Test not, find not

AN epidemic of a respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in China in December 2019. On February 11, the World Health Organisation (WHO) named the disease coronavirus disease 2019, or COVID-19. After infecting around 81,000 people and killing 3,162 people in China, COVID-19 spread to 113 more countries, infecting more than 37,000 people and killing 1,130 as on March 11. On that day, exactly one month after giving it a name, WHO declared COVID-19 a pandemic. At the time of writing, more than a million people have been infected and more than 50,000 died. And as this epidemic repeats a trajectory of exponential growth, as seen in China, it is stretching health care systems across Europe and the United States to their breaking point.

In India, the first COVID-19 infection was reported in Kerala on January 20. From early March, the virus started to spread across India; currently, 30 out of the country’s 36 States and Union Territories (U.Ts) are affected. On March 11, a high-level Group of Ministers under the chairmanship of the Union Health Minister met and announced drastic travel restrictions with effect from March 13 until April 15 banning the entry of foreigners and suspended all visas, barring a few categories. On March 19, Prime Minister Narendra Modi spoke to Indians at 8 p.m. and asked them to observe a “Janata curfew” on Sunday March 22.On March 23, Modi addressed the nation, again at 8 p.m., to announce a 21-day nationwide lockdown from midnight.

The available medical literature on COVID-19, though limited, shows that it is a highly infectious disease. Even if a person is asymptomatic, a condition that normally may last 5 to 14 days after getting infected, 28 days in extreme cases, the infected person will transmit the virus to others, and it is airborne too. Highly infectious diseases follow a trajectory of exponential growth, and unless, steps are taken to flatten the curve, which means reducing the speed of transmission of the infection rather than the number of cases, the infection will stress or break health care systems; these are designed to take care of non-infectious diseases and other health issues.

No country in the world, no matter how wealthy, is in a position to create a mammoth health care system to deal with the possibility of an epidemic. This is because 90-95 per cent of this capacity would remain unutilised most of the time. Despite the now-prophetic and dire warnings from Bill Gates and others, countries do not plan and build infrastructure for epidemics for two reasons: one, because it would amount to a suboptimal use of resources and, two, because it would not be possible to predict the nature of an epidemic and what resources may be required to counter it.

Thus, the only rational approach to managing an epidemic is to apply methods of early detection, followed by containment and, if available, vaccination and medication. The world was in a way blindsided by COVID-19, which caught everyone short; vaccines are anywhere between a year or even two years away, and therapeutic medicines are non-existent. That leaves containment as the only viable approach to COVID-19.

Travel advisories

Since the source of COVID-19 was clearly foreign, alert governments ought to have thought of stopping carriers arriving from abroad. The Ministry of Health and Family Welfare (MoHFW) issued its first travel advisory on January 17, which obviously meant tracking the possibility of human-to-human transmission. The second advisory, issued on January 26, seemed to concede that such transmission was possible through close contact with an infected person.

India’s containment strategy at that crucial point was thermal screening, which solely targeted symptomatic travellers from China in the beginning and which was later extended in stages to include travellers from a handful of high-risk South East Asian countries. What should be noted here is that in a highly networked world dominated by West Asian travel hubs, many travellers transit through airports in that region even though their journeys may begin in the East. Such intricacies of world travel, where direct flights cost more than ones that swing through one or even two hubs, escaped the attention of the MoHFW mandarins.

WHO Situation Report No. 39 dated February 28 upgraded the global threat level from Corona virus from “high” to “very high”; before that, “very high” was reserved for China alone. But Indian authorities continued to let their nationals into India without any screening. It was only on March 6 that the MoHFW finally woke up and issued instructions to conduct universal thermal screening of all international passengers. It did not seem to matter to the Ministry that each day lost through lethargic decision-making may cost the country gravely.

