The interplay between policy and COVID-19 outbreaks in South Asia: Longitudinal trend analysis of surveillance data

Sarah B. Welch, Dinushi Amanda Kulasekere, P. V. Vara Prasad, Charles B. Moss, Robert Leo Murphy, Chad J. Achenbach, Michael G. Ison, Danielle Resnick, Lauren Singh, Janine White, Tariq Z. Issa, Kasen Culler, Michael J. Boctor, Maryann Mason, James Francis Oehmke, Joshua Marco Mitchell Faber, Lori Ann Post*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Background: COVID-19 transmission rates in South Asia initially were under control when governments implemented health policies aimed at controlling the pandemic such as quarantines, travel bans, and border, business, and school closures. Governments have since relaxed public health restrictions, which resulted in significant outbreaks, shifting the global epicenter of COVID-19 to India. Ongoing systematic public health surveillance of the COVID-19 pandemic is needed to inform disease prevention policy to re-establish control over the pandemic within South Asia. Objective: This study aimed to inform public health leaders about the state of the COVID-19 pandemic, how South Asia displays differences within and among countries and other global regions, and where immediate action is needed to control the outbreaks. Methods: We extracted COVID-19 data spanning 62 days from public health registries and calculated traditional and enhanced surveillance metrics. We use an empirical difference equation to measure the daily number of cases in South Asia as a function of the prior number of cases, the level of testing, and weekly shifts in variables with a dynamic panel model that was estimated using the generalized method of moments approach by implementing the Arellano–Bond estimator in R. Results: Traditional surveillance metrics indicate that South Asian countries have an alarming outbreak, with India leading the region with 310,310 new daily cases in accordance with the 7-day moving average. Enhanced surveillance indicates that while Pakistan and Bangladesh still have a high daily number of new COVID-19 cases (n=4819 and n=3878, respectively), their speed of new infections declined from April 12-25, 2021, from 2.28 to 2.18 and 3.15 to 2.35 daily new infections per 100,000 population, respectively, which suggests that their outbreaks are decreasing and that these countries are headed in the right direction. In contrast, India’s speed of new infections per 100,000 population increased by 52% during the same period from 14.79 to 22.49 new cases per day per 100,000 population, which constitutes an increased outbreak. Conclusions: Relaxation of public health restrictions and the spread of novel variants fueled the second wave of the COVID-19 pandemic in South Asia. Public health surveillance indicates that shifts in policy and the spread of new variants correlate with a drastic expansion in the pandemic, requiring immediate action to mitigate the spread of COVID-19. Surveillance is needed to inform leaders whether policies help control the pandemic.

Original languageEnglish (US)
Article numbere24251
JournalJMIR Public Health and Surveillance
Issue number6
StatePublished - Jun 2021


  • 7-day lag
  • Acceleration
  • Bangladesh
  • Bhutan
  • COVID-19
  • COVID-19 surveillance
  • Dynamic panel data
  • India
  • Jerk
  • Maldives
  • Pakistan
  • South Asia
  • Speed
  • Sri Lanka

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Health Informatics
  • Medicine(all)


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