There’s need for a smart testing policy for Covid-19

India’s response to the Covid-19 pandemic has entered its eighth month since the first nationwide lockdown was imposed. The country’s efforts to contain the pandemic has yielded a mixed bag of results so far. Owing to the enforcement of one of the most stringent lockdowns globally, India was able to limit the initial spurt of cases and work towards accentuating capacity in the health sector to deal with the pandemic. With the easing of lockdown, we have witnessed a sustained increase in the caseload with strong regional variations.

The government has given high visibility to its achievements such as sustained lowering of case fatality rates, which at 1.5 per cent, is at its lowest since March 22, high rates of recoveries, which, at 90.62 per cent currently, is much above the global average. However, focussing only on successes without taking a critical look at shortcomings and analysing lessons learned in the process will lead to complacency among the implementers and overconfidence among the people.

There’s already enough evidence of a perceptible trend among the younger sections of the population that the worst is over, and they can get back to the old normal. This is far from the reality because Covid-19 is still very much around and remains a threat in the ensuing winter months.

To begin with, we need to reflect on our approach towards testing since the outbreak of the pandemic. It began with reluctance to the WHO approach of maximising testing. Only later did we realise the importance of maximising coverage of testing. India has now tested more than 100 million samples, with a drastic increase in testing since August 2020.

Potential for second wave

It is imperative that we look at testing as a continuum instead of an isolated step. It involves various steps starting from identifying the right type of test kits, strengthening, and expanding testing centres to making it accessible to marginalised sections of the society through last-mile connectivity. This becomes critical, as the pandemic has surged into the hinterlands, and owing to limited healthcare infrastructure and erratic health seeking behaviour, it has the potential to cause a second wave of new infections..

Initially, our testing strategy relied entirely on a single reliable method of testing with Reverse Transcription-Polymerase Chain Reaction (RT-PCR), which is cost intensive, has longer turnaround time for test results, and needs trained manpower and knowledge to run these tests. Thereafter, Rapid Antigen Tests (RAT) came with a lot of promise with ease of testing and affordability.

Based on the guidelines issued by Indian Council of Medical Research (ICMR), the States were advised to use RAT in combination with RT-PCR, not just in clinical care settings, but for epidemiological and screening purposes. But evidence has demonstrated that RAT has lower sensitivity and has shown specificity parameters of 60 per cent, which makes them unreliable for use not only in a healthcare setting but even for epidemiological purposes.

State governments have used RAT kits in combination with RT-PCR for confirmation of Covid positivity. In the last two months, the percentage of rapid kits used for testing has progressively increased to 45 per cent and this has resulted in inaccuracies in data, i.e. in many cases, the States have not followed up negative RAT tests with RT-PCR tests, resulting in lower positivity rate across the nation.

In comparison, the HIV testing policy, which evolved 20 years back, depended on highly rated rapid kits of 95 per cent and above sensitivity and specificity. Two or more kits with different antigens were used for confirmatory testing for screening and voluntary testing. This had helped in the rapid scaling up of testing facilities all over the country.

Future testing strategy

It is therefore important at this stage to relook our testing policy and the strategies adopted for scaling-up of testing for Covid-19 to reach the populations most at risk.

First, we need to look at rapid kits with high sensitivity and specificity levels and replace the existing substandard ones. Ease of testing, availability of testing facilities, and quick results are the criteria that should guide the selection of a reliable test kit. The ICMR and the Central Government should limit their role to choosing the right kits after proper evaluation and establishing testing protocols. Implementation, which involves the location of testing centres, accessing the most at-risk populations, procuring and distribution of test kits, should be the responsibility of the State governments.

Even though the pandemic has raged on for eight months now, the ICMR only recently introduced voluntary testing in its policies, and even now it is not being adequately publicised. Testing centres should be located not just in healthcare settings but in the community as well so that people are encouraged to go for voluntary testing.

New test kits like Crispr-Feluda hold a lot of promise because of the accuracy and ease of testing. Such tests should quickly be brought on board and procured following simplified procedures. Separate protocols should be worked out using exclusively rapid tests for non-clinical settings.

Access and affordability should be the key to an effective testing strategy. The priority criteria for testing has been spelled out (elderly people, people with comorbidities, children, expectant mothers, etc). But efforts to create a database for these groups who are most at risk has not been taken up nationally except for sporadic efforts in Kolkata and Bengaluru. This database will be useful later for vaccine purposes also, and needs to be created at a local level.

Lastly, the reach of testing can be extended to the last mile only by community involvement. The present policy is entirely government-driven and enforcement-oriented. It is important to change the paradigm to a bottom-up response, emphasising people’s participation, especially communities most affected. A smart testing policy should be simple, easy to understand and implement, quick in giving results, contain proper linkages with the healthcare system at various levels. Equity should be the guiding principle that can assure that the benefits reach the most deserving and those who are poor and marginalised.

The writer is a former Health Secretary, Government of India. Views are personal.

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