and management of staff involved in COVID-19-related activities. [9] But for some private primary care physicians, this pandemic has affected their practices and resulted in loss of livelihood. [10] Taking into consideration the non-specific manifestations of this infection, even more pressure is placed on primary care physicians in making decisions on which suspected/confirmed COVID-19 patients to send home, refer to a specialist or send to hospital. [11] Despite the rapidly evolving body of literature on COVID-19 disease, the level of primary healthcare physicians' knowledge about the disease and the available interventions is lacking which has only added up to the panic. [12] Primary physicians can be an important link in early interception of the disease and educating them is the only way to fight it out. So, the present study was planned to elucidate the change in epidemiology of the coronavirus and characterize its potential impact in Gwalior district during the two waves. Analysis of health data was done with the following objectives:

(1) To study and compare the demographic profile of COVID-positive cases during the two waves in Gwalior.

(2) To study case fatality rate (CFR) as mortality indicator with its association with demographic determinants during the two waves.

The present study was a cross-sectional study done in Gwalior, Madhya Pradesh, India. In this, COVID-19-related data were collected from the integrated disease surveillance programme (IDSP) unit of Gwalior district and were analysed. The study is based on the analysis of available secondary data. Written permission was taken for data retrieval and its utilization for research purpose only. The age-sex distribution of patients during the two waves is shown in [ Figure 1 ]. Table 2 shows that the age group 61-70 years was worst affected in terms of fatalities with maximum deaths (28.1%). CFR in age group 61-70 years was 4.27% and 2.35%, respectively, for first and second wave. During the first and second wave, CFR was highest in the 81-90 age groups, that is, 15.65% and 5.23%, respectively. A total of 68.4% deaths occurred among the males. In both waves, CFR was also seen to be higher among males 1.47% and 0.81%, respectively. Among the residents of urban areas, CFR during first and second waves was observed as 1.43% and 0.80%, respectively. During the second wave CFR was increased to 16.13% from 2.77% in the first wave for the patients who were admitted in treatment facilities, showing the high fatal nature of virus during the second wave.

By observing Table 2 , it was found that for all the variables during the second wave CFR was lesser as compared to the first wave except for two situations. First, among the people residing in the rural areas and second, among individuals admitted in the treatment facility.

The month of April (2021) bears the brunt of the cases as maximum cases (43.5%) were reported in this month only; in other words, the peak of the second wave was observed in April [ Figure 2 ]. While during first wave maximum cases were seen in September 2020 which recorded 10.22% cases (peak of first wave) followed by August 2020 (6.34%), in the remaining months, proportion were less than 5%. CFR was seen highest in the month of February 2021 (2.5%) period of end of first wave, second highest CFR was seen in August 2020 just before the peak of first wave, followed by May 2020 (1.68%), October 2020 (1.68%), September 2020 (1.46%). In the months of April 2021 and May 2021, CFR was 1.12% and 0.14%, respectively. Overall case fatality was found as 0.98% [ Table 3 ].

The first case of COVID-19 in Gwalior was reported in the last week of March 2020, the total number of infected had reached 51425 and the number of deaths had reached 506 as of 17 May 2021. This article compares the demographic characteristics of and response to the two waves of COVID-19 in Gwalior during 2020-2021 to provide a reference for the next step in epidemic prevention and control and also as a means for general practitioners and family physicians to improve their adaptive performance in various dimensions in response to COVID-19. [9] Looking at the total number of COVID-positive cases during the first and second waves, it is obvious that the second wave is much more aggressive and have approximately double the number of cases than the first wave. There could be several factors responsible for the increased number of cases in the second wave. It is observed that the mutant virus has more effective transmission capability and its incubation period is also lesser. There has been a widespread disregard to the 'COVID appropriate behaviours or CAB' by the public and the quality of masks used are highly variable. N-95 masks are not much favoured masks in India, due to their higher costs, and the majority public are using either the indigenous masks made of clothes or are repeatedly using the same and worn-out masks. The sharp rise can also be attributed to the higher testing. [13] Comparing the age-wise percentage distribution of cases during both the waves, it was found that the percentage distribution was more or less the same, mean age of the cases during the first wave was 40.80 ± 17.13 years while in the second it is 40.46 ± 16.94 years. This is in contrast with the general perception that older population was infected in the first wave and younger population in the second. [13] Dr. VK Paul, member of the Niti Aayog, in a press conference said that there is no significant shift in the age distribution of COVID-19 cases in the second wave as compared to the first. Data show that in the last pandemic wave people under 30 years of age constituted 31% [14] The total age-wise percentage of COVID cases in Gwalior district is in line with the national data where maximum number of cases were seen in the age group 21-40 years and the percentage shows a decreasing trend with each passing decade.

