In fight against Covid, in­creased test­ing and bet­ter in­fra crit­i­cal

The test­ing value chain is com­plex and has sev­eral bot­tle­necks, which must be eased

Hindustan Times (Jalandhar) - - HT SPOTLIGHT - Priyanka Ag­gar­wal, Kshi­tij Vi­jay­vargiya and Sid­dharth Jain let­ters@hin­dus­tan­times.com The ar­ti­cle is writ­ten by Priyanka Ag­gar­wal, Man­ag­ing Di­rec­tor and Part­ner at BCG, Kshi­tij Vi­jay­vargiya, Part­ner at BCG and Sid­dharth Jain, Pro­ject Leader at BCG. Views

NEWDELHI: Di­ag­nos­tic test­ing for Covid-19 has been the topic du jour in In­dia – from gov­ern­ment of­fices to board­rooms to on­line cha­t­rooms. De­bates range from whether we are do­ing enough test­ing to whether we are test­ing the right peo­ple. Con­tin­u­ous me­dia cov­er­age on avail­abil­ity of test kits, qual­ity of the kits and ef­fec­tive­ness of test­ing pro­to­cols has of­ten led to con­fu­sion on how to ex­pand test­ing ca­pac­ity.

It is now well ac­cepted that we are in a marathon fight against the Covid-19 pan­demic. In­dia has been in a na­tion­wide lock­down since March 25 that has been ex­tended twice -- to May 17 -- with some re­lax­ations in re­stric­tions. This was es­sen­tial and well­timed -- help­ing re­duce the spread of the dis­ease (the dou­bling rate of cases, 3.4 days prior to the lock­down, is 11 days cur­rently) and pro­vid­ing time to ramp up the health­care in­fra­struc­ture. How­ever, in this bat­tle be­tween lives and liveli­hoods, we can­not ig­nore the crip­pling im­pact the lock­down has had on In­dia’s econ­omy. Al­ready the un­em­ploy­ment rate has risen to 23%, from 8.4 % in mid-March.

Di­ag­nos­tic test­ing is an im­por­tant weapon in this fight. It helps to iden­tify in­fected in­di­vid­u­als and treat them; also it helps in break­ing the chain of trans­mis­sion and sup­ports de­ci­sion mak­ing on eas­ing re­stric­tions. Coun­tries like South Korea have al­ready shown how large-scale test­ing can con­trol the dis­ease with­out re­sort­ing to a na­tion­wide lock­down.

IN­DIA: CUR­RENT STATE OF TEST­ING

Covid test­ing in In­dia has evolved rapidly. Un­til midMarch, test­ing was fo­cused on only symp­to­matic in­ter­na­tional trav­ellers or symp­to­matic con­tacts of such trav­ellers in the be­lief that the spread was largely re­stricted to in­ter­na­tional trav­ellers.

Over time, with iden­ti­fi­ca­tion of cases with no travel-re­lated his­tory, th­ese guide­lines evolved to in­clude symp­to­matic lo­cal pa­tients, health­care work­ers, asymp­to­matic con­tacts of con­firmed cases and pa­tients ex­hibit­ing SARI (se­vere acute res­pi­ra­tory in­fec­tion) and in­fluenza like symp­toms. Cur­rently, In­dian test­ing guide­lines stand in line with those of coun­tries like South Korea and Ger­many.

With the new guide­lines in place, test­ing has been ramped up by over 35 times dur­ing the last five weeks from an av­er­age of 2,000 tests / day (last week of March) to more than 70,000 tests (early May). A heart­en­ing in­di­ca­tor is that with the scal­ing up of test­ing, pos­i­tiv­ity rates have re­mained one of the low­est in the world at ~4%. See Ex­hibit 1.

This in­crease has been driven by mul­ti­ple gov­ern­ment in­ter­ven­tions. More than 150 test­ing labs have been ad­di­tion­ally ap­proved in the last four weeks. Pooled test­ing pro­to­cols in lo­ca­tions with low pos­i­tiv­ity rates have been cre­ated and test­ing has been in­cluded in the Prad­han Mantri Jan Ar­o­gya Yo­jana (PMJAY) pack­age.

SHIFT­ING TO THE NEXT GEAR

Viewed this way, the over­all pic­ture does not seem as grim as many have claimed. How­ever, re­view­ing the state- wise sta­tus of test­ing, it is seen that there are wide dis­par­i­ties which point to the need for ur­gent seg­mented ac­tion. Re­fer to Ex­hibit 2

States in Quad­rant I (e.g. West Ben­gal) are see­ing low test­ing rates de­spite high pos­i­tiv­ity and need to im­me­di­ately ramp up test­ing to un­der­stand the true spread.

States in Quad­rant II (like Delhi and Ma­ha­rash­tra) show a high spread while hav­ing high test­ing rates. Th­ese ge­ogra­phies have had many out­breaks in clus­ters and need to con­tinue large-scale test­ing to iden­tify and treat pa­tients.

Many states fall in Quad­rant III (e.g. Bi­har) where test­ing has been sub-scale. While they cur­rently see low pos­i­tiv­ity, they need to en­hance test­ing to un­der­stand the spread and sup­port de­ci­sions to open up grad­u­ally.

While cu­mu­la­tive cases in In­dia have ex­ceeded 40,000, a gran­u­lar re­view shows eight cities con­trib­ute over 45% of cases, while 250+ dis­tricts have no re­ported cases. This, in ad­di­tion to the con­cen­tra­tion of growth of Covid-19 in par­tic­u­lar ar­eas, al­lows for a re­gional re­view to de­cide on lift­ing lock­down re­stric­tions. This could be sup­ported with thor­ough test­ing to en­able in­formed de­ci­sion mak­ing.

