It was in late March that Dr N.N. Mathur, director of Lady Hardinge Medical College (LHMC), was informed that the hospital in central Delhi would serve as a Covid facility, but largely to supplement the testing and treatment capacity of the two major Covid hospitals in the National Capital Region-the All India Institute of Medical Sciences (AIIMS) in Jhajjar and Delhi’s Lok Nayak Jai Prakash Narayan (LNJP) Hospital.
It took Dr Mathur’s team around two weeks to set up 60 beds and 17 ventilators for the new facility. “We didn’t initially anticipate more [patients than this] because of the lockdown,” he recalls. But, as on June 16, LHMC had treated twice that number of Covid patients, set up 100 more beds at the nearby YMCA premises, added 60 ‘Covid suspect’ beds and plans to add 30 more treatment beds. In total, the same staff that once handled 60 beds is now managing 254 beds.
Not a single Covid bed at the hospital is empty. “We prepared well, but noticed a shift in mid-May. Suddenly, we had more severe cases, more asymptomatic cases. But the severe cases haven’t increased as much as the general Covid cases,” says Dr Mathur. As Covid numbers continue to rise, many other hospitals around the country are adding to their bed strength. But that by itself will not be enough.
With 366,945 Covid infections, as on June 18, India is now the fourth worst-affected country in the world. However, despite the surge, the numbers in India are nowhere close to doubling as fast as they did in the US or Spain in the days ahead of their peak. “Had we not enforced a lockdown, we could have gone from a few cases in March to where we are now in a much shorter span of time. Our curve is upwards, but it is not a sharp ascent,” says Dr V.K. Paul, member of the NITI Aayog.
An ICMR (Indian Council of Medical Research) serology survey of 26,400 people in 83 districts from 21 states reveals that only 0.73 per cent cases showed past exposure to Covid. This suggests that infection is still largely contained, having spread more widely in the country’s red and orange zones.
Source: Union ministry of health and family welfare, ICMR, state health departments (Graphic by Tanmoy Chakraborty)
Indeed, five states account for nearly 70 per cent of the cases-Maharashtra, Delhi, Tamil Nadu, Gujarat and West Bengal. The spike in infections in Delhi is the most alarming, with a positivity rate (number of positive cases for every 100 people tested) of 15 per cent (June 18), the national average being 5.8 per cent. If it took five tests to find a positive case in Delhi on May 14, by June 13, it took only 2.7 tests-this is indicative of the infection spread.
Our national death rate continues to hover around 3 per cent. Of the 11,903 deaths as on June 17, 83 per cent were from the same five states as above. Though the curve for death cannot be predicted, it has been noticeably sharper in the past week-2,500 deaths were recorded between June 10 and 17, while the first 5,000 fatalities took 80 days and the next 5,000 17 days.
To deal with the challenge of rising numbers as well as chart out a strategy for Unlock 2.0 starting July 1, Prime Minister Narendra Modi chaired a video-link meeting with the chief ministers of 14 states and the lieutenant governor of Jammu and Kashmir on June 17. The conference included the five states with the worst case load.
Source: Union ministry of health and family welfare, ICMR, state health departments (Graphic by Tanmoy Chakraborty)
The prime minister pressed these states to urgently utilise their testing infrastructure and focus on quick diagnosis and contact-tracing as the foremost strategy for containing the Covid spread. He also made it clear that there won’t be any fresh lockdowns in the country. “Unlock, unlock, unlock is the way forward,” Modi said.
Instead, the fight against Covid will include public awareness, prioritising expansion of health infrastructure and most importantly-testing, tracing and treatment. “We must commit to testing, tracing and treatment and should not focus only on case numbers but equally on mortality numbers,” says Dr Randeep Guleria, director, AIIMS, Delhi.