In the second wave, the pattern of sex-wise case distribution was similar, where males are more infected than females, but gender difference was smaller than those of the first wave. A rise of 9% can be seen in the female cases from first wave to the second, a finding similar to that of a study conducted in Babol, North of Iran by Seyed Farzad Jalali et al. [15] where 8.8% increase was seen in the female cases during the second wave. Current study shows that the odds for infection were 1.5 times higher in females during the second wave, possibly because they are over-presented in the care professions and hence are more exposed to infections. [16] Moreover, women are usually responsible for family and domestic work and become the primary caregivers of people affected by COVID-19 in their household (especially children and the elderly), a situation that has been amplified during confinement. [17, 18] Urban and rural distributions of cases were similar in both the waves with maximum number of cases residing in the urban areas, although there was an increase in the confirmed cases and the risk of infection among the people residing in rural areas in the second wave. Urban living conditions such as population density, agglomeration of people in transport infrastructures and crowding in educational, shopping and healthcare centres facilitate virus transmission. [19] Gupta et al. [20] in a study reported that there was a gradual shift of infections from urban to rural areas; however, the numbers kept increasing in the former. Resumption of limited public transports and human movements transmitted the virus from highly infected areas to villages and towns.

A significant increase in the home-isolated cases as compared to those admitted in treatment facility was seen during the second wave. Also, the home-isolated cases were approximately 3.5 times more in the second wave than the first. This was partly due to the clearer picture about the disease and its classification and partly due to acute shortage of beds in the treatment facilities. With the increase in the testing capacity and change in the testing guidelines over the time, the number of cases increased unexpectedly, hospitals overwhelmed and medical system was in crisis. Increased burden of number of patients added to the misery of poor doctor patient ratio. The primary care physicians working in hospitals serving COVID-19 patients were forced to not only urgently face the demands of coping with medical issues related to COVID-19 but also to immediately figure out how to deliver information on dealing with suspected COVID-19 patients and mapping institutional flows to cope with COVID-19. [9] As per the media report, on 31 March, Madhya Pradesh said it had provision for 20,139 isolation, oxygen and ICU beds and there was no need for concern. The state then had only 2332 new cases and 17,096 active cases. Within 2 weeks, the state had 68,576 active cases, of which 12,248 were new infections and the total number of afflicted overtook installed bed capacity in the state.

To ease the burden, doctors are advising mild patients to opt for home isolation or a homecare package with a reliable hospital. [21] Another important observation of this study is that the percentage of deaths increased in the age group 31-60 years during the second wave while the percentage of death was more in the age group 61-90 years during the first wave. The mean age of dead individuals was 64.16 ± 15.42 years in the first wave while it is 59.97 ± 13.56 years in the second; this clearly shows that comparatively more mortality occurred in the younger age group in the second wave. Similarly in Spain the proportion were significantly higher for young deaths in the second wave. [22] Surprisingly the second wave did not witness overall deaths in the same proportion as with the increased number of confirmed cases. In fact, the percentage of total deaths during the second wave was less than that of the first; this can be attributed to the different recommendations regarding timely diagnosis and treatment; studies worldwide suggest that mortality levels were significantly reduced in the second wave. [15, 19, 23] Widespread use of corticosteroids proved to be a game changer in limiting the mortality. [23] In the gender-wise distribution of deaths, males were in higher number in both the waves but the percentage decreased in proportion to the decrease in the percentage of confirmed cases of males in the second wave. The Global Health 50/50 project has reported that men have more severe cases of COVID-19 and more deaths [24] due to several factors. First, biological differences: women generally have a stronger immune system than men, which could explain their lower susceptibility to infection. [25] Second, some chronic COVID-19-related diseases (such as chronic respiratory diseases) are more common in men. Third, men have a higher prevalence of smoking and excessive alcohol consumption, which is also related to chronic diseases. [24] In Barcelona, the rates of excess mortality during the two waves were higher among men. [26] In this study, it was seen that the overall CFR and the variable-wise CFR had decreased in the second wave except for two situations: first, among people residing in the rural areas probably due to higher number of cases in the second wave and low health infrastructure and facilities in the rural settings, and second, among individuals admitted in treatment facility because in the second wave due to the unexpected rise in the number of cases only the more severe once or the critically ill patient got the opportunity to acquire a bed in the treatment facility hence more mortality and high CFR. Guihong Fan et al. [27] proposed that harvest effect, better testing capacity, age structure of the infected people, increased transmissibility of virus in young healthy adults and children, and favourable environmental factors might have led to a reduced CFR in the second wave.

