India is considering expanding the case definition for COVID-19 by including the six symptoms that the CDC recently added in its list of symptoms list. These include chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell. These are added to the list of symptoms such as cough, shortness of breath, difficulty of breathing and fever.
“We [need to] recognise our population, whether they will be able to recognise these symptoms. We are undertaking a small study with asymptomatic patients of COVID-19 admitted in the hospitals to assess whether they are suffering from these symptoms. When we say symptoms, we need to understand that first people should have those symptoms, they should be able to recognize them, and most importantly, they should feel that the symptoms are worth reporting,” said Dr Raman R. Gangakhedkar, head, epidemiology and communicable diseases, ICMR. He was speaking via video-conferencing at a media interaction on COVID-19 in Kerala.
At the event, Gangakhedkar defended India’s testing strategy by arguing that India was testing adequate numbers, and that tests would be expanded as and when the need be. “We should not compare our testing strategy to that of other countries such as the US. These countries have a non-existent public health system. In these countries, the disease had already reached the community level, and large numbers were affected, hence the high testing rates. Though our testing rates differ across states, we have adopted testing along with aggressive contact tracing, so that we reach the right people,” he said.
Contact tracing has been possible only because India has a good public health system, in which, Kerala has been the leader with one of the best public health systems in the country, Gangakhedkar said. “We have to remember that this is a contact-driven infection and adequate exposure is required to acquire it, and hence, contact tracing is the best strategy,” he said.
The issue of “test, test, test”—referring to the WHO DG’s directive that countries must test aggressively—Gangakhedkar, also the ICMR’s main spokesperson on COVID-19, said that the issue had been blown out of proportion. On April 29, Maria Van Kerkhove, technical lead, COVID-19, WHO Health Emergencies Programme, clarified, “When we say 'test, test, test' it does not mean test everyone in the population. It means to have aggressive case finding, test all suspect cases, and test all of their contacts who develop symptoms”.
India could run up to 1.25 lakh tests per day in government laboratories, Gangakhedkar said. “We have sufficient kits to last until May 15. Though we have other reagents available, the RNA extraction kits continue to be an issue. But more have ordered and there will never be a situation when we would have to suspend tests because of shortages,” he said. Alternate mechanisms such as NGS (next generation sequencing) to diagnose infection could also be considered if need be. Other diagnostic machines such as GeneXpert and Truenat used for TB have also been approved for COVID-19 screening.
Gangakhedkar said that with RT-PCR, the issue of sensitivity had to be understood—the test cannot differentiate between live and dead viruses. This meant that even if a person was “cured” of the disease, their cells could still have the virus fragments – although dead – that could be detected by the RT-PCR test. “The test may be positive but the person cannot infect others at that point,” he said.
On the issue of rapid antibody test kits, Gangakhedkar said that their utility was low, and only for surveillance purposes. “They don’t help in early diagnosis as some people think. Besides, since they are first generation tests, developed for this infection for the first time, they are not as perfect as those developed for say, HIV,” he said.
There wasn’t enough evidence to even say that if the antibodies detected by these tests offered protection, or how long the protection would last. “If I have to take an example, I would take that of H1N1, where even vaccine generated antibodies only offered protection for about nine months. It’s a new disease, we are discovering new things every day,” he said.
