Locking down is not enough. Ramp up testing
The national lockdown is necessary, but it is not a cure.
Managing the coronavirus pandemic (Covid-19) still needs a widespread testing, identification, tracing and isolation strategy. India must initiate widespread testing, issue screening and confirmatory test protocols, evolve a randomisation process for surveillance testing, and identify high-risk locations. Only this can control the spread of the virus, or it will re-emerge once the lockdown is lifted.
Testing is not expensive and it can be done at a massive scale. The lockdown is the opportunity cost of not testing early — a loss of about Rs 10,000 crore a day in taxes in addition to spending on mitigating the effect on hapless individuals. The opportunity cost in lost taxes of a seven-day lockdown could pay for screen testing our whole urban population — and we are locked down for 21 days. So far, we have tested barely 25,000 people. We need to do much more.
The testing strategy would be determined by capacity — which is hopefully being built up rapidly; test kits and personnel to test and interpret results; a logistics chain, if needed, to carry the sample from the person to the lab; and an electronic system to convey the results back to the person, with clear instructions on what a person who tests positive should do.
If there are capacity limitations in the infrastructure for polymerase chain reaction (PCR)-based tests currently in use, the initial screening test can be done using rapid testing methods, such as South Korea’s antibody test, which gives quick results. Its reported over-prediction of the presence of virus is not a disqualification as a screening test, which is confirmed using PCR testing. The fact that the Indian Council of Medical Research (ICMR) is interested in such tests is heartening news.
The ICMR already has a protocol for testing of symptomatic persons. People infected before the lockdown will start showing symptoms during the lockdown, and even with limited transmission, it will spread to family and neighbours. We must widely and insistently communicate, especially in dense urban settlements that people need to come for testing, if they are symptomatic. Such people will form a cluster to be tested — this is allowed in the current protocol, but contact in such settlements needs to be defined widely.
Such insistent communication is also necessary in villages, especially those with returning migrants. This is essential to identify clusters of infections.
Going beyond, and this is key, ICMR needs to urgently to revise its protocol to allow widespread asymptomatic surveillance testing.
First, begin by randomised testing of people in dense urban settlements using voter lists. These can be in slums, unauthorised colonies, resettlement sites, old cities. If the virus takes root in such settlements, it will spread very rapidly.
Second, have randomised testing of people allowed to move around during the lockdown. It is important that their identity be recorded, while issuing passes to move during the lockdown. These include police officials and sanitation workers, but also vegetable vendors, delivery persons, grocers, pharmacists, mediapersons among others. Maintenance staff in apartment complexes are particularly vulnerable, especially in complexes with possible cases of infection.
And three, have randomised testing of migrants who have returned home to smaller towns or villages from the larger cities – villagers know which households have returning migrants. There are already reports of such people being labelled and isolated, which may be good, and occasionally discriminated, which is definitely not good, even from the point of view of controlling transmission.
Initially, surveillance testing can be prioritised in the migrant intensive districts identified in the report of the government’s Working Group on Migration. Just 56 districts — 25 in Uttar Pradesh, 20 in Bihar, three in West Bengal, two in Karnataka and Uttarakhand and one each in Odisha, Rajasthan, Jharkhand, and Maharashtra — account for half the male inter-state migration. This is best implemented though the panchayats and will need significant information and communication support to assuage the anxieties of people about testing. These 56 districts have around 35,000 panchayats that can serve as the initial sites of intervention.
Randomisation of returning migrants and people allowed to move during the lockdown can be done through a protocol involving their Aadhaar numbers.
Increase in testing (especially using antibody tests, which will identify people who have had the infection but are not currently contagious) will naturally increase the number of reported infections. This should not cause alarm, if properly communicated. Currently, there is no communication about testing beyond laconic ICMR press releases. This needs to change and the media and people should be educated about plans to expand surveillance testing and protocols to be followed for isolation following positive test results. Post communication, the testing itself can begin after a week. This will also allow people infected before the lockdown to develop Covid-19 symptoms.
But testing alone will not stop the virus unless we are able to isolate infected people, preferably in local facilities. Odisha has been ahead of the curve by allocating Rs 5 lakh to each panchayat to get this infrastructure and systems in place. This cost, for all the panchayats in the migrant-intensive districts, is just Rs 1,800 crore. Extending this to all panchayats in India would be Rs 10,000 crore — a rational investment in public health, if the virus becomes endemic. We also need to prepare health care facilities to receive patients in large numbers — even build hospitals/quarantine facilities in football fields, as Assam is doing. The lockdown is the time to prepare so that the health care system is not overwhelmed and mortality is mitigated.
The bottom-line is that the ICMR must allow widespread testing and states must start doing so and report to a common database. Without this, it may not be possible to avoid a second lockdown.