Subject: Social Justice

The Indian Council of Medical Research (ICMR) has issued an advisory for using pooled samples for testing of COVID-19 in order to increase the number of tests conducted by laboratories across the country.

COVID-19 containment measures are pacing up across the country. However, it is argued that we are lagging in the number of tests to be carried out.  With certain limitations, pooled testing promises an edge over individual testings of suspected patients.

What is pooled testing?

• In a pooled testing algorithm, samples of multiple individuals are put together in a tube and screened through the PCR test.
• In case the pooled test turns out to be positive, individual samples are tested, which is referred to as pool de-convolution.
• If there’s no positive result, all individual samples in the pool are regarded as negative, resulting in substantial cost savings.

What the ICMR has recommended?

• ICMR has advised that while more than two samples can be pooled together, the number should not exceed five samples to avoid sample dilution, which can lead to false negatives.
• This method can be used in areas where the prevalence of COVID-19 is low, which means a positivity rate of less than two per cent.
• In areas with a positivity rate between two to five per cent, sample pooling of PCR screening may be considered in a community survey of surveillance among asymptomatic individuals.
• Samples of individuals with known contact with confirmed cases or healthcare workers should not be included in the pooled samples.
• Also, ICMR has said pooling of sample is not recommended in areas or population with positivity rates of over five per cent.

Benefits of pooled testing

• Using this method, substantial costs and testing kits are saved.
• For instance, if a pooled sample consists of the samples of five individuals and it tests negative, the cost of four testing kits is saved and more number of people are covered with fewer resources.
• Significantly, pooled screening can also help in tracking down the asymptomatic cases of the disease, thereby tracking community transmission.
• But in case the sample tests positive, all individuals need to be tested separately.

The Centre has approved a centrally funded ‘India COVID-19 Emergency Response and Health System Preparedness Package’ with the objective of strengthening national and state health systems.

About the Package

• The package is 100 per cent centrally funded project under the National Health Mission.
• It will be implemented in three phases from January 2020 to March 2024.
• It aims at strengthening national and state health systems to support prevention and preparedness, procurement of essential medical equipment, consumables and drugs, etc.
• The three phases of the project are Phase – 1 from January 2020 to June 2020, the second phase is from July 2020 to March 2021 and the third phase from April 2021 to March 2024.

What are the major activities planned under this package?

• The key activities to be implemented under Phase -1 includes support to states/UTs for the development of dedicated COVID-19 hospitals and other hospitals, isolation blocks, negative pressure isolation rooms, ICUs with ventilators, the oxygen supply in hospitals etc..
• The central package will also assist the state/ UTs for the Procurement of Personal Protection Equipment (PPE), N95 masks and ventilators, over and above what is being procured and supplied by the govt.
• The activities under the first phase also include the disinfection of hospitals, government ambulances, etc.

Delhi CM has announced a “5T plan” created by his government to contain COVID-19 spread in Delhi. These five Ts are testing, tracing, treatment, teamwork and tracking-monitoring.

5Ts strategy

1)Testing

• Testing when done on a mass scale enables the actual data of people affected by novel coronavirus.
• Like South Korea, Delhi will be testing on a large scale.
• Through rapid testing, the government will also be able to identify COVID-19 hotspots and take necessary action.

2)Tracing

• The second T is tracing, which involves identifying and quarantining people who have come in contact with infected persons.
• Delhi authorities are taking the help of police to trace whether the people who have been advised to self-quarantine are actually doing it or not.

3)Treatment

• The third component is the treatment.
• Serious patients who are suffering from heart diseases and patients above 50 years will be isolated in hospitals and the rest with minor symptoms will be kept in isolation in hotels and dharamshalas.

4)Teamwork

• The fourth element of the five-point plan is teamwork and collective efforts are being made to fight the virus.
• All State governments must learn from each other and work together.

5)Tracking and monitoring

• The fifth T is tracking and monitoring.
• The state should ensure that all these measures are in place and all the systems are functioning smoothly.

Also read:

‘Bhilwara Model’ for containment of coronavirus

Bhilwara in Rajasthan was one of the early hotspots of the COVID-19 outbreak. The government responded with extraordinarily aggressive measures — and the ‘Bhilwara model’. The success of the model is attributed to the fact that Bhilwara, which was the first district in Rajasthan to report most number of covid cases has now reported only one positive case since March 30.

What is the Bhilwara Model?

• The Bhilwara COVID-19 containment “model” refers to the steps taken by the administration in Rajasthan’s Bhilwara district to contain the disease, after it emerged as a hotspot for coronavirus positive cases.
• Bhilwara district was among the most-affected places in India during the first phase of the COVID-19 outbreak.
• The measures taken by the state govt. included imposing a curfew in the district which also barred essential services, extensive screening and house-to-house surveys to check for possible cases.
• It went for detailed contact tracing of each positive case so as to create a dossier on everybody they met ever since they got infected.

What did the administration do as part of the containment strategy?

