Chinks in the armour

Print edition : July 17, 2020

A health worker spraying disinfectant in a COVID-19 test ward at the Rajiv Gandhi Government General Hospital in Chennai. Photo: B. Velankanni Raj

A sanitation worker sprays bleaching powder in Avadi, Chennai, during the lockdown, on June 30. Photo: M. Vedhan

Health care workers at a school that has been turned into a centre to conduct tests for COVID-19, in New Delhi. Photo: ANUSHREE FADNAVIS/REUTERS

At Undavalli village near Vijayawada, after coronavirus cases were reported in the vicinity. Photo: K.V.S. GIRI

As of June 26, from among the States, while Maharashtra, Delhi, Tamil Nadu and Gujarat accounted for nearly two-thirds of confirmed cases, Maharashtra, Delhi, Tamil Nadu and Telangana accounted for the same fraction of active cases, pointing to a rapidly changing scenario in Telangana which at one stage was tending to move off the exponential line. Photo: Stabhra Sinha, Institute of Mathematical Sciences, Chennai

As bravado, false pride and an apparent refusal to adopt a scientific approach mark the Union government’s strategy to fight COVID-19, the pandemic is steadily marching to its peak.

Fourteen months after his infamous remark about the Prime Minister’s “56-inch chest”, Union Home Minister Amit Shah displayed the same sense of false pride and bravado when he said on June 28 that the country would win both the war—the confrontation with China on the Line of Actual Control (LAC)—and the fight against COVID-19 under the leadership of Narendra Modi.

While the LAC battle is for strategists and defence experts to analyse, the second the duo is sure to win, however long it might take. The fight on the COVID-19 front appears—both from news reports and from what is evident on the ground—to be driven mainly by the Prime Minister’s Office (PMO) and the national executive by keeping scientific expertise and advice at bay, and the spread of the disease, five months after the country saw its first case, will in all likelihood decline and slowly peter out. That is because, with the current increase in the number of infections still hugging the exponential line, eventually the virus will not have enough people to infect and the spread will decline and herd immunity will slowly set in—a natural epidemiological scenario. Even then the Modi-Shah regime is bound to claim that as its victory, when in reality it not only did not do the right thing in terms of non-pharmaceutical interventions (NPIs) such as lockdowns but also prevented medical and health experts from doing what they know best.

In the last issue of Frontline, evidence for the last clause above was highlighted. The manner in which the government shared with the nation sero-surveillance data, which provide an indication of the disease prevalence in the country, revealed less than it hid. As quoted in the last issue, the Progressive Forum of Medicos and Scientists (PFMS) had roundly criticised the total lack of urgency in the publication of sero-survey results by the Indian Council of Medical Research (ICMR).

Even the protocol to be followed in the sero-surveillance of the 60-odd districts (classified into four categories) that had been identified was published online only on June 20, just about when the last issue of Frontline was closing, which itself was about six weeks after the survey data had been gathered and the analysis was on. The protocol does have some information about the sero-survey, though not all that was pointed out in the last issue. Some of it is indeed revealing, which will be discussed here.

As mentioned in the earlier article, this sero-survey was a serial cross-sectional survey conducted with a sample size of 24,000 distributed equally across four strata of districts categorised on the basis of the incidence of reported cases of COVID-19—zero cases, low incidence, medium incidence and high incidence. We had observed earlier that the post-survey press briefing on June 11 by the ICMR’s Director General, Balram Bhargava, had not defined the four categories, which, fortunately, have been defined in the published protocol.

The sero-surveyed districts were to be categorised according to the reported COVID-19 cases per million population (zero, low: 0.1-4.7, medium: 4.8-10 and high: >10). As mentioned before, the classification at the time of the survey (mid May) was based on the number of reported cases as on April 25. Fifteen districts from each stratum were to be selected randomly for a total of 60 districts.

In addition—this information had not been given in the briefing—the top 10 cities in the country reporting the highest number of cases were also to be included to be considered as hotspots, which roughly ties up with the 71 districts that Bhargava showed in the table projected at the briefing. It had been reported in the media that in these 10 hotspot cities, sero-survey had revealed that as much as 30 per cent of the populations could be infected. Of course, the ICMR dismissed this as being speculative, but the correct data are yet to be published or shared. The protocol, however, suggests that the survey sampling of hotspot zones was done on the assumption of a maximum seropositivity of 5 per cent.

With the total number of cases having crossed a milestone mark of 500,000 on June 27 (which stands at 566,840 as of June 30) and with nearly 19,000 confirmed cases being added daily, India now has the dubious distinction of being ranked fourth among the countries of the world even though it had enforced probably the strictest lockdown measures (in four phases) in the world. With cases per million population being in their thousands in all the top-10 COVID-19-hit cities of the country, which include Jodhpur and Indore, the classification might appear highly incongruous. But on April 25, which was just at the end of the second phase of the lockdown, the total number of cases stood around 25,000, about one-twentieth of the current number of confirmed cases. Even then the categorisation would seem already somewhat removed from the ground situation.

However, the more pertinent aspect of the survey as stated in the protocol, which shows the ICMR in a really in bad light, is the following. The published protocol says:

“The WHO [World Health Organisation] suggests three possibilities to conduct the sero-epidemiological investigation: cross-sectional investigation, most apt after the peak transmission is established; repeated cross-sectional investigation in the same geographic area (but not necessarily the same individuals each time) to establish trends in an evolving pandemic; and longitudinal cohort study with serial sampling of the same individuals. Establishing cohorts [the last possibility] during a pandemic being resource intensive, and India being [as of April-end] in the early stages of the pandemic, the second option is the most appropriate choice to guide public health response.

