Testing and Tracing: Case for a Relook
The Drug Controller General of India has given emergency approvals to vaccine candidates being manufactured in India. The Government of India is also keen on a nationwide rollout through a mass vaccination campaign. While the focus should be on ensuring an effective and equitable strategy for vaccine deployment, India must also align its resources to ensure a good test and trace strategy is in place to mitigate the risks of vaccination.
Even post-vaccination, there is a possibility of a new virulent strain spreading the infection. States failing to trace over 500 potential carriers of the highly transmissible UK strain shows that there are gaping holes in India’s strategy to combat the pandemic.
The World Health Organisation (WHO) maintains that testing and tracing contacts is a reliable strategy. Even, in economic terms, it is a low-cost tool for containing the infection that is highly effective as compared to other interventions.
As the world reconnects through the movement of people, more strains will emerge. Without a good contact tracing machinery in place, valuable time will be lost in recognising if the infections are a result of a new strain or old one.
This document reviews India’s current strategy to test and trace individuals with COVID-19 infections and suggests recommendations for improvement.
Testing
Technological advancements over the last three decades have ensured that reliable testing tools (RT-PCR, antigen and antibody tests) were available in a matter of months from the index case of COVID-19. However, the Indian response has been poor due to multiple factors.
Extrapolating from the experiences of countries in Europe and the UK, the government prioritised the purchase of ventilators and reserving beds. While this was a proactive effort, the immediate focus should instead have been on first testing and identifying the infected to contain the pandemic rather than treating those who were infected. As a result, India faced a shