Title: An Epidemiological, Strategic and Response Analysis of the COVID-19 Pandemic in South Asia: A Population Based Observational Study

Background: South Asia has performed relatively better than initially during the COVID-19 pandemic. The overall burden and response have remained dynamic in the region with certain countries outperforming others despite limitations in health resources. Methodology: Using a population-based observational design, all 8 South Asian countries were analyzed using a step-wise approach. Data were obtained from government websites and publicly available data for population dynamics and other facilities. Results: South Asian countries have a younger average age of their population. Our ndings demonstrate the inequitable distribution of resources centered in urban metropolitan cities within South Asian countries. Certain densely populated regions in these countries have better testing facilities and healthcare facilities that correlate with lower COVID-19 incidence per million populations. Trends of urban-rural disparities are not clear given the lack of clear reporting of the gap within these regions. COVID-19 vaccination lag has become apparent in South Asian countries with the expected time to complete the campaign being unfeasible as the COVID-19 pandemic progresses. Conclusion: The focus on response in the South Asia countries has been on controlling peaks rather than curbing them. With a redesign of governance policies on preventing the rise of COVID-19 promptly, the relief on the healthcare system and healthcare workers (HCWs) will allow for adequate time to roll out vaccination campaigns with equitable distribution.


Background
Eight countries constitute South Asia including Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka, together forming the South Asian Association for Regional Cooperation (SAARC). As of May 10, 2021, this region is responsible for 25.26 million (15.83%) of the total number of COVID-19 cases and 0.29 million (8.69%) COVID-19 deaths globally (1). The South Asian countries are home to 23.75% of the global population and the transmission of COVID-19 in this region has remained dynamic (2). Initial projections predicted a higher burden of COVID-19 cases and deaths given the lack of adequate healthcare infrastructure to support the COVID-19 pandemic in South Asia (3,4). Additionally, the presence of highly dense populations within urban settings and overall socioeconomic vulnerabilities in South Asia led to great concern from public health bodies across the globe (5). Within the developed countries, many patients that were admitted to the hospitals and at higher risk of mortality were minority ethnic groups including South Asians (6). Various underlying factors that were cited included a higher risk of comorbidities, especially diabetes which has been shown to increase the relative risk of the hazard ratio for mortality due to COVID-19 (7). The triad of compromised public health infrastructure, undertrained human resources, and contributory environmental factors have all been cited as vectors for further viral transmission in the South Asian region (8,9). We aimed to elucidate the epidemiology, preparedness, and strategies contributing to the dynamic spread of COVID-19 in this region. Further, we expanded on speci c countries that have been unable to contain the pandemic.

Methodology
The study follows a population-based observational survey by obtaining data from government websites Other sources including peer-reviewed articles on the MEDLINE database, and journals including the New England Journal of Medicine (NEJM), The Lancet, British Medical Journal (BMJ), and the Journal of American Medical Association (JAMA) were also reviewed to obtain the latest updates on countries within SAARC. The analysis was conducted using data from government websites reporting reliable data ( Fig. 1).

Current Situation In Saarc
Data were monitored between March 1, 2020, to May 10, 2021, to understand the transmission patterns among people within SAARC. Three countries have had the highest burden of reported COVID-19 infections, namely India, Pakistan, and Bangladesh, which have the highest population amongst the eight SAARC countries. As of May 10, 2021, over 24.63 million cases have been identi ed among these three countries, which is likely to be underestimated. Screening methods have incorporated airport screening from international travelers with no testing for intra-country travelers. Such screening is bene cial yet does not capture all the patients who are in their incubation period. Government-imposed social distancing and lockdown measures have been bene cial in the SAARC countries. However, the testing capacity and facilities have been sub-optimal. The three most impacted countries, India, Pakistan, and Bangladesh, had continued to report high cases in the post-lockdown period after June 2020.

Age-distribution Patterns
The median age of the population in SAARC countries ranges from 22.8 to 34 years in 2020 (Fig. 2).
Among SAARC countries, the COVID-19 was reported most frequently among the age group below 50 years (10). A higher number of younger and middle-aged populations have been infected by COVID-19 in the SAARC countries. Attributed factors include environmental and individual including potential ignoring of social distancing protocols due to their compelling reason to continue working and maintaining employment (8). Higher incidence in the younger age groups has also been suspected due to effective following of social distancing and social welfare programs among older age groups (11). The casefatality ratio (CFR) among the SAARC countries was 1.14%, lower than the global CFR of 2.08%. India has the highest burden of deaths within the SAARC countries yet has a CFR of 1.09% which may be understood by its age distribution pattern. Globally, the most vulnerable age group to contract COVID-19 infection is within the age range of 18-64 years. However, the rate of death was 45 times higher among 30-39-year-olds and 8,700 times higher among those aged 85 years and older (12). Given the younger population of SAARC countries, it may be an underlying reason for the relatively lower CFR in this region.

