Are states like TN testing enough people for COVID-19? Public health experts say no

Public health experts say mass testing of people will be needed to detect whether there has been community transmission of the virus in the country.

Coronavirus Health

Allegations have now surfaced in Tamil Nadu that health officials in the state are refusing to test suspected coronavirus patients, who have travel history. Tamil Nadu has recorded one case of coronavirus till date. This, even as testing for coronavirus remains low in the state.

As of Saturday evening, only 79 samples have been tested from passengers in Tamil Nadu. While 78 samples tested negative, one sample tested positive for COVID-19. Tamil Nadu has four testing centres – King Institute of Preventive Medicine & Research, Guindy, Chennai; Theni Virology Diagnostic Laboratory Network (VRDL); Thiruvarur VRDL; and Tirunelveli VRDL. Samples have also been sent to the National Institute of Virology, Pune.

What’s more, there have been several allegations that that the Rajiv Gandhi Government General Hospital in Chennai, Tamil Nadu’s nodal hospital for coronavirus, has turned away persons who have shown symptoms of the disease, and who have travel history.

Speaking to TNM, a Chennai-based doctor who works at a private hospital in the city, alleged, “For the past two weeks, we have been seeing patients with travel history from places like Singapore, Vietnam, Qatar and other places. We have a separate fever desk that collects patient history. But when we refer these patients, who show symptoms of coronavirus, to the government hospital, they refuse to test them unless they show severe symptoms like respiratory illness.”

He further alleged that authorities passed the buck to private hospitals, asking them to follow up with suspected coronavirus patients. This despite protocol mandating that private hospitals refer any suspected cases to the government health centre. “They just tell patients who go to Government Hospital (GH), you don’t fit the symptoms for testing, come only if you have breathing difficulty,” the doctor said, adding that health officials were also not advising these patients to self-isolate.

Gayatri Khandhadai, a Chennai-based activist who had recently traveled to Southeast Asia and Europe, also raised similar allegations. In a series of tweets, Gayatri alleged that despite her travel history and having a mild flu, she was not tested, with health officials asking her to come back when her symptoms were more serious. Slamming the state government, she called out their unpreparedness to handle the pandemic and said she had decided to opt for social isolation.

Shocked at the TN government response to Corona. I went to the GH to get tested given my recent travels to Southeast Asia and Europe. They told me to come back when my symptoms were more serious. I offered to pay for the test and they said they won't take blood samples. 1/1 — Gayatri Khandhadai (@gayatrikl) March 14, 2020

Another passenger who recently returned to Chennai from Italy, now a hotspot for the coronavirus in Europe, also alleged that she had been turned away by health officials in Tamil Nadu. “I’ve been living in Italy for a year. I came back to India on March 1 and went to get screened for the virus. I was running a low grade temperature and was refused the test. They told me to come back ‘when I showed more symptoms’,” said the passenger to TNM.

Director of Public Health and Preventive Medicine, Dr K Kolandaswamy, however, said there was no reason to panic, stating that health officials in the state were following guidelines and protocols prescribed by the World Health Organisation, the National Centre for Disease Control and the state government.

When asked why Tamil Nadu’s testing was low compared to Kerala, he said, “In TN we had only one positive case and we took samples from eight family members who were in close contact. Whereas in Kerala, the number of infected is 19, they might have taken at least 8-10 samples per case. Naturally their number will go up to 200.” He further said that laboratory tests may not be able to detect the initial two-three days of infection, which is why the government has advised a double quarantine period (28 days) for those with travel history and symptoms of the virus.

“Testing someone for coronavirus is something that the doctor has to decide. It is not possible to test everyone and there is no need for it either. There must be trust in the professionals. For instance, a passenger who has come from a foreign country cannot just opt to test him/herself for coronavirus. Without any symptoms there are people coming in to ask if they can be tested,” said Dr Kolandaswamy, adding, “First, people will have to inform the control room if they have travel history and symptoms then the doctor will decide. We have specialists doing these tests, not just MBBS doctors. There is huge pressure. Travel history alone is not a criteria. Their symptoms, clinical condition, etc will also have to be taken into consideration. Protocols clearly state the testing criteria.”

He also stated that Tamil Nadu has enough testing kits: “This has nothing to do with testing capacity. We have four centres and can increase it to any number.”

