Focus on Covid-19 deaths, not disease spread

For many months now, India’s cities have focused their battle against the coronavirus on social distancing, quarantine and testing. People have stayed home, shunning crowded spaces; masks and pocket sanitisers have become part of one’s clothing, and a cough and mild fever have had people lining up to be tested.

For all these pains, India is now sitting atop 47 lakh Covid cases. We are adding an incredible one lakh cases a day. At this rate, in a matter of weeks, India will be crowned the Covid capital of the world.

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So we clearly got something wrong. Do we give up the fight, and go Ram bharose?

Not quite, is the answer from a group of experts. But their advice is radical: Don’t worry about mass testing or large containment zones. It’s too late for all that. Concentrate instead on protecting the vulnerable, and make testing and containment highly focused, letting normal people go about their lives as near normal as possible.

“As the virus spreads like wildfire, the strategy needs modification to identify those at risk of having complications,” said Oommen John, a public health researcher at the George Institute for Global Health. “We can’t have one blanket strategy for the entire country.”

In other words, health services need to target their response towards high-risk individuals, health care workers, elderly people with comorbidities and those going in for surgeries.

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India’s new mantras in the fight against Covid-19 should be micro-containment, micro-surveillance, targeted testing and death aversion. One way to achieve this is to adequately train frontline health workers to quickly identify hypoxia patients (those with a shortage of oxygen) so that they can be immediately put on supplementary oxygen. Many
of these recommendations are to be found in a recent report released by three prominent public health associations.

The most important of the new interventions will need to come in testing. Expanding the testing net indiscriminately in cities like Delhi, Mumbai, Bengaluru and Chennai, where lakhs have tested positive and sero-surveillance surveys show exposure of an even larger population, makes little sense. A preoccupation with mass and indiscriminate testing diverts attention from essential, inexpensive and achievable public health measures.

“Indiscriminate testing is useless. Since neither the RT-PCR nor the rapid antigen test can pick up all the positive cases [both give significant numbers of false negative results], in a country with 130 crore people, the health system would eventually end up doing only the tests and nothing else….” K Srinath Reddy, President, Public Health Foundation of India told DH.

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The current benchmarks for adequacy of testing are 140 tests per million population per day, and a sample positivity rate of less than 5%. Indiscriminate testing is aimed at meeting this target. “Testing by itself is not a control strategy. Daily testing of more than one million, mostly ill-defined population, is imposing heavy economic cost without commensurate benefit for control effort. There is a need to relook at the testing strategy in a way that it results in guiding the public health response and effectively limiting the spread of the disease,” the report by the Indian Public Health Association, Indian Association of Preventive and Social Medicine and Indian Association of Epidemiologists said.

Experience from other countries indicates that increased testing does not prevent deaths from Covid-19. Japan and Sri Lanka with one of the lowest testing rates have the lowest fatality. Canada has dramatically reduced community spread with half of the testing capacity of the USA, which is reeling from the pandemic despite having the world’s highest per capita testing rate.

“Using testing to prevent transmission of SARS-CoV2 on a large scale is like using the weather report to prevent global warming,” Alexander McAdam of Boston Children’s Hospital and Matthew Pettengill of Thomas Jefferson University, Philadelphia, critics of the mass testing theory, said.

Two-pronged approach

Public health specialists said testing strategies in densely populated urban areas and rural areas should be different depending on the transmission dynamics.

In most cases, by the time the testing is done and the results are made available, the infection has already spread to close contacts. This is more pronounced in rural areas.

With two-thirds of India’s population living in villages, where the spread of the disease appears to be limited as of now, the big challenge for the administration is to prevent a rapid spread of the virus in the countryside. Testing and containment may be useful for that purpose if the district administration knows local transmission dynamics. “Unfortunately, such district level monitoring is non-existent in the majority of the 700 plus districts,” said Oommen John.