India needs to ramp up COVID-19 testing, learn from South Korea & avoid US’ mistakes

The key is for India to expand its laboratory capacity — the turnaround time for test results should be brought down to less than six hours.

Hyderabad: There have been 110 COVID-19 cases reported in India until 16 March 2020, and two deaths. The government has stepped up its response to the coronavirus threat by establishing guidelines, constituting rapid response teams, organising a National Training of Trainers workshop, and initiating public service announcements, among other things.

Front line workers are reportedly tracking an estimated 4,000 contacts of those with confirmed infections, while another 42,000 individuals are under community surveillance.

Though these efforts are commendable, India needs to ramp up its efforts and respond more aggressively. The key to this is rapidly expanding our laboratory capacity — the turnaround time for test results should be brought down to less than six hours.

Nothing illustrates the dire need for this than contrasting the responses to COVID-19 between South Korea and the United States.

What South Korea did

One of the most efficient responses to COVID-19 came from South Korea. The epidemic there started in mid-February, and the government quickly scaled testing services by involving the private sector.

It was able to do 10,000 tests daily at the peak of the epidemic, used these to identify the infected individuals, and then isolated and treated them, also putting in control measures. This ensured the situation was brought under control swiftly.

South Korea has reported 8,162 cases with 75 deaths, translating to a death rate of less than 1 per cent compared to 3.7 per cent globally.

What US did

In contrast, the US bungled the testing availability at multiple points — it did not initially accept World Health Organization approved tests, the tests it sent to states were flawed, and it did not let the private sector play a role in testing.

In the meantime, the epidemic simmered, which has now led the US to declare a national emergency. It is now trying to rectify the mistakes by buying bulk test kits from Roche, and giving grants to private labs to develop similar tests.

Until 15 March, the US has reported 1,678 cases with 41 deaths (death rate 2.4 per cent). With community spread confirmed in the country, there are probably many infections that are not being diagnosed due to a shortage of test kits. Absence of evidence (no/inadequate testing) should not be construed as evidence of absence (no infection/epidemic).

The testing situation in India

The National Institute of Virology (NIV) is the nodal reference laboratory for COVID-19 testing in India. Additionally, 51 testing labs and 56 collection labs are currently functional.

While appreciable, there should be clarity about the role of these 51 labs (screening vs confirmation), daily capacity (number of tests) and the turnaround time for test results to be available and communicated. These are crucial performance indicators in controlling an epidemic, and can make a major difference in being able to respond expeditiously.

For instance, the sample from the patient from Kalaburgi was collected on 9 March, but results were only available on 11 March. By this time, reportedly, 34 people in Telangana and 44 in Karnataka had come in contact with the patient.

For confirmed cases of COVID-19, hospital authorities have to usually wait for two negative results before discharging a patient. Delays in receiving these test results will mean that beds are unnecessarily occupied, and new COVID-19 patients would not be able to access these when there is a surge in demand.

Diagnosis bottleneck

An effective COVID-19 response requires us to quickly identify, isolate and treat positive cases to break the chains of transmission.

The current strict testing protocol, which seems to be largely routed through the NIV for confirmation of diagnosis, has become a bottleneck in the response effort, and may jeopardise it. All the 51 labs and future additions to the network need to be supplied materials for testing, such as reagents, test kits and PPEs. They need to be staffed with trained personnel who can quickly run tests, in multiple shifts if needed, interpret the tests and provide results promptly to facilities in their region. The lab network should also be expanded, including up to district level.

Complementing the expansion of laboratory capacity, the criteria for suspect cases (those eligible for testing) needs to be relaxed. Current testing criteria are persons with respiratory symptoms and pertinent travel history, and close contacts with lab confirmed cases. However, we also need to exclude the possibility of community transmission (unknown chains of transmission).

We should not let a Trojan horse inside unknowingly. The risk and cost is too high for this. We need to test all in-patients with Severe Acute Respiratory Illness or severe pneumonia. We should allow for clinical discretion from medical professionals to request for testing of their patients if they suspect COVID-19 infection.

When testing is done at scale, it will stress test the whole laboratory system, exposing critical bottlenecks and weak links.

In Italy, the northern region refused to follow the strict national guidelines and made testing widely available. The country was able to detect a simmering epidemic just in time, but even with that, its health system is at the break point now. The US also stuck to a strict testing criterion, but when a sample from a flu study participant was tested for COVID-19, the authorities detected an unknown chain of transmission, and realised their folly.

The ICMR has announced plans to do a more expansive similar exercise using samples from influenza-like illness patients. It plans to test a small number of samples regularly in 51 labs across the country from 15 March onward. We feel this is inadequate, given that the risk and cost of a full-blown epidemic is very high. We should try to do as many tests as possible urgently. It is easier and cheaper to put down a spark than a full-blown fire.

Rapid scaling

India needs to achieve scale fast. To achieve this, the government can procure test kits from South Korea or any other source in the short term.

It needs to involve quality private sector facilities to expand our testing capabilities. The government should encourage biotech companies and labs to develop and manufacture validated tests at the earliest. If needed, a retail price ceiling can be fixed to control costs. At the height of the epidemic in Wuhan, China deployed 3 mobile BSL Level 3 labs and brought down the turnaround time from two to three days to less than six hours. This shows the importance of laboratory capacity not only in preventing epidemics (containment) but also in control (mitigation).

It’s imperative India augments its testing infrastructure at the earliest to flatten the COVID-19 curve. This will also prepare us for testing to be widely, easily and cheaply accessible in future, under a drawn-out global pandemic scenario.

Dr Manjunath Shankar is a public health specialist. He participated in the US CDC Emergency Response (Modelling Task Force) to the West African Ebola outbreak in 2014-15.

Dr Anant Bhan is a researcher in global health, bioethics and health policy.