Looking at the monthly trend of COVID-19 cases in the Gwalior city [ Figure 2 ], the two waves had distinct characteristics. The first wave was insidious in onset and progressed gradually reaching its peak in 6 months with maximum number of cases and deaths in September 2020 while the second wave took off quickly reaching its peak in just 1.5 months' time in April 2021 and the numbers in terms of cases and deaths were devastating. Initially during the first wave the city was in a state of complete lockdown and the fear of acquiring the disease was high; this did not let the disease grow exponentially, but as soon as the state went into the different phases of unlock, the migration and the reverse migration started with more and more people interacting with each other, the disease kept on spreading and finally reaching its peak. In October 2020 the cases started declining, various research shows that seasonality is a common feature of viral infections in humans and various animals. [28, 29] In fact, mounting evidence suggests that COVID-19 has the potential to become a seasonal illness like seasonal influenza. [30] Legislative assembly by-elections in the month of November 2020 resulted in the surge of COVID cases and deaths due to increased interaction among population.

With the decrease in temperature in coming months, the cases and deaths started declining significantly; this shows that a particular range of temperature may be required for virus replication and growth. [31] The government was satisfied with preventive measures to control the first wave since the infection rate declined during the end of 2020 reaching its lowest during the first week of February 2021. People became complacent not knowing what they were about to face in the near future; March 2021 saw an acute surge in the cases and in April 2021 the cases and deaths went out of proportion flooding the hospitals with severe cases. Several independent factors like arrival of new, more contagious, variants of the virus, mask hesitancy, a widespread disregard to the 'CAB' probably from adherence fatigue were working side by side leading to such a situation. [13, [32] [33] [34] [35] While human-to-human interactions play a great role in viral diffusion, temperature and humidity can still alter human behaviour in the external environment; all these factors ultimately contribute to high SARS-CoV-2 transmission. [36] [37] [38] [39] It is important to emphasize that no single variable is sufficient to explain the evolution of the pandemic. There are multiple vulnerabilities that, combined over space and time, lead to a greater or lesser incidence of the virus. [19] As the pandemic shows no sign of slowing, it is critical that primary care physicians continue to be supported in their front-line role, which involves reaching out to their communities and being sensitive to their needs as guardians of their local communities. Primary healthcare will need to continuously reinvent and transform itself as any healthcare system's ability to manage infectious disease outbreaks will undoubtedly be crippled without an effective primary care sector. [9, 12, 40] Limitation

The work profile of the individual was not included which may have an effect on the infectivity and the outcome of the disease.

There was no direct contact with the participants so it was not possible to incorporate all the socio-demographic variables of the study participants.

The world is witnessing something extraordinary generations have never seen; the virus is continuously evolving and so should be the knowledge regarding its characteristics and measures to control it. Lockdowns cannot be sustained indefinitely so a data-driven approach should be adopted to curb the transmission and to prevent severe illness and deaths from COVID-19 and to minimize the social and economic loss resulting from this pandemic. This study recommends that more stringent action to be taken when a surge is detected, premature relaxation of some intervention must be avoided and public must be made aware of the strict implementation of CAB (COVID appropriate behaviours). The effect of climatic variables on the transmission of the disease should be integrated into disease prevention and mitigation strategies and finally involving primary care physicians in the planning and action for this emerging pandemic and structuring the policies according to the needs of specific areas.

