Kerala should liberalise testing, say experts as daily sample collection drops

Public health experts TNM spoke to say that Kerala must widen its testing criteria if it wants to stop community transmission of coronavirus.
Kerala should liberalise testing, say experts as daily sample collection drops
Kerala should liberalise testing, say experts as daily sample collection drops
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Kerala breathed a collective sigh of relief, two days in a row, after the state reported no new cases of coronavirus. As on March 19, Kerala has 27 positive cases, a figure that hasn't changed since Monday evening. But several health experts have raised questions if the lack of detection of new cases has to do with Kerala’s revised testing guidelines.

On March 12, the Kerala government issued new guidelines for testing and treatment of COVID-19 patients. The Kerala Health Department’s fresh guidelines not only differ from the Centre’s prescribed testing criteria, but also further narrow it down. 

The Union Health Ministry’s guidelines state that anyone who has international travel history and symptoms of COVID-19 (fever, cough and breathing difficulty) or exhibits these symptoms after coming into contact with a confirmed coronavirus patient can be tested. However, Kerala has now chosen to limit its testing to only those who have severe symptoms of the coronavirus and travel history or contact with a confirmed case. “Patients with mild symptoms are advised not to come to hospital for testing and treatment. Testing is not going to change the clinical course or management of the patient with symptoms,” reads Kerala’s revised guidelines.  

Kerala is not ‘defying’ the Union government’s testing guidelines, explains Dr Jacob John, who formerly headed Indian Council for Medical Research’s (ICMR) Centre for Advanced Research and emeritus professor at Christian Medical College (CMC), Vellore. “The Epidemic Diseases Act gives states certain freedoms. But each state should not make its own policy and everyone should follow the national guidelines,” says the virologist.  

Another public health expert, T Sundararaman, who is a former director of the National Health Systems Resource Centre, also points out that national testing guidelines set by ICMR (which is taken up by the Centre) should be the norm across states. “States can come up with an alternate policy if they have strong reasons to do so,” he says.   

The state currently has four testing centres including the National Institute of Virology’s field unit in Alappuzha. Dr Jacob John says, “Kerala has the advantage of having the NIV’s Alappuzha field unit and is able to do more test samples than other states, with the exception of Delhi and Maharashtra. Kerala should be liberalising or widening testing because only then you will know what is happening.” 

Noting that the even the national policy limits testing to only those with international travel history, Dr Jacob John says, “You cannot identify community transmission if the national policy ties down testing to foreign introduction. Any new onset of symptoms such as fatigue, fever and cough should be tested. Not testing persons is an age-old game India has played. If a person tests positive, you are going to put them in isolation. You can slow down the spread, you are buying time for everyone.” 

Sundararaman also calls the testing guidelines - both by the Centre and Kerala - ‘inadequate’. “I think people who are sick and sick enough to require hospitalisation, all should be tested. Kerala needs to monitor whether community transmission is happening. And for that you need to test on scale,” he notes.  

The public health expert further says, “There must be a sentinel size, where all people are tested so you can pick up early enough All severe cases must be tested. It can’t be arbitrary. We must have a certain database. There must be a sampling plan and design. These are minimum requirements.” 

So, have the number of testing samples reduced in Kerala since the March 12 guidelines?  

TNM analysed data provided by the Kerala government between March 9 and March 18. There has been a gradual reduction in the number of daily samples being tested for coronavirus, after the revised guidelines were issued on March 12.   

On March 9, Kerala had collected a total of 807 samples. At the time only the National Institute of Virology was testing samples in the state. Kerala had then recorded six positive cases. Over the course of the next two days, Kerala collected 173 samples on March 10, and 199 samples on March 11. By this time, Kerala had four centres testing samples. However, on March 12, the guidelines were revised to limit the criteria for testing. 

The daily collection of samples peaked to a high of 338 on March 13, before it began to gradually decrease over the next few days, going down to 250 daily samples on March 15, and 170 on March 17. 

As on March 18, Kerala had collected a total of 2550 samples, but the state managed to add only 83 more samples from the previous day. 

And although Kerala may have reduced its daily testing, health officials have at the same time ramped up its surveillance since the new guidelines came into effect. Data provided by the Health Department show that the number of persons under observation have increased by a whopping 2194%.  On March 9, Kerala had 1116 persons under surveillance, out of which 149 people were in designated isolation facilities. That number has massively jumped to a total of 25,603 persons in home quarantine and in isolation across the state on March 18. Significantly, those placed in isolation in designated facilities have seen a slight dip since March 12. This may be on account of the policy to test and treat only those who have severe symptoms of COVID-19.

Given that the Centre controls the supply of testing kits, Kerala may have chosen to limit its samples, fearing a shortage of supply.. States like Chhattisgarh had expressed concern that the Centre would not be able to supply kits if it widened its testing sample. However, Dr John points to a lack of planning on the part of authorities for any limited supply of testing kits. He says, “Any lab that can synthesize RNA or DNA synthesis, can make their own kits. But who is responsible for quality? We had time from February 1 to sort this all out.” 


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