Visa suspension of travellers from China started from February 5. The travel advisory issued on February 26 advised a 14-day quarantine for travellers with a travel history to China, Singapore, South Korea, Iran and Italy. Japan was added to this list on March 2. The March 5 travel advisory mandated a “corona-negative” certificate from passengers arriving from or who had visited Italy or South Korea. Despite the indications that these countries were by then hotspots of the disease, this was not with immediate effect but only from March 10. It was only on that day that the MoHFW seemed to wake up to the possibility that people who had travelled abroad could have come into contact with infected people or vectors during their stay or during transit at airports or even in flight. However, the advisory was aimed at only passengers with a travel history to China, Hong Kong, South Korea, Japan, Italy, Thailand, Singapore, Iran, Malaysia, France, Spain and Germany. They were advised self-imposed quarantine for 14 days from the date of arrival. This was not, however, legally mandated.

On March 11, after the WHO declared COVID-19 a pandemic, for the first time, a high-level meeting chaired by the Union Health Minister was convened, and the government decided to suspend all existing visas with effect from March 13. The visa-free travel facility for OCI (overseas citizen of India) cardholders was also suspended. Finally, only on March 19 did the government take the long-delayed decision to announce that no incoming scheduled international commercial passenger aircraft would be allowed to disembark its passengers (foreign or Indian) on Indian soil after 20:01 p.m. GMT on March 22.

According to MoHFW figures, 1,524,366 passengers have been screened until March 22. The timelines of the MoHFW’s advisories, a chart of the spread of the disease among the Indian populace and the loss of lives are included for a clearer picture of India’s containment strategy and progress.

Efficacy of thermal screening

As India’s containment strategy was limited to thermal screening of travellers, first from China, then from a few other countries and, finally, all international travellers, it is imperative to see how effective this was in containing the import of COVID-19.

A study by Billy Quilty et al . of the London School of Hygiene and Tropical Medicine, published on January 31, estimated that 46.5 per cent of infected travellers would not be detected, depending on the incubation period, sensitivity of exit and entry screening, and the proportion of asymptomatic cases. Airport screening is unlikely to detect a sufficient proportion of infected travellers to prevent them from entering a country. This finding is endorsed by a study by Katelyn Gostic et al. of the University of Chicago, published on February 24, which found that even under best-case assumptions screening would miss more than half of the infected people.

This finding by international experts was endorsed by a study dated February 29 carried out by a team of scientists led by Sandip Mandal et al. from the Indian Council of Medical Research (ICMR) and published in The Indian Journal of Medical Research . Titled “Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach”, it categorically said that in order for airport screening to have an appreciable effect on delaying the establishment of transmission of COVID-19 in India, it would need to have near-complete capture of incoming COVID-19 cases, including asymptomatic ones.

These scientific studies prove beyond doubt that the MoHFW’s strategy to stop the spread of COVID-19 by containing import of the disease through thermal screening and focussing on symptomatic patients was flawed by design. The porous strategy let many asymptomatic travellers enter society unmonitored, and it was left to State governments to trace and chase them down when they started to show symptoms.

Another failure was limiting the thermal screening to arrivals from certain countries designated as high risk. Most airports and aircraft are carriers of COVID-19 because of the intermingling of passengers from across the globe. The high number of infections detected in returnees from Gulf countries, as noted in Kerala, can logically be attributed to global transit air hubs such as Dubai, Abu Dhabi and Doha even though the Gulf countries had relatively few cases at the time of the travel ban.

The MoHFW’s travel advisories clearly show how liberal India was with international travellers and non-resident Indians. Every time a travel restriction was imposed, there was a gap of two to three days before it came into effect.

On the day the Prime Minister mooted the symbolic and eventually ineffective “Janata curfew”, COVID-19 had infected more than 200,000 people and taken some 8,800 lives in 166 countries; in India, it had infected 180 persons and taken more than 20 lives.

Enough scientific pronouncements and literature are available globally that declare that the passing of the limit of 100 people infected and the failure to trace the origin of infection are tell-tale signs of community transmission. It has also been established that beyond this level, the COVID-19 infection entered an exponential growth trajectory.

