Can’t confirm community transmission unless we test more: Infectious disease expert

Dr Vinay of Apollo Hospitals speaks about the novel coronavirus, its status in India, testing conditions and quarantine period.
Can’t confirm community transmission unless we test more: Infectious disease expert
Can’t confirm community transmission unless we test more: Infectious disease expert
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Even as India crosses the 5,000-mark on the number of COVID-19 positive patients, the rapid rise in infection has necessitated a discussion on the actions (or lack thereof) of the Centre and state governments in managing the pandemic so far.

Several questions are raised every day to authorities on the amount of testing done by the country, the criteria for testing suspected cases and the overall imposition and management of the nationwide lockdown. TNM speaks to Dr Vinay Devraj, an infectious diseases expert from Apollo Hospitals, Bengaluru to know more about India’s status in tackling the COVID-19 situation.

How do you see the pandemic situation in India as of now? Do you think we still have an uphill task or do you think we are nearing the stage of plateauing?

To be honest, the wishful thinking is that the number of cases will come down soon. But looking at what has happened in other countries, we will get more cases than what we have seen till now. The lockdown is probably delaying the cases from coming out in the open.

The lockdown is now two weeks in. Presuming that there could be infective cases which have already entered into the system about 10-14 days ago, considering the longest incubation period of 14-20 days, we might come to know the real situation (of the number of cases and the overall graph) over the next one week or so.

It is difficult to predict how this will turn out at this juncture. But with the lockdown ongoing, the patient may still have symptoms like the common cold and might not have been able to approach hospitals or get tested, unless it is very severe, due to the lockdown. I think the seven to ten days will decide and determine the actual situation in India.

India still says that there is no community transmission except in certain pockets. How do you see this statement?

Not trying to contest what the government data says, but it is only a question mark. Are we really testing that effectively and following up all symptomatic cases? Are all the symptomatic cases reaching the government centre and approaching them for a test?

Initially, the government felt that only those who have symptoms and travel history will be eligible for a test. The criteria laid down by the Indian Council for Medical Research (ICMR) three weeks ago should have evolved by now; three weeks is a long time.

There is no more international travel, which was an essential condition for testing samples as per ICMR guidelines. People without these, but having mild symptoms, might not be getting tested at all. So to really understand and say community transmission is there or not, we need extensive testing.

We accept that the testing might not be as aggressive as was done in countries like Singapore and South Korea due to whatever reasons. Till we test all symptomatic people and symptomatic contacts of positive cases, we will not know the real picture. Until then, we will not be able to comment on or rule out or confirm community transmission.

The general belief among those in the medical community is that the testing might not have been that extensive for whatever reasons, which is understandable. But I think the testing strategy has to evolve more. ICMR has to widen the scope of testing. It has to include more people even those with symptoms of respiratory illness at this point in time.

There are a lot of inputs around the amount of testing India has done and many experts are justifying the current status of testing the country has adopted given the size of population and the available resources. How do we understand this?

There are always multiple ends to an argument. If you look at it, not just from a scientific viewpoint, but also from a common sense viewpoint— what we need to understand is we are in a stage of transmission which is very similar to what has happened in the USA and Italy. A lot of cases in India are milder cases. Very few cases are critical. Therefore, this is the right time to test more.

If we identify those milder cases, isolate them and quarantine all their contacts who may or may not be sick, you might block community transmission at an early stage. If we have a sudden increase in the number of cases and your number of testing kits are the same, how many will we test?

When we miss the bus where we can test when the symptoms are mild, the strategy will fall flat because we are holding it for later. I think testing must be done when the opportunity is there, which is at present. This is the most opportune moment since we have locked the country down. So it gives a good opportunity for authorities to actively seek people, identify their contacts and keep them all isolated or quarantined. The chain of community transmission can be reduced by this, if not blocked completely.

While it has been globally accepted that the incubation period for SARS-nCoV2 is 0 to 14 days, there was a patient who was tested positive recently after 19 days. Do you think this changes a lot of things?

I think we should not go by the belief that the incubation period is 0-14 days. The experience we have right now is based on whatever we are learning from other countries. The average incubation period is 5-7 days. The longest of the incubation period recorded in a few cases is 14 days. But there have been exceptions where it has gone up to 21 or even 28 days.

I think it is safe to presume that even at 28 days, transmission can happen. A 14 day- quarantine is safe if the authorities are able to rigorously keep track of people and their symptoms. It is not just sending selfies when they are in quarantine. It is also about monitoring their symptoms on a daily basis.

People in quarantine are generally asymptomatic and might turn out to be positive or negative for COVID-19. But if a person is symptomatic, you have to presume they are positive unless otherwise proven. We have to isolate him to prevent the spread of infection. For a person in quarantine, we won't know when he will develop symptoms. For that reason, if we cannot actively monitor him daily, then it is better to quarantine them for 28 days.

A quarantine of 28 days might not necessarily match the incubation period, but at this point, it is keeping in mind the safety of others around them. Is it too cautious, aggressive to extend the quarantine period to 28 days? Yes. Is it necessary? I would say so.

How do you think a country like India can manage a pandemic of this scale?

I think there are three levels of management we can think of at this moment. First is at a personal level, which is to be exercised by the people themselves. People should realise that this is something we as a society have not faced before. Hence simple steps matter. Maintain social distancing upto six feet between each other. If you are symptomatic, please wear a mask or a cloth over your face. Do not cough in public, follow cough etiquette, etc. Follow guidelines.

At a government level, it has to check if people are able to follow the instructions properly. It has to see how well they can apply the lockdown without affecting the economy much. There are issues about the economy, feeding the poor, taking care of salaries etc. It is a tough job for the government, I agree. But I think at no point should the government become lax and the lockdown be removed for a longer duration until we are sure that the community transmission is coming down.

The third is at a healthcare level. Now, nobody in the world is sure of the exact mode of managing this pandemic. What we know is people evolve through a stage of symptoms which start off mild and then become severe. Some people become worse, many get better too. We have understood this part of it. We don't know what medications work and there are a lot of studies and trials going on around it. Fortunately, the lockdown has given us time to prepare ourselves. Every hospital must designate centres which will manage people who are suspected of and positive for this disease. We need to have a plan. We cannot wait for the cases to come in and then start managing. Because it snowballs soon and the healthcare system will collapse if it is overburdened. Plan beforehand.

Healthcare system has to be vigilant, the government has to be vigilant and then people have to be responsible. I think we can control it to a great extent if this is all in place.

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