New Delhi: Hasibul Nisha, 35, from Dwarka in New Delhi, has been suffering from a dry cough, cold and fever for six days. Her family is worried it might be COVID-19, which has affected more than 200,000 people globally and killed more than 8,000, and is slowly spreading in India. They said they visited three nearby private hospitals in Moti Bagh for tests but were turned away

Nisha’s daughter, Zareena Sheikh, has kept abreast with all COVID-19 advisories and updates and said she believes her mother has similar symptoms. “The doctor keeps giving paracetamol tablets to my mother…The hospitals were really crowded and the doctors said that this is not how checking [for COVID-19] will be done,” Sheikh said

Nisha has no recent history of travel to any affected country and has not been in contact with any confirmed COVID-19 patient that could qualify her for free testing. If Nisha has COVID-19, it could mean community transmission, of which there is no evidence, Indian health authorities insisted once again at a press conference on March 19

Only someone who has symptoms of the disease, such as a cough, fever and breathlessness, can get tested under India’s COVID-19 testing guidelines, if they fulfil one of these conditions: they should have traveled to an affected country and/or had contact with a confirmed case

Until now, India has tested 12,426 people--nearly 9.2 tests per million people. By contrast, Italy had tested 165,541 people until March 18, 2020, or 2,740.75 tests per million. South Korea, which has been able to stabilise the spread of the disease, with a low fatality rate of 0.9%, had tested 295,647 people until March 18, 2020--5,729.6 per million--and is continuing to mass test 20,000 people every day, for free. The UK is testing about 1,500 cases daily--846.7 per million people--and is planning to ramp this up to 10,000.

“Test, test, test” is the message that World Health Organization Director General Tedros Adhanom Ghebreyesus gave to all countries on March 16, 2020.

“We need to be doing more testing, we have a very restrictive testing criterion right now… and these [testing] numbers are too low,” said Anant Bhan, a Pune based researcher in global health, bioethics and health policy.

As of 9 a.m. on March 20, 2020, India had recorded 195 COVID-19 cases, of which 163 are Indians and 32 foreigners. Four people have died while 19 have been discharged after treatment. Confirmed cases have increased by 106% over the last five days. [See our COVID-19 tracker here.]

Restrictive testing criteria

A country is at stage one of the spread of a disease if it only has imported cases--those coming from another infected country. Stage two is localised transmission, in which those coming in contact with an imported case contract the disease. At stage three, community transmission takes place, when even those with no such contact with an imported case test positive for the disease. The fourth stage is an epidemic when a disease spreads more than what would normally be expected, based on the WHO’s criteria for that disease. Once it spreads across the world, it is termed a pandemic, as COVID-19 is now

The Indian Council of Medical Research (ICMR), India’s apex body for biomedical research, tested 826 symptomatic patients from hospitals to find out whether the virus was also affecting people in the community with no travel history or contact with an infected person.

The tests were negative, ICMR said in a March 19 press release. On March 18, 2020, the ICMR had said that negative cases showed that COVID-19 had not reached the stage of community

transmission in India. With no community transmission, India does not need more widespread testing, the government posits

“826 cases are really not enough to detect community transmission,” said Gautam Menon, a professor of physics and biology at Ashoka University, Sonepat. “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.”

For a country of India’s size, the ICMR’s cample is too small, said Om Shrivastava, an infectious diseases specialist at Jaslok Hospital in Mumbai.

South Korea, which had 8,413 total cases as of March 18, 2020, had tested 5,729.59 per million people compared to India. Taiwan, with 100 confirmed cases, had tested 18,812 samples.

“As far as testing for the localised transmission [stage-two] is considered, we are doing enough,” R. Gangakhedkar, head of epidemiology and communicable diseases at ICMR, said on March 16, 2020. “We have not yet reached the stage [that would require] mass testing.”

“Today, till now based on our combined efforts there is no community transmission because we are able to verify cases,” said Lav Agarwal, joint secretary of the Ministry of Health and Family Welfare (MoHFW), at the March 19 press conference. “When community transmission starts, it becomes difficult to say from where did the patient catch an infection, which is not the case so far… You can easily say that there is no community transmission in India.”

It is unlikely that we have managed to track every case that has come in and it is possible that the disease is spreading in the community and the reason we have not picked it up is because most of these cases are yet to be found, Menon said.

“You need more testing, not less, to find out what is the status of your country,” in terms of stage 2 or 3, agreed Shrivastava.

The ICMR is more cautious. “ICMR is just trying to test, which we have found to be negative. We can’t say anything at this point about community transmission beyond that. We are trying to test further and increase the sample to get better results,” Rajni Kant, director of the Regional Medical Research Centre of the ICMR, told IndiaSpend on March 19.

