It’s been two weeks since the Indian Council for Medical Research (ICMR) changed the testing strategy for COVID-19. The May 18 advisory narrowed testing to nine categories. Among the key changes is that asymptomatic pregnant women, who were mandatorily tested for COVID-19 five days before delivery if they were from a cluster or containment area, now no longer need to be tested. Only pregnant women who display symptoms of Influenza like illness — acute respiratory infection, fever and cough — need testing.
While ICMR has not offered any explanation for its May 18 change in testing strategy, with a large percentage of COVID-19 patients being asymptomatic in Tamil Nadu (98% in Chennai as per some estimates), the move by the apex body for medical research has drawn flak from practitioners and others.
Dr K Kolandaswamy, former Tamil Nadu Director of Public Health (DPH), insists that pregnant women be tested, irrespective of whether they display symptoms or not. “Doctors and other caregivers who are handling pregnant women will feel more confident. The care will be better,” argues Dr Kolandaswamy. Given that the virus is highly transmittable, the former DPH also notes, “There are pregnant women who are high-risk — they may have hypertension and diabetes. If you test a pregnant woman and she tests positive, you can isolate them and not put others at risk if they are in the same ward. It is beneficial to other high risk mothers who are admitted in general wards.”
So, how are doctors dealing with the change in testing strategy?
A doctor at a government hospital in Chennai says that health officials had earlier directed them to create a separate ward for COVID-19 patients and non-COVID-19 patients. A separate theatre was also spared to perform C-sections at the government hospital, she says.
“Positive patients were isolated. They were then treated separately. Now we don’t know. Because we are asked to treat only the symptomatic people,” says the doctor, who adds that they are still trying to screen as many patients as possible.
The government doctor points out that the hospital has been seeing a steady increase in the number of pregnant women who have tested positive for the coronavirus. “We have treated 75 COVID-19 patients, maybe 35 delivered. Around 15-20 are yet to deliver. Last week, we had one case per day. This week three to four per day. More and more cases are coming. Last month, it was one per week,” she says.
With asymptomatic patients not being tested, doctors like her are forced to treat every patient as a positive case. “We see to it that we are not in close contact with the patient. We question them, and when we are examining, we ask them not to talk cause conversation when we are very close is another problem,” she explains.
And while the full personal protective equipment (PPE) is used only at the time of delivering positive patients, they choose to wear other gear for those who are asymptomatic given Chennai’s sweltering heat.
“Yes, it is very difficult. But what we do is we have an N95 mask and face shield and an apron type of gear. Wearing the full PPE suit is not possible in the labour ward set up. We wear a surgical apron type in the labour ward,” she says
As far as the wards are concerned the doctor says that with patient admissions restricted, beds are placed wide apart to ensure physical distance between women.
However, the obstetrician observes that visitors of patients also pose risk to both hospital staff and others. The doctor says, “One problem is, we are checking the patients but we are not checking the attenders. They come with maternity patients from containment zones. We are not able to control the attenders. So 100% we can’t say that all these patients are negative. Though they may have (COVID-19).”
As far as private hospitals are concerned, several obstetricians are still insisting that patients who are likely to deliver be tested for COVID-19 before they get admitted.
Dr Kurian Joseph, of Joseph Hospitals, a private hospital in Chennai, says, “We can’t honestly be scared of every single patient coming. So every patient, a day before they come for elective induction of labour or anything, we get the test done. It takes 24 hours. I don't know why ICMR came up with the new guideline not to test asymptomatic cases. But we have been able to bypass that. And we are still doing it for all the patients.” However, he adds, “The labs are getting a lot of flak from the government for that.”
Dr Kurian also flags another issue, where patients testing positive were only allowed to be treated in the approved list of COVID-19 hospitals in the state. “Earlier the issue was that even if they tested positive, we couldn’t take them. Now gradually, the Health Department is saying that if it is positive and they are asymptomatic, you can continue treating in your hospital.”
But beyond the risk of exposure to other patients and health professionals due to ICMR’s new strategy, Dr Kolandaswamy offers another reason to test all pregnant women who are likely to deliver soon. He says that they provide the state a good sample to test for community spread of the disease. “Pregnant women come from different backgrounds, multiple social sections, and communities. They make an excellent default sample for surveillance,” says the former DPH.
Health Minister C Vijayabaskar clarified that there is no ban on testing. He told Times of India, “We only don’t want any indiscriminate testing to allay fears in asymptomatic individuals. This may lead to abuse of kits. RT-PCR is a precious resource now. It cannot be wasted.”