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

Woman in India gets a swab test

India has now crossed the million mark and has the third largest number of coronavirus cases in the world after the US and Brazil.

That's not surprising given its huge population, but its smaller neighbours have also been hit hard by the virus.

We've been looking at what's happening in Pakistan, Bangladesh, Nepal, Sri Lanka and Afghanistan.

Global hotspot

With cases doubling every 20 days, India is now a global hotspot for coronavirus. The numbers are still rising fast.

However, the number of daily cases elsewhere in the region has followed a different trajectory, with confirmed infections showing a downward trend in most countries, after steep increases in May and June.

In Pakistan, with the second-highest number of total cases in the region, there is cautious optimism about the downward direction of the infection curve.

From a peak in mid-June of almost 6,000 new infections each day, that figure has fallen to less than 2,000 by mid-July.

However, concerns remain and some say it's too early to conclude that the virus is under control.

Similarly, Bangladesh, which has seen a total caseload of 196,323 as of July 16, saw its highest daily cases between mid-June and the beginning of July.

After that, it has seen a downward curve in positive cases, with the infections currently doubling every 28 days.

Afghanistan's doubling rate is slower than its neighbours', currently every 41 days. But questions have been raised about the reliability of its official figures.

Nepal and Sri Lanka have much lower levels of infection overall. In Nepal, the government imposed a lockdown which went on for 100 days. In that period, most of the cases detected were in areas bordering India.

Recent trends show daily numbers coming down, but experts suggest that may partly be because cases in the community are going undetected.

Sri Lanka has had spikes of infections since April but has managed to keep numbers low. It has implemented a tight lockdown, traced contacts of positive patients and imposed strict quarantine rules for those infected.

"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.

Low rates of testing

South Asia has about a quarter of the world population, but only 11% 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, when you compare it with the population size, the numbers have been "sub-optimal".

For instance, India has scaled up its testing over time and has so far conducted 10.3 million tests. Pakistan has carried out more than 1.6 million.

But per capita tests in these countries are far lower than in many other countries.

Moreover, 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 seen a downward trend, and the reliability of those tests has also been called into question because of a scandal around the sale of fake negative test certificates.

In Nepal, a little over 300,000 tests have been conducted as of July 16. 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.

Testing data for Afghanistan is not available and the Red Crescent has recently 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 cases 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 32 and 26 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 every 25 tests until June 14. Data after that is not available.

Unreliable statistics

Deaths recorded in these countries are far lower than in western countries, whether we look at absolute numbers or per head of population.

