India must change its testing strategy

By: |
April 17, 2020 3:00 AM

In a war, you don’t only use your best weapons, you use everything in your arsenal. This has to be the maxim in our fight against Covid-19.

Private labs were allowed to test from March 23.

I arrived in India on March 13, from Switzerland. I was in France for a few days before that. On my arrival at the Indira Gandhi International Airport, I was screened for temperature, and allowed to leave. I was NOT asked to self-quarantine, nor given any specific instructions on Covid-19. I decided to self-quarantine, in case I was a carrier. I am glad I did that because four people who had attended the meeting with me in Geneva tested positive for Covid-19.

On March 16, I started feeling unwell. I had a fever, felt fatigued and had dry cough. As these seemed like Covid-19 symptoms, I called the helpline and got through to them after hours of trying. Helpline staff said it must be regular flu due to change in season. Stumped at his surety, I gave my travel history, but I was met with the same dismissive approach. I was asked to visit the hospital and was told not to get my hopes high about a test.

I was told a doctor would decide if I needed a test or not. When I asked about potentially exposing others during my travel to the hospital, the conversation appeared over as the helpline person did not have an answer. Since I do not belong to a high-risk age category, I decided to self-isolate at home. As I stay alone and don’t have a car at my disposal, I planned to call an ambulance and get to the hospital if symptoms worsened. Meanwhile, I wanted to know if someone could collect a test sample from home. I couldn’t get through to the helpline numbers, so I wrote an email to the address posted on the Ministry of Health’s website; I have not received any response yet.

Meanwhile, private labs were allowed to test from March 23. So, I went to the website of Dr Lal Pathlab and found that I had to get a prescription from a local doctor for testing. I called Lal Pathlab and told them that clinics in my area are shut due to the lockdown, and hence, I can’t get a prescription. I said to them that even if I find a doctor, it would mean stepping outside the house and potentially infecting others. Even after that, they refused the test without a prescription, citing “government rules”. After much persuasion, they said that they ‘may’ be okay with an online prescription, but, they will vet it first, and decide whether to collect the sample from home or not.
The bottom line is that I came from a meeting where people were found positive for Covid-19; I had symptoms similar to Covid-19, and I have not been tested.

I have fully recovered since and still in self-quarantine at home. I decided to tell this story because I think there are a large number of people like me who might be ‘undocumented cases’. I am not sure if they self-quarantined and avoided potentially infecting others. With testing made so difficult for a privileged person like me, I cannot imagine the plight of those less privileged. Until we make testing easier and accessible we will not be able to track, identify and isolate the infected.

PS: Little wonder numbers in India are so low.”

Above is the gist of a conservation and message exchange I had with a friend regarding his experience of getting a test done for Covid-19. I am writing this because, from all that I read, it is clear that getting a test for Covid-19 is still an arduous task in India.

But, across the world, health experts are demanding easy and large-scale testing because they are highly concerned about what they call ‘silent spreaders’. Silent spreaders are people who spread the disease unknowingly or to avoid the social stigma. The silent spreaders include asymptomatic, pre-symptomatic and undocumented symptomatic cases.

i) Asymptomatic cases are people who carry the active virus in their body, but never develop any symptoms. They, however, shed virus and can infect others. Studies show that as many as one in four people infected with Covid-19 could be asymptomatic.

ii) Pre-symptomatic cases are infected people who are incubating the virus and would show symptoms only after a few days or even weeks. They also transmit the virus to others.

iii) Undocumented symptomatic cases are people who have mild symptoms, but didn’t get tested because of lack of access to testing or the stigma attached to the disease. They have a very high potential to spread the disease.

It is quite clear from the data on the number of tests conducted in India that we are just focusing on symptomatic cases. This is because the Indian Council of Medical Research (ICMR) guidelines recommend testing of largely symptomatic cases. Other than that, only asymptomatic family members of infected people, and asymptomatic healthcare workers are being tested. But, the fact is this, prescribed regime leaves a large number of potential cases untested. With a stigma now attached to this disease, people are even less forthcoming to get tested.

So, how do we deal with the situation?

First of all, we have to recognise that we have been very conservative with our testing strategy. Consider the following:

i) For a long time, ICMR only recommended RT-PCR method for testing individuals. RT-PCR, while accurate, takes a lot of time in testing and limits our capability in doing large-scale tests. We are still doing only 20,000-25,000 tests a day—minuscule, compared to what is required.

ii) Private labs were allowed to test only from May 23—seven weeks after the first case was detected in India. So, we did not utilise a large pool of resources at our disposal for quite some time.

iii) The ICMR issued guidelines for the rapid antibody blood test only on April 4—nine weeks after the first reported case. Mind you, Korea started the quick test in mid-February. As far as March 31, ICMR reportedly did not approve Kerala government’s plans for rapid testing.

iv) On April 13, a full ten weeks since the first confirmed case, ICMR issued an advisory on pooled testing using RT-PCR. Even this advisory limits the number of samples to five and only for areas where the prevalence rate is low. For comparison, Israel has allowed pooled testing of as many as 64 samples using the standard PCR testing procedure.

ICMR advisories, therefore, are at least a month behind global developments. One can understand the desire for accuracy, but there has to be a balance between accuracy and speed. As things stand today, we are not getting this balance right. So, first, we will have to massively enhance rapid tests and pooled tests to increase the number of tests, and bring some balance in our testing strategy.

Secondly, we are not utilising all the testing capabilities in the country. There are at least 600 colleges in the country that are teaching biotechnology courses. A biotechnology college would have a PCR, if not RT-PCR. Besides, there are a large number of RT-PCR/PCR with private research centres as well. We should involve these colleges and research centres in testing.

Lastly, we must start large-scale community testing. We can do pooled tests and use mobile centres to collect samples. We should not restrict community testing to only hotspots, though hotspots can be prioritised. This is the only way to capture undocumented cases and halt the spread of this virulent disease.

In a war, you don’t only use your best weapons, you use everything in your arsenal. This has to be the maxim in our fight against Covid-19.


The author is CEO, iFOREST. Twitter: @Bh_Chandra. Views are personal

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