14 March 2020
India continues to respond to COVID-19 with a focus on “imported” cases. With the current limits on testing for the virus, the Indian government is likely blind to the full scale of local transmission. SANJEEV VERMA / HINDUSTAN TIMES / GETTY IMAGES
On Friday, 707 employees of a Noida-based leather company were put in home quarantine after one employee at the firm tested positive for COVID-19. The infected employee, a 46-year-old man, had recently returned from Italy, which has emerged as one of the nations worst affected by the virus outside China. The number of confirmed cases in Italy stands at 17,660, jumping by over 2,500 in twenty-four hours. Italy’s COVID-19 death toll is already 1,266—meaning seven percent of confirmed cases in the country have been fatal.
Prior to the mass quarantine at the leather company, the infected employee had continued to work even after showing initial symptoms of infection. Health ministry officials clarified that quarantine does not indicate suspected infection. “We are in touch with the people who’ve been recommended to isolate themselves,” Lav Agarwal, a joint secretary at the ministry, said at a press briefing on Friday. “If they show symptoms, they will be moved to a quarantine centre and given appropriate medical attention.”
The circumstances of the case, and the quarantine in response to it, indicate a serious chance of local transmission of COVID-19—that is, transmission that has not occurred outside Indian borders. At two separate press briefings held on Friday, both the health ministry and the Indian Council of Medical Research—also a government body—downplayed the possibility of local transmission. The latest Situation Report from the World Health Organisation, issued on Thursday, categorised India among countries having local transmission. India has joined countries such as Italy, Korea and China in the category, all with high burdens of the virus and ongoing human-to-human contagion domestically.
In its response to the COVID-19 pandemic, the Indian government continues to operate under the assumption of having to deal with what the WHO categorises as “imported cases only”—where transmission has been limited to international travellers alone. This is reflected in the decision to cancel all but a small set of visas, largely sealing the country’s borders, and to limit testing for the virus to those with a history of recent international travel and individuals who have had contact with them. The WHO’s indication that India is working under a faulty assumption shows the government’s present approach to the pandemic to be hugely inadequate. With the current limits on testing, India is likely blind to the scale of local transmission.
“I’d trust the WHO report because they have clearly-defined criteria,” a health-policy expert with a private think-tank explained, speaking on condition of anonymity. The government shut borders a few days ago, the expert said, but it is clear that many asymptomatic carriers of COVID-19—people who had yet to show symptoms of infection—came into India in the last weeks. “We don’t know who they are, and we are not trying to find them aggressively.”
The expert had a grim prognosis. “I feel there is undetected local transmission going on,” he said. “This is not something that can be hidden. The cases will start showing up at hospitals within a week, and we will then get a full measurement of how many cases we missed during these days.”
“At the moment, my sympathies lie with the government—not because I work for them but because I believe they are genuinely doing their best,” a government medical official said, insisting on anonymity. “I do think the testing should be more liberal, but I know that the government is working hard at procuring and validating the quality of testing kits. The minute they feel confident about their resources, they will expand testing criteria.” Only a handful of government-accredited laboratories have been allowed to test for the virus, with private laboratories excluded. “The government is not averse to the idea of working with the private sector,” the official said, and “they will do it when testing kits become available.”
South Korea is the only country so far to allow universal testing, free of cost, for anyone showing symptoms. Its fatality rate for confirmed COVID-19 cases is 0.7 percent. The WHO has reported a 3.4 percent fatality rate globally. Scientists estimate that universal testing helps lower the death rate, in addition to the transmission rate, by allowing early detection and intervention. Everyday that India fails to expand its limited testing regime means vital time lost in controlling the pandemic’s effects.
Agarwal, at the press briefing, contradicted scientific evidence to say that “the mortality rate is very low.” He said the government is “fully aware of what needs to be done,” and added that, within India, “this is not an epidemic.” He recommended social distancing to mitigate the risk of contagion. By the latest counts, India has had 83 confirmed cases of COVID-19, with two resulting in death.
Agarwal added that roughly four thousand people are currently under self-quarantine. The Times of India has reported one case where a woman, recently back from a honeymoon in Italy, repeatedly evaded quarantine and continued to travel even after her husband tested positive for COVID-19.
In a first-of-its-kind study published on Thursday in The Lancet, a medical journal, scientists examined risk factors associated with severe disease and death in adults hospitalised with COVID-19. The study examined records on 191 patients treated at two hospitals in Wuhan—the point of origin of the global outbreak—who had been discharged or had died by 31 January. (The authors note that their findings might be limited by the study’s sample size.) Roughly twenty-five percent of patients were admitted to intensive care, and 17 percent of patients required ventilator support. Of the 191, 54 died in hospital—28 percent—and 137 were discharged. The study showed that old age is a major factor in the virus proving fatal. The median time between them exhibiting symptoms and being discharged was 22 days. If these numbers are any indication of what awaits India, with any sizeable outbreak the burden on ICU beds and ventilators in the country will quickly outstrip availability.
Among the new things the study reported was data on the duration of viral shedding—the amount of time that an infected person can be infectious to others. The median duration of viral shedding in the surviving patients was 20 days—with a range from 8 to 37 days—and the virus was detectable until death in the 54 non-survivors. “The extended viral shedding noted in our study has important implications for guiding decisions around isolation precautions,” one of the lead authors noted. For a country like India that is just starting to mitigate infection from COVID-19, the challenge is enormous.
Correction: This story earlier erroneously stated that the health ministry and Indian Council of Medical Research denied the possibility of local transmission at press briefings held on 13 March. The story and the headline have been corrected for accuracy. The Caravan regrets the error.