India has ostensibly demonstrated a remarkable ability to control the spread of the COVID-19 virus within its borders. In the eight weeks since the first reported COVID-19 positive case in India, official figures published by the Government of India as of March 17, 2020 stood at an aggregate of 140 confirmed positive cases (of which not even one of them is in intensive care).
What is even more remarkable is that these numbers run contrary to every trend globally available on the spread of COVID-19.
This brings us to India’s policy for testing for COVID-19, which is contained in the Government of India’s Ministry of Health and Family Welfare issued Guidelines for notifying COVID-19 affected persons by Private Institutions. These guidelines are identical to the WHO Report guidelines, except for the deletion of one word. The effect of this deletion has unrecognizably changed the manner in which India tests and reports COVID-19, jeopardizing India’s ability to fight the spread of COVID-19.
The word is "Probable"
The WHO Report guidelines require a suspected COVID-19 case to undergo testing. The two main categories of people who qualify for testing are: (i) someone with acute symptoms AND who has traveled to an affected region during the previous 14 days; and (ii) someone with acute symptoms AND having been in contact with a probable or confirmed COVID-19 case.
The second category of testing suspected cases is critical to curbing local transmission by testing persons who may have come in contact with suspected cases. However, the guidelines issued in India have omitted the word “probable”, therefore requiring testing of only those in direct contact with someone who already has been confirmed in a laboratory of being COVID-19 positive. Direct contact been interpreted by practitioners to mean patients who live in the same home with a relative with confirmed COVID-19.
India tests only 50-60 persons for COVID-19 a day
It was therefore no surprise when Dr. Balram Bhargava (Secretary of the Department of Health Research and Director-General of the Indian Council of Medical Research) confirmed to media on Monday that although the 52 authorized laboratories in India have the capacity to process 5,000 samples a day, India has processed only 50-60 samples a day.
Let this sink in.
Only 60 persons have been tested per day for COVID-19 in a country with a population of 1.3 billion.
Furthermore, given the population and size of India, each authorized laboratory to test for COVID-19 on average needs to cater to over 25 million people (that is more than the population of Delhi or Mumbai). Despite this, these laboratories have processed less than 2 samples a day on average, underscoring how restrictive the requirements are to qualify as a suspected case to be tested for COVID-19.
In a country where more than 70% of the population relies on private healthcare, it is inconceivable that COVID-19 testing for the entire country is entrusted to 52 government run laboratories. There are two government run laboratories situated in Bengaluru. We visited both. The facilities were deserted, and access highly restricted. Doctors that we spoke to confirmed that testing was restricted to those having visited affected countries and those who had direct contact with confirmed cases. According to a Business Insider report, in Korea, 3,692 people per million population were tested for COVID-19. Based on our analyses of available data, India have tested less than 0.6 persons per million as of now.
Testing, Isolation and Contact Tracing
Dr. Tedros Adhanom Ghebreyesus (Director-General of WHO) at a media briefing on March 16, 2020 said, “We have also seen a rapid escalation in social distancing measures, like closing schools and cancelling sporting events and other gatherings. But we have not seen an urgent enough escalation in testing, isolation and contact tracing – which is the backbone of the response. [. . .] We cannot fight a fire blindfolded. And we cannot stop this pandemic if we don’t know who is infected. We have a simple message for all countries: test, test, test. Test every suspected case.”
India would do well to follow this advice. We have closed our schools and colleges, and postponed the IPL. But we have failed to implement the backbone of the global response to the COVID-19 pandemic, which is to test, isolate and contact trace.
We cannot isolate, and we cannot contact trace when we do not test.
If India has a problem with sourcing enough testing kits to be able to effectively test suspected cases of COVID-19, we should make that a priority. But to tweak the WHO definition of a suspected COVID-19 case to exclude contact with “probable” cases is disingenuous. It shows an unwillingness to face up to the responsibilities India has in combating this global health issue that threatens to bring the world into an economic recession.
Public health specialists in India agree that the actual number may be much higher than 140. What we do not know is how much higher. If we use the United States model (which has had its own troubles with testing) and correct for our population, we could have approximately 27,450 confirmed cases. However, if we use the Italy model, we could have approximately 719,000 confirmed COVID-19 cases in India right now.
In Voltaire’s words, India may be guilty of all the good that she did not do. Test. Test. Test. Test every suspected case.