Why we urgently need more tests

ACTION NEEDED Experts call for an overhaul of testing protocols in India to fight the virus that has killed over 7,000 people worldwide

NEWDELHI:THERE is an urgent need for India to dramatically expand the pool of patients getting tested for the new coronavirus disease (Covid-19), allow voluntary testing, and rope in the private sector, said medical experts on Monday, calling for an immediate overhaul of testing protocols to fight the disease that has killed over 7,000 people worldwide.

As of Monday, authorities had tested barely 9,000 people despite having at least 300,000 kits, putting India in the bottom rung of countries, and possibly robbing doctors of accurate information about the spread of the infection.

Globally, nations such as South Korea have been successful in using aggressive testing regimens to control the spread of the virus while others such as the United States and Italy have been criticised for their sluggish pace of testing. While India has tested only 6.8 people per million residents, South Korea has tested 4831 people. The number stands at 42 in the US.

“I am quite concerned by the lack of adequate testing. India has the resources. If you don’t test, how would people know they have the disease? If people don’t know, then how will secondary infection be prevented?” asked Ramanan Laxminarayan, director of Center for Disease Dynamics, Economics & Policy.

India’s current strategy is to test only symptomatic people with a history of travel to global hotspots or those with close contact with a positive case, with those showing symptoms getting priority. But this has led to widespread panic with many worried about symptoms.

Designated government hospitals continue to turn away many people without symptoms who travelled from affected countries and wanted to get tested even though symptoms may take up to 14 days to appear.

“The government needs to broaden screening criteria for testing as you cannot control any epidemic without testing people. One of the reasons people don’t follow home quarantine properly is because they don’t know the gravity of the situation; you put the real picture out and see how they will cooperate,” added Laxminarayan.

The government, however, insists it has the situation under control. “India doesn’t need to test more. We do not want to create unnecessary panic by allowing indiscriminate testing,” said Lav Aggarwal, joint secretary, ministry of health and family welfare.

“A technical committee in the health ministry decides the testing protocol. As of now, they have not suggested widening the testing net, but since it is a constantly evolving situation, the committee is periodically reviewing the protocol, and will revise it, if necessary,” he added.

But experts worry that the delay might prove dangerous in the fight to avert the deadly community transmission phase of the disease where it spreads between people who have neither travelled to global hotspots nor been in contact with positive cases.

In the absence of adequate testing, medical professionals say it is difficult to know if the strategy to stave off community transmission is working. “The assumption that we don’t have community transmission is only an assumption,” said Laxminarayan.

To add to the problem, testing of random samples – which has begun at 50 of India’s 106 Virus Research and Diagnostic Labs – is still woefully short, with institutes testing just 20 people each with severe acute respiratory infections, which includes pneumonia, for the coronavirus. Random testing is important to gauge the spread of the infection and the paltry numbers are not representative in a country with a population of 1.3 billion.

Experts say the government will need to expand its testing criteria to control the surge in numbers that the country is likely to witness soon. Aggressive testing is also important to give authorities and the people a realistic idea of the infection at a time when many patients are fleeing quarantine centers and suppressing symptoms.

“How we see things right now, people are not following home quarantine dos and don’ts. These people could develop symptoms and infect others. What we need is effective screening at the points of entry that should include testing them at the airport itself,” said a senior expert in infectious disease management, requesting anonymity. The expert pointed out that rapid tests with quick results may be a solution.

“There are not enough designated laboratories and even if it takes five hours for test results to arrive, because of rising numbers lag time is increasing, which is evident in discrepancy between the data shared by the states and the Centre. Rapid tests could work in such a situation as our numbers are high and it’s only going to increase,” he said.

India has the capacity to test 300,000 samples for Covid-19 at Indian Council of Medical Research (ICMR)-RUN 62 virus research and diagnostic laboratories (VRDLS) across India, and also in the virus laboratory run by the National Centre for Disease Control (NCDC) in Delhi.

ICMR is scaling up testing capacity further and has placed an order for one million testing reagents from Germany. Nine more laboratories for testing and sample collection are being added to the network.

“The ICMR has a network of 106 VRDLS that can be pressed into action, if required. As of now we don’t feel the need to test more people as there is no evidence of community transmission available,” said Dr RR Gangakhedkar, head, epidemiology division, ICMR.“YOU can say we are not testing enough if there is community transmission, but in case of localised transmission, as we see in India right now, the numbers being tested is enough,” he added.

But on the flip side, without adequate random testing, there is no way to know if the spread is only through localised transmission. As numbers grow, it will also be important to rope in the private sector in a country where more than two-thirds of the population depends on private healthcare. Such intervention should come sooner rather than later, say experts.

“We should plan to involve the private sector for testing as it has wider reach than the existing centres. It is important,” said Dr Lalit Kant, infectious disease expert.

Dr Harsh Mahajan, founder of Mahajan Imaging, said, “The private sector is willing and capable, and should be engaged if not in testing then at least sample collection.”

Some government officials said involving the private sector had its risks. “If I test in private sector then will I be able to successfully do contact tracing? Will the status of positive cases be disclosed to government accurately? These are risks that we run when involving private sector, as we see in notification of disease such as tuberculosis,” said an official on condition of anonymity.

Aggarwal, however, said the government was not averse to involving the private sector. “But there is no need for it now,” he said. Not everyone is in agreement, and examples from US and Italy don’t inspire confidence.