India has low testing rate, needs to scale up surveillance: Analysis
A new analysis by Indian epidemiologists has revealed that the country has one of the lowest Covid-19 testing ratios compared to other affected countries and that its infection containment measures may not be adequate because of this. India has conducted only 47 tests per million population as of April 5, compared to 2,753 in the UK, 4,572 in the US, 8,800 in South Korea and 22,918 tests per million population in the UAE.
The analysis also found that in Indian states where testing was more, fatalities were comparatively lower. Kerala, which has the highest testing rate of 276 tests per million population, has one of the least case fatality at 0. 65%. But Madhya Pradesh, Bihar, Punjab, West Bengal, and Gujarat have higher case fatality average (of about 3% to 9%) compared to the national average of 2.3%. Testing is also low in these states with about just 15 tests or less per million people.
The authors-- Giridhara R Babu, Professor and Head, Life Course Epidemiology at Public Health Foundation of India (PHFI); Tarun Bhatnagar, scientist at ICMR-National Institute of Epidemiology; and Deepa R, a research associate at PHFI; have warned that low testing but high fatality rate states may be missing positive Covid 19 cases.
The authors have divided the states into four categories -- states with a high rate of testing and low case fatality (such as Delhi, Kerala and Tamil Nadu) where early diagnosis may be resulting in better outcomes; two states with high testing and yet high fatalities (Maharashtra and Karnataka) where authors are trying to understand if it’s because of elderly patients with co-morbidities; states such as Arunachal Pradesh, Jharkhand and Uttar Pradesh with low testing and low fatalities; and states such as West Bengal, Bihar and Madhya Pradesh that have less than 20 tests per million but a case fatality rate of 3 to 5%.
The authors explained that a lockdown cannot be continued for a very long time. To contain the disease, India will need more surveillance, extensive tracking, testing and isolating cases. “In summary, containment measures need to be improved in all states by increasing the number of tests. Also, syndromic surveillance and symptomatic quarantine measures are useful strategies to improve containment measures. States which have inadequate testing, poor early detection efforts, and higher case fatality will pose greater challenges in the future. If the cases are not detected early, then those who develop complications cannot be referred timely and, therefore, can succumb,” the authors wrote in BMJ Global Health journal’s blogs. The analysis has not been peer-reviewed yet.
Since January 24, a little over 100,000 tests have been conducted in India, according to Indian Council of Medical Research (ICMR) data. ICMR has approved at least 200 labs (both public and private) for testing through RT-PCR machines and is in the process of identifying other government and private labs, research institutes and medical colleges that have the capability and infrastructure to undertake testing for inclusion into the Covid-19 testing network. It is also procuring 0.5 million rapid testing (blood test) kits for mass testing, to be deployed in states where maximum cases are being reported.
“We have to look at the cost and availability of tests. We can’t compare ourselves with US, UK or South Korea. One has to realise the size of our country and state of our economy...We have to try and see how much we can expand testing and at the same time isolate and contain clusters carefully. I think we are doing better than many European countries,” said Dr Shobha Broor, senior virologist and former head of the AIIMS department of virology.
Authors of the BMJ analysis said it’s important that states make testing and detection data public. “It is more than two months since the first observed COVID19 case was diagnosed in India. We still have minimal data to understand the epidemiological trajectory of COVID 19 in India. The biggest limitation for our analysis is that state-wise testing, detection, and case-specific details are not made available in the public domain.”