Article

COVID-19 Pandemic in Rajasthan: Journal of Health Management

22(2) 129–137, 2020
Mathematical Modelling and Social © 2020 Indian Institute of
Health Management Research
Distancing
Reprints and permissions:
in.sagepub.com/journals-permissions-india
DOI: 10.1177/0972063420935537
journals.sagepub.com/home/jhm
Shiv Dutt Gupta1, Rohit Jain2 and Sunil Bhatnagar3

Abstract
Background: Mathematical modelling of epidemics and pandemics serves as an input to policymakers
and health planners for preparedness and planning for the containment of infectious diseases and their
progression in the population. The susceptible–exposed–infectious/asymptomatic–recovered social
distancing (SEIAR-SD) model, an extended application of the original Kermack–McKendrick and Fred
Brauer models, was developed to predict the incidence of the COVID-19 pandemic and its progression
and duration in the state of Rajasthan, India.
Objective: The study aimed at developing a mathematical model, the SEIAR-SD model, of the COVID-
19 pandemic in the state of Rajasthan, for predicting the number of cases, progression of the pandemic
and its duration.
Materials and methods: The SEIAR-SD model was applied for different values of population propor-
tion, symptomatic and asymptomatic cases and social distancing parameters to evaluate the effect of
variations in the number of infected persons, size of the pandemic and its duration, with value of other
parameters fixed in the model. Actual reported cases were plotted and juxtaposed on the prediction
models for comparison.
Results: Social distancing was the crucial determinant of the magnitude of COVID-19 cases, the pro-
gression of the pandemic and its duration. In the absence of any proven treatment or vaccine, effective
social distancing would reduce the number of infections and shorten the peak and duration of the pan-
demic. Loosening social distancing will increase the number of cases and lead to a heightened peak and
prolonged duration of the pandemic.
Conclusions: In the absence of an effective treatment or a vaccine against COVID-19, social distancing
(lockdown) and public health interventions—case detection with testing and isolation, contact tracing
and quarantining—will be crucial for the prevention of the spread of the pandemic and for saving lives.

Keywords
COVID-19 pandemic, mathematical model, SEIAR-SD predictive modelling, social distancing

1
Chairman and Distinguished Professor, IIHMR University, Jaipur.
2
Senior Manager, Research Management Unit, IIHMR University, Jaipur, India.
3
Joint Secretary, Department of Medical Education, Government of Rajasthan, India.
Corresponding author:
Shiv Dutt Gupta, IIHMR University, 1, Prabhu Dayal Marg, Near Sanganer Airport, Jaipur, Rajasthan 302029, India.
E-mail: sdgupta@iihmr.edu.in
130 Journal of Health Management 22(2)

Introduction
The World Health Organization (WHO) declared the COVID-19 infection a public health emergency
and, subsequently, a pandemic affecting almost the whole world. The disease is caused by Severely
Acute Respiratory Syndrome (SARS) coronavirus-2, which is more contagious and virulent than the
SARS coronavirus. At the time of writing, over 4 million persons have been confirmed to be affected by
the COVID-19 infection globally, and over 276,000 (6.88%) people have died. About 35 per cent cases
have recovered from the disease. The pandemic posed a serious threat to the health of the people
worldwide and emerged as a serious concern of the global health community and governments, especially
since there is no available effective treatment or vaccine against the disease. In India, the first case of the
SARS coronavirus-2 was reported on 30 January 2020. The state of Rajasthan, which is the largest state
in India, reported its first case on 2 March 2020 in Jaipur. The national and state governments made a
serious effort to contain the spread of the disease and the resultant morbidity and mortality in the
population.
Many researchers have attempted to predict the number of infectious cases of the COVID-19 outbreak
(Fang et al., n.d.; Nesteruk, 2020; Song et al., 2020; Zhang et al., 2020). The present study has attempted
to develop a mathematical model based on the reported cases in the state of Rajasthan since the start of
the outbreak to predict the number of cases and the progression of the pandemic in the state of Rajasthan,
using the susceptible–exposed–infectious/asymptomatic–recovered social distancing (SEIAR-SD)
predictive model.

