Thousands of coronavirus cases may be silently spreading through India’s cities as efforts to trace the contacts of people who have tested positive for covid-19 have not been nearly as thorough as they need to be, public health experts said.
States with high infection rates such as Maharashtra and Delhi are testing very few contacts for every confirmed case. There is a large variation between states in the number of contacts being tested. While Delhi tested just 2.1 contacts per confirmed case, Maharashtra did 2.3, West Bengal 3.4 and Bihar 5.9, according to data released a week ago by the Indian Council of Medical Research (ICMR). Karnataka has tested 47.4 contacts and has fared much better than others.
“Contact tracing is not happening the way it ought to be as the growth rate in positive cases has not declined in India. I feel the situation will only worsen. The testing rate has to go up considerably, for which tracing is paramount. At present, even those with mild symptoms are not being tested,” said Dr Prakash Chandra Gupta, director, Healis Sekhsaria Institute of Public Health, Navi Mumbai, and visiting scientist, Harvard TH Chan School of Public Health.
Health experts fear the lifting of the 75-day lockdown will further complicate efforts to stem the spread of infections as people visit crowded places such as malls, temples and shopping complexes. Although India has somewhat slowed the pace of new infections, it has failed to flatten the covid-case curve as well as some other countries have despite one of the most stringent lockdowns. Nearly 10,000 new cases were reported across India in 24 hours as of Tuesday morning.
Efforts to curb infection rates, including testing and contact tracing, have varied across states as India doesn’t have enough trained workers to do primary tracing and re-check those traced, or enough rapid response teams with doctors and epidemiologists who can confirm a positive case, said Dr Jugal Kishore, a member of the Centre’s rapid response team for covid-19 and head of community medicine at Safdarjung Hospital, Delhi. “Our focus has always been on testing rather than primary prevention. It’s also true that when more than 30% of people are asymptomatic, contact tracing is a challenge,” he said. “What we need now is secondary prevention—early diagnosis and treatment.”
States witnessing a rise in the number of cases and struggling to identify source of infections—Maharashtra, Delhi, Odisha, Bihar and West Bengal—need to be pushed hard to do aggressive contact tracing, experts said.
“Manpower continues to be a big challenge in the healthcare industry,” said Dr Giridhar R. Babu, professor and head, life course epidemiology, Public Health Foundation of India. “Even during the pandemic, crucial posts in government hospitals have remained vacant. The challenge post-lockdown is to trace clusters and monitor unprotected behaviour. It is also important to have a solid plan for reverse quarantine.”
The coming weeks are crucial as people are returning to work and businesses are opening up. “The only good thing is that among those who are getting tested, the positivity rate is less than 6%, compared to some major countries,” said Dr Gupta.
Contact tracing is critical, as a Johns Hopkins study has showed that each infected person can spread the virus to two or three others. This means that if one person infects three others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections.
“India cannot shift focus from contact tracing at this time. The cluster containment strategy in Unlock 1.0 needs vigorous contact tracing and we are capable of it,” said Dr Prasanta Mahapatra, dean, Institute of Health Systems, Hyderabad. He said India demonstrated this in the first and second phases of the lockdown, but the administration has gradually slackened. “The Centre is now putting the onus of containing the virus on states.”
States need to widen testing to understand the true number of cases. Dr U.S. Vishal Rao, a member of the covid-19 consultative group to the principal scientific advisor for government of India, said: “There is a gap between performing and non-performing states in contact tracing. This is dangerous as citizens have begun to move from one state to another and we are unable to identify the source of infection and arrest it.”
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