Rigid testing criteria

While the WHO and other experts prescribe social distancing, washing hands regularly with soap, keeping hands away from the face, wearing face masks, and so on, to flatten the exponential trajectory, they also insist on wide scale testing to detect infections so that infected people can be isolated. WHO Director-General Dr Tedros Adhanom Ghebreyesus exhorted countries to “Test, test, test”, saying that this was the “backbone” of the global response and emphasising that it was not possible to “fight a fire blindfolded” and that social-distancing measures and handwashing would not alone extinguish the epidemic.

On January 15, the ICMR received the laboratory protocols from the WHO to conduct reverse transcriptase-polymerase chain reaction tests by taking a swab from inside a suspected patient’s nose or the back of his throat. The ICMR’s protocol was in the beginning limited to testing symptomatic patients from the designated countries alone. It selected 13 virus research and diagnostic laboratories (VRDLs) in 11 States in addition to the apex laboratory at the National Institute of Virology in Pune for COVID-19 testing. After February 29, this was enhanced to 31 VDRLs. Even as late as March 13, the ICMR was only testing about 5,900-plus samples, which implies a test rate of 4.4 people per million (ppm) of the population. The tests were extended to all international travellers on March 17 following persistent questioning by experts and the media; notably, the tests were still confined to symptomatic cases.

On March 20, the ICMR decided to extend the testing to all hospitalised patients with severe acute respiratory illnesses as also to asymptomatic direct and high-risk contacts of confirmed cases. By March 20, the ICMR’s testing was enhanced; rates now reached 10.3 ppm but were still far lower than many other countries. The graph created from this data source shows how other nations were testing their people on that date and how poor India’s testing was.

Meanwhile, many experts also questioned the ICMR’s low testing strategy. Health reporters repeatedly questioned this as more testing revealed more positive cases. The ICMR was forced to extend its testing to more samples, and as of April 2, it has tested 5,5851 samples, a rate of 41 ppm. As more samples were tested, India started to detect more and more positive cases. This evident as on March 13, when 81 positive infections were identified from 5,934 samples, or 1.36 per cent of the total number of samples, while this increased on April 2 to 2,056 positive infections from 55,851 samples, or 3.68 per cent of the total number of samples.

As the infections crossed the 2,000 mark at a fast pace, the ICMR was forced to deploy large-scale rapid antibody tests to test asymptomatic patients in the hotspots identified in the country, and its testing criteria were published on April 2.

The ICMR was forced to enhance testing, increase the number of laboratories that could carry out testing and introduce the rapid anti-body tests thanks to the efforts of a handful of enthusiastic women journalists covering the health beat in Delhi who upped the ante against the snail pace of testing. It is not known whether it was a problem of inventory or some other issue.

The discrepancy in the total number of positive cases shown on the websites of the MoHFW and the ICMR created confusion and doubts. Further to this, the ICMR, did not release data on March 25 and then only released data for March 27. Instead of examining this discrepancy, the MoHFW announced that the ICMR would not publish the data and all data would be published on Ministry’s website.

Opaque system

The MoHFW website shows just a dashboard of the all-India data and a table of State-wise cumulative figures of confirmed cases, recovered cases and deaths. Although this website until recently provided the total number of passengers screened at airports, it does not provide the number of tests done either at the all-India or State level. There is no archived data, so one cannot track data over time. The website is so rudimentary that it fails to update the States’ data even hours after the respective State government websites publish the same. A small group of enthusiastic journalists repeatedly asked questions about this throttling of information, the export of medical protective gear even after WHO recommended that countries enhance their inventory, India’s inventory of test kits, and so on. Neither the Union Health Minister nor the Prime Minister held a press conference to clear the air; instead, this task was left to officials of the MoHFW and scientists of the ICMR.

The media’s continuous probing irritated the government, which was waiting for an opportunity to gag the media. When the Supreme Court was hearing a public interest litigation petition relating to the plight of migrant workers due to the lockdown, the Solicitor General pushed for a media gag order. The Supreme Court sided with the government and, on March 31, directed that the media were to refer to and publish only the official version of developments. After this order, the next press conference ended up with three questions!