data in detail

Scroll table to see more data

*Deaths per 100,000 people

US 139,931 42.8 3,699,785
Brazil 78,772 37.6 2,074,860
UK 45,273 67.4 294,066
Mexico 38,888 30.8 338,913
Italy 35,042 57.8 244,216
France 30,152 46.4 174,674
Spain 28,420 60.9 260,255
India 26,816 2.0 1,077,781
Iran 13,979 17.1 271,606
Peru 12,998 40.6 349,500
Russia 12,323 8.5 770,311
Belgium 9,800 85.3 63,706
Germany 9,091 10.9 202,580
Canada 8,892 24.0 111,875
Chile 8,445 45.1 328,846
Colombia 6,516 13.1 190,700
Netherlands 6,136 36.0 51,591
Sweden 5,619 56.3 77,281
Pakistan 5,568 2.6 263,496
Turkey 5,475 6.6 218,717
Ecuador 5,282 30.9 73,382
South Africa 4,948 8.6 350,879
China 4,644 0.3 85,314
Egypt 4,251 4.3 87,172
Indonesia 4,143 1.5 86,521
Iraq 3,691 9.6 90,220
Bangladesh 2,618 1.6 204,525
Saudi Arabia 2,447 7.3 248,416
Argentina 2,220 5.0 122,524
Bolivia 2,106 18.5 58,138
Romania 2,009 10.3 36,691
Switzerland 1,969 23.1 33,492
Philippines 1,831 1.7 67,456
Ireland 1,753 36.4 25,750
Portugal 1,684 16.4 48,390
Poland 1,624 4.3 40,104
Ukraine 1,504 3.4 60,077
Guatemala 1,443 8.4 33,809
Afghanistan 1,181 3.2 35,475
Panama 1,071 25.6 52,261
Algeria 1,068 2.5 22,549
Japan 986 0.8 25,156
Dominican Republic 971 9.1 51,519
Kyrgyzstan 900 14.3 24,606
Honduras 891 9.3 32,793
Nigeria 778 0.4 36,107
Austria 711 8.0 19,655
Moldova 680 16.8 20,794
Sudan 673 1.6 10,682
Armenia 641 21.7 34,877
Denmark 611 10.6 13,173
Hungary 596 6.1 4,333
Belarus 495 5.2 65,953
Serbia 461 6.6 20,498
Yemen 443 1.6 1,581
North Macedonia 414 19.9 9,026
Kuwait 407 9.8 58,904
Israel 406 4.8 49,575
Kazakhstan 375 2.0 70,339
Cameroon 373 1.5 16,157
Czech Republic 358 3.4 13,855
Azerbaijan 349 3.5 27,133
United Arab Emirates 338 3.5 56,711
El Salvador 335 5.2 11,846
Finland 328 5.9 7,318
Oman 318 6.6 66,661
Bulgaria 299 4.2 8,638
South Korea 295 0.6 13,745
Morocco 269 0.7 17,015
Norway 255 4.8 9,028
Bosnia and Herzegovina 246 7.4 8,161
Kenya 225 0.4 12,750
Greece 194 1.8 3,983
DR Congo 193 0.2 8,324
Ethiopia 163 0.1 9,147
Senegal 163 1.0 8,669
Qatar 154 5.5 106,308
Mauritania 153 3.5 5,813
Haiti 146 1.3 7,053
Ghana 145 0.5 27,060
Kosovo 130 7.0 5,617
Bahrain 124 7.9 36,004
Malaysia 123 0.4 8,779
Australia 122 0.5 11,802
Mali 121 0.6 2,472
Croatia 120 2.9 4,253
Zambia 120 0.7 2,980
Slovenia 112 5.4 1,946
Luxembourg 111 18.4 5,483
Albania 111 3.9 4,008
Venezuela 110 0.4 11,483
Nicaragua 99 1.5 3,147
Somalia 93 0.6 3,111
Ivory Coast 91 0.4 13,912
Cuba 87 0.8 2,445
Uzbekistan 83 0.3 16,429
Lithuania 80 2.9 1,932
Chad 75 0.5 889
Liberia 70 1.5 1,088
Estonia 69 5.2 2,021
Niger 69 0.3 1,104
Sierra Leone 65 0.8 1,701
Palestinian Territories 59 1.2 8,549
Thailand 58 0.1 3,249
Tajikistan 57 0.6 6,834
Djibouti 56 5.8 5,003
Madagascar 55 0.2 6,849
Central African Republic 55 1.2 4,485
Malawi 55 0.3 2,810
Costa Rica 54 1.1 10,551
Burkina Faso 53 0.3 1,047
Andorra 52 67.5 880
Equatorial Guinea 51 3.9 3,071
Tunisia 50 0.4 1,348
Congo 49 0.9 2,633
Libya 48 0.7 1,791
Channel Islands 47 27.6 583
Gabon 46 2.2 6,315
South Sudan 43 0.4 2,191
San Marino 42 124.3 699
Nepal 40 0.1 17,502
Lebanon 40 0.6 2,775
Guinea 39 0.3 6,491
