There are two schools of thought when it comes to testing & India is doing what it possibly can with the limited resources available
Many experts are urging the Indian government to test more. The World Health Organisation (WHO) too has been asking governments the world over to conduct mass testing in order to identify, isolate and thereby contain the Coronavirus.
But India, led by the Indian Council for Medical Research (ICMR) as the strategy making body, has decided not to be entirely WHO compliant. And this means that the country and its state governments have chosen to conduct targeted and specific testing rather than the mass testing that is currently advocated by the WHO.
“There is a wrong understanding that less sample testing means we are not efficient,” K Shanmugam, Chief Secretary of the state of Tamil Nadu told The Lede. “Sample testing can be done only in symptomatic patients. Hence the number does not matter. Only the number tested to the number of positive patients gives an idea of the severity,” he said.
The Lede has conducted an exhaustive research of the trend in testing of the five south Indian states. This has thrown up trends that can help us understand the rationale behind India’s targeted approach. Let us take each state as a separate case study.
Andhra Pradesh, according to medical bulletins, began testing as early as February 03. As is evident from the below table, the state did not progress very far or fast in tests. By the end of February, the state had done just nine tests for COVID-19.
Come March and data began to be recorded towards the end of the first week. By March 07, the state had sent 32 samples to the National Institute of Virology, Pune, for testing.
The first positive showed up on March 12, a person who had come from abroad.
But it was only from March 18 that the testing picked up a little and moved into double digits per day from single digits.
And this was because, the earlier tests were being sent only to NIV Pune, but as the ICMR swung into action, more labs began to be approved for testing.
“By the time we started getting positive cases, Gandhi Hospital in Hyderabad was ready,” Jawahar Reddy, Health Secretary of Andhra Pradesh told The Lede. “We were sending the confirmatory tests to NIV. The first centre that was allowed to test for COVID-19 in AP was SIMS, Tirupati, in mid-March.”
Andhra now has four approved labs for testing samples of COVID-19. Of these, three can also perform confirmatory assays. “We are hoping to get approval for another three labs by April,” said Reddy. “Once we get that, we will have seven labs for testing.” The three labs which are yet to be up and running are in Guntur, Kadapa and Vizag.
The Health Secretary said that the state has the capacity to conduct 240 samples per day as of now with around 3000 testing kits in hand. He explained how the testing process works in two shifts.
“We have created an app to monitor the movement of the samples,” he said. “The first sample starts from all collection centres at 10 am. Whoever has come the previous night and in the morning, up to 9 am, we wait for them. At 10 am the samples start to the lab. These samples will reach the labs in 4-5 hours depending on the distance of the lab from the sample collection centre. These samples will be tested at 6 pm in the evening. At 7 pm in the evening again, the second batch of samples start going to the labs. Those samples are tested the next day at 9 am in the labs. So the first testing starts at 9 am and the second testing starts at 6 pm. We are recruiting now and we hope to do three shifts soon,” he said.
When queried about why the testing has been spotty in the state, the senior bureaucrat explained that it was due to the protocol issued by the ICMR. “The protocol so far was that whoever showed symptoms and had a foreign travel history was to be tested. Now they (the ICMR) have enhanced the scope. They have asked us to test the contacts of positive patients and to test them even if they don’t show symptoms,” he said.
A constraint has been the availability of test kits, which has restricted the state from doing the mass testing advocated by the WHO.
“Recently the government has approved some local testing kits. Now we have placed an order for 30,000 kits with MyLabs. Once we get it, I want to test all foreign returnees and their contacts. Another thing is that the ICMR had asked us to test patients who had ARD (Acute Respiratory Distress). Luckily so far no one who had ARD has shown positive,” he said.
Andhra Pradesh has deployed its village volunteers, local pointspersons in each village, to go door to door and survey people with symptoms of COVID-19.
A source in the Andhra government told The Lede that the data would be collated and once more testing kits arrive, anyone with any symptom of the virus would be tested.
Tamil Nadu began testing in early March, around the time India had reported 29 cases. Although no specific data has been provided, state Health Minister C Vijayabaskar began tweeting about home quarantine and thermal screening of passengers at the international airports by March 05.
By March 07, Tamil Nadu had its first positive case of the Coronavirus. Data of number of samples tested is available only from March 10 – a total of 74 samples had been given for testing. Up until March 16, the state struggled with testing, averaging about one test a day.
Post March 17 though, the speed of testing was ramped up. This is likely due to the fact that the state managed to procure more kits around this time.
The Health Secretary of the state Beela Rajesh told The Lede last week that they had the capacity to test 60 samples a week and that they had 500 testing kits.
But today, the state is a lot more confident about testing. With 1500 testing kits and an order for 30,000 more kits, like Andhra Pradesh, the government is planning to expand scope of testing.
Approvals for three private labs too will help the state in ramping up testing.
Telangana paints a picture of caution at present, with increasing numbers of patients testing positive. With large numbers of passengers returning to Hyderabad from abroad, the state has had its hands full.
Telangana has many lapses in its data but from what was made available to journalists, the state, although bogged down by a late start, managed to ramp up testing in a short span of time.