Methods
An extended version of the susceptible–infectious–recovered (SIR) model of Kermack and McKendrick
(1991) was applied for developing a prediction model for the COVID-19 pandemic in Rajasthan for
estimation of the number of COVID-19 cases (Tomie, 2020). It assumes that as an infectious disease is
introduced in a population, its progression will be determined by the availability of the susceptible
population (S), transfer rate of infection from an infected person (I) and those recovered or killed by the
disease (R). Brauer (2006) further improved the SIR model by introducing exposure to infection and
asymptomatic cases, the susceptible–exposed–infectious/asymptomatic–recovered (SEIAR) model. The
population is further characterised into: exposed but do not acquire the infection (E) and asymptomatic
(A)—those who acquire the infection without symptoms but are infectious. Exposed and asymptomatic
would move to the R stage in the model.
The SEIAR-SD model (Figure 1) is an extension of the SEIAR model that includes one variable,
social distancing. The susceptible individuals are further categorised into two groups, one that strictly
practised social distancing and did not come in contact with infected persons (SD2) and the other with no
or loose social distancing norms, with the risk of exposure to the infection (SD1). The model assumed
that once an infected individual is introduced into a virgin population where it is implied that all are
susceptible, each infected person would transmit the infection at a rate β to susceptible individuals who
come in contact. The basic reproduction number (R0) determines the progression and rate of new
infections (Tomie, 2020). If R0 > 1, then the infection assumes an epidemic form. The epidemic dies out
when R0 < 1. Figure 1 outlines the transmission and progression of disease.
Gupta et al. 131

Figure 1. Schematic Diagram: SEIAR-SD Model

Source: The authors.

The SEIAR-SD model is expressed in the following differential equations:

dS
   S ( K i I  K A A)  f1 S
dt

dE
  S ( K i I  K A A)   S DI ( K i I  K A A)  p E   I  p   E
dt

dI
  I  p  E   I
dt

dA
 p E    A
dt

dR
  I   A
dt

dS D1
 f1 S  f 2 S D1   S D1 ( K i I  K A A)  dS D 2
dt

dS D 2
 f 2 S D1  dS D 2
dt
132 Journal of Health Management 22(2)

where
S = susceptible population;
E = exposed to risk of infection;
I = infected individuals (symptomatic cases assumed to be infectious);
A = asymptomatic cases assumed to be infectious;
R = removed from the susceptible population (recovered/dead);
SD = social distancing; and
dS/dt, dE/dt, dI/dt, dA/dt and dR/dt, respectively, represent changing rates in population at time t,
in S, E, I, A and R.
β is the transmission rate of infection from an infected person to susceptible individuals coming
in contact.
ω and γ represent transfer rate from E to I and that from I to R, respectively, and ω′ and γ′ refer to
transmission rates from exposed to asymptomatic and from asymptomatic to R.
p is the proportion of asymptomatic infections, and KA and Ki represent relative risk of infection
among asymptomatic and symptomatic individuals, respectively.
d refers to transfer rate from social distancing to no social distancing (SD2 to SD1), and f1 and f2
are transfer rates from S to SD1 and SD1 to SD2, respectively.

Results

Incidence and Time Distribution of COVID-19 in Rajasthan

A total of 2,800+ cases of COVID-19 laboratory-confirmed by reverse transcription polymerase chain
reaction (RT-PCR) were detected in Rajasthan up to 20 April 2020. The state of Rajasthan came under
national lockdown from the mid-night of 24 March 2020. On that day, only 45 RT-PCR-confirmed cases
were reported.
Model 1: For simulation of the pandemic in the 80 million people of Rajasthan, we assumed R0 = 3.0,
1/γ = 8, SD = 85 per cent of the population, p = 0.7 (as 70% asymptomatic cases have been reported so
far), 1/ω = 7, 1/ω‫= ׳‬8, 1γ‫ = ׳‬6, Ki = 6.12, KA = 6.8, f1 = 0.001, d = 0.002 and f2 = 0.125. We predicted that
the pandemic period would continue till July 2020, with an estimated number of a total of 34,080 infected
individuals during the duration of the pandemic (March–July 2020). The number of cumulative
symptomatic and asymptomatic cases are estimated at 10,224 and 23,856, respectively (Figure 2). The
peak of the pandemic curve would be reached in mid-May. We also fitted the actual reported number of
cases on a daily basis and observed a close synchronicity between the predicted pandemic curve and
actual reported cases.
To validate our prediction model, we also modelled the actual data from the COVID-19 spread in
China and found a good synchronicity between the predicted pandemic curve and the actual reported
data (Figure 3) (Germany, 2020).
Gupta et al. 133

Figure 2. Prediction Model and Actual Reported Cases in Rajasthan (Model 1)

Source: The authors.

