ICMR changes strategy for coronavirus testing in India
ICMR has said foreign returnees must stay in quarantine for 14 days and tested only if they become symptomatic.
ET Online|Last Updated: Mar 21, 2020, 04.42 PM IST
The Indian Council of Medical Research (ICMR), on Friday, reiterated that there were no documented cases of community transmission of coronavirus in the country, and that it
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Bengaluru: As public health experts continue to wonder why India has such low rates of diagnostic tests for COVID-19 per capita, a recently published study by ICMR scientists indicates the council may have ignored its own analysis on the need for more aggressive testing.
A mathematical model prepared by ICMR scientists almost two months ago suggested that simply isolating symptomatic international air passengers could not have helped delay a COVID-19 epidemic in India.
In the model, published in a paper this month, scientists from the Indian Council of Medical Research (ICMR) compared a scenario of ‘no airport screening’ with three other scenarios in which airport screening detected all symptomatic cases. The researchers found that even flawless screening couldn’t have delayed a COVID-19 epidemic in India by more than 2.9 days because such screening wouldn’t capture infectious people who weren’t yet showing any symptoms (a.k.a. pre-symptomatic cases).
The model also suggested that the only strategy that could appreciably ‘flatten the curve’ for India would be extensive testing of symptomatic people with no travel history, allowing up to 50% of all COVID-19 infections to be identified.
These findings raise serious questions about ICMR’s reluctance to widen testing beyond people with a travel history until only last weekend.
Jacob John, a professor of community medicine at Vellore’s Christian Medical College, said, “I believe the testing of only travel-related cases was a serious error.” As of March 17, ICMR had tested only 500 community cases of severe acute respiratory illness (SARI). The agency changed its strategy only on March 20, to include all SARI and pneumonia cases.
Further, after WHO director general Tedros Adhanom Ghebreyesus asked all countries to “test, test, test”, ICMR officials claimed to have written to WHO’s India office that Ghebreyesus’s statement was unwarranted because it didn’t apply to countries like India with no evidence of community transmission.
When asked why ICMR waited so long to widen community testing, despite the agency’s own model suggesting otherwise, the paper’s coauthor and epidemiologist Tarun Bhatnagar said logistical constraints had played a part. “This is not Singapore or South Korea, which are like a single Indian state. We have to take a balanced approach to see that we are using our resources in an optimal manner,” he told The Wire Science.
However, by ICMR’s own admission, India had ample capacity to conduct tests for COVID-19, and so a shortage wasn’t the cause for the slow ramp-up. Raman Gangakhedkar, another coauthor of the paper, has said previously that ICMR was only using 10% of its testing capacity. The reason it wasn’t expanding further, he explained, was because there was no evidence of community transmission.
This conclusion was in turn seemingly based on negative test results from 500 SARI samples – a sample size that other experts have called inadequate for a country of over 1.3 billion people.
Coronavirus | Cases surge; ICMR denies community transmission
SPECIAL CORRESPONDENTNEW DELHI, MARCH 29, 2020 23:37 IST
UPDATED: MARCH 30, 2020 09:18 IST
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A girl stands amid smoke as municipal workers fumigate an area in Ahmedabad on March 29, 2020.
A girl stands amid smoke as municipal workers fumigate an area in Ahmedabad on March 29, 2020. | Photo Credit: AP
Since the lockdown was announced on March 24, India has added between 75-100 cases a day on average.
India on Sunday reported more than 100 new cases of COVID-19, bringing the overall case load to 979.
“There have been six deaths in the past 24 hours,” said Joint Secretary in the Union Health Ministry Lav Agrawal at a briefing.
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“We have identified certain emerging hotspots and [will] investigate, on a war footing, what action can be taken there,” he added. However, none of the officials at the briefing specified the hotspots or the number of cases at these locations.
The Indian Council of Medical Research (ICMR) said testing for new cases has been stepped up to 30% of the nation’s capacity.
Coronavirus | Why are only a fraction of cases tested?
Director-General of ICMR Balram Bhargava had said earlier this month that the country could theoretically test upto 70,000 samples a week.
Head of Epidemiology and Communicable Diseases at ICMR, Raman Gangakhedkar, said there was no estimate yet of whether the nationwide lockdown — now into its fifth day — had managed to check community transmission. “If we all observe the lockdown strictly then there’s a chance that we will soon reach the peak number of cases,” Dr. Gangakhedkar added. The ICMR continues to maintain that there are no instances of community transmission.
