Even as the pandemic appears to be rapidly slowing down in most parts of India, the rate of decline in many of the smaller North Eastern states continues to be slow.

In some states such as Sikkim, Manipur and Meghalaya, the decline in the number of active cases has not resulted in the lowering of test positivity rates – the number of positive cases per 100 samples tested – suggesting that chains of transmissions have not been effectively terminated and the drop in absolute numbers is artificial and a result of low testing.

The test positivity rates in Nagaland, Arunachal Pradesh and Mizoram are on the decline, but much higher than the national average. Tripura’s graph has marginally inched upwards too last week, but its positivity rate is still much less than these states.

Assam’s trajectory reflects the broader national trend to a large extent.

Manipur’s woes

The situation in Manipur is particularly concerning. After a steady dip since the last last week of May, the state’s test positivity rate has seen a rise in the last two weeks. On June 30, the state’s average test positivity rate calculated over the last seven days reached a high of 12.8% from the 8.8 % two weeks ago.

To make matters worse, the daily growth of new confirmed cases has also seen a steady uptick in the last one week.

Manipur's test positivity rate over time. Credit: covid19india.org

The trend has worried the state’s health officials. “We are also perplexed why the positive rate is still so high despite so many restrictions in place,” said a senior health official requesting anonymity as he was not authorised to speak to the media.

Manipur reached its peak thus far in the last week of May. Since then, the number of new cases steadily went down till about one week ago. “We thought we had peaked, but we are now puzzled as to why still so many cases and deaths,” said the official.

Manipur's new cases over time. Credit: covid19india.org

Since May, the state which has seen just over 38,000 cases has reported around 740 Covid-19 deaths.

In the last couple of weeks, the virus has started rapidly spreading in the fairly remote tribal-dominated hill districts of the state. “Earlier the problem was in the two most populated districts of Imphal West and Imphal East,” said the official. “We have contained it there, but now it is increasing in the hill districts.”

In Tengnoupal district, bordering Myanmar, the weekly test positivity rate over the last seven days as of June 29 was in the high twenties, said the health official.

On June 29, the state government suspended the Free Movement Regime along the Indo-Myanmar border for a month.

Manipur’s principal secretary, heath and family welfare, V Vumlunmang acknowledged that the high positivity rate was a cause of concern. “We are tracking that and monitoring it on a day-to-day basis,” he said. “We are strengthening contact tracing and putting in place micro-containment measures in localities and villages.”

But the state’s struggles to contain the pandemic despite its spare population seem to be at least partly due to its limited testing. After reaching a peak of over 8,000 daily tests in the second week of June, the number has dropped to less than 5,000 in the last week of the month. Consequently, the positivity rate has shot up.

This suggests that some infections are going under the radar leading to continued transmission of the virus. After all, only when a person tests positive, they are isolated to prevent them from spreading the virus to other people.

The state has a daily capacity of 1,500 RT-PCR or reverse transcription-polymerase chain reaction tests that are recommended for diagnostic purposes, said Vumlunmang. However, the state has been doing less than 1,000 RT-PCR tests daily on an average, instead deploying the less reliable rapid antigen tests for the rest.

But health officials said the problem was not capacity as much as convincing people to get tested. “People are not coming out to test, we are going to their homes, but still they do not agree,” said a state health official. “We cannot force them beyond a point.”

Manipur's daily tests over time. Credit: covid19india.org

Same story in Meghalaya

The hill state Meghalaya is also reporting a high positivity rate that has started to inch up again in the past week. On June 30, the average positivity rate of the state calculated over the last seven days shot up to 13%

Meghalaya's test positivity rate over time. Credit: covid19india.org

However, unlike Manipur, this has not coincided with any notable daily growth in new cases.

Yet, that may not be a true reflection of the situation as the state’s daily tests have substantially decreased since the last week of May when it hit a peak of over 5,000 tests, which is roughly the state’s daily capacity. The average number of daily tests in the state in the week ending June 30 was around 4,000.

Meghalaya's daily tests over time. Credit: covid19india.org

Like Manipur, state officials blamed it on people’s reluctance to get tested. “The number of testing is not high as it should be because people are very hesitant to get tested,” said Ram Kumar, director of Meghalaya’s National Health Mission. “We try to convince them that this wave is dangerous, but it’s becoming more difficult because this lockdown has gone on for so long and people are wary of being isolated and not being able to work if tested positive.”

Meghalaya's new cases over time. Credit: covid19india.org

A vaccination problem

Apart from low testing, another thing ties Manipur and Meghalaya together: low vaccination coverage. The two states have the lowest vaccine coverage among the smaller states in not just the North East, but the entire country.

That, public health experts say, could also be one of the reasons behind the positivity rates continuing to be high. “We have had a very big hesitancy issue in Meghalaya,” said Sandra Albert, director of Shillong’s Indian Institute of Public Health, an affiliate organisation of the Public Health Foundation of India. “That is definitely one aspect of it.”

Not only Meghalaya, large parts of the North East, particularly areas dominated by ethnic tribes, have seen beset by vaccine hesitancy. Manipur’s hill districts have some of the lowest vaccination rates in the country.

Yet it is difficult to draw neat patterns. Despite its vaccination coverage – the second highest in the country – Sikkim’s positivity rate is the highest in the country.

While conceding that it was not ideal, the state’s health secretary K Sreenivasulu said an overwhelming number of them were asymptomatic. “We don’t have enough testing infrastructure but we have tried to make up for it by high vaccination,” he said.

Indeed, since May 1, Sikkim has seen 160 deaths with a case fatality rate that is almost half of both Meghalaya and Manipur in the same period – despite the small hill state seeing a surge in positivity rate in recent times owing to a small number of tests. Ditto with Tripura which boasts of one of the highest vaccination coverages in the country.

On the other hand, officials in Manipur and Meghalaya said a fairly high percentage of their positive patients were symptomatic.

A North East phenomenon

Irrespective of vaccination rates, the average rate of decline of cases in the smaller states of the North East is slower than most other parts of the country.

Ram Kumar, director of Meghalaya’s National Health Mission, said that was likely because people lived in less dense settings in most of these areas. “Unlike a place like Delhi where it spreads really quickly, it takes time for the virus to spread here,” he said.

What he meant was: In densely populated places, the virus infects a higher number of people in a shorter period of time – resulting in more explosive outbreaks that tend to burn out sooner.

That apart, as public health expert Albert pointed out, the second wave arrived later in the North than the rest of India.