The data available began from March 15 and by then 375 samples had already been sent for testing.
By March 26, the state had completed over 1300 tests and found 45 positive patients.
Officials at Telangana’s Health Department were not available to explain this trend to The Lede despite repeated phone calls.
Karnataka, after initial confusion, appears to be on track now and moving very fast in terms of testing.
By March 03, the state had already tested 256 samples.
By March 10, four positive cases had been found. Karnataka has sped up its testing in leaps and bounds and has, to date, tested close to 3000 samples, with 64 positive cases.
Officials from Karnataka’s Health Department were not available to speak with The Lede despite several phone calls.
However late on Saturday evening, Jawaid Akhtar, Additional Chief Secretary, Health and Family Welfare, Karnataka, said in a press conference that Karnataka was further upping the ante.
"Karnataka has decided to put all the primary contacts of a positive patient into a government sponsored quarantine. These contacts will be classified as high risk primary contacts who will be kept at a hospital in isolation. The second category is the not so high risk primary contacts who will be kept at a Government guest house or hotel. There are about 1,000 plus primary contacts. The government's decision comes in the wake of the health squads quarantining 31 patients so far for violating the norms of home quarantine. The high risk category are those who have lower immunity levels because of co-morbidities like high BP, heart ailments, diabetes etc," he said.
While Kerala has been hailed as a model system of public health in India, it had the advantage of being an early mover as far as COVID-19 is concerned.
The first case of the virus was detected in Kerala when Keralite students from the Wuhan province of China arrived home on January 31. Samples were immediately taken and the students kept in isolation.
Kerala also began to test other passengers arriving from abroad and by February 01 they had sent 39 samples for testing. The same day, one of the students was detected as Coronavirus positive.
By February 03, Kerala had three positive cases and went into “State Specific Disaster” mode. Four days later, the state had tested 285 samples and there were no further positives. The State Specific Disaster Declaration was withdrawn on February 07 and the testing reduced.
By February 21, the testing had reduced to an average of three per day and the three positive patients had even been discharged.
Come March and as India began to take heed of the Coronavirus, Kerala promptly hit the accelerator on testing.
By March 08, they had almost doubled the number of tests done in the whole of February. Four positive patients were detected.
Kerala’s testing numbers have been steadily increasing and as a result, so have the number of positive cases.
As on March 27, the state has crossed 5600 tests and 164 positive cases have been identified.
The Lede attempted to contact Health Department officials in the state but they did not wish to comment.
V Ravi, Senior Professor and Head of Public Health Virology at Bengaluru’s NIMHANS has a four decades track record that combines the knowledge of public health and viral pandemics.
Speaking to The Lede, the professor stated clearly that the WHO model would not work for India but that a “middle path” needs to be adopted from hereon.
“The WHO is basing its recommendations mainly from South Korea,” he said. “The South Korean approach was to massively expand testing, detect more and isolate and quarantine people. That is the advantage of the WHO model.
But the Indian model is targeted testing. It saves a lot of resources. One test alone costs Rs 6000 and this is only the cost of the primers, probes and reagents involved. This is not counting human resources, electricity and other overheads. In fact, the actual cost would be double this if we take all that into account – around Rs 12,000. Because it is being done predominantly in government labs, it is cheaper,” he said.
Explaining the reason for the targeted testing strategy adopted by India, Professor Ravi said that it was a combination of the shortage of the testing kits as well as the density and sensitivity of the population of the country.
“The reagents for the testing are not easily available. All are being sourced from just one to three labs and there is a big shortage. ICMR is advocating only NABL-accredited kits. Mass testing will cause panic. Imagine if we ask everyone to come for tests, what will happen? Those who have money will stand in queue and get it done. The poor will be left out. Also the tests can be negative today but positive tomorrow. How many times can we test the same person?” he asked.
The middle path that Professor Ravi advocates is more than what state governments are currently doing but less than what the WHO advocates.
“All those who fulfill the standard surveillance case definitions should be tested,” he opined. The surveillance case definitions provided by the ICMR to states is dry cough, fever and respiratory distress.
“We need to expand the tests a bit more. Anyone fulfilling surveillance case definition has to be tested. It will happen, it is inevitable. After some time, there will be so much pressure that I think state governments will act on their own.”
The professor is pleased at the lockdown announced by the government and says that it should help mitigate the spread, as long as it is followed.
But he also warns that there already is community transmission and that it would take some time for the numbers of those infected to show up.
“The effect will be seen after 10 days. Symptoms of those currently quarantined will come up around April 07 to 10. The logic behind a 21-day lockdown is to tide over the 14-day incubation period and the additional seven days is for spread. This lockdown will contain community transmission on a large scale,” he said.
When asked whether India should do more to follow the WHO guidelines, the professor deferred to pragmatism over idealism.
“WHO will give overall recommendations which are ideal. But where are the resources, where is the manpower and how are we going to implement them?” he asked. “The practical strategy is to identify fever, dry cough, shortness of breath in people and test them as rapidly as we can.”