Featured image: A doctor collects a sample from a woman for COVID-19 test in a Red Zone area of Bemina during ongoing nationwide lockdown, in Srinagar, Thursday, April 30, 2020. Photo: PTI/S. Irfan
Testing has been India’s bane during the COVID-19 pandemic. But while efforts to increase testing would generally be welcomed, there is one area where the policy of testing in India remains grey. And that is regarding testing all hospital admissions.
As of today, testing all hospital admissions for COVID-19 is not recommended by the ICMR in its testing guidelines – the exception being pregnant women residing in containment areas or infection clusters. And yet, numerous private hospitals have made COVID-19 test mandatory before admitting elective and even emergency patients, despite the government issuing a clarification on this issue, asking hospitals not to test asymptomatic patients who need healthcare services for COVID-19. What are the arguments in favour of and against routine testing of all hospital admissions?
On the face of it, testing for COVID-19 should be a non-issue. Firstly and most importantly, the novel coronavirus is a highly transmissible virus, and studies show that up to 44% of the infection may be transmitted by pre-symptomatic patients (i.e. individuals who have COVID-19 but do not yet show any symptoms of the same).
Thus, it is clearly not possible to identify all COVID-19 patients based on history alone. One such patient could infect several healthcare workers (HCWs) and can significantly impact hospital services – this has previously led to lockdowns of many hospitals in Mumbai. Furthermore, the hospital then has to test several of its own HCWs (all from its own pocket), with Jaslok Hospital reportedly having tested nearly a thousand staff members. Thus, the implications of missing a single COVID-19 patient can be enormous.
Secondly, patients are not always honest about their history of contact or symptoms because of the fear of being refused treatment, making it difficult for doctors to rely on history alone for triaging patients for testing.
Thirdly, testing hospital admissions increases India’s overall testing figures. For a country barely testing its population due to conservative (and often ambiguous) testing criteria, every drop in the testing puddle – there is no ocean metaphor possible here – makes a difference. Undertaking contact tracing and breaking the chain of transmission is helpful. Furthermore, hospitals routinely carry out testing for HIV, hepatitis B and hepatitis C preoperatively for all patients. Adding another viral test does not seem out of the ordinary.
And finally, the ICMR does recommend testing all pregnant women who are in labour or are likely to deliver in the next five days. It gives no explanation as to why only pregnant women are exempted from its rule of not testing asymptomatic admitted patients. Is it because they are more vulnerable (but then why exclude old-aged patients and those with comorbidities), or is it out of concern for the newborn (who are actually least vulnerable as per the data we have)?
Irrespective of this, extending the logic to all admitted patients is not unreasonable. Similarly, recently, the Maharashtra government tested about 167 asymptomatic journalists, with almost a third testing positive for the coronavirus infection, indicating how widespread the disease already is. If testing asymptomatic journalists is fine (with substantial positive results), there is no reason why doctors should not test admitted patients.
There is also a school of thought, although I wouldn’t list it as a reason, that patients who test negative for the coronavirus infection will be admitted more comfortably especially by the smaller hospitals and nursing homes, who may otherwise turn patients away due to a combination of fear and limited resources to bear potential HCWs’ infection or a lockdown. There have indeed been several instances of patients being turned away by hospitals.
However, there are some equally reasonable concerns about mandatory testing of COVID-19. Firstly, of course, is the cost and the delay in patient management. The test is rather expensive, capped at Rs 4,500 by the government. Most labs have a turnaround time of a day or longer in giving the results, which can delay patient care. Furthermore, whom to test or not remains a grey zone.
Usually, a patient will have at least one relative accompanying him or her during the hospital stay, and often two relatives doing 12-hour rotations of sorts. With that logic, should the relatives be tested as well, which would cause a multifold increase in cost? Similarly, the question of what to do for OPD patients remains unanswered. They would be sitting in the waiting area for some time before meeting the doctor; these waiting areas could be a potential hotbed for the transmission of infection. A rapid antibody test could be an answer to many of these vexing issues, but unfortunately isn’t available yet in India.
The second argument is the limitation of the test itself. RT-PCR has a sensitivity of about 70% for detecting COVID-19, which means we will miss three out of ten COVID-19 patients, a substantial number. A negative test may lull the HCWs into a false sense of security, making them more likely to acquire the infection from such a patient. A more prudent strategy would be to just assume that every patient admitted is positive and wear appropriate protective gear accordingly, which is something all hospitals now follow.
This then begs a question: how does a positive or negative test make any difference to the way the patient will be treated in the hospital? One could make a fair argument that a COVID-19 patient would need to be kept away from other patients, and not allowed to be admitted in common hospital wards or shared rooms. But then patients getting admitted into private individual rooms should not be tested by that logic.
Stigmatisation if one tests positive and being refused treatment is a major fear for the patient. This is particularly true for affluent patients in cities where dedicated COVID-19 hospitals are limited to mainly government institutes.
An equally important issue to consider is the steady erosion of trust in doctors amongst the population at large. Hence, fingers are bound to be raised by mistrustful patients or populist media outlets on compulsory testing despite the central guidelines, in spite of all the reasons mentioned earlier. Besides, the additional cost billed to the patient due to the use of protective gear and other safety-related ancillary expenses is often not covered by insurance. This may lead to a scenario which could be easily exploited on the news or social media without providing the proper context.
Unfortunately, a small subset of hospitals is also doing an additional blanket pre-admission CT chest for screening for COVID-19 patients along with the RT-PCR test. This was started initially due to the fear of the lockdown by health authorities if any HCW tests positive, as CT results come much faster than RT-PCR. This is, however, something recommended against by all international societies (apart from specific clinical and epidemiological circumstances) due to its poor accuracy and the fact that the patient movement unnecessarily exposes many others in the facility. Now that many health authorities have clarified that hospitals will not be locked down, this practice needs to be re-evaluated by the hospitals.
Overall, one reasonable equivalence for COVID-19 testing would be the triple H testing. It is done routinely for all pre-surgical patients, and this practice is accepted across the country and internationally as well, despite the stigma attached to HIV. Similar to our discussion above, universal safety precautions are always followed across all hospital surgeries, irrespective of the test result.
There is however often an extra step which many HCWs may take for patients who test positive, besides keeping them mentally more alert. But more importantly, it brings this hitherto unknown patient into the healthcare system, allowing us to treat him or her for the HIV or hepatitis, improving the patient’s overall outcome, and preventing further transmission as well. A similar logic can be applied to COVID-19 testing as well.
Overall, there are several reasons for and some against COVID-19 testing of all admitted patients. Doctors will strive to strike the balance between protecting patients and preserving the healthcare system. While treating any urgent or life-threatening condition without waiting for any test result is a given, we need a more rational and practical set of comprehensive guidelines for non-urgent or elective admissions from the government to enable hospitals and smaller nursing homes to practice medicine safely. Unfortunately, until then, it will remain a ‘damned if you do and damned if you don’t’ scenario for most doctors and hospitals.
Dr Akshay Baheti is an assistant professor at a hospital in Mumbai. The views expressed here are the author’s own.