The wave of Chinese virus induced flu and related illness seems to have abated in Europe but seeing a second wave in the US. It continues to rise in Brazil and other South American countries. In India, the illness does not seem to show any signs of abatement though the recovery rates are closer to sixty percent. States like Karnataka that seemed to have controlled the outbreak are seeing fresh waves. There seems to be a continuous upward curve in Maharashtra and Tamil Nadu though some early signs of flattening are visible in Delhi. It’s been nearly five months since the virus was first detected in India aside of Wuhan returnees and there still are no signs of peaking. This naturally brings to the fore the question of control of the disease.
Without doubt, most cases are asymptomatic or at most the mild or moderate symptomatic. In fact, not even 5% of the total active cases are currently in ICUs. The death rate is low around 4% of the total case load. Of course, this differs from state to state but barring few states like Delhi, Maharashtra, Gujarat, Tamil Nadu, the death incidence seems to be low. Among all countries, the death incidence (death per million population) is among the lowest. Moreover, the metric Wo as defined by economists Dr. Arvind Virmani and Dr. Surjit Bhalla seems to be hovering around 0.25 or so which indicates the virus is recessionary state but not wholly under control. There are causes of concern yet. As the government plans for Unlock 2.0, it would be instructive to analyse the possible strategy going ahead.
The current positive rate (positive results per 100 cases) is just over 6%. The initial stages had a positive rate between 4-5% and now with the increase in tests, it is also increasing. Yet the differentials at state level are high. Tamil Nadu is showing positive rate around 15% while Telangana is showing in excess of 30%. Maharashtra and Delhi too are reporting around 15% positive rates. At higher positive levels, it is evident that infection is way ahead to the public knowledge and thus becomes imperative for higher testing. Many states remain conservative in testing. Therefore testing strategy needs to be recalibrated.
The testing capacity while has increased to more than 3 lakhs tests per day, yet given the size of India and the current increase in case loads does not seem to be sufficient. India has to invest massively in testing capacity. Indian test incidence (tests per million of population) is still relatively lower. It is just over half a percent of population has been tested. India can continue to follow the strategy but it will be a long haul to the peak and the consequent decline in cases. Further this would impact the economy. Contrary to assumption that economy would be best served by opening up, it would be best served by massive increase in testing thus allowing an early isolation of the patients thus decline in reproduction ratio. India while increasing its capacity adopted a certain strategy but now the expansion in testing capacity has slowed down. In fact capacity utilization is only around 60% or so. What India does need to do is to rapidly increase the capacity and also the number of tests.
The symptomatic patients obviously will get tested as do those who come from the high risk zones. Their contacts too will be tested. Yet what is getting missed perhaps the silent asymptomatic something that seems to have Bangalore for instance in the last few days. This group is likely to spread the incidence higher. The approach would have to be not just increased testing but increased number of people being tested. In fact, it makes sense to go in for pooled testing on a large scale. The people within a cluster like family or co-workers etc. could be pool tested. If it results positive, it could be deemed the cluster as positive and thus follow up measures undertaken. This would make sense given the close proximity in which the cluster lives is likely to generate a spread. Instead of quarantining them and observance or undertake separate testing, deem them to be positive. If a family of four or five or six are pooled and test returns positive, either way the negative members too would be in a high risk, so ensure they are quarantined in COVID centres or rooms till everyone recovers or the time passes for the symptoms to emerge or not to emerge. The pooled tests will increase the number of people being tested thus higher coverage of the population with the error tended towards the positive side. If India can build up a capacity of 5 lakhs pooled tests per day and assuming on an average around 5 are tested per pool, around 25 lakhs will be tested per day. To add if India adds another five lakhs of individual testing, in total around 30 lakhs will be tested which will translate into around 9-10 crore population being covered in a month or so.
Accompanying the RT-PCR tests offered by various firms approved by ICMR, there are also antigen tests which are being scaled up. These tests give the results fast though a test shows a sensitivity of around 80-90% while specificity of near 100%. Since the negatives are shown negative thus no false positives, the errors are likely to be in false negatives. Yet, these tests can be undertaken on a massive scale. If India could build up a capacity of 15-20 lakhs tests per day with small amount for pooled antigen testing, India could very well test 7-8 crore population in about a month or so. The recheck for false negatives could depend on the other symptoms. Further there are antibody tests which if executed on a large scale than a sample size as being done now could further scale up the testing capacity. The antibody tests with the RT-PCR or antigen could indicate in combination the probable duration of infection. If antibodies are present in RT-PCR positive or antigen positive, it is likely that a couple of weeks elapsed since infection and if asymptomatic could very well be discharged. Evidence indicates the virus ceases to spread after 10 days of infection, though traces might be found in the body for a considerable period of time.
PM Modi is known to execute on scale. Each of his policies have entailed the scale in execution. This too mandates one. If there is someone who can think big and execute the same on mission scale it would be PM Modi. Therefore, it is imperative that he does build up on the same and get over with the virus. The piecemeal or calibrated approach might yield increasing negative externalities in the mid to long run in terms of impact on economic recovery among other things. There is a need to achieve closure. India has done very well relative to other countries. As India begins Unlock 2.0, India cannot afford to lose the advantage. India need to seize the opportunity and bell the cat of testing followed by contact tracing thus bringing the Chinese flu under complete submission at least until the vaccine or a cure is discovered.
Thoughts on Theory and Practice 