Prevalence of COVID-19 in Rural Versus Urban Areas in a Low-Income Country: Findings from a State-Wide Study in Karnataka, India

Although the vast majority of confirmed cases of COVID-19 are in low- and middle-income countries, there are relatively few published studies on the epidemiology of SARS-CoV-2 in these countries. The few there are focus on disease prevalence in urban areas. We conducted state-wide surveillance for COVID-19, in both rural and urban areas of Karnataka between June 15-August 29, 2020. We tested for both viral RNA and antibodies targeting the receptor binding domain (RBD). Adjusted seroprevalence across Karnataka was 46.7% (95% CI: 43.3-50.0), including 44.1% (95% CI: 40.0-48.2) in rural and 53.8% (95% CI: 48.4-59.2) in urban areas. The proportion of those testing positive on RT-PCR, ranged from 1.5 to 7.7% in rural areas and 4.0 to 10.5% in urban areas, suggesting a rapidly growing epidemic. The relatively high prevalence in rural areas is consistent with the higher level of mobility measured in rural areas, perhaps because of agricultural activity. Overall seroprevalence in the state implies that by August at least 31.5 million residents had been infected by August, nearly an order of magnitude larger than confirmed cases.