India's Low Number Of Coronavirus Cases Could Be Result Of Low Testing

NEW DELHI — India has sent over 6,700 samples for testing, placed around 42,000 people under surveillance, detected over 80 coronavirus cases and has had two deaths. The number of cases and the death toll are low for a country of 1.2 billion people, especially when compared to countries like Italy, Iran and South Korea which have far less people and far more cases. 

But experts say one reason for India’s low figures could be its narrow criteria for testing people, which the Government of India needs to broaden in order to detect how far COVID-19 has truly spread. By way of example, South Korea, which has a population of 51 million, has tested about 250,000 people since 20 January, many in drive through testing centres that have been set up especially to combat the pandemic.

In a conversation with HuffPost India, public health expert T Sundararaman, former director of the National Health Systems Resource Centre, a government body, and former dean of School of Health System Studies at the Tata Institute of Social Science (TISS), explained the trajectory of the disease, how many are at risk, and why the Indian government needs to start testing more people and soon. 

“This is the beginning of the pandemic. Once the community spread starts in India, it will go up substantially,” said Sundararaman. “Is the community spread already happening? We can’t be sure.”

Edited excerpts

Where are we at right now?

We have been lucky so far. The measures of containment that the government has started have been reasonably good. To that extent, as you can see, we are very low in the total number of cases. Now that may not remain the situation. That is the main thing. This is the beginning of the pandemic . Once the community spread starts in India, it will go up substantially. Is the community spread already happening? We can’t be sure.

Why can’t we be sure?

Of all the countries, we have tested the lowest amount. We have tested a total of some 6,000 to 7,000 samples. Whereas South Korea, which has less people than Tamil Nadu, has tested 250,000. There is a huge difference in the amounts we are testing. 

Why is that?

We are sort of claiming — we have not officially said so — that there is no community spread because most of the cases are only from contact and imported cases. People who have been abroad or people who have contacted people who have returned from abroad. If you see the criteria that the government has put for testing, they have put a criteria that more or less makes it mandatory to test only these people. So anyone walking in with common cold like symptoms or viral fever, asking to be tested, will not get tested. As a result, it’s a self fulfilling prophecy. You are actually not being able to detect whether community spread is happening or not. There is no reason why India will not have community spread. 

What is the criteria for testing presently?

The criteria for testing is that you have some of the typical symptoms plus you’ve either returned from a foreign country or you have been in contact with a person from a foreign country or somebody with the coronavirus.

Why did we limit the criteria?

This is also a time of seasonal flu. There will be a few million people with what we call viral fever and we have no capacity to test all the fevers that turn up at our door. We have only established 52 (testing) labs of which only half are possibly functional. Maybe a bit more now. Fifty two labs spread across India is not a great deal. 

If you look at it internationally, there are so many VIPs who have got the disease. So many ministers, Tom Hanks and his wife, it does not disproportionately select celebrities — simply put, you are testing all of them and they are getting themselves tested. The critical bit is a much higher level of testing, which is not really happening here. And I think at some point we need to do it. 

Given how many we are — and so many of us may have the seasonal flu — the government’s limits seem reasonable. 

The government needs to expand to 600 (testing) centres or so. You should have one testing centre in every district. At some point, you will need that. That’s the first thing. 

The second is that this is true that you can’t actually test every fever. But any fever with respiratory systems suggestive of early pneumonia, shortness of breath, should be tested. You should not wait for a contact relationship. You should be offering the test much more widely now. A much wider testing would have helped us establish community spread early and mark certain places for social distancing. But once community spread is established, your ability to actually limit that spread is somewhat limited.Some extent of social distancing will help. It will slow down the pandemic . The pandemic  is not likely to go away but it is likely to flatten the curve. 

Are 600 centres enough? Do we have the manpower with the proper training to fill them?

This does not require much training. This is done as the same model as many Rapid Diagnostic Tests. You have district hospital laboratories that generally have the ability to do these tests. The problem they are saying is the virus itself is very infective. You have to be very careful in handling the sample. That is a problem. 

You do need to ensure that your district hospitals have the capacity to do that. A district in India is a very large place. Some districts are larger than many countries. The largest districts will have 50 to 60 lakh people. So just to have one known centre testing there is just not enough. They do need to develop those capacities. 

If we say that the peak is likely and it will come later — even if only one percent require ventilators —  you are going to require an awful amount of ventilators and respiratory emergency management. For every 10 lakh population, you will need to have an ICU center with ventilator capacity. 

Where are we right now in terms of handling a coronavirus outbreak ?

A lot of our medical colleges will be equipped to deal with this. But our district hospitals — except in some southern states and some of the more developed states — many district hospitals are not. Even if they are, and have a ventilator, they are very tightly equipped. The whole thing is on a very minimalist design. You always said let’s keep the Public Sector to the minimum and leave the rest to the Private Sector. But actually the Public Sector should have redundant unused capacity. There should be some slack in it. Whenever there is an emergency or disaster, the Public Sector should be able to expand and take on the extra load.  

How bad could it get? Could you explain in figures. 

Even if community transmission is established — that may be the case even now — we don’t know because we are restricting our testing to international travel. As it goes on — in the coming two months — the spread will be low, but it will start again in July.

In July?

The usual seasonal flu pattern has one peak now and one large peak happens later. In India, it’s especially in the later part of the monsoons.

What are the figures like?

