Chhattisgarh reports likely community-transmission case of COVID; centre maintains denial
On 30 March, Dr Harsh Vardhan, India’s health minister, chaired a meeting to review the nation’s COVID-19 testing strategy. While the Modi administration has been reluctant to expand testing, the novel coronavirus has marched away from India’s megacities, and emerging evidence suggests that testing gaps will hamstring efforts to contain hotspots in smaller cities and rural areas. In late March, the Chhattisgarh government, which is among the states that adopted a liberal testing policy that goes beyond the guidelines issued by the Indian Council of Medical Research, was faced with indisputable evidence of community transmission.
The state government had tested random samples and found that a senior citizen, who uses a wheelchair and lives in a basti—an unauthorised colony—near one confirmed case of COVID-19, had tested positive for the virus. According to the state health department, the patient had no travel history, no contact with any international travellers and could not provide any information that could trace the source of his infection. By all indications, the senior citizen’s infection was a case of community transmission. Multiple officials in the state’s health department have expressed concern that this case is emblematic of undetected infections within the community.
The Chhattisgarh government determined that the senior citizen had been infected during a house-to-house survey within a three-kilometre radius of a different confirmed case. The state has been one of the few to proactively test people and demonstrate this level of hyper-vigilance, which is an urgent necessity that the central government has failed to act on. The identification of such a case, with no history of travel and no record of contacts with other positive cases, is a clarion call to scale up testing, aggressively isolating those who test positive and preparing hospitals for the coming surge in cases.
According to TS Singh Deo, Chhattisgarh’s health minister, “the story” of the state’s fight against COVID-19 started in early March, with his government trying to convince the central government to expand their testing criteria. “At that point, the testing was entirely controlled by ICMR,” he said. “The testing facilities were controlled by them, and testing kits were also only with them.” On 16 March, Deo wrote to the health ministry calling upon them to “expand the criteria for testing,” noting that it was “too restrictive.” On March 31, he tweeted that although guidelines had been relaxed to some extent after his letter, “it has not been followed up with supply of large number of testing kits.” He continued, “Please do help Chhattisgarh @PMOIndia and @ICMRDELHI.”
On 1 April, Deo wrote to Vardhan again, this time urging the ICMR to formulate guidelines for the use of rapid antibody testing kits for COVID-19. He then tweeted, “Requesting the Central Govt & @drharshvardhan to ensure that @ICMRDELHI formulates comprehensive guidelines for use and purchase of Rapid Tests for #COVID19 as these tests have been used effectively across the world and are needed for expanding testing capacities.”
Despite calls from the state to scale up testing, as recently as 30 March, Lav Agrawal, a joint health secretary, maintained that there is no community transmission in India. When a journalist asked a question on the issue during a press briefing, Agrawal responded, “We should stop using the word ‘community’ in government communications and enforce a ban on the word to avoid any confusion.” He added, “We have to come out of this semantics. Nowhere are we saying there is community transmission. It is only local transmission in this country, let me repeat it.”
In its latest situation report, published on 31 March, the WHO has categorised India among the countries in the stage of local transmission, which form the majority across the world. But the Indian government has complicated the situation by creating additional categories of the stages of transmission. While the WHO identifies the transmission using broad categories of “imported cases only” and “local transmission,” the Indian government has muddied the waters with four categories—imported cases, local transmission, community transmission, and epidemic. The WHO does not categorise any of the epicentres of the virus, including Italy and Spain, as showing “community transmission,” because these come under its classification of local transmission. But by creating a category of community transmission, and denying that COVID-19 in India has reached that stage, the central government has effectively contradicted the WHO’s classification of the scale of the infection in the country.
“This debate is now getting increasingly irrelevant,” Dr Yogesh Jain, a community doctor and activist who runs a rural clinic in Chhattisgarh, said. “The need to scale up testing is urgent but this revision of testing criteria will become unnecessary in four weeks, when our hospitals are likely to be flooded with cases.” By that point, Jain added, “we will then need a diagnostic criteria merely based on clinical symptoms and signs,” because hospitals will by then be overwhelmed with people coming in with respiratory distress, which is characteristic of COVID-19.
At the individual level, liberal testing allows for informed clinical decisions, and at the community level, it informs policy decisions by giving governments a clearer picture of the full scale of transmission. For this very reason, Tedros Adhanom Ghebreyesus, the director general of the World Health Organisation, had criticised the restricted-testing approach of several countries during a press briefing on 16 March. “You cannot fight a fire blindfolded. We cannot stop this pandemic if we don’t know who is infected. We have a simple message for all countries: test, test, test.”
Globally, scientists are advocating liberal testing, including of asymptomatic cases, because understanding the mild cases can help researches get a handle on the spread of the disease—how it is spreading and how widespread it has become. The existence of a substantial but undetected number of COVID-19 carriers raises concerns for Indian citizens and its healthcare workers, as these infected individuals will inadvertently spread the virus without knowing they are sick.
In a paper published in the journal Science on 16 March, the authors have gathered evidence that in China, the epidemic was driven by a lot of undetected cases. The paper estimated that about 86 percent of all infections early in the first outbreak of the disease were transmitted by people who never got sick enough to go to the doctor. It further noted, “Per person, the transmission rate of undocumented infections was 55% of documented infections, yet, due to their greater numbers, undocumented infections were the infection source for 79% of undocumented cases.”
Scientists around the world are watching India’s COVID response with growing concern. Madhukar Pai, the Canada Research Chair in Translational Epidemiology & Global Health at the McGill University, in Montreal, said he had no doubt that India needs to test more people. “Everywhere in the world right now, testing is one of the most critical interventions,” Pai told me in an email interview. “Without testing, we have no way of knowing which fevers are Covid-19, and cannot really track the evolution of the epidemic.”
When asked if, epidemiologically, India could be an outlier with factors such as a hot summer and a higher immunity causing fewer infections, he wrote, “I hope India is an outlier, but I don’t see any rationale for that. With greater testing, the real magnitude will become clearer.” Pai added, “There are other countries (e.g. Singapore, South Africa, even China) with high temperatures and the epidemic has not spared them. If Indians had ‘good immunity’ then India would not have such a high burden of infectious diseases like Tuberculosis, dengue, malaria, pneumonia, and diarrhea.”
In fact, not only has the centre not sufficiently increased testing, there is little information about the testing kits that have been approved, which in turn makes it difficult for labs to procure the government-approved kits. On 27 March, Scroll reported that India had approved 18 testing kits made by private companies. The same day, Malini Aisola, the co-convenor of the All India Drug Action Network, wrote to ICMR seeking details about the basis on which these kits were approved. On 31 March, she tweeted that she had still received no response or information about the kits.
Chhattisgarh, which has emerged as one of the states to take a lead in proactive testing, has reported nine cases so far, five of which were imported from the United Kingdom. “If our initial protocol had listed U.K as one of the origin countries that required testing, we could have caught these cases at the airports, and quarantined them,” Deo told me. Not testing at that point, has led to more infections. The senior citizen was treated and discharged this week. It is amply clear that the demand for testing will only grow as the pandemic proceeds. We now know from global experience that countries that successfully avoided being overwhelmed by COVID-19, such as Singapore and South Korea, were able to do so because they used extensive and liberal testing guidelines, making it available for free.
India has so far failed on that front. Meanwhile, as of the afternoon on 1 April, the health ministry had reported 1,598 confirmed cases and 38 deaths.