Coronavirus pandemic: Test, test, test, the WHO has exhorted the world; how has India fared and is the ICMR paying heed?
The coronavirus epidemic exists only to the extent it has been clinically confirmed in people who have been tested for it, a fact worth repeating in the Indian context. It’s the only means we have of understanding how much and how fast the disease has spread
“God has been kind. We are not in the stage of community transmission (of COVID-19 ).”
This was the reassuring claim made on 12 March by Lav Agarwal, a joint secretary in the Ministry of Health and Family Welfare, in an official press briefing held to announce decisions taken by the high-level group of ministers formed under the directions of Prime Minister Narendra Modi, to monitor the coronavirus pandemic in India.
Going by the Health Ministry’s statement, India is still in Stage 2 (local transmission) of the epidemic and not Stage 3 (community transmission) – an all-important difference that determines the level of alertness and actions taken to contain its spread.
"As soon as we get any information on community transmission we will be the first to inform you," Agarwal added on Saturday.
But, the ministry’s own prior statement, issued as early as 5 March, said otherwise. "Since, in addition to COVID-19 cases related to travel, some cases of community transmission have also been observed, it has been decided to involve district collectors and states have been asked to form rapid response teams at the district, block and village levels.”
Why the discrepancy?
By definition, community transmission describes the stage where the disease has already been spread by first or second level contacts into the wider community. Aggressive random testing of the population is the only way to detect this, given that COVID-19 is contagious even when 'asymptomatic', ie, the disease doesn't produce any visible symptoms in the infected, especially the young, but they are still able to pass on the infection.
As the World Health Organisation (WHO) Director-General Tedros Adhanom Ghebreyesus has said: "We have a simple message to all countries – test, test, test. All countries should be able to test all suspected cases, they cannot fight this pandemic blindfolded."
But not only has India conducted fewer tests than most other countries in terms of absolute numbers (14,811 tests), India also has one of the lowest test rates in the world, with 10.5 tests per million people as of 21 March.
The result is a situation where, India, with its low 271 (as on March 21st) confirmed cases, is broadly in the same league as the UAE, which has 140 confirmed cases, but the UAE is testing at a rate of 1,200 times more than that of India’s. (The global record for testing – number of tests per million – is presently held by Iceland, which is testing at a rate more than 2,500 times higher than India).
The government’s stance on community transmission has been questioned by several public health experts. In a recent interview with Huffington Post, T Sundararaman, former director of the National Health Systems Resource Centre, spelt out exactly what was wrong: "They have put criteria that more or less makes it mandatory to test only these people (people who have come from abroad and those they have contacted). So, anyone walking in with common cold-like symptoms or viral fever, asking to be tested, will not get tested."
Echoing this view, Yogesh Jain, founder of public-health NGO Jan Swasthya Sahyog, recently said, “The explanation offered by the ICMR is that there is no evidence of community transmission in the country. This rationale — or lack thereof — reminds me of an old aphorism: the absence of evidence is not evidence of absence."
Ramanan Laxminayanan, director and senior fellow at Center for Disease Dynamics, Economics and Policy, had this to say to the Hindustan Times: “Community transmission began in India two to three weeks ago, around the same time as other countries. India is not an exception to the way the virus behaves. We just haven’t tested a representative sample that the country’s population of 1.34 billion demands.”
The ICMR’s position on the lack of community transmission is derived almost entirely from the results of its ‘sentinel surveillance’ programme, implemented until now by 51 designated research and diagnostic laboratories (VRDLs) spread across the country. Only 826 samples of people suffering from severe acute respiratory illnesses have been tested under this programme, initiated way back on 15 February.
It’s a low sample size for any country in the world, and much more so for the world’s second-most populous nation, and a highly mobile one at that. As per latest reports, 111 labs across the country will be functional from Saturday.
This approach remained in place even as cases exploded in countries where the earliest cases were detected around the same time as India. For example, the first case in Italy, the country regarded as the worst-hit, was recorded on 31 January, a day after India confirmed its first case in Kerala on 30 January.
The ICMR and health ministry’s positions hint that India's testing rate may be a matter of policy. Speaking to NDTV, a senior official at ICMR, Dr Raman Gagankhedkar, went on to list all the problems that may be brought up with massive testing, including, that of the tests leading to the discovery of more cases.
Gagankhedkar’s views were backed up by his boss and the head of the ICMR, Dr Balaram Bharghava, who has reiterated the Health Ministry’s logic on community testing – saying that India hasn’t’ detected community transmission, and therefore, it does not need to significantly increase testing.
The latest media reports indicate that a sudden jump in cases – 50 new cases were confirmed on Friday – may have prompted the government to open up testing to all and to rope in the private sector for testing.
However, the latest revision of testing guidelines issued on 20 March does not specify such an ‘open to all’ policy, which means there’s still no official sanction for mass random testing that’s immediately required to detect community transmission.
The COVID-19 epidemic exists only to the extent that it has been clinically confirmed in people who have been tested for it; an obvious enough fact, but one worth repeating in the Indian context. It’s the only means we have of understanding how much the disease has spread, and how fast, above all. Everything else – screenings, travel restrictions, shutdowns, ‘social distancing’ – is a precautionary measure which must necessarily be based on the number and nature of confirmed cases.
So far, the Centre’s approach has been to simply ignore the question of mass testing, and thereby deny the existence of community transmission.
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