A strong case for testing
India has a total of 901 Covid test labs and is testing close to 150,000 samples a day, which is to be doubled by the end of June. However, this has not been uniform across states. An analysis of data, from end of May to early June, shows a drop in test numbers of the five worst-affected states and a corresponding increase in the total positivity rate (see A grim battle ahead). Delhi showed a downtrend between June 3 (6,543 tests) and June 9 (5,353 tests)-a period when cases in the city shot up by 41 per cent.
Daily testing in Maharashtra, home to one in every three national cases, also dropped 7 per cent between May 29 and June 9. Gujarat and West Bengal had nominal changes to their total daily tests while Tamil Nadu marginally increased its numbers. This has public health officials worried, as testing is the only way to isolate positive cases, protecting not just these individuals but equally those around them.
“States fear case numbers will go up if they test more. They are not working on pooling in available resources,” says Dr K.K. Aggarwal, former head of the Indian Medical Association (IMA). He adds that while the entire population need not be tested, India hasn’t yet covered even 5 per cent of its people. As far as tests per million go, India is at 3,800, Pakistan at 3,600, the US at 73,000 and Brazil at 50,000.
The average time for test results is 48 hours, but this varies. In West Bengal, it takes up to five days and there is a backlog of 60,000 samples. The state says despite having 36 RT-PCR (reverse transcription polymerase chain reaction) machines, there is a limitation of testing capacity and lab manpower. Each machine, depending on its type, can run 54 to 500 tests a day.
Some states have shown the way out. “Pooled tests increase the capacity of RT-PCR machines by five times,” says Dr Anjali Jain, head of microbiology at King George’s Medical College, Lucknow. Uttar Pradesh, one of the first to begin pooled testing, scaled up from 3,000 tests daily in April to 15,000 in June. The ICMR has also allowed the use of TrueNat machines (used for TB diagnosis) and Cobas 8800 (a device similar to the RT-PCR machine) to amplify the DNA in a sample, which then helps detect the presence of the novel coronavirus in the standard RT-PCR test.
The TrueNat machine is cheaper and more widely available while the Cobas can run 4,000 tests. To address the staff crunch in labs, states like Rajasthan and Kerala have allowed final-year students and trained field workers to lend a hand. “If you want to test, you will find a way to do so even in challenging times,” says Dr Aggarwal.
Analysts are particularly concerned for states that, despite having the infrastructure for testing, are focusing on symptom-screening-a strategy that was used to screen international returnees at Indian airports in March and proved to be ineffective. Bihar has been doing only 500-600 RT-PCR tests daily, but has screened over 100 million for flu-like symptoms.
Telangana, which is conducting an average of 250 RT-PCR tests daily, too, plans to do ‘fever symptom’ tests in the vicinity of Covid patients’ homes. “Covid cases could develop symptoms in five days or a week later. Purely checking for flu symptoms is not an accurate assessment. One needs to focus on contact-tracing or rapid tests,” says Dr T. Jacob John, noted virologist. Periods of low testing in West Bengal, Delhi, Gujarat and Maharashtra have led to a simultaneous or subsequent surge in infection.
There is hope that the introduction of rapid antigen tests will improve diagnosis in all states. These tests rely on nasal swabs and detect proteins or antigens that are a part of the Covid virus. The crucial difference between these and rapid serology tests is that the latter detects antibodies present in the blood sample in response to any infection, while rapid antigen tests look for a substance that is unique to the Covid virus.
Unlike RT-PCR-considered the gold standard in testing-rapid antigen tests can give results in under 30 minutes. The rapid antigen kit cleared by ICMR is supplied by South Korean firm SD Biosensor from its manufacturing facility in Haryana. It has a specificity or ability to detect true negatives between 99.3 and 100 per cent-the higher this figure, the more reliable the test is. Delhi has begun using these tests in its containment zones.
