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

Shruti Menon - BBC Reality Check
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 1.4 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 21 days, India's numbers are rising fast after it relaxed a strict lockdown, imposed in the last week of March.

India has been seeing record numbers of daily cases, as it continues to ramp up its testing, currently conducting over 500,000 tests each day.

Charts showing cases in S Asian countries

However, other countries in South Asia seem to be on a different trajectory, with confirmed infections showing 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 2,000 by mid-July.

However, the government has voiced concern about citizens not wearing masks and observing social distancing, especially with the Eid holiday coming up.

And Bangladesh, which had a total of 223,453 cases as of 27 July, saw its daily cases peak between mid-June and the beginning of July, and has since also seen a downward curve.

Boy in Afghanistan gets his temperature check

Afghanistan's rate of increase is slower than its neighbours', although there are questions about the reliability of its official figures.

Nepal and Sri Lanka have much lower levels of infection.

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 restrictions in several provinces, as infections have been going up in some densely-populated urban areas.

Sri Lanka 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 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.

Sri Lanka has recently lifted the lockdown ahead of forthcoming parliamentary elections.

How much testing is done in South Asia?

South Asia has about a quarter of the world population, but only 12% 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 size.

India has has so far conducted 10.7 million tests. Pakistan has carried out more than 1.9 million.

Bar chart comparing different countries on testing

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, at its peak, conducted over 31,000 tests per day, but this has been scaled down since the last week of June, and they are not testing those without symptoms.

A recent government survey conducted in and 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. There's also been a scandal around the sale of fake negative test certificates.

In Nepal, a total of 335,000 tests had been conducted as of 26 July. The government had said earlier that they would conduct 10,000 tests per day from July, but testing remains low, at around 4,000 a day.

Bar chart showing countries rate of testing per confirmed case

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 every 34 and 24 tests respectively. But Bangladesh is identifying one positive case for every five tests carried out, which is well below the WHO benchmark.

Nepal was finding a positive case for every 18 tests until July 24, 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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