PCR tubes being placed in a thermal cycler. Photo: Karl Mumm/Wikimedia Commons, CC BY-SA 3.0.
The COVID-19 pandemic is a worrying public health emergency for India. As is the case in such emergencies, both journalists and public health experts are thirsty for data about the Indian government’s efforts to contain the SARS-CoV-2 virus. Such data allows these groups to ascertain if the efforts are adequate. It also makes the non-expert citizen more confident that the government has a coherent, well-thought-out strategy in place, and encourages them to follow government advisories on interventions such as social-distancing.
Unfortunately, between the three central health agencies coordinating India’s COVID-19 responses today – the Ministry of Health, the Indian Council of Medical Research (ICMR) and the National Centre for Disease Control (NCDC) – there have been multiple instances of both miscommunication and opacity.
Here are some examples, and my experience dealing with them as a Bengaluru-based reporter.
My experiences reflect those of many other reporters, especially those based outside Delhi who don’t have physical access to officials from these agencies, and can’t ask questions at the ICMR’s and health ministry’s televised press conferences. This isn’t ideal because the practice of public health is impossible without clear communication.
Example 1: Opacity on how India is testing for community transmission
As of March 19, the ICMR has been standing ground that there is no evidence of community transmission in India. But as public health experts have been repeating for ages: “If you don’t look, you will not find.” And there are several questions about whether ICMR is looking hard enough for COVID-19 cases.
ICMR’s testing strategy, shared during its March 17 press conference and in this document, has two parts. The first part applies to people with travel history from 14 high-risk countries. These people are first quarantined, and if they develop symptoms, samples from their throat and nose are sent to one of ICMR’s network of Virus Research Diagnostic Laboratories (VRDLs) to test for the presence of the virus that causes COVID-19. At the same time, everyone who has come in contact with lab-confirmed patients is also quarantined. If any of these ‘contacts’ develop symptoms, their samples are sent to VRDLs for tests. People who don’t meet any of these criteria can’t ask to be tested for COVID-19 (again, as of March 19).
The second part of the strategy involves the so-called “community-acquired cases”, or people with no recent travel history as well as no contact with people with recent travel history.
To detect SARS-CoV-2 transmission in this group, 51 VRDL labs have begun testing 20 samples a week from patients with severe acute respiratory infections (SARI) (with the goal of testing 1,020 samples in all). According to the WHO, SARI is a term to denote instances when a patient has developed fever and cough in the last 10 days and needs to be hospitalised. On the March 17 press conference, ICMR scientist Nivedita Gupta announced that such patients are chosen after they have tested negative for other causes of SARI.
By then, ICMR had already received the results of 500 such tests – all negative. Based on this, Gupta and her colleagues said it was unlikely India was home to any community transmission. In other words, ICMR believed that COVID-19 cases in India were restricted to people who had recently travelled to nations like Italy and the UAE (i.e. deemed ‘high-risk’). On the morning of March 19, ICMR told ANI that it had received results from 326 more tests, also all negative. So it seems unlikely that ICMR has changed its stance on community transmission in India.
826 samples tested, none of them are positive so far: Indian Council of Medical Research (ICMR) to ANI on random samples tested so far to rule out community transmission of COVID-19 pic.twitter.com/sUpWjdc9I4
— ANI (@ANI) March 19, 2020
However, many public health experts have questioned the legitimacy of this stance. Among them, Gagandeep Kang, a microbiologist and executive director of Delhi’s Translational Health Science and Technology Institute, said during a web-discussion on Wednesday that the 20 samples the VRDLs were testing may not be proportionate to the number of SARI cases in the region where the VRDL is located. For example, if a region has more than a hundred SARI cases and the VRDL is randomly testing only 20 samples for COVID-19, the chances of missing an instance of COVID-19 are higher than in a hospital with 50 cases where the VRDL tests 20 samples. “I don’t know whether there is a patient denominator to go with the sample testing data,” Kang said.
In the ICMR press conference, Gupta partially answered a question about the denominator, saying some VRDLs hadn’t registered even 20 SARI hospitalisations, suggesting the sample size of 20 may be enough. However, discussions with other VRDLs suggest the number of samples each VRDL receives to test is varying widely.
For example, King George’s Medical University, Lucknow, a member of the VRDL network, has been receiving many more than 20 SARI samples each week, according to Amita Jain, head of its department of microbiology. Asked if the hospital had observed any unusual increase in the number of SARI cases, Jain said the lab typically sees such a spike with the onset of warm weather, but that is within expected seasonal patterns.
Meanwhile, Sarada Devi, the head of the microbiology department at the Government Medical College, Thiruvananthapuram – another VRDL – said they have been unable to collect even 20 samples per week.
The head of a third VRDL, located at Karnataka’s Shimoga Institute of Medical Sciences, said their lab had registered no SARI cases at all.
To understand how ICMR was accounting for this variation between VRDLs, I reached out to both Balram Bhargava, the director-general of ICMR, and Gupta but did not receive replies.
Example 2: Opacity on whether NCDC is looking for COVID-19 in its influenza-like illnesses network
It’s unclear today whether India is testing people with influenza-like illness (ILI) for COVID-19. Doing this would improve the chances that it would catch community transmission early. The WHO case definition of ILI is slightly different from that of SARI; the former includes patients with fever and cough but those who don’t need hospitalisation. So testing for COVID-19 in the ILI network would bring even outpatients1 under the government’s radar.
India already has a network for ILI surveillance that it can take advantage of, Giridhar R. Babu, an epidemiologist at the Public Health Foundation of India, said. This network is run by the NCDC and collects samples from people with ILI each month, and tests them for H1N1 influenza.
