COVID-19: Kerala takes a regressive step by narrowing testing criteria

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If samples of people with mild symptoms to be tested each day is indeed delaying testing of more severe cases at this early stage of the pandemic, one shudders to think what it would be if and when community spread becomes widespread in Kerala.

Even as the World Health Organization has been urging countries including India that have reported many laboratory-confirmed COVID-19 cases to become more aggressive in testing, India continues with its restrictive testing strategy. In India, testing of people showing symptoms suggestive of novel coronavirus infection is confined to people with either travel history to high risk COVID-19 affected countries or close contacts of laboratory confirmed COVID-19 cases.

If India’s restrictive criterion for testing does not instil confidence, Kerala, which is seen a role model for the rest of the country in containing highly pathogenic outbreaks, has shockingly further narrowed down the criteria for testing. On March 12, Kerala Health Ministry issued revised testing guidelines based on current risk assessment. According to the guidelines, people who have come from countries with ongoing novel coronavirus (SARS-CoV-2) transmission and contacts of confirmed/suspect cases with no comorbidities and exhibit only mild symptoms — low grade fever, mild sore throat, cough, rhinitis or diarrhoea — will not be tested for coronavirus.

Rational behind the new guidelines

“Testing is not going to change either the clinical course or management of the patient with mild symptoms,” the guidelines say. The rationale that testing people with mild symptoms which are non-specific would delay the testing of more deserving cases is highly problematic and may prove counterproductive.

According to Dr. Nivedita Gupta of ICMR, maximum number of samples that National Institute of Virology (NIV) unit in Alappuzha received in a single day was around 100 and as low as 10 on some days. Two more labs — Government Medical College, Thriuvananthapuram and Government Medical College, Kozhikhode — in the State will in a day or two begin confirming cases without sending samples to NIV unit in Alappuzha. One more lab would have started screening samples early this week. With the capacity to test more samples each day is all set to increase very shortly, it is unclear why the State has issued the revised guidelines. If it’s an attempt to keep the numbers artificially low, it will prove counterproductive.

If the number of samples of people with mild symptoms to be tested each day is indeed delaying testing of more severe cases at this early stage of the pandemic, one shudders to think what it would be if and when community spread becomes widespread in Kerala.

Cases will go undetected

Since about 80% of COVID-19 cases exhibit only mild symptoms and will recover without needing special treatment, the decision not to test them would mean that a vast majority of COVID-19 cases will go undetected. This is so wrong from the epidemiological point of view as the true case load will not be recorded. In fact, with the rest of the country looking up to Kerala in containing the spread of the virus, one would have expected the State to adopt a testing strategy that is more expansive — testing all contacts soon after being traced immaterial of clinical manifestation.

With people with mild symptoms not being tested, the real danger of allowing them to spread the virus cannot be dismissed. A few studies and the experience of many countries suggest that infected people start spreading the virus even before symptoms show up. The infectiousness only increases when people start exhibiting symptoms. Though the guidelines say that contacts and people with travel history should be under “strict home isolation”, the false sense of security when not tested might increase the likelihood of such people not following home isolation strictly. In fact, stricter quarantining would be needed for symptomatic people.

Threat to contact tracing strategy

When the State displays great rigour in tracing contacts and insists on home isolation for a period of 14 days, not testing them when they show symptoms goes against the grain of contact tracing strategy. There will be great danger of contact tracing backfiring when people who willingly self-isolate are not tested when symptoms show up. It is unethical too.

Kerala cannot claim that there are that there are no new cases and the pandemic is under control in the State when it does not test people in quarantine exhibiting mild symptoms.

Published in The Hindu on March 17, 2020

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