The ICMR press release did say that surveillance is being expanded to include more areas, especially where COVID19 cases have been reported, without giving any more details

Testing kits

The ICMR has not provided information on the number of testing kits available with them. If testing is ramped up to meet the level of South Korea, which has stabilised the spread of the infection, in part by testing 5,729.59 per million, India would need 7.7 million kits, our calculations show

Currently, India has enough resources to do the required tests, Gangakhedkar of ICMR said, and is also importing “one million probes from Germany”

But Menon said more clarity is needed, as the government has not shared many details.

Too few being tested

About 72 government laboratories were testing for COVID-19 in India, as of March 18, 2020. These labs have a capacity of 9,000 tests a day, Lokesh Sharma from the ICMR told IndiaSpend. In addition, the government has set up two new testing locations, one in the National Capital Region and one in Bhubaneshwar, each with a capacity to test 1,400 per day, the official said. This takes India's testing capacity to 11,800 each day. The ICMR also plans to have 49 more functioning labs, according to this press release from March 17, 2020.

In addition, the ICMR is also randomly sampling patients who display influenza-like illnesses or acute respiratory illnesses, said Balram Bhargava, the director general of the ICMR

"Testing will only happen as per guidelines, we don't want any unnecessary panic,” said Agarwal, the MoHFW joint secretary, at a March 16 press conference.

But this lack of testing itself could create a panic, as is the case with Nisha and her family and the four families we spoke to who wanted to get tested because they believed they had symptoms.

“If the number of cases and deaths keep rising then it will only enhance the panic that we are already starting to see and that is a scary prospect. Not testing because you want to prevent panic does not make much sense,” Bhan, the health expert, told IndiaSpend. ”We should be more ambitious and aggressive in our testing strategy.”

“If I am a clinician and I have a patient who doesn’t fit into the testing criteria of travel or direct contact, I should be able to use my clinical discretion to request for a test because I strongly suspect COVID-19 infection,” Bhan said. “We can’t rule out the possibility that it [community transmission] might not happen,” but India needs to be ready for the worst-case scenario

At Delhi’s Charak Palika Hospital, one of the three places where Nisha tried to get tested, Medical Officer Sapan Verma reiterated Bhan’s sentiment. “A doctor’s call should be trusted more, we should be able to recommend patients for a test, it will help control the situation.” He was not among the doctors that Nisha consulted, however

The hospital has created a separate ward for patients with viral fever, “but there are so many patients who are very anxious and think they have the virus”, Verma said, adding, “We can only refer them to Ram Manohar Lohia if they have a travel history, we haven’t been able to refer anybody so far.”

Asymptomatic cases missed

Evidence from other countries suggests that asymptomatic patients, who move around carrying the virus without presenting any symptoms, are the hardest to detect and pose the greatest risk of spreading the infection further. The current restrictive cohort method of detecting community transmission makes it impossible to detect them, experts told IndiaSpend.

“Even if a patient is asymptomatic, he or she could be shedding the virus, so we will need to keep that in mind. If our testing numbers are not consistent with the rest of the world then we need to do better,” said Shrivastava.

Private sector involvement

To enhance testing capacity, the Indian government has said it will allow some shortlisted private labs to begin testing, based on the guidelines that only those with a travel history or contact with an infected person and symptoms of the disease be tested.

One of the challenges with private testing is contact tracing, said Gangakhedkar, the ICMR scientist.

Another is the cost--the test costs about Rs 5,000 but it is currently free for everyone. The ICMR has asked private diagnostic facilities and hospitals to also offer the test for free.

“Will they [private labs] be doing it for free is another question, if not then is the government willing to put a price ceiling?” Bhan said.

The ICMR said on March 17 that it is in talks with high-quality private labs, without naming any company

Social isolation and shutdowns

Worldwide, countries trying to stem the spread of the disease have closed schools and educational institutions, impacting over 849.4 million children and youth across 102 countries, while 11 countries have implemented localised school closures, according to UNESCO’s global monitor of school closures.

Across India too, all educational institutions, gyms, cultural and social centers, pools and theatres have been closed from March 18 to March 31, 2020, as per a government advisory. The government has advised that all mass gatherings and unnecessary travel be avoided and has recommended social distancing.

Barring certain exceptions, all citizens above the age of 65 and below the age of 10 are advised to stay home, all concessional rail and air travel has been suspended, and school and college examinations have been postponed, according to this March 19 press release. The government has said it will not allow any international commercial flights to land in India for a week from March 22, 2020. The MoHFW has also asked state governments to ensure that all private companies allow employees to work from home.

Several countries, including France, Spain and Italy, are under a complete lockdown, with only essential movement allowed

Correction: The story has been updated to show that India's testing capacity for COVID19 is 11,800 tests per day, and not 1,400 as we said earlier. We regret the error.

(Tiwari is a principal correspondent with IndiaSpend. This story was edited by Shreya Khaitan.)

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