“Test, test, test,” is among the most resounding messages issued by Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO), during the coronavirus pandemic. However, when it comes to COVID-19 testing, is India falling behind?
“We have not seen an urgent enough escalation in testing, isolation and contact tracing – which is the backbone of the response,” Tedros said on March 16th. He said that “the most effective way to prevent infections and save lives is breaking the chains of transmission. And to do that, you must test and isolate.” However, it appears that the strength of existing COVID-19 testing efforts is in doubt.
Recent reports suggest this to be the case, with The Hindustan Times reporting that India is coming up short in terms of COVID-19 testing. This comes despite moves taken by the relevant authorities to expand COVID-19 testing in the country – perhaps most notably soliciting the participation of the private sector. In March, the Union Ministry of Health and Family Welfare elected to permit privately-run laboratories deemed to be of “high quality” to test for COVID-19.
The Indian Council of Medical Research (ICMR) announced at the time that it had ordered one million testing kits. 178 labs have been approved for COVID-19 testing in India to date, of which 49 are privately-run.
At a recent meeting with the ICMR, the Council of Scientific and Industrial Research, and the Department of Science and Technology and Biotechnology, Union Health Minister Dr Harsh Vardhan “directed that all efforts should be made to procure requisite testing kits and reagents urgently and supply them to the laboratories across the country,” according to a government press release.
In addition, Vardhan “directed that it should be ensured that states have all the required facilities and it should be ensured that they do not face any shortages on account of testing kits, reagents or equipment. He also directed that extra support shall be given to those states/UTs [union territories] who are not having any laboratories/testing facilities as well as to northeastern States and [the] UT of Ladakh.”
However, as reported by The Hindustan Times, “although the country has opened up testing to private laboratories, questions remain on the availability of testing kits and if unrealistic standards have been set for them.” The report goes on to note that, COVID-19 testing in India is “a sixtieth of that in the UK, a 82th of that in the US, and a 241th of that in South Korea.” India’s testing rate is appraised at 32 per million, whilst questions have been raised as to whether COVID-19 testing guidelines in the country are too restrictive.
The Hindustan Times notes that the ICMR has approved just four of seventeen commercial testing kits submitted for approval. It cites “several experts” who argue that the stipulation of “a 100 percent condordance [sic] among both true positive and true negative samples (sensitivity and specificity)” is “unrealistic and restrictive.” In addition to commercial testing kits, the ICMR allows for the use of COVID-19 testing kits that have received the CE mark designating conformity with European Economic Area environmental, health and safety standards, or that have been approved by the US Food and Drug Administration.
As of March 30th, 38,442 COVID-19 tests have been conducted in India according to Dr Raman R. Gangakhedkar, the head of epidemiology and communicable diseases at the ICMR. “We are still at less than thirty percent of our testing capacity,’ Gangakhedkar said at a press conference.
Identifying five gaps in India’s response to COVID-19, The Economic Times notes deficiencies in COVID-19 testing. It contrasted India with “countries like South Korea [who] were able to contain the virus because of their aggressive testing.”Perhaps India’s most notable response to the COVID-19 pandemic was the imposition of a stringent national lockdown last week. However, some have argued that this will not do enough to prevent the spread of COVID-19 unless measures such as robust testing are undertaken.
“The lockdown may help “flatten the curve” and buy the authorities some time, but that means little if they do not take advantage by aggressively testing, isolating confirmed cases, and performing contact tracing,” Vidya Krishnan wrote in The Atlantic. Krishnan does note that the Government has argued that, given the sheer size of India’s population, “widespread testing is not feasible.”
An IndiaSpend analysis of COVID-19 testing across eleven states published last month suggested that the more states test for COVID-19, the more confirmed cases they report. The report contrasted Kerala and Maharashtra with states such as Andhra Pradesh, Odisha and West Bengal. Kerala and Maharashtra, IndiaSpend noted, tested 4,516 and 2,144 samples for COVID-19 respectively at the time its report was published (March 25th, 2020). By contrast, at that time, Andhra Pradesh, Odisha, and West Bengal had tested five, three, and two tests per million people respectively. In Kerala, 137 tests had been conducted per million people. The disparities between states in terms of the strength of their COVID-19 testing must be addressed to ensure that the full scope of the outbreak in India can be assessed and responded to.
At the time of writing, the notion of large-scale community transmission of COVID-19 on a large scale has been disputed by authorities. “We can consider that we are in the community transmission stage only when there are about twenty to thirty percent [of] cases with no clue on how they got the virus,” said Rav Agarwal, joint secretary in the Union Ministry of Health and Family Welfare. “If India enters that stage, we will not hide it. We will tell people so that we can step up the level of alertness and awareness.”
However, some have argued that without scaling up COVID-19 testing, it cannot be certain that India has not reached the community transmission stage of the COVID-19 outbreak.
In an earlier report, IndiaSpend noted that community transmission could not be ruled out without more robust testing for COVID-19. The report cited Om Shrivastava, a Mumbai-based infectious disease specialist, who asserted that “you need more testing, not less, to find out what is the status of your country” in terms of community transmission. Shrivastava added that “if our testing numbers are not consistent with the rest of the world then we need to do better.” This is vital in ensuring there is no community transmission on a large scale.
In the same report, IndiaSpend quoted Gautam Menon, a professor of physics and biology at Ashoka University in Sonepat, who said “we really need to test random people who exhibit a range of symptoms for COVID-19 not just the most extreme symptoms, because these will typically manifest in only a very small fraction of patients.”
K. Sujatha Rao, a former Secretary of the Union Ministry of Health and Family Welfare, has similarly expressed concerns about the rate of COVID-19 testing in India. “There is a need for India to do massive testing…to see that people who are out in the community are infected or not,” she said. “The people in the community should be tested and identified because you don’t know where the virus is…testing has to be expanded.”