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Reports from State health authorities put the death toll from COVID-19 at 29, with 1,121 positive cases. Maharashtra reported two fatalities, while J&K and Delhi reported one each on Sunday. Maharashtra and Kerala continued to have the most cases at 203 and 202 respectively. Kerala reported 20 new cases, while 1.41 lakh people are under observation, State Health Minister K.K. Shailaja said. Maharashtra had 22 new cases, with 10 from Mumbai.
Coronavirus | Cases surge; ICMR denies community transmission
Since the lockdown was announced on March 24, India has added between 75-100 cases a day on average. According to district-wise updated figures from the Union Health Ministry, Mumbai recorded the highest number of cases at 81, followed by Kasargod in Kerala with 78. Bangalore came next with 26.
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The National Pharmaceutical Pricing Authority has asked States to coordinate with manufacturers of gloves, hand sanitisers and masks to address shortages in these products. The list mentions 35 manufacturers of gloves, 49 makers of sanitisers and 34 mask makers.
As of Sunday, coronavirus infections have been recorded in 188 countries. There were 6,83,694 cases according to covidindia.org, an independent tracker, and 32,155 deaths globally.
The thrust of the government is to ensure that the lockdown restrictions are strictly adhered to, said Mr. Agrawal. Delhi has seen a surge in migrants packing up and trying to leave the city for their homes in Uttar Pradesh and Bihar mainly but stranded in the city want of transport. The Central government reiterated directions to States to ensure that people stayed put and they be provided food, water and shelter.
Government Drops First Hint of Community Transmission in India
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Some patients suffering from severe acute respiratory illness (SARI) without any history of international travel or contact with anybody infected by the novel coronavirus (SARS-CoV-2) have tested positive for the virus, the government said on March 28, 2020.
The comments by Raman Gangakhedkar, head of the Indian Council of Medical Research (ICMR)’s epidemiology division, at a press conference in New Delhi were the first official indication that the novel coronavirus disease, COVID-19, may have infected patients outside the limited criterion of overseas travel history.
Gangakhedkar did not divulge the number of such patients who had tested positive but only said that they were “sporadic”. He downplayed that this could indicate community transmission of COVID-19.
Out of nearly 110-120 samples tested for SARI, as many as 10% had been confirmed positive for COVID-19, sources from ICMR said.
Stage 3 of the coronavirus epidemic in India, known as community transmission, is the phase in which the source of infection cannot not be known or traced either to international travel or contact history.
“Even if the number is small, this is an indicator that India is likely in stage 3,” T. Sundararaman, former head of the Union Ministry of Health and Family Welfare’s National Health Systems Resource Centre, said.
It was wrong on the part of the government to deny such a ‘reality’ by taking refuge in the fact that such positive cases were less in number, he added.
“Absence of evidence is being used as evidence of absence. When one links it with our very [low] sampling, it is worrying,” he said.
“Despite being expanded on paper, the testing criteria remains limited in practice. It is difficult for an acute respiratory illness patient to be tested for COVID-19 in reality, despite guidelines saying so. I think it is no longer a matter of discussion in which stage we are but rather channelise all our resources in preparing hospitals for stage-3,” he told Down To Earth.
Emergency preparations afoot
Meanwhile, officials across India’s states seem to scrambling in order to prepare the health infrastructure for stage-3.
A WhatsApp message late on the night of March 27 to a senior official of Chhattisgarh jolted him out of his slumber. “Book all private hospitals, clear all roads from remote areas to district hospitals, count and clean all ICU instruments and please put all available ventilators at your direct control,” the message read.
The official is among those managing the state’s response to the pandemic. Within five minutes of him receiving the message, he also received a call from a senior official in neighbouring Odisha. “How many ventilators are there in Raipur? And how many affected people?”
In the next 20 minutes, senior officials directly in charge of the fight against COVID-19 in nine states, including Kerala, Odisha, Madhya Pradesh and Uttar Pradesh, undertook an extensive assessment of the situation.
“Unofficially, Delhi [shorthand for ICMR, which comes under the government] has confirmed community transmission occurring at a speed and reach higher and wider than expected,” an official from UP said.
Also read: Four Reasons It’s Hard to Believe India Doesn’t Have Community Transmission
The influx of thousands of migrants to and from these above states since March 26 has added to the panic.
By the evening of March 28, official spokespersons of Odisha and Chhattisgarh hinted that community transmission was imminent.
