How ICMR’s COVID-19 Testing Strategy Compromised India’s Fight Against Pandemic

On March 26, Lav Agarwal, Joint Secretary, Union Health Ministry, had asserted: “We can consider we are in community transmission stage only when there are about 20 to 30% cases with no clue on how they got the virus". He then added, "If India enters that stage, we will not hide it.”

On March 30, Agarwal again said that the country was currently in "local transmission and limited community transmission phase. If we use the word 'community' then there is speculation. Kindly allow us to use the word community but not in the context you have interpreted.” 

Is Agarwal’s claim correct? What exactly is community transmission, and why is it so crucial in the fight against the pandemic? Moreover, what makes it such a contentious matter that questions are constantly raised about official claims in the media?

According to the Indian Council of Medical Research (CMR), the apex health research body of India and the nodal authority tasked with testing patients for COVID-19 in India, there are four stages to its spread: Stage 1 is of ‘imported cases’ (first carriers of the virus entering a country), Stage 2 is ‘local transmission’ (people infected locally through contact with the first group), Stage 3 is ‘community transmission’ (when those with no known contact with the first two groups test positive), followed by Stage 4, when infections peak to form a full-blown outbreak, such as in Italy.

While every stage is crucial, community transmission, or Stage 3, is especially so from the government’s perspective; because it represents the phase where infections balloon out of control. It’s imperative to do extensive testing early enough, so that the maximum number of cases are identified and isolated quickly. The detection of community transmission is also crucial in determining when – or whether – to opt for harsh measures, such as lockdowns.

The timeline of ICMR’s testing strategy is as follows:

*Initially, tests were restricted to symptomatic individuals with an international travel history, and anyone who had come into contact with a confirmed positive case.

*On March 17, healthcare workers managing respiratory illness were included in the list of those who could be tested, if they had developed symptoms.

* On March 20, all hospitalised patients with Severe Acute Respiratory Illness, as well as all asymptomatic direct and high-risk contacts of a confirmed case, were added to the list.

*In addition to testing for the selected groups above, the ICMR had initiated ‘sentinel surveillance’, or random testing of persons suffering from severe respiratory or flu-like illnesses, conducted exclusively to detect community transmission. On March 21, ICMR issued an order allowing accredited private labs to test for symptomatic cases, under the guidance of a physician.

Given that that it controls provision of testing kits, and the tests themselves are conducted exclusively in its accredited labs, in strict adherence to its guidelines, the ICMR is fully in control of the COVID-19 testing process in India. What this means is that despite health being a state subject, state health departments are entirely reliant on ICMR when it comes to COVID-19 testing.

Disturbing Questions

The ICMR’s testing strategy is highly restrictive; and limited to those groups mentioned in its testing advisory (and listed above). While these restrictions have been steadily relaxed to include new groups, what is striking is that until March 16, only imported cases and their contacts could be tested for COVID-19 in India. In fact, media reports show that patients with symptoms similar to COVID-19 were refused testing in several Delhi hospitals because they did not have travel history or known contact with a confirmed case. The doctors they approached had cited ICMR guidelines to refuse the tests.

Until March 20, the only groups that ICMR allowed to be tested in India, were those that fall under Stages 1 and 2 – imported cases and their contacts. In other words, during the entire period the ICMR was denying community transmission in India, the agency’s own testing guidelines prohibited any potential case of community transmission from being tested.

Commentators have already described India’s national lockdown as the harshest in the world, beating even that of ‘authoritarian’ China. A chorus of concerned voices, from public health experts such as Vikram Patel of Harvard Medical School to former Reserve Bank of India governor Raghuram Rajan, have questioned the effectiveness of this draconian national lockdown in controlling the spread of the epidemic, and highlighted its potentially catastrophic impact on the poor.

The supposed merits of the lockdown apart, it’s worth noting that the chief purpose of a lockdown is to prevent – or at least, stagger - community transmission (Stage 3). A lockdown imposed too early (in Stage 1 or 2) imposes unnecessary hardships on people at a time when narrowly focused actions, such as screening and contact tracing, are far more effective in preventing the epidemic’s spread. A lockdown imposed too late is a lot worse; it confines people to their homes and neighbourhoods at a time when the epidemic has already spread into the community.  

The single most important factor that determines when to impose as serious a measure as a lockdown is testing, the only sure means to detect early signs of community transmission. We now know that ICMR’s testing strategy was designed precisely to not detect community transmission until very recently, even as the agency continues to assert that community transmission has not occurred in India. Since ICMR was not testing for community transmission until days before the lockdown was imposed on March 24, and continued to deny it has happened, this essentially suggests that the decision to impose a lockdown on India was an irrational and arbitrary, lacking in any scientific basis.

Even more shockingly, since this led to hospitals turning away patients with COVID-19-like symptoms, the ICMR’s testing strategy has quite likely increased the epidemic’s spread in India. It would be impossible to determine how many potential COVID-19 cases have been refused tests in hospitals across India from January 31, when the first confirmed positive cases were detected in the country. But we can be sure that in the absence of testing, isolation and quarantine, each of those patients are likely to have infected countless others in their families and communities.