Again, it has proven hard to find out whether the ILI network has been roped in for COVID-19 surveillance. When I asked NCDC director Sujeet Kumar Singh on phone whether ILI samples were being tested for SARS-CoV-2, he responded in the affirmative. However, when asked how many samples had been tested thus far and how many came back positive, he said it would be premature for him to share the answers.
Meanwhile, neurovirologist Ravi Vasanthapuram, at Bangalore’s National Institute of Mental Health and Neurosciences (NIMHANS), one of the labs in the NCDC’s ILI network, said his lab hadn’t yet begun testing for COVID-19 cases. Although the lab had been asked if it was ready to start testing, it had not received a subsequent notification to begin testing, Vasanthapuram told me.
To make matters more confusing, the King George’s Medical University and the Shimoga Institute of Medical Sciences, both part of ICMR’s VRDL network, said they were testing ILI cases for COVID-19.
If so, why hasn’t the health ministry revealed that they are testing ILI cases, in addition to SARI? And why haven’t all labs been roped in, including major southern ones such as NIMHANS? Third, what have their tests found?
These questions aren’t just theoretical. To claim unequivocally that there is no community transmission in a country of over 1.3 billion people, as ICMR officials have, requires clear and rigorous reasoning. Neither 829 negative SARI samples, nor 500, will be enough to establish this unless we know more about how these samples were selected to begin with.
Choosing which samples to test is critical, Anupam Singh, an assistant professor of medicine at Ghaziabad’s Santhosh Medical College, said. This is because the current testing method for detecting the SARS-CoV-2 virus’s genetic material, called reverse transcriptase polymerase chain reaction (RT-PCR), throws up several false negatives.
To get around this problem, RT-PCR tests must be administered to only those samples derived from people who have developed very specific clinical symptoms, even among SARI and ILI patients. For example, a paper published in February by scientists in Wuhan suggests a triaging strategy to identify patients most likely to have COVID-19. Patients with chills, sore-throat, cough, elevated white blood cells, fever and a chest CT scan that suggests viral pneumonia need not be tested for SARS-CoV-2. However, they continue, a CT scan suggestive of viral pneumonia means the patient is likelier to be infected with the virus, and should receive the RT-PCR test. In the latter case, even if the result is negative, the test may have to be repeated before declaring the patient COVID-19 free, Singh said.
Again, there is little clarity on what methods ICMR and the NCDC are using – if any º to select SARI and ILI patients for tests.
Example 3: Miscommunication about India’s transmission ‘stage’
There have been other examples of confused messages from the health ministry in the last month alone, precipitating incorrect reports in the press. For example, on more than one occasion, health ministry officials have said that India does have community transmission – only to subsequently walk back on their statement, and ‘clarify’ that they meant local transmission, which means all COVID-19 cases are either ‘imported’ or their contacts.
Using the terms community transmission and local transmission interchangeably is a problem because they stand for two distinct phases of an outbreak. Much of ICMR’s testing strategy today is based on the assumption that there is no community transmission in India, and this strategy is likely to change only when this assumption changes.
Example 4: Miscommunication about why ICMR is not expanding testing criteria
Finally, it’s not clear why ICMR has chosen to not expand its testing strategy to include patients who have not travelled abroad (except if their samples have been collected as part of SARI/ILI surveillance).
While ICMR officials said during the March 17 press conference that this was because they didn’t believe there was community transmission, ICMR’s epidemiology chief Raman Gangakhedkar shared different reasons during an interview to NDTV. He said that if India began testing more people, it would find more positive cases, and the government would have a tough time isolating them all.
These two lines of reasoning are vastly different, and the second one makes ICMR seem irresponsible. While ICMR would be right to deny community transmission based on a reasonable testing and sampling strategy, not testing people because the people may not act on the results makes little sense.
If this is what the government really fears, the health ministry must make a greater effort to counsel people about isolation. More importantly, ICMR must clarify why testing has been so restrictive thus far.
Why communication matters in public health
Communicating clearly is a core part of public health because public-health isn’t just about building surveillance systems and infrastructure but also about enabling people to change their behaviour in the right ways. In the ongoing COVID-19 pandemic, a lot depends on how responsibly Indians practice containment strategies such as social distancing, hand-washing, quarantining and reporting to designated hospitals when they develop COVID-19 symptoms. All these are voluntary actions that the government doesn’t have the resources to enforce.
So for people to perform these actions of their own accord, they must first trust that the government is holding up its side of the bargain. They must trust that the government’s strategy to control an outbreak is coherent and logical.
But how easy is it to believe this if decision-makers are not transparent about their decisions? Without transparency, and given India’s history of hiding outbreak data from the public, it’s hard for citizens, reporters and independent public health experts to verify any government claim.
It is high time that the health ministry, ICMR and the NCDC set up active public communication cells that proactively share information on a regular basis. Such information should include daily case-numbers, number of tests conducted per day, testing algorithms and sampling methods.
Such information must also not be restricted to reporters who have access to Delhi-based officials but should be distributed to health journalists around the country. One way to do this is to open health ministry press conferences, which are currently streamed live, to questions from remote attendees as well. Only then will the Indian government win the public trust it needs to contain COVID-19.
Note: This article was edited to clarify that the VRDL labs intend to test 1,020 samples, not that they have already tested them, and that the health ministry should have revealed the two institutes are testing for ILI cases, and not their participation itself.
Priyanka Pulla is a science writer.
Those who don’t need to be admitted because they don’t have severe symptoms, like difficulty breathing↩