Activities at the village-level in states like Odisha and Uttar Pradesh point to enhanced alertness. Odisha has granted panchayats Rs 5 lakh each for isolation exercises and critical medical expenditure. Focus on mapping out infrastructure has heightened.
While all these are standard practices of preparedness, the message originating from Delhi and being officially communicated with urgency to district collectors has added to the fear that government assessment of the situation is different than what it has been projecting.
“We all know stage 3 is a reality. With or without declaration, we have to prepare,” a senior official dealing with the Chhattisgarh chief minister’s team on COVID-19, said. “But the official internal communications of the last 24 hours are pointing to certainty about it.”
Delhi’s Chief Minister Arvind Kejriwal had also posted a tweet to this effect: “I have received the report from the panel of doctors headed by Dr [S.K.] Sareen recommending measures to prepare for a potential stage-3 outbreak of COVID-19 in Delhi.”
The state government was ramping up capacity for an eventuality of 1,000 daily positive cases for testing, treatment and isolation, he added.
Also read: ICMR Study Suggests Its Testing Strategy Was Flawed
Thus far, India has had quite a few instances of people testing positive for COVID-19 without any prior international or contact history.
A 20-year-old man from Tamil Nadu had tested positive for SARS-CoV-2 on March 18.
The state’s health minister C. Vijaya Bhaskar described his case as “domestic”. The patient had a travel history of Delhi. “We have not been able to find any other contact or international travel history,” Sampath Palani from the state’s health department told Down To Earth on March 28.
Madhya Pradesh’s Indore, Chhattisgarh’s Raipur and Odisha’s Raipur have also reported such cases.
Banjot Kaur and Richard Mahapatra are reporters at Down To Earth magazine. This article was originally published on Down To Earth and has been republished here with permission.
Coronavirus: What is community transmission?
India says it won't hide the truth from its public if it enters what's called the community transmission stage, or Stage 3, of the coronavirus outbreak. But what exactly does that mean? Here's a detailed explainer.
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Ganesh Radha-Udayakumar
Ganesh Radha-Udayakumar
New Delhi
March 29, 2020UPDATED: March 29, 2020 13:23 IST
The government recently said that if India's coronavirus outbreak reaches the community transmission stage, "we will tell people so that we can step up the level of alertness and awareness." We explain what that term means. (Photo by Reuters/Taken in Mumbai, on March 28, 2020)
HIGHLIGHTS
India's caseload crosses 1,000; over 2 dozen dead
Lockdown till April 14; migrant worker exodus a worry
Community transmission: We take a closer at a key concept
India's coronavirus caseload is growing fast -- over 1,000 people now have, or have had the virus -- but experts from the Indian Council of Medical Research (ICMR) say evidence of community transmission is scarce.
But what exactly is that?
Well, it's got to do with our ability to tell how patients got infected.
At the community transmission stage (the "Stage 3" you keep hearing about), a disease spreads in the population is such a way that people don't know how they were exposed to the contagion: they haven't travelled to a part of the world that's currently battling an outbreak, or haven't been in contact with someone they know has the coronavirus.
Chezney Schulte, a public health official in the US state of Missouri, put it like this to local channel KMIZ:
"You are racking your brain thinking, I must have gotten it out in the community by going about my day-to-day life...I just don't have that person I can pinpoint it down to where I would have gotten it."
'If India enters that stage, we won't hide it'
Back home, the Press Trust of India reports that three people who were found to be infected with the coronavirus -- after the ICMR announced a major expansion of its testing criteria -- had no exposure history.
But ICMR's Head of Epidemiology and Communicable Diseases, Raman R Gangakhedkar, said there were "some sporadic cases where people are not revealing their exposure history", but the numbers weren't "significant enough to assume that the virus is spreading rapidly".
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"We can consider that we are in the community transmission stage only when there are about 20 to 30 per cent cases with no clue on how they got the virus."
- India's Ministry of Health and Family Welfare
CORONAVIRUS: QUICK FACTS
Previously unknown type called Sars-CoV-2. First detected in China.
Causes potentially fatal respiratory disease called Covid-19.
Elderly and patients with pre-existing conditions at greater risk.
On March 19, a few days before India imposed an ambitious nationwide lockdown to enforce social distancing, the ICMR said more than 800 random samples tested to detect community transmission had come out negative.
"We can consider that we are in the community transmission stage only when there are about 20 to 30 per cent cases with no clue on how they got the virus," said Lav Aggarwal, a joint secretary in the Ministry of Health and Family Welfare, later in the week.
"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."