French Guiana 37 13.1 6,655
Mayotte 37 14.3 2,782
Uruguay 33 1.0 1,044
Benin 31 0.3 1,602
Latvia 31 1.6 1,192
Montenegro 30 4.8 2,072
Paraguay 29 0.4 3,629
Angola 29 0.1 687
Slovakia 28 0.5 1,979
Singapore 27 0.5 47,912
Guinea-Bissau 26 1.4 1,949
Zimbabwe 25 0.2 1,478
Syria 25 0.1 496
Isle of Man 24 28.5 336
New Zealand 22 0.5 1,553
Cape Verde 21 3.9 2,014
Eswatini 21 1.8 1,729
Tanzania 21 0.0 509
Suriname 20 3.5 1,001
Cyprus 19 1.6 1,037
Guyana 19 2.4 327
Maldives 15 2.9 2,930
Georgia 15 0.4 1,028
Togo 15 0.2 774
Martinique 15 4.0 262
Saint Martin 15 40.3 79
Sao Tome and Principe 14 6.6 743
Guadeloupe 14 3.5 195
Diamond Princess cruise ship 13 712
Sri Lanka 11 0.1 2,708
Jordan 11 0.1 1,214
Bahamas 11 2.9 138
Iceland 10 3.0 1,922
Mozambique 10 0.0 1,435
Jamaica 10 0.3 774
Mauritius 10 0.8 343
Malta 9 2.0 676
Bermuda 9 14.3 153
Trinidad and Tobago 8 0.6 137
Taiwan 7 0.0 451
Comoros 7 0.8 328
Barbados 7 2.4 104
Lesotho 6 0.3 359
Myanmar 6 0.0 341
Rwanda 5 0.0 1,539
Monaco 4 10.3 109
Gambia 4 0.2 93
Réunion 3 0.3 624
Brunei 3 0.7 141
Aruba 3 2.8 111
Antigua and Barbuda 3 3.1 76
Namibia 2 0.1 1,203
Turks and Caicos Islands 2 5.3 75
Belize 2 0.5 40
MS Zaandam cruise ship 2 9
Botswana 1 0.0 522
Burundi 1 0.0 310
Cayman Islands 1 1.6 203
Liechtenstein 1 2.6 86
Curaçao 1 0.6 28
Montserrat 1 20.0 12
Western Sahara 1 0.2 10
British Virgin Islands 1 3.4 8
Uganda 0 0.0 1,065
Vietnam 0 0.0 382
Mongolia 0 0.0 287
Eritrea 0 0.0 251
Faroe Islands 0 0.0 188
Gibraltar 0 0.0 180
Cambodia 0 0.0 171
Seychelles 0 0.0 108
Bhutan 0 0.0 87
French Polynesia 0 0.0 62
St Vincent and the Grenadines 0 0.0 38
Fiji 0 0.0 26
Timor-Leste 0 0.0 24
Saint Lucia 0 0.0 23
Grenada 0 0.0 23
New Caledonia 0 0.0 22
Laos 0 0.0 19
Dominica 0 0.0 18
Saint Kitts and Nevis 0 0.0 17
Papua New Guinea 0 0.0 16
Greenland 0 0.0 13
Falkland Islands 0 0.0 13
Vatican 0 0.0 12
Saint Barthelemy 0 0.0 6
Saint Pierre and Miquelon 0 0.0 4
Anguilla 0 0.0 3

Please update your browser to see full interactive

This information is regularly updated but may not reflect the latest totals for each country.

** The past data for new cases is a three day rolling average. Due to revisions in the number of cases, an average cannot be calculated for this date.

Source: Johns Hopkins University, national public health agencies and UN population data

Figures last updated: 19 July 2020, 11:30 BST

This appears to be an encouraging sign, but it also calls into question the reliability of data in a region with a poor track record of spending on health infrastructure.

"Many deaths are not reported within the vital registration system and the causes of deaths are mis-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 is "quite stark".

"The most plausible explanation is that the populations in South Asia are made up of far more younger people than say in Europe and the US," professor Siddiqi said.

The average age of the population in these countries ranges between 18 and 34.

Additional research by Waliur Rahman Miraj in Dhaka and Rama Parajuli in Kathmandu

Read more from Reality Check

Send us your questions

Follow us on Twitter