Figure 3. Fitting of Data from Hubei, China (Model 5)

Source: The authors.

Model 2: Keeping all the parameters same as those used in Model 1, in Model 2, pandemic curves were
simulated for varying levels of social distancing in the population, at 90 per cent, 85 per cent and 80 per
cent. For a value of 80 per cent, a sharp and broader peak was obtained. Increasing the social distance
level to 85 per cent and 90 per cent resulted in a shorter peak and shorter duration of the pandemic curve
(Figure 4).
134 Journal of Health Management 22(2)

Figure 4. Prediction Model with Different Social Distancing Scenarios (Model 2)

Source: The authors.

Figure 5. Prediction Model Showing Total Number of Cases, Peak and Duration of Pandemic Curve (Model 3)
Source: The authors.

If social distancing is strictly followed, that is, 90 per cent, the expected number of infections would
be 21,492 (symptomatic 6,448; asymptomatic 15,044). If lenient social distancing is practised (80%), the
number of estimated total cases would rise to 61,000 (symptomatic 18,531; asymptomatic 43,240). The
number of estimated cases would rise geometrically if the social distancing norms are loosened and
person-to-person contact increases.
Gupta et al. 135

The peak would remain identical in varying social distancing norms, but the duration of the pandemic
will be prolonged with relaxing social distancing norms.
Model 3: We also modelled laxity of social distancing and the mixing of people who were adhering
to social distancing norms previously, that is, moving from the SD2 to the SD1 status at varying values of
d = 0.001, 0.0025 and 0.004. The probability of mixing was introduced in the model, and its effect on the
pandemic curves, number of cases and duration of the pandemic were evaluated (Figure 5).
In the case of extreme mixing of the population, d = 0.004, the number of cases, both symptomatic
and asymptomatic, would rise astronomically to beyond 127,000, the peak of the pandemic curve would
be heightened, and the duration of the pandemic would be prolonged. But if, as in a good case scenario,
the population is mixing at d = 0.001, the total number of cases will continue to be low, at about 34,000,
with one-third symptomatic cases, the peak will be shortened, and the duration of the pandemic will be
reduced.
Model 4: Keeping Model 1 parameters fixed and with variability in d and f2 values, we evaluated the
effect of various combinations of d and f2 values on the progression of the pandemic. The model predicted
that more people moving to social distancing from no social distancing would lead to a lower-height
curve, shorter duration of the pandemic and low number of cases (Figure 6).

Figure 6. Prediction Model for Differential Transfer Rates of People Between Social Distancing Groups SD1 and
SD2 (Model 4)
Source: The authors.
136 Journal of Health Management 22(2)

Discussion
Various mathematical models are in circulation to predict the number of COVID-19-infected persons
in India, a country with 1.34 billion people, during the current pandemic. COVID 19 infection
reproduction rate (R0) may influence size and progression of the pandemic in the world. Mathematical
models could be used as tools of studying the dynamics of disease transmission and behaviour of
pandemics of acute infections like the COVID-19 and the success of social and public health
interventions (Oliveira, 2020). We used an extension of the SIR model developed by Kermack and
McKendrick. We factored in social distancing and asymptomatic cases in the model equation. The
model can be used as a tool to study the effect of social distancing on the spread of the disease and
public health interventions to control the pandemic.
However, the SEIAR-SD model has inherent limitations. It assumes that the mixing of the population
is random and that the population size is unchanged. It also does not account for migration. The lockdown
following the outbreak of the pandemic led to a massive exodus of millions of labourers for their
hometowns across the states in India. The present model could not adjust for this unprecedented
phenomenon that continues till date, and no data is available on this mass displacement of population.
We could not evaluate the effect seasonality. The pandemic started in winter and is continuing through
the summer with the same vengeance. The model predicts that the pandemic might tail off during the
rainy season, but it is anybody’s guess. Changing strains of the coronavirus have been reported, but the
model does not account for changing antigenicity and virulence. We have assumed social distancing to
the extent of 80 per cent during the lockdown, but it can never be measured in real terms. Hence, keeping
in view these limiting factors, modifications in the model are required to arrive at more refined estimates.
The feasibility of reining in the pandemic would critically depend on the changing value of R0. Greater
the value of R0 > 1, greater would be the spread of the infection (Hébert-Dufresne et al., 2020). Our
model suggests that strict social distancing measures, such as a lockdown, would significantly decrease
the number of COVID-19 infections. We have validated our model on data from China, available in the
public domain, and found a good fit, which gives an assurance that our assumptions and model are truly
reflective of the magnitude of the coronavirus infection and its spread among the population of Rajasthan.
We restricted our modelling to the population of Rajasthan, as India is a geographically and socially
diverse country and any single model for the entire population of the country may not represent the true
behaviour of the pandemic.
Behavioural interventions, such as social distancing, confinement in homes and the continuous use of
personal protective measures, may prove to be effective at controlling the spread of the infection (Tyson
et al., 2020).
Efforts are on to develop a vaccine effective against the new coronavirus strain. However, it will not
be available in the market for the next 10–12 months. Until then, social and behavioural interventions,
and classical public health measures of isolation, prevention and control of infectious diseases, are the
only weapons against COVID-19.
Mathematical models should be used with a word of caution for an interpretation of the disease
estimates. These predictions are based on mathematical modelling and certain assumptions regarding
disease transmission rates, effectiveness of social distancing/lockdown and public health measures of
epidemic control and prevention, such as early detection, isolation and treatment of affected persons and
containment measures. Human behaviour, human biological response and characteristics of the causative
organisms may not be captured completely by mathematical numbers and equations.
Mathematical modelling is a continuous and an evolving process. It will require in-depth analysis to
evaluate the effectiveness of various social distancing methods, the effect of a partial lockdown,
Gupta et al. 137