When people’s lives are at stake, it is quite distressing to witness the MoHFW’s slapdash information management and poor data dissemination after it had arrogated to itself the right to publish such data. On the one hand, the Indian government touts digital India and greedily grabs every bit of data it can on its citizenry; on the other, it hides vital information that could, if made available in the public domain for analysis, prevent the worsening of a looming calamity. Outrageously, no State-wise testing data are being presented by the MoHFW. This is information is critical because it can help identify clusters or hotspots of the disease, thereby enabling better and speedy targeting of scarce human and material resources to tackle the impact of COVID-19.

State-wise testing data

Given this state of affairs, this author tried to collect State-wise testing numbers by trawling through health department websites, public relations department bulletins and Twitter handles of various functionaries of State governments and U.Ts. This was an essential exercise if one was to understand how each State was faring and to establish a statistical correlation between positive cases and representative sampling numbers.

Certain State governments and U.Ts provide detailed information through bulletins and dashboards on their websites; others neither give out any information nor update their websites for weeks together. Eventually, data from 30 from States and U.Ts were collated and analysed as of April 2.

States such as Kerala and Maharashtra that attempted more testing from the beginning found more positive cases early on. But States such as Tamil Nadu and Delhi that dragged their feet on testing in the initial days have witnessed a sudden spurt of cases in recent days. This clearly indicates the asymptomatic nature of cases, which porous thermal screening and the rigid testing regime failed to capture. A look at how the ppm value of these 30 States and U.Ts differ helps one understand how much of a representative population is captured through the testing. Fourteen States and U.Ts are testing above the national average of 41 ppm, while 16 are testing below. The Andaman & Nicobar Islands (343 ppm) is at the top but with a much smaller number of tests and Kerala (224 ppm) is second followed by Delhi (150 ppm) and Goa (108 ppm). In contrast, the larger States led by West Bengal (6 ppm), Uttar Pradesh (12 ppm), Madhya Pradesh (13 ppm) and Bihar (14 ppm) are testing at a terribly low level. This data makes it clear which States India should concentrate on when it goes for the next round of rapid antibody tests.

Bungling along

The limited testing strategy of the ICMR and the porous thermal screening system the MoHFW employed likely resulted in the entry of many asymptomatic travellers. In recent days many health workers have tested positive for COVID-19. This is probably because of transmission from asymptomatic cases; health workers without proper protective gear have been exposed while treating COVID-19 patients in isolation wards. It is now obvious that if the Modi government had restricted air travellers at least one or two weeks before it eventually did so, that is, soon after the WHO declared all countries as high risk (on March 2), it would have been in a better position to detect, trace and control the spread of the virus. For example, if a compulsory quarantine of all air travellers for three weeks had been made mandatory from early March, travel to India may have reduced by at least 50 per cent. Meanwhile, the time could have been better utilised to either delay the lockdown or to prepare for it instead of letting the economy drift into chaos as is happening now.

In fact, the paper published by the ICMR scientists about the vulnerability of the thermal screening process points out that Indian scientists were fully aware of its limitations and knew that a loose strategy would ultimately lead to the situation that India is in now. As the spread of COVID-19 gathers pace—a 23 per cent increase in the number of cases in a single day between April 2 and April 3, when the number of cases breached the 3,000 mark—the ICMR was considering the possibility of issuing “revised” testing guidelines, confirming India’s status as the laggard in the global battle against the deadly virus. The inescapable conclusion that can be drawn from the evolution of India’s testing protocol for COVID-19 is that its narrow design at inception was meant to not detect early signs of community transmission. Its sole motto seems to have been: test not, find not.

It is telling that Modi was willing to give international travellers almost four days’ notice before shutting down airports but was happy to give ordinary Indians—among them the most vulnerable people in the country—just four hours to prepare for the disastrous lockdown that forces millions to choose between the virus and starvation.

James Wilson is a civil engineer and an avid data cruncher.