JOIN USThe Union Ministry of Health and Family Welfare (MoHFW) wrote on Friday to state governments asking them to make sure ‘mild, very mild, pre-symptomatic’ COVID-19 patients had proper home isolation facilities before letting them go into home isolation.
On the same day, Lieutenant Governor of Delhi Anil Baijal mandated five days of government quarantine for COVID-19 patients in Delhi. Though this has not pleased the Delhi government, it seemed to be a small step in the right direction (since withdrawn).
When the COVID-19 pandemic started sweeping India in March, the Indian Council of Medical Research (ICMR) framed the discharge policy based on the existing understanding of the COVID-19. The patients who were tested positive in RT-PCR tests needed to be cleared by a chest radiograph and declared negative in two consecutive RT-PCR tests, before getting discharged.
This also resulted in many positive patients remaining in hospitals for a longer time, as some of them with high viral loads would not get tested negative even after half a dozen tests and 21 days.
While the COVID cases kept increasing, the ministry issued a new discharge policy on May 8. The new policy classified COVID cases into three categories: 1) Mild, very mild/pre-symptomatic 2) Moderate 3) Severe.
Patients with mild, very mild, pre-symptomatic and moderate cases were to be discharged after 10 days of symptom onset and no fever for three days. More importantly, the MoHFW said there was “no need for testing prior to discharge”. The patient was to be under home isolation and self-monitor his/her health for seven more days.
The patient needed to be recovered clinically and tested negative once by RT-PCR, after symptoms went away, only for severe cases. About 80% of positive cases being asymptomatic meant they would be home-isolated. The local administrations needed to ensure they stayed home.
The ministry said that many countries have changed the criteria for discharge from ‘test-based strategy’ to ‘symptom-based strategy’ or ‘time-based ‘strategy. It cited an ICMR review of laboratory data which showed negative results for COVID-19 after an average duration of 10 days of the first RT-PCR test, and reduction in viral load after a week of symptoms, which means the patient becomes less infectious after 10 days.
An FAQ by the ministry says: Unless there is a fear of resurgence of infection and subsequent transmissibility of an infection, resolution of clinical manifestation is usually taken as an evidence for cure. It rules out the risk of an increase in transmission from patients thus discharged.
To complement this, on May 10, the ministry issued a revised guide for home isolation, for very mild/ pre-symptomatic patients. This said: 1) The case should be diagnosed as ‘very mild/ pre-symptomatic’ by an authorised physician; 2) The person “should have the requisite facility at their residence for self-isolation and also for quarantining the family contacts”; 3) Caregivers should be available at home and they should take preventive medication; 4) The patient must self-monitor his/her health and self-report it. It also gave a strict set of do’s-and-don’ts for the patients, caregivers and the family.
For asymptomatic patients being home-isolated, the new policy meant they had to continue home isolation for 17 days after getting tested positive and no less than 10 continuous days. They did not have to be tested negative before they went out.
What’s the catch? The new policy seems to have improved India’s recovery rate. However, when we say India’s recovery rate exceeds 54%, it includes 1) all asymptomatic cases tested positive but are not in hospitals, and 2) all mild and very mild cases, which are not tested negative for COVID-19, who have completed the mandatory quarantine period.
The problem is, nobody knows for sure whether they are now negative or positive. The policy assumes that they will be cured after 10 days. There is no foolproof mechanism to enforce quarantine norms on such people.
The negative implications of this policy can be far more serious. Remember a senior citizen COVID-19 patient who was found dead in a bus stop in Ahmedabad, after the hospital authorities dropped him where he “requested” himself to be dropped? The hospital said he was a ‘mild’ case, so got discharged in two days as per the ‘policy’. This is just an example of the mess that can happen.
There are far more serious implications of just letting positive people stay home. There cannot be a better example than Delhi that pushed people into home isolation but could not enforce quarantine norms. The result: In June second week, Delhi saw nearly ⅓ of daily tests turning positive!
Survival of the fittest?
Being the second most populated country in the world, there are crores of people in India who are vulnerable to COVID-19. Sample these to imagine the scale of the vulnerable population:
A survey by the Karnataka government shows that about 36% of the surveyed houses have senior citizens, numbering about 60 lakh, out of which 15.9 lakh houses have elders with comorbidities. That’s a minimum of 15.9 lakh extremely vulnerable senior citizens in Karnataka alone! The same survey classifies 63.7 lakh houses in Karnataka under the risk category.
India has 6% of its population aged 65 and above (senior citizens) according to the World Population 2019 report, which is about 8.2 crore going by conservative estimates.
There were 6.5 crore diabetics in India, according to the National Health and Family Survey—2016.
There were 199 cases of HIV and Tuberculosis per one lakh people (about 26 lakh people) in India in 2018.
COVID-19 has proved fatal for senior citizens and people with comorbid conditions across the globe. If asymptomatic cases are allowed to go out without being tested negative, it will end up being a game of ‘survival of the fittest’ for the rest.
Now, the good news: Not all states are enforcing this policy. Kerala treats its positive cases in hospitals and sends them home only when they turn negative clinically. Tamil Nadu keeps people in home isolation but tests them for negative results before declaring them as recovered. The states with poor health infrastructure and saturated health systems are following it.
The Centre has finally realised the perils of the flawed implementation of its quarantine policy and has written to states asking that its May 10 policy be followed to the T.
This is just a small step in controlling the contagion. In an ideal world, every asymptomatic patient would be tested negative before being declared ‘recovered’, to ensure the vulnerable are safe.