This is where the dif­fer­ent avail­able test­ing op­tions lend them­selves to ap­pro­pri­ate use cases. We have the gold stan­dard RT-PCR (re­verse tran­scrip­tase poly­merase chain re­ac­tion) tests that de­tect the pres­ence of a vi­ral genome in the body; they can be de­ployed largely in iden­ti­fi­ca­tion of in­fected pa­tients and treat­ment. Th­ese are ex­pen­sive and need spe­cialised molec­u­lar di­ag­nos­tic equip­ment and trained pro­fes­sion­als to op­er­ate the equip­ment.

On the other hand, sero­log­i­cal tests de­tect the pres­ence of an­ti­bod­ies (that de­velop in the body as an im­mune re­sponse) and are use­ful to de­tect past in­fec­tions. While such tests are less use­ful in im­me­di­ate re­sponse (and should not be used for clin­i­cal di­ag­no­sis), they can be used to track dis­ease de­vel­op­ment. They could also as­sess in­di­vid­u­als who are im­mune and can be safely brought back to the work­force. An­ti­body kits were added to our test­ing regime, but were chal­lenged due to a few faulty kits. With ad­di­tional kits get­ting ap­proved, the qual­ity of test kits should be reg­u­larly con­firmed through pe­ri­odic qual­ity checks

We should think of th­ese tests as weapons in our arse­nal, and de­ploy a seg­mented ap­proach for test­ing in In­dia, which is cus­tom­ized by re­gion de­pend­ing on the cur­rent level of dis­ease spread.

See Ex­hibit 3

* High dis­ease spread and high growth: Con­tinue large scale RT-PCR test­ing to sup­port iden­ti­fi­ca­tion of cases. De­ploy rapid test­ing in hotspots to quickly as­sess com­mu­nity im­mu­nity

* High dis­ease spread but low growth: Lever­age com­bi­na­tion of an­ti­body tests to test herd im­mu­nity cou­pled with RT-PCR tests for di­ag­no­sis

* Low dis­ease spread and high growth: Lever­age pooled test­ing at scale to quickly iden­tify new hotspots

* Low dis­ease spread and low growth: Lever­age RT-PCR tests for In­fluenza-like-ill­nesses /SARI cases and health­care work­ers and sero­log­i­cal test­ing to mon­i­tor dis­ease sur­veil­lance

OPERATIONA­LISING THE RAMP-UP

The test­ing value chain is com­plex and has sev­eral bot­tle­necks. Start­ing from sam­ple col­lec­tion where it is cru­cial to en­sure avail­abil­ity of skilled phle­botomists (peo­ple trained to draw blood from a pa­tient) with full pro­tec­tive per­sonal equip­ment (PPE).

Sub­se­quently, the lab test­ing process re­quires avail­abil­ity of tech­ni­cians with train­ing in molec­u­lar bi­ol­ogy, in­fra­struc­ture such as biosafety rooms, suf­fi­cient kits and reagents and fi­nally RT-PCR ma­chines – the most crit­i­cal equip­ment needed in the cur­rent molec­u­lar test­ing regime.

While gov­ern­ment in­ter­ven­tions have en­sured suf­fi­cient sup­ply of kits (with enough stocks to con­duct 100,000 tests / day for the next two months and ramp-up be­yond this as needed), PCR ma­chines, sam­ple col­lec­tion process and re­gional lab avail­abil­ity may emerge as fu­ture bot­tle­necks.

Given this, it is rec­om­mended to fo­cus on four pri­or­i­ties:

Lab Ca­pac­ity: Ad­dress re­gional dis­par­i­ties in lab ca­pac­ity. States like Jhark­hand and Chat­tis­garh have less than five labs while labs in Gu­jarat are near ca­pac­ity with cur­rent dis­ease spread. Pri­vate sec­tor col­lab­o­ra­tion can help plug th­ese gaps

* PCR ma­chines: ~400 PCR ma­chines are avail­able in ap­proved labs in In­dia cur­rently. This is suf­fi­cient to con­duct 70-80,000 tests / day in the pub­lic sec­tor and 30-40,000 tests / day in the pri­vate sec­tor. The pos­i­tive side is that In­dia al­ready has a suf­fi­cient in­stalled base (1400+ ma­chines) across pub­lic and pri­vate sec­tor and ca­pac­ity can be ramped up even more by adding th­ese ma­chines to the ap­proved list

* Setup of fever clin­ics to en­able sam­ple col­lec­tion: Tak­ing learn­ings from South Korea and other coun­tries, In­dia should set up fever clin­ics in each lo­cal­ity to do screen­ing and sam­ple col­lec­tion

* Lever­age in­no­va­tions: In­no­va­tions like pooled test­ing, nanore­ac­tion based tests and RT-LAMP (Re­verse Tran­scrip­tion Loop-Me­di­ated Isother­mal Am­pli­fi­ca­tion) tech­nol­ogy could fur­ther en­hance ca­pac­ity

Di­ag­nos­tic test­ing is cru­cial to the fight against Covid. As we move into a post-lock­down era and con­tem­plate re­cov­ery, gov­ern­ment of­fi­cials, cor­po­rate lead­ers and health­care ex­perts will all have to con­front the need for test­ing. Un­for­tu­nately, it is nei­ther sim­ple to im­ple­ment nor a panacea to all prob­lems. It will be im­por­tant that all stake­hold­ers (pub­lic and pri­vate sec­tor) work jointly to ad­dress this chal­lenge and bring forth their re­spec­tive strengths to help win this fight.

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