The Rural Front Line

Why testing for surveillance—not universal testing—is necessary to contain COVID-19

21 April 2020
A doctor wearing a protective suit stores a swab in a test tube to test for COVID-19 in Mumbai on 8 April 2020. In the eyes of many, universal testing has become the primary proxy for action against coronavirus.
Prashant Waydande / REUTERS
A doctor wearing a protective suit stores a swab in a test tube to test for COVID-19 in Mumbai on 8 April 2020. In the eyes of many, universal testing has become the primary proxy for action against coronavirus.
Prashant Waydande / REUTERS

This is the third piece in a series titled “The Rural Front Line,” by Yogesh Jain and Naman Shah, about the COVID-19 pandemic. Jain and Shah are both doctors working with Jan Swasthya Sahyog, a public-health initiative based in rural Chhattisgarh, who are writing the pieces in their individual capacities. Over the course of the series, they will address the issues they witness on the ground while dealing with the virus, and discuss how policy decisions affect the lives of India’s rural residents. Disclosure: Shah is a part of the national task force on COVID-19’s research group for epidemiology and surveillance. 

Perhaps no aspect of this pandemic has caught the public’s eye as testing has. At Jan Swasthya Sahyog, in Ganiyari village in Chhattisgarh’s Bilaspur district, testing for coronavirus remains a challenge. We are a 100-bedded hospital, providing essential health services in a land where there is not much else for the marginalised. We try to do it well and at low cost, with a lean workforce. Around two weeks back, three of our staff fell ill—two nurses, who are roommates, and a young doctor developed fevers and coughs. It could have been any respiratory infection, including COVID-19; they needed tests. With testing, we could reasonably rule out the disease. Or else, we would quarantine these frontline staff, losing their services for 14 days. 

Our hospital has the right recipe for testing. The lab is advanced, even rich, for a rural hospital. Dedicated, experienced technicians and a talented young microbiologist run the show. All manners of body fluids pass through and they detect all varieties of diseases. While a real-time polymerase chain reaction machine—used for testing coronavirus—is missing, we have the GeneXpert, which can detect minuscule amounts of tuberculosis in samples, fortunate for a society overflowing with that disease. A COVID-19 cartridge for the GeneXpert is now available, but it can only be procured from a faraway place that we cannot reach and at a price we cannot afford. 

At the least, we hoped to collect and send our own samples for testing—swabs of the back of the nose and throat. We had the containers and transport liquid. The unexpected roadblock was the device used to swab—a 15-centimetre long stick with a wad of sterilised, synthetic fibres at the end. It was out of stock in local markets. We contacted the district health authorities for help, but the state has its own supply issues. It was even sold out on the e-commerce platform Amazon. These are strange shortages in strange times. 

Our staff went to the nearest sample-collection centre in Bilaspur town, 45 minutes away. From what the nurses and the young doctor told us, the centre was easy to find—in a well-marked building, separated from the rest of the medical college campus. It is always interesting to receive healthcare when one delivers it daily. They found the doctor examining them was kind and knowledgeable. They were aghast when no one took a temperature, blood pressure, or heart rate—aptly named vital signs. There are recommendations to maintain a distance from suspected patients except for the physical exam, but no one suggests forgoing the exam altogether. The doctor did not even apply a stethoscope.

After a careful review of symptoms, risks and travel questions, the centre’s doctor recommended COVID-19 testing. The lab in-charge rejected the idea. Confusion ensued. Many calls were made. Until recently, only symptomatic healthcare workers who were managing respiratory distress or severe acute respiratory illness were eligible for testing. With rapidly changing advisories, the testing centre understandably struggled. Finally, with the intervention of the district health officer, the lab collected samples. From there, the sample travelled for another three hours to the state capital Raipur. Our staff returned and remained quarantined for two days until the reports came. Negative. We breathed a sigh of relief. We wondered if this is the situation at our hospital, where we have long-standing relationships with cooperative, local networks, what happens to others? 

Yogesh Jain is a pediatrician, public-health worker and co-founder of the Jan Swasthya Sahyog. He is a graduate of AIIMS and an active physician, and contributes to state, national and international policies.

Naman Shah is an infectious disease epidemiologist and family-medicine physician at Jan Swasthya Sahyog. He has worked in pandemic influenza planning, disease-control research, and programme management with health departments, the Indian Council of Medical Research and the World Health Organisation.

Keywords: The Rural Front Line COVID-19 Indian Council of Medical Research Testing kits