The consequences are unimaginable.

Designed not to detect?

The only other basis of ICMR’s denial of community transmission comes from the results of its sentinel surveillance programme. As of March 19, only 826 samples were tested under this, none of which were positive. However, many unanswered questions surround this programme, starting with its minuscule sample size, virtually meaningless for a country like India, with its 130 crore population.

Also, sentinel surveillance was initiated on February 15, and by the end of that month, tests were being conducted in 16 designated Viral Research and Diagnostic Laboratories (VRDL) that are part of ICMR’s network. By March 15, the number of labs conducting sentinel surveillance had expanded to 51.

Several questions arise: How many samples were collected in February, when potential cases can be reasonably assumed to have been sparse, as the incubation period for those infected by COVID-19 to show symptoms may be as much as two weeks? Recall that India had recorded only three confirmed cases of COVID-19 in February, and all three were detected in Kerala.

This brings up a related question: what locations were the samples for sentinel surveillance collected from? Here, it should be noted that contrary to the ‘national’ spin it has been given by ICMR and the Health Ministry, community transmission is a local phenomenon by definition. For example, the US recently confirmed the first instance of community transmission of COVID-19, based on a single case in California.

What of Agarwal’s claim that community transmission requires 20-30% of positive cases to have no known contact with either imported cases or their contacts? What is the basis for such a claim? In fact, if this is indeed the Health Ministry’s yardstick for confirming community transmission in India, a few thousand – if not lakhs – of Indians will be infected, before it is met.

The ICMR’s testing strategy is rather opaque, especially when it comes to the details of its testing criteria and the means by which they were arrived at. This makes it impossible to independently verify the effectiveness of its methods, or the very efficacy of its design beyond a point – a grave matter, which has been pointed out by journalists covering the COVID-19 pandemic in India.

Community transmission is here, and now

To understand just how irresponsibly India’s apex medical research body and their masters in the Health Ministry have handled this unprecedented crisis, and specifically the crucial matter of community transmission, we must go back to March 5. In a media release issued that day, the Ministry acknowledged that cases of community transmission have indeed been observed in India, and had even asked states to form rapid response teams to counter it.

However, on March 12, quite inexplicably, it went back on this statement, dismissing the cases as instances of ‘local transmission’. Since the Ministry did not reveal any details, we don’t how the cases were detected or where. But, we do know that officially, at least, there was very little basis for it to make such a claim; it was simply not testing for it. Or, at the very least, not enough.

However, as the number of cases (1,251) climbs sharply and COVID-19 induced deaths (32) increase, the Ministry may not be able to keep up its act for much longer. On March 24, a highly placed official broke ranks with the establishment to reveal that India had indeed entered Stage 3 (community transmission).

Girdhar Gyani, convenor, COVID-19 Hospital Task Force, told The Quint, “We are calling it Stage 3. Officially, we may not call it [that]. It is the beginning of the 3rd stage.”

Gyani, who had attended a meeting of prominent doctors and healthcare providers chaired by Prime Minister Narendra Modi on March 24, went on to make an even more startling admission. He said that doctors have been turning away patients with COVID-19-like symptoms because “the government does not have enough testing kits.”

These revelations only confirm the fears aired repeatedly by independent voices asserting that community transmission was very much here. These include Dr. Gagandeep Kang, executive director of the Translational Health Science and Technology Institute, Dr. Arvind Kumar of Sir Ganga Ram Hospital, New Delhi, and Dr. Ramanan Laxminarayan, director of the US-based Centre for Disease Dynamics, Economics and Policy and advisor to the World Health Organisation or WHO and the Indian government . Notably, the latter two have even gone to the extent of saying community transmission has occurred in India at least a month ago.

The implications are enormous; starting with the fact that the numbers all of India have been glued to these past few weeks, and which had determined how seriously the public had taken the threat of the pandemic; may have been utterly worthless. And that may very well have been the point; the truly strategic aspect of ICMR’s ‘testing strategy’ may have been political.

Heavy price to pay

The arbitrary definitions, skewed testing criteria and numerical acrobatics that define ICMR’s COVID-19 ‘testing strategy’ bring to mind the saying: "There are three kinds of lies: lies, damned lies, and statistics." It is ICMR’s ‘designed not to detect’ testing strategy that has allowed the Union Health Ministry to keep the number of confirmed COVID-19 cases in India anomalously low, and to deny the presence of community transmission. It has fed the illusion that India was the big exception to the global pandemic that has ravaged almost every other major country.

Since ICMR directly reports to the Health Ministry, the ultimate blame must lie with the Central government, which has compromised India’s all-too-crucial strategy to fight COVID-19 to suit its own political goals. But, the price for this may be considerably more deadly than we can imagine.

The writer is a freelance journalist. The views are personal.