• The “Bhilwara model” of tackling COVID-19 cases involves, simply, “ruthless containment”.
• Within three days of the first positive case the district health administration in Bhilwara constituted nearly 850 teams and conducted house-to-house surveys at 56k houses and of 280k people.
• Thousands were identified to be suffering from influenza-like illness (ILI) symptoms and were kept in home quarantine.
• Intense contact tracing was also carried out of those patients who tested positive, with the Health Department preparing detailed charts of all the people whom they had met since being infected.
• The state also took the help of technology, using an app to monitor the conditions of those under home quarantine on a daily basis along with keeping a tab on them through GIS.
• The administration backed up the surveys by imposing a total lockdown on the district, with the local police ensuring strict implementation of the curfew.
• The patients were treated with hydroxychloroquine (HCQ), Tamiflu and HIV drugs.

What were the challenges the administration faced in imposing these extraordinary measures?

• The biggest challenge that the administration faced was containing the rising number of cases after the initial outbreak.
• The doctors of the private hospital who had tested positive had come into contact with numerous people including the staff and patients who visited the private hospital during the period when the doctors were already infected.
• Some of these patients had come from other states and after the first case of COVID-19 was detected.
• The government also had an uphill task ahead of them assembling the teams of doctors, auxiliary nurse and midwives and nursing students who went to conduct the house-to-house surveys.
• Owing to the fact that Bhilwara, a thriving textile city with an estimated population of 30 lakh, it was also a difficult task for the government to strictly impose the curfew uniformly in all areas.

Context

As India enters the second week of a national lockdown imposed in response to COVID-19, it is still unclear how well prepared the healthcare system is in dealing with the pandemic.

Need for roping in the private healthcare

• No indication of an increase in expenditure on health: A preparedness plan has to address all levels of care in terms of infrastructure, equipment, testing facilities and human resources in both the public and private sectors.
• However, so far, the Central and State governments have given little indication of bringing an increase in public expenditure on health.
• So, an already overburdened public health system will be unable to meet the increase in moderate and severe cases of COVID-19 that would require hospitalisation.
• Need for the comprehensive national policy: While some individual private sector companies have come forward with offers of creating capacity and making it available to COVID-19 patients, there is a need for a comprehensive national policy to ensure that private healthcare capacity is made available to the public.
• Some states like Chhattisgarh, Rajasthan, Madhya Pradesh and Andhra Pradesh have already roped in the private sector to provide free treatment.

What the government should do?       

• Provide universal health service: The governments at the Centre and in States have to take responsibility for providing universal health services free of charge and accessible to all.
• Tap into private sector capacity: This will require governments to not just expand the capacity within the public sector, but also to tap into the available capacity in the private sector.
• Faced with a serious health emergency, the silence of the government on the expected role of the private sector is intriguing.
• Include COVID-19 testing in PM-JAY: The National Health Authority has recommended that the testing and treatment of COVID-19 be included in the PM-Jan Arogya Yojana (PM-JAY) but this proposal is still awaiting clearance.
• Form the central command: The governance of the health service system is clearly fragmented and has created anxiety among the public.
• There is a lack of a visible central command, which should be created under the supervision of the Union Health Minister, aided by a team of experts.
• They should be tasked to make policies as and when required and communicate them to State governments, taking into account an evolving situation.
• Ensure that there is no cost to the patient: There have been some tentative measures taken by States to allow individuals seeking testing for COVID-19 to access private laboratories at subsidised rates.
• At present, the government has put a cap on the cost at ₹4,500 per test, which is a burden for even a middle-class patient.
• The poor will clearly have no access to this and the government itself does not have adequate facilities to meet the increasing demand. It is here that the government needs to ensure that there is no cost to the patient.
• Create adequate testing facilities: At this point, and certainly, before the lockdown is lifted, it is absolutely essential that adequate testing and quarantine facilities are created.
• The Central government has already taken over some private hotels to accommodate persons quarantined for COVID-19.
• One way of expanding such facilities would be for the government to ‘take over’ private corporate laboratories and hospitals for a limited period.
• Standard treatment protocol: The political directive for such a move needs to come from the Central government while ensuring that the Ministry of Health provides standard treatment protocols for health personnel.

Learning lessons from Spanish and British experience

• The Spanish government issued an order bringing hospitals in the large private corporate sector under public control for a limited period.
• This tough decision was taken with the understanding that existing public healthcare facilities would not be able to cope with the sudden, if short-term, rise in COVID-19 cases.
• British trade unions have demanded that the government make the 8,000 beds in 570 private hospitals in the country available.
• They have argued that while beds in private hospitals are lying empty, there is a severe shortage of beds in public hospitals.
• The unions have also been critical of the U.K. government decision to rent these beds at an exorbitant cost to the exchequer.

Way forward

• Rope in the private healthcare sector: In India, private corporate hospitals have, in the past, received government subsidies in various forms and it is now time to seek repayment from them.
• They are also well poised to provide specialised care and have the expertise and infrastructure to do so.
• Bring in the universal public healthcare: Universal public healthcare is essential not only to curb outbreaks but also to ensure crisis preparedness and the realisation of the promise of the right to health.