“…The initial survey would serve as a baseline to determine the seroprevalence of SARS-CoV-2 infection in the community and in high-burden cities as well, while the subsequent rounds would help to monitor the trends of infection in the community. This information will also guide the strategy for making decisions related to lockdown options at a district level. The objectives of this serosurveillance are to estimate and monitor the trend of seroprevalence for SARS-CoV-2 infection in the general population and high-burden cities, determine the socio-demographic risk factors for SARS-CoV-2 infection and delineate the geographical spread of the infection in the general population and hotspot cities” (emphases and parenthetical remarks added).

Well, well. Since the first round has just been completed and the results are yet to be published, is that meant to imply that the country is still in an evolving pandemic with the peaking still months away? It would seem so. Given that, it is not clear when the subsequent rounds of sero-surveillance (in the same identified districts) will be undertaken and their results published or shared with the districts/States, if they will be taken up at all. According to the protocol, the “subsequent rounds… will depend on the results from the first round and the ensuing epidemic situation in the country…. Instead of waiting for the end of the epidemic, repeated serosurveys carried out at regular intervals can be a useful tool to monitor the epidemic precisely.”

And to boot, the survey results are supposed to guide the “strategy for making decisions related to lockdown options at district level”. While the government has just announced the rules for the second un-lockdown phase at the gross national level, save high burden areas and containment zones, which will run through July 1 to July 31, individual districts, cities and States—faced with soaring numbers of cases—are set to reimpose lockdowns, obviously with no guiding strategy from the Union Health Ministry or the ICMR. From the laggardly pace at which these surveys are being done, it would seem that by the time the ICMR gets its act together to conduct the second round, the country may well be nearing the peak, if not the end, of the epidemic. The surveillance, according to the protocol, was to be “directly monitored by the apex scientific working group on epidemiology and surveillance established for COVID-19 by the ICMR”. The working group, as reported in the last issue of Frontline, was not even privy to the basic data of the survey. They were shared with the PMO and the top bureaucracy of the government first!

In an earlier Frontline article (May 8), it was pointed out, on the basis of the results of a sentinel survey of severe acute respiratory infection (SARI) patients, how community transmission was occurring even as the government was in denial. The ICMR survey had found 40 of the 104 cases surveyed (from 36 districts in 15 States) had no apparent link to an identifiable source of infection. The government still seems to be in denial as is evident from the June 29 WHO situation report, which is based on government submission. According to a recent report in The Telegraph (India), the researchers of this survey were not even sure if the research paper would be published at all. Ultimately it did appear (which is what the Frontline story was based on), but they were prevented from naming the 36 districts which showed evidence of community transmission. As pointed out in an earlier article (Frontline, June 5), despite the published evidence of the ICMR’s own sentinel survey, its revised testing strategy of May 18 ignored that evidence and just slightly revised the earlier strategies as if there was no community transmission.

Now, on June 23, however, over two months after the sentinel survey results were published, in its Testing Strategy v. 6 it has deceptively revised the protocol, which is tantamount to a tacit admission of community transmission. The last para of the main document on the revised strategy now says “testing should be made widely available to all symptomatic individuals in every part of the country… ICMR advises all concerned State governments, public and private institutions to take required steps to scale up testing for COVID-19 by deploying combination of various tests as advised above.”

In the last v.5, testing of symptomatic individuals were restricted to “all symptomatic (with symptoms of influenza-like infection, or ILI) individuals 1. with history of international travel in the last 14 days; 2. who are contacts of laboratory confirmed cases; 3. who are health care workers/front-line workers; 4. who are SARI patients; and, 5. who are within hotspots/containment zones; as well as asymptomatic direct and high-risk contacts of a confirmed case to be tested once between day 5 and day 10 of coming into contact”. Now it has advised to include all symptomatic individuals, with no attendant qualification as in v.5. But this revised strategy should have been in place at least two months ago.

As Sanjay Rai, Professor of Community Medicine at the All India Institute of Medical Sciences (AIIMS), New Delhi, and president of the Indian Public Health Association, has been quoted as saying: “In community transmission, the focus should turn to mitigation…While testing, contact tracing, and isolation of patients should continue, the focus should shift to minimise deaths through early case detection, triage, and ensuring that adequate hospital facilities are available to manage the surge in cases…. In Delhi with its surge, a mitigation strategy is already in place.”

As of June 26, among the States, while Maharashtra, Delhi, Tamil Nadu and Gujarat accounted for nearly two-thirds of the confirmed cases, Maharashtra, Delhi, Tamil Nadu and Telangana accounted for the same fraction of active cases, pointing to a rapidly changing situation in Telangana, which at one stage was tending to move off the exponential line (Figures 1 & 2).

Test postitivity rate

The test positivity rate (TPR) is the percentage of tests that are returned positive. If, given the scale of the epidemic, the surveillance is efficient enough to detect any resurgence, one will have a low positivity rate. On the other hand, a high positivity rate is indicative of the testing strategy being limited to people with high suspicion of infection. This is likely to miss new chains of transmission in the community. A sero-survey is supposed to guide towards an efficient testing strategy, which unfortunately is out of pace with the rapid surge in infections in different regions of the country. Inefficient testing in many States is very evident.

According to the WHO, the daily positivity rate ought to be below 5 per cent for at least two weeks before relaxing public health measures. TPR is believed to be better than tests per million (TPM) as an indicator of testing adequacy, as testing coverage should be seen relative to the size of the epidemic rather than the size of the population. Table 1 shows TPRs and TPMs for all the States. The table clearly shows which States have failed to get a handle on the size of the epidemic, either by their well-conceived containment strategies or by the fortunate circumstances arising from their geographical, demographic, economic and commercial status. And it is these failed States that are driving the national scene today.


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