(1) The mean age of infected individuals was almost similar in first and second wave while more mortalities occurred in the younger age group during the second wave as compared to the first. (2) Males were infected more in both the waves but there was 9% rise in infection among females during the second wave; also the risk of infection was 1.5 times higher among females in the second wave. (3) The distribution of cases were higher in urban areas in both the waves but second wave saw an increase in the number and risk of cases among rural population. (4) Due to the enormous number of cases during the second wave, the home-isolated cases were 3.5 times more as compared to the hospitalised once. (5) Lack of predictability and preparedness were evident in the second wave.

COVID-19 coronavirus pandemic

Can New Mortality Data Explain India's Low COVID Death Numbers

Covid-19: India is at centre of global vaccine manufacturing, but opacity threatens public trust

live-updates-global-c oronavirus-cases-surpass-30-million-2297214

Explained: The peak of India's second wave of Covid-19 is in sight, but end may still be far away

How bad is the second wave

Winter planning now! Association of Schools of Public Health in the European Region (ASPHER)

India's daily COVID-19 cases p a s s 4 0 0 , 0 0 0 f o r f i r s t t

Primary care physicians' narratives on COVID-19 responses in Japan: Professional roles evoked under a pandemic

COVID-19's crushing effects on medical practices, some of which might not survive

The coronavirus outbreak: The central role of primary care in emergency preparedness and response

Primary health care physicians' perspective on COVID-19 pandemic management in Qatar: A web-based survey

Differences between first wave and second wave of COVID-19 in India

Significant Shift in Age Distribution of Covid Cases: NITI Ayog Member

Epidemiologic comparison of the first and second waves of coronavirus disease in Babol, North of Iran

Socioeconomic inequalities in COVID-19 in a European urban area: Two waves, two patterns

COVID-19: The gendered impacts of the outbreak

The Lancet. The gendered dimensions of COVID-19

Do local characteristics act in a similar way for the first two waves of COVID-19? Analysis at intraurban level in Barcelona

COVID-19 outbreak and Urban dynamics: Regional variations in India

The second wave: Crisis and containment

Second versus first wave of COVID-19 deaths: Shifts in age distribution and in nursing home fatalities

Health indicators in hospitalized patients with SARS-CoV-2 pneumonia: A comparison between the first and second wave

Disaggregated data and health disparities

Coronavirus COV-19/SARS-CoV-2 affects women less than men: Clinical response to viral infection

Barcelona Public Health Agency. # COVID19aldiaBCN: How does COVID-19 affect the city of Barcelona

Decreased case fatality rate of COVID-19 in the second wave: A study in 53 countries or regions

Seasonality of infectious diseases and severe acute respiratory syndrome-what we don't know can hurt us

Seasonality of respiratory viral infections

Immunological characteristics govern the transition of COVID-19 to endemicity

Is coronavirus disease (COVID-19) seasonal? A critical analysis of empirical and epidemiological studies at global and local scales

2 8 t h W H O Regulatory Update on COVID-19

COVID-19 Weekly Epidemiological Update

Comparison of the second and third waves of the COVID-19 pandemic in South Korea: Importance of early public health intervention

The current second wave and COVID-19 vaccination status in India

SARS-CoV-2 in the environment: Modes of transmission, early detection and potential role of pollutions

Understanding COVID-19 diffusion requires an interdisciplinary, multi-dimensional approach

Strong social distancing measures in The United States reduced the COVID-19 growth rate

Social distancing, population density, and spread of COVID-19 in England: A longitudinal study

The impact of COVID-19 on private and public primary care physicians: A cross-sectional study

Authors would like to thank Dr. Manish Sharma, Chief Medical and Health Officer, Gwalior district for giving us permission to obtain and utilize COVID-19-related data available in IDSP Unit of Gwalior for research purpose.

Nil.

There are no conflicts of interest.