The capacity of COVID-19 Testing
The testing capacity of SAARC countries has received attention with Bangladesh being criticized for testing a maximum of 15,000 tests for a population of 165 million (13). All the SAARC countries that had a high positivity ratio expanded their testing centers in the past year. The overall tests conducted in the countries with the heaviest burden of COVID-19 per 100 million people were the highest in India. Further, the number of testing facilities available per 100 million people is demonstrated in Fig. 3. Interestingly, India has performed the highest number of tests per million people followed by Bangladesh and Pakistan when compared to their testing capacity, demonstrated in Fig. 3. However, the overall burden of COVID-19 remains the highest in India. Across all these countries, there has been a gap between the testing centers in proportion to the population density. There is the minimal infrastructure to access rural and remotelylocated districts, compounded with social distancing protocols, which points towards the availability of testing centers primarily in urban and semi-urban settings (14). There has been a recent spike in the incidence of COVID-19 across the SAARC countries which has been attributed to the downplaying of the nature of the pandemic, lack of precautionary measures taken among citizens, and delayed responses by the governments to contain the pandemic. Countries including Bhutan, Maldives, Nepal, and Sri-Lanka have performed much better than their SAARC counterparts due to timely action, and effective measures such as social distancing (9).

Responses to COVID-19
Following the con rmation of the rst COVID-19 diagnosed case in each SAARC country, the number of critical days it took for the government to impose a lockdown was variable with Sri Lanka taking action before its rst con rmed case. All the South Asian countries had imposed a lockdown within 1 month of the rst diagnosed case except India, which took nearly 7 weeks to implement on March 25, 2020. However, South Asia took formidable action quicker than the United States, United Kingdom, and European countries. Despite nationwide lockdowns being implemented between March 15 to 25, 2020, the number of COVID-19 cases has continued to rise. The interventions in South Asia have focused on implementing strict lockdown measures through suppression. In-depth analysis has demonstrated the lack of adequate containment of COVID-19 among ve countries including Afghanistan, Bangladesh, India, Nepal, and Pakistan. Overall, the CFR in South Asia has been observed to be lower than that of the developed countries. However, individual analysis of Pakistan and India places both these countries in the top 20 countries with the CFR and deaths per 100,000 populations. Figure 4 demonstrates the cumulative COVID-19 cases for all 8 South Asian countries since the start of the pandemic.
The majority of the heavily burdened countries in South Asia (India, Pakistan, and Bangladesh) have their population residing in rural areas with their economy dependent upon agriculture. The healthcare system in South Asia follows a decentralized system with healthcare provision available through public and private hospitals in three countries (India, Pakistan, and Bangladesh). Limitations of healthcare resources among different states or regions within India, Pakistan, and Bangladesh have been cited as causative for inadequacy to limit community transmission. As of May 10, 2021, India has set up 2,542 testing facilities for its total population of nearly 1.38 billion people. The number of testing centers in Pakistan is 139 with its total population of 224 million people. Bangladesh received criticism for its inadequate number of testing facilities and since has set up 459 centers for its population of 166 million. There is a signi cant gap in the capacity of the testing center to serve more populated districts. The number of COVID-19 testing facilities per population density falls short as the most densely populated states have a relatively lower number of testing centers and a higher burden of case per million populations (table 1). In the South Asian region, there has been a shortage of hospital beds per state division. For instance, the number of beds in Islamabad, Pakistan, shows the availability of beds to be 1 for every 38 patients on average per 1 million people. States such as Uttar Pradesh in India and Dhaka in Bangladesh are observed to be more competitive due to a stronger healthcare system before the COVID-19 pandemic.  (13). These gaps identify a centrality of testing centers in urban metropolitan regions within the country as well as concentrated tertiary healthcare provision. It can be stated that these South Asian countries have a higher discrepancy in terms of allocation of hospital services, and testing centers. In India's recent wave, the number of testing centers and hospital bed facilities did not rise in proportion to the number of COVID-19 cases as well as medical staff and other technical facilities (15). The healthcare system in these countries has been cited as under-equipped to serve all the population not only in rural and remote settings but also urban settings as the cases increase in the metropolitan areas. With a substantial amount of vaccination supply being provided by COVAX partners, two primary roadblocks need to be addressed during the vaccination campaign by South Asian countries that have lagged. There is an immediate need to increase the vaccine supply and re-strategize the setting for the distribution campaign. For instance, the rural population constitutes 63-65% of the three countries with the highest burden of COVID-19 (17). However, these settings have a scarcity of public health and primary care clinics (18). This warrants an equitable distribution through collaboration with primary care facilities and their communities. Alongside, as the vaccination campaign is rolled out, it is pertinent to control to high rate of COVID-19 transmission witnessed by certain South Asian countries. Such containment measures may be possible through transparent reporting of the data in a timely manner by the government, stopping mass religious or political gatherings, tracking hotspots, and necessitating masks and social distancing.

