Confusion, Mismanagement As Delhi Revises COVID-19 Testing Policy
The new order will significantly restrict COVID-19 testing in Delhi, at a time when cases continue to surge.
On Tuesday, 2 June, even as Delhi reported 1,298 new COVID-19 cases in a single day, the state government issued a quiet order that would severely restrict testing of suspected patients. Between 2 and 3 June, the number of cumulative tests in Delhi remained unchanged (2,23,607).
To be specific, asymptomatic people would not be eligible for COVID testing in Delhi any more, except ‘direct and high-risk contacts with comorbidities (diabetes, hypertension, cancer patients) and senior citizens’. The order had tweaked the testing strategy notice issued by the Indian Council of Medical Research on 18 May in a seemingly tiny (yet massive) way: by removing the term ‘asymptomatic’ (figure 1) and adding the particular conditions instead.
ICMR: Asymptomatic direct and high-risk contacts of a confirmed case to be tested.
Delhi: Direct and high-risk contacts with comorbidities (diabetes, hypertension, cancer patients) and senior citizens to be tested.
Unsurprisingly, the order mentioned no reason or explanation for the change. It is worth noting here, however, that Delhi Health Minister Satendra Jain, while responding to a question on the discrepancies between the bed availability on the Delhi Corona-App and the actual number of vacant beds, had said that asymptomatic positive patients had been ‘window shopping’ for hospitals and occupying the much-needed facilities meant for more serious patients.
Chief Minister Arvind Kejriwal, in a digital address on 6 June, expressed that the government’s priority is to save lives. “If out of panic, every asymptomatic person keeps rushing to get tested, our system will collapse. We have sufficient labs and infrastructure, but if 1,000 people walk in for testing daily, our system won’t be able to handle and more serious patients would be denied the care they need. Asymptomatic and mild patients will be fine, but symptomatic people need treatment. It must be known that Delhi’s testing number is one of the highest in the country.”
But the irony of limiting tests as the number of deaths and cases rise daily in one of the hardest-hit states in the country is baffling, and its implications for the containment of the disease are huge. FIT speaks to doctors to understand how.
‘This Could be Disastrous’, Say Experts
A quick lesson on the basics of the disease will be enough to point towards the absurdity of the decision.
- Around 80% of COVID-19 patients show mild or no symptoms of the disease, while still being carriers of the virus.
- Even asymptomatic close contacts of a confirmed case, who would automatically be at a very high risk of being infected, are excluded from the testing criteria.
- This means that the revised policy would essentially not cover at least 80% of infected individuals; who would remain unaware of their status, thereby setting in motion a spiralling chain of transmission.
- With the lockdown opening, this spread is only expected to escalate.
Naturally, this will lead to further spread of the disease and overburdening of the healthcare systems, causing more loss of life. So how does not testing people who could (by a very high likelihood) be carriers of the disease, make any sense?
Dr Shahid Jameel, a leading virologist and CEO of DBT/Wellcome Trust India Alliance, tells FIT, “This whole policy is crazy. Restricting the gathering of data can never be a good thing. If you can’t measure it, you can’t know the scale of the problem, and you can’t work towards solutions to make it better.”
“Delhi had been doing fairly well in its testing. Now suddenly, such a policy revision is strange. My fear is that this decision is guided by the fact that the number of cases is increasing, making the authorities politically uncomfortable. It really confirms my fears that the pandemic is being driven more by political interests rather than public health. But politics should have nothing to do with the outbreak.”Dr Shahid Jameel
“The problem is that no reason accompanied the order. The government just gave out the notice without explaining why it felt the need for this change. There’s no coordinated strategy or clarity,” he adds.
But even if the intent of the government is to paint a merry picture by showing fewer cases, a deeper look into the numbers could actually prove to be counter-productive. Dr Sumit Ray, critical care specialist in Delhi, explains how.
“If there are more number of people who are being tested, the case fatality ratio, or the proportion of deaths to the total cases, is expected to be low. That would give the people a greater sense of assurance. If the number of tests (denominator) decreases, then the case fatality rate will go up.”Dr Sumit Ray
Look at Tamil Nadu, for instance. Even though its testing number is much more, the death rate in the state is not surging (under 1%). On the surface, the high number of cases may look worrying, but when you dig deeper, you realise that most people have mild symptoms and only a few may succumb to the disease. That is reassuring, he says.