Testing in the south

Neighbour Kerala meanwhile, which has reported 22 cases of COVID-19 including the first in India, has tested 1,897 people for the virus as of Saturday. Kerala has three testing centres in the state.

Karnataka, which has recorded six positive cases of coronavirus, has collected a total of 731 samples as of Saturday. On March 14 alone, Karnataka collected 92 samples and sent for testing to five approved centres in the state.

As of Saturday, Telangana has collected a total of 353 samples, with two testing positive for SARS-CoV-2, which is the virus. Like Tamil Nadu, Andhra Pradesh which has one positive case, has collected only 70 samples so far.

Who is eligible for testing?

India has focused on screening passengers arriving in the country in international airports. The government’s protocol restricts COVID-19 tests to people with symptoms (cough, fever, or difficulty in breathing) who have travelled to affected countries recently (Italy, Iran, South Korea, France, Germany, UAE etc) or who have come in contact with a COVID-19 patient and have symptoms of the disease.The health ministry categorises such passengers as Category A or high risk, and they are sent for isolation and testing.

Many Indians who returned from abroad have complained that they could not get themselves tested for the virus. Those who have returned from abroad and do not show symptoms of the disease are not tested.

Is India’s testing inadequate?

Across India, over 90 cases of COVID-19 have been reported. India has tested 5,900 people – which is around five out of every million people – for the virus. In comparison, South Korea, for example, has tested over 1,40,000 people so far. The country’s government tested as many as 10,000 samples in a day adhering to the belief that free and universal testing will help in detection of cases and lower the death rate. Currently the death rate in South Korea is 0.7% of confirmed cases.

India currently has 65 laboratories equipped for COVID-19 testing while around 1 lakh testing kits are available. India can conduct up to 10,000 tests in a day currently. The central government is of the belief that there are no community transmissions in India right now – that is, there are no patients who have had no known contact with another confirmed case, or travelled from a country affected by the virus. Further, the government says that it is well equipped to contain the current outbreak. This is despite the World Health Organisation (WHO) categorising India among countries having local transmission.

What public health experts say

Public health experts say that travel restrictions and advisories alone are not enough to curb the spread of the virus and mass testing of people will be needed to detect whether there has been community transmission in the country.

Public health experts contend that the current scale of testing in India is not enough to contain the spread of the virus. “Since the virus is already in India, it is important to trace the contacts of all infected people to ensure that we are not missing any human to human transmission. It is better to be over cautious now than repent later. The logical way to ensure there is no local transmission is to monitor contacts of all travellers, and positive cases, through the incubation period of 14 days,” Giridhara Babu, a professor of epidemiology at the Indian Institute of Public Health, told Caravan Magazine.

Others contend that states should strengthen surveillance and test at inter-state borders as well. "When we speak about India's protocol, yes it (testing) might seem insufficient, but one has to keep in mind the size of the country as well so for now, this seems okay. I would ideally want the states to strengthen surveillance and testing in inter state borders as well," said an official to TNM.

Dr Sylvia Karpagam, a public health researcher, argued that testing was just one aspect of containing the pandemic, and that the real need of the hour is to focus on strengthening the public health system. "Testing just gives information to people about the number of positive cases but in terms of managing the outbreak, we need to focus on other universal precautions and strengthen the public health system to ensure testing is locally available. Passengers who have come from affected countries should be quarantined as per the protocol laid out by the government. They (passengers) should be tested if they are showing symptoms. People should not crowd and overburden tertiary hospitals at this time," she said.

Concurring with Tamil Nadu’s Dr Kolandaswamy, Dr Sylvia also said, "In the incubation period, the tests do not always show up as positive. It is not realistic to expect testing facilities to be suddenly available as it is a new virus"

In an attempt to check for community transmission, India is planning to test over 1,000 samples of influenza or pneumonia-like illnesses taken from people without travel history or contact with people affected by COVID-19. “We don’t want to do indiscriminate testing, but it is also important that we are not missing out on community transmission. If we find a positive case anywhere, then the strategies would be completely different,” a senior scientist with the Indian Council of Medical Research (ICMR) told Indian Express.

(With inputs from Anna Isaac and Anjana Shekar)