Tracing the asymptomatic
The World Health Organization (WHO) estimates the likelihood of an asymptomatic case infecting others as up to 40 per cent. “When a person tests positive, the focus turns to their family. They must be tested. But we cannot rule out other people the individual might have interacted with. If they are symptomatic, they themselves can come forward for a test, but if they are not, they will live in ignorance,” says Dr Girish Tyagi, president of the IMA in Delhi.
While the ICMR policy allows testing of only those asymptomatic people who are high risk or direct contacts of positive cases, states have differing policies on who is ‘high risk’. Delhi ruled out all asymptomatic testing (except for those with comorbid conditions) in early June only to revoke the order in 10 days.
In West Bengal, says state IMA chief Dr Ujjwal Kumar Sengupta, tracing of asymptomatic contacts has nearly come to a stop. “In April and May, contact-tracing of positive cases was methodical. All people in the offices and residential buildings of Covid cases were tested and isolated. But this is not happening any more,” says Dr Sengupta.
In Maharashtra, the government insists its new initiative, which imposes isolation on the 15 people in closest contact with a positive patient, will be effective. Yet, just a week ago, a positive patient from Mumbai’s Pratiksha Nagar was admitted to hospital, but his septuagenarian parents, wife and children were not tested. “Poor planning, wrong allocation of resources and higher transmission are the consequences of not testing or under-reporting,” concedes Dr Anand Bang, member of the Maharashtra government’s committee on healthcare. “No government wants to show higher infection numbers.”
Good examples of contact-tracing for asymptomatic cases are Rajasthan and Kerala, where mobile phone and location records through the Aarogya Setu app were used to trace Covid patients’ movements. “We used technology for greater tracing accuracy. If you isolate the infected quickly, the virus spread will be much slower,” says Dr Amar Fettle, nodal officer of the Kerala health department.
Focus on fatalities
Public health experts now advise states to make low death count their first priority, instead of trying to keep infections down. “You cannot eliminate a viral infection entirely, but you can save people from succumbing to it,” says Dr John. This can be achieved through a proven combination of prompt diagnosis and accessible treatment.
To its credit, India has been steadily adding to its Covid treatment infrastructure. Till June 9, the country had 958 dedicated Covid hospitals, 32,362 ICU beds and 120,104 oxygen-aided beds, according to the Union ministry of health and family welfare. Some 21,494 ventilators were available for Covid beds, with orders placed for 60,848 more.
Despite this, Mumbai has already faced a shortage of beds. In Bengal, the demand for beds is so high that patients are often released as soon as symptoms subside, without the confirmatory Covid-negative test. And, only a week ago, there was an acute scarcity of beds in Delhi, with reports of patients being turned away by hospitals that were running to capacity. Unlike neighbouring Rajasthan, which set up 17,000 oxygen-aided beds and 1,300 ICUs, the national capital had prepared no more than 10,816 beds (of which 5,770 are occupied as on June 18).
The situation prompted Union home minister Amit Shah to step in. Working with Delhi chief minister Arvind Kejriwal, some 30,000 additional beds were announced on June 15-20,000 in hotels and clinics, a 10,000-bed makeshift hospital. Around 500 railway coaches will also provide beds.
The additional capacity will cater to Covid patients with moderate to severe symptoms, and those who cannot isolate at home. This has prompted concerns of a shortage of doctors and nurses in these new units, which the state hopes to address by the end of June. At present, beds in non-hospital settings are attached to a larger hospital for medical monitoring and treatment.
“Delhi is a clear case of low testing and bed shortages impacting the death rate,” says Dr Tyagi. Delhi had a death rate of less than 1 per cent in April; it is now higher than that of the national figure at 4.04 per cent.
The five worst-affected states are examples of why testing, tracing and treatment should continue to be the focal point of our national and state-level Covid management policy. It is no longer purely a numbers game. Infections will rise, but how fast they do and how effectively we protect the vulnerable is what will matter in the weeks ahead. n
-with Kiran D. Tare, Romita Datta, Rohit Parihar, Amitabh Srivastava and Amarnath K. Menon