Discussion
There has been a notable difference in the testing strategies, laboratory strategies, and healthcare provision among and within South Asian countries (9). The differences across regions result in the presentation of inhomogeneous data. So far, South Asia has been observed to have lower CFRs which may be underestimated. The CFR of Pakistan is the highest in the South Asian region yet Pakistan has the lowest testing capacity in the South Asian region as noted in our analysis. However, in the initial phase of the COVID-19 pandemic, Pakistan's CFR was signi cantly lower which leads to the importance of an inadequate surveillance system. With a growing number of cases, the CFR has increased in Pakistan which presents two possible dilemmas: 1) the number of individuals being tested is more severely ill resulting in an overestimation of CFR, and 2) the number of mild-to-moderate COVID-19 cases are under-represented due to under-testing of patients. A bias noted in the trends of CFR in South Asian countries may be present due to ongoing improvement in the testing capacity. The insu cient facilities and the ensuing community transmission during the early stage of the pandemic have not been met with adequate governance in the South Asian countries due to premature and discontinuation of social distancing policies (19).
Following trajectories of lockdown and post-lockdown trends in the SAARC countries, smaller countries were able to control their COVID-19 transmission. However, the three most affected countries (India, Pakistan, and Bangladesh) eased lockdowns without curbing the transmission of COVID-19 cases. Before recommending nationwide lockdowns during the ongoing wave of the COVID-19 pandemic, certain highly dense hotspots need to be taken into consideration such as Mumbai, Karachi, and Dhaka, the three most populated urban cities in India, Pakistan, and Bangladesh (9). Selective hotspots require localized lockdowns for 2-3 weeks with active surveillance and strict quarantine measures to control the outbreak from aggravating in these countries. A public health approach necessitates curbing the peak (the exponential growth in COVID-19 infection requiring medical supplies) a few weeks before it occurs. Gaps in response preparedness including shortages in hospital beds, ventilators, quarantine facilities, and lack of standardized treatment protocols due to different variants present delays in the healthcare system (20). SAARC countries have received resources such as testing kits, ventilators, vaccinations, and aid from international regulatory bodies. However, the overall health expenditure in the three most impacted and populated countries (India, Pakistan, and Bangladesh) is less than 1% of GDP (21). The total availability of hospital beds is lower than 10 per 1000 populations in all the SAARC countries except Bhutan (22). Further, the World Bank has predicted that SAARC countries will face their worst economic crisis due to the ongoing COVID-19 pandemic.
Within the socio-economic context of South Asia, the health systems already witnessed a scarcity in healthcare resources. The COVID-19 pandemic further aggravated the gaps in healthcare resources (14). The pressure to ease lockdowns was also felt due to the economic losses faced by these countries. As such, in the South Asian context, the lack of clarity within the urban-rural disparity in testing, vaccination access, and treatment presents as a challenge. High-burden countries (India, Pakistan, Bangladesh, Sri Lanka, and Afghanistan) have reported shortages in medical supplies such as oxygen, hospital beds, and personal protective equipment (PPE) (23). Alongside, the detection of emerging strains in India was compounded with a lack of mitigation strategies and the catastrophic second wave of COVID-19 in the country (15). With South Asia and other countries overestimating their status of herd immunity, it is pertinent to eliminate false reports (24). Misinformation concerning COVID-19 infection and vaccination needs to be addressed through education in attempts to eliminate vaccine hesitancy and application of safety protocols (masks, distancing) (25). A limitation of the available data from the government sites is the potentially substantial underestimation of the actual scenario.

Conclusions
The South Asian countries consist of a younger average population age demographic with urban settings being more densely populated. The urban-rural disparities have not been documented in national datasets despite the high ratio of populations belonging to rural settings. Medical supplies and health infrastructures are primarily focused in urban cities. Trends of COVID-19 burden in more populated regions are associated with an overwhelmed healthcare system and healthcare workers (HCWs) with draining medical supplies. The focus on restructuring the COVID-19 response in these countries ought to shift by curbing peaks before they occur and prepare vaccination campaigns with equitable distribution within these countries.

Declarations
Ethics approval and consent to participate: NA Consent for publication: All authors consent to publication.
Availability of data and materials: The datasets generated and/or analyzed during the current study are available in country-speci c government and publicly-available data repositories: iedcr. Competing interests: The authors declare that the research was conducted in the absence of any commercial or nancial relationships that could be construed as a potential con ict of interest.
Funding: NA Authors' contributions: MHS, JS, AR, SHB contributed to the drafting, original draft preparation, methodology, and nal review of the manuscript. AS and ZS performed the analysis, and were a major contributor in writing the manuscript. ICO supervised the study and the guarantor. All authors read and approved the nal manuscript.
23. Sarfraz A, Sarfraz Z, Anwer A, Sarfraz M, Siddiq J. Availability, Use, and Satisfaction of Personal Protective Equipment Among Healthcare Workers: A Cross-Sectional Assessment of Low-and Middle-Income Countries. J Occup Environ Med. 2020;62 (11).

Figure 2
Median Age of SAARC Countries in 2020.

Figure 3
Page 13/14 The number of testing centers per 100 million people and rate of testing per 1000 people in the SAARC countries with the highest COVID-19 cases.