If we look at the proportion of infection — we have figures of mortality, we have figures of what proportion in China have been infected. There is a study that shows that it seems to be infecting older people more  — even if they are not elderly — that means they are 30, 40, 50 — below 20 and 30 it drops off. Now the proportion of population of the people who are above this particular age group is 40% to 50%. And if we say one-third to half of them are infected, you may have, at its peak, 30% to 40% of the population at risk for infection. But the good news is that more than 95 percent of them won’t be critical. The proportion requiring ICUs and ventilation may be lesser. But that is still a huge amount for India. 

Why will only a small percent be critical?

This is the nature of this viral disease and many such viral diseases. You’ve had viral fever? That’s the flu. All of us have had. Most of us recover. It takes two days, three days, seven days, and you recover. It’s as simple as that. You have a fever, you lie down, you take rest, you take warm water and you recover. That is what will happen to most people. 

How many people will be infected — in figures, please. 

Let me give you an estimate. It is better to express in a district of two million population. About one million would be above the age of 30, and if half of them are infected that would be about five lakh — three lakh to five lakh — would get infected. And one percent of them would be 3,000. But those 3,000 people coming to a district hospital for hospitalisation is a problem. You are hoping that you won’t get into those numbers. Even this number of severe cases could be lowered considerably if effective mitigation measure are in place. 

The 80 percent who get infected but don’t get serious get immune to the disease. Soon the majority of the population develops herd immunity. This herd immunity is because they have gone through subclinical infection. Soon there are so many immune people, the disease cannot spread like before. After some time, the disease dies out. 

Do we have the facilities to handle the people who will need hospitalisation?

No, we don’t have. But this is the worst case scenario. Let’s hope it doesn’t come to that. But we do need district hospitals. Although this is a disproportionately small number of people — coming at a given time — this is a huge surge. You are anticipating a surge that will overwhelm your system. 

Should we not be doing more?

Correct. I hope we are doing more but I have not heard enough about what we are doing at the district hospital level. 

The time to be prepared is now?

I think we have two to three months to prepare for it. I think we are hoping for a better outcome, but we should do more than hope for it. Sooner or later, that’s not going to work.

You are saying two things: first, we should expand detection and second, we should prepare for the worst case scenario. 

Correct. We need to be doing much wider testing for case detection so we can have a more intelligent approach to social distancing instead of a general ban on where you can go. And we need to combine it with preparation.

How helpful is social distancing?

Social distancing is going on, a bit unrealistically I must say. For the poor, the economic catastrophe is going to be worse than the health catastrophe. The loss of livelihood, the hit on livelihood, is going to be worse than the health catastrophe. At some point, we should not go so overboard with it that we forget that if livelihoods are seriously damaged, they will die of other things.

How are you going to tell a woman who sells flowers or a vegetable vendor to stay at home? What will they eat? Every day they have to do their particular thing. Many people will need to work. For a slight illness, who stops going to work? Those people can be infected and spreading disease. Some of this rather gratuitous advice is alright for an upper middle class style of living where you have the means to achieve some of this. People who are living precariously on the brink will be pushed off. If the restaurants shut down. If tourism shuts down. If the handicraft trade shuts down then what will people eat. You can’t destroy the economy. What you need to do is wider testing.

We are trying to stop the virus spreading to rural areas. Does that make sense?

One of the reasons the spread will happen is that many people before developing fever are already spreading the virus. And there are cases that one can be infected but doesn’t develop frank symptoms, or has mild symptoms, but who can also spread the disease. A community spread is when you can identify a case who cannot say from whom he has got the disease. 

So this man who had visited Saudi Arabia and came back. Saudi Arabia was not one of our proscribed nations. He didn’t know there was an outbreak there. He came in and did not have a fever. He developed a fever six days later. Then he died. By then, he had been across so many places. For the one person who died, we know. But for all the other people who came along with him, but who did not die, we don’t know. We haven’t tested them. 

Do we have enough safety gear for our health workers?

We will actually have to increase it far far more. Right now, in many states, they don’t have enough gloves for the routine procedures in the labour room etcetera. We have been designed as a minimalist system. And here we have a maximal problem. 

This is something we should be doing now?

Yes. The district hospital should have an ICU, it should be able to do blood transfusion and oxygen supply. These are all minimum requirements. The southern states are reasonably prepared in these terms. But eventually they will get overwhelmed. If you go into UP, Bihar, Jharkhand, you may not find this (minimum requirements) at all.  They may have a couple of ventilators, but in use and in readiness to be able to expand, it will be much more difficult.

Are we looking at a meltdown?

The government has time. The virus is at the door. It has really not made its entry in a really big way — it may have made an entry but it hasn’t had an impact. If you can anticipate and prepare for the worst case scenario, then you should.

If it is business as usual, are we looking at an apocalyptic situation?

Really, no. Pandemics burn out. But it could cost huge numbers. But over a time herd immunity develops. It passes a peak and then it starts improving. We have seen that in China. It’s not just the containment that has helped. It is also the herd immunity. All those who had to get infected have got infected. The peak has crossed. But the cost will be a substantial increase in mortality over the baseline. 

That seems like a doomsday scenario. What is worse than lots of people dying.

No. There is a doomsday scenario when the recovery rate is poor. For example, SARS (Severe Acute Respiratory Syndrome) or MERS (Middle East Respiratory Syndrome) — MERS has something like 30% to 40% mortality. There are other diseases with a very high mortality rate. The one percent mortality that is preventable should be prevented. 

(Editor’s note: In response to the question how many people will be infected — in figures —an earlier version of the answer said that half of one million is 50 lakhs. It is five lakhs and the one percent infected would be 3,000 to 5,000. The error is regretted).

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