Is Scarcity Driving the Change?
But again, why the government changed the policy remains unclear. The Chief Minister’s latest address is indicative of an approach to streamline resources. A doctor from a government hospital in Delhi told FIT, the revised guidelines could be justified if feasibility or scarcity of resources is the concern; in terms of money, availability of tests and beds. “We cannot directly assume that the intentions of the government are bad. Maybe because the numbers are exponentially rising, there is a need to streamline resources to those who may need it more. A single RT-PCR test result takes 30 hours to come. This can lead to a backlog and affect those who feel sick and need urgent treatment. So capacity and practicality need to be considered.”
“Undoubtedly, testing asymptomatic patients is important. But this has to depend on the availability of the resources. If we can test asymptomatic people without compromising the testing or treatment of symptomatic people, only then should we carry on with expanded testing. But if we have limited resources, we need to choose.”Doctor at Government Hospital in Delhi
But this doesn’t mean that in the absence of testing, asymptomatic individuals do not follow the precautions. “The only way to contain the spread is for everybody to maintain social distancing and take preventive measures. Consider every person as a potential source of infection.”
“Nevertheless, it would have been better if the government had clearly mentioned the reason, supported by data, for why it decided to restrict testing. It is very important at this point to maintain transparency in communication. There may be limitations on their part, maybe. But ideally, transparency should be maintained.”Doctor at Government Hospital in Delhi
What Happens to Contact Tracing?
Responding to the new policy, Dr KK Aggarwal, president of the Confederation of Medical Association of Asia and Oceania (CMAAO), has been quoted as saying that excluding asymptomatic people does not make sense. "First of all, if you'll not test them, they would continue to move freely as a spreader or potential carrier. If they are young and their immunity is strong, they may recover quickly, but what happens to people with co-morbidity or old age who may come in their contact? Secondly, the ICMR has issued a guideline which states may or may not choose to follow. It is not an act or binding law. But the states are choosing to reduce the testing as it suits them," he said.
If such a policy is, indeed, implemented, then it needs to be supplemented with further instructions to ensure the problem isn’t aggravated. Dr Vikas Maurya, Director & Head, Dept. of Pulmonology & Sleep Disorders at Fortis Hospital, Shalimar Bagh, tells FIT,
“We are expecting the government to issue some clarifications in the coming days. There are a lot of gaps in this order. If we don’t test asymptomatic people, what happens to contact tracing? It needs to be mandated that even if they can’t be tested, asymptomatic contacts of positive patients must be traced and isolated. There needs to be such a supplementary policy to make sure they don’t become spreaders. They must be quarantined and isolated, and if they do end up developing symptoms, we can go ahead and test them.”Dr Vikas Maurya
“Things are not so clear yet. We expect some new information from the government soon. Everybody’s waiting for more clarification.”
How This Will Affect Non-COVID Services
Moreover, the impact of such a restricted testing strategy would extend beyond just COVID-19 patients. People requiring other healthcare services are also often required to get tested for COVID. The new policy would exclude them if they do not have symptoms, indelibly obstructing their access to treatment for other complications.
Dr Maurya says, “It needs to be assured that surgeries, deliveries and other treatments are not hindered if a person is not able to get tested.”
“What this also means is that for these non-COVID procedures, the doctors need to be provided with PPEs and full COVID suits, as they would not know if a patient is infected. So if such a policy is instituted, a lot of other things will have to be worked out, including the PPE supply for all treatment procedures.”Dr Vikas Maurya
The implications run way beyond what appears at the surface. As FIT had earlier reported, COVID-19 patients are at a higher risk of dying if they undergo any surgery - minor or elective. Dr Sumit Ray explains that even though emergency surgeries cannot be denied regardless of a person’s COVID status, certain semi-urgent procedures can be postponed to mitigate any complications.
Now if surgeries are, in fact, performed without knowing the COVID status of an individual, wouldn’t that put an infected person at a higher risk of fatal complications?
The questions are endless, but so far, we have no answers. In the last few days, with reports of people being denied the very basic facilities, of hospitals refusing to admit extremely sick patients, of even symptomatic patients struggling to get tested, and of residents of Delhi losing their loved ones to gross negligence - the Delhi government’s mismanagement of the pandemic has come under the spotlight. And the new testing policy has only added to concerns of its mishandling of a consistently-worsening public health crisis.
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