geographic distribution and socio-economic determinants on the future mathematical modelling of

outbreaks and epidemics.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of
this article.

Funding
The authors received no financial support for the research, authorship and/or publication of this article.

References
Brauer, F. (2006). Some simple epidemic models. Mathematical Biosciences and Engineering, 3(1), 1–15. https://
doi.org/10.3934/mbe.2006.3.1
Fang, Z., Huang, Z., Li, X., Zhang, J., Lv, W., Zhuang, L., … Huang, N. (2020). How many infections of COVID-19
there will be in the “Diamond Princess”-Predicted by a virus transmission model based on the simulation of
crowd flow. ArXiv. https://arxiv.org/abs/2002.10616
Germany, S. G. (2020). Prediction of COVID-19 outbreak in China and optimal return date for university students
based on propagation dynamics. Journal of Shanghai Jiao Tong University (Science), 25(2), 140–146.
Kermack, W. O., & McKendrick, A. G. (1991). Contributions to the mathematical theory of epidemics—I. Bulletin
of Mathematical Biology, 53(1), 33–55. https://doi.org/10.1007/BF02464423
Hébert-Dufresne, L., Althouse, B. M., Scarpino, S. V., & Allard, A. (2020). Beyond R0: Heterogeneity in secondary
infections and probabilistic epidemic forecasting. MedRxiv. https://doi.org/10.1101/2020.02.10.20021725
Nesteruk, I. (2020). Verification of coronavirus epidemic predictions for mainland China. 10–13. https://doi.
org/10.13140/RG.2.2.17231.43681
Oliveira, G. (2020). Refined compartmental models, asymptomatic carriers and COVID-19. MedRxiv. https://doi.
org/10.1101/2020.04.14.20065128
Tomie, T. (2020). Relations of parameters for describing the epidemic of COVID―19 by the Kermack―McKendrick
model. MedRxiv. https://doi.org/10.1101/2020.02.26.20027797
Tyson, R. C., Hamilton, S. D., Lo, A. S., Baumgaertner, B. O., & Krone, S. M. (2020). The timing and nature of
behavioural responses affect the course of an epidemic. Bulletin of Mathematical Biology, 82(1), 1–28. https://
doi.org/10.1007/s11538-019-00684-z
Song, P. X., Wang, L., Zhou, Y., He, J., Zhu, B., Wang, F., … Eisenberg, M. (2020). An epidemiological
forecast model and software assessing interventions on COVID-19 epidemic in China. MedRxiv. https://doi.
org/10.1101/2020.02.29.20029421
Zhang, Y., You, C., Cai, Z., Sun, J., Hu, W., & Zhou, X.-H. (2020). Prediction of the COVID-19 outbreak based on
a realistic stochastic model. MedRxiv. https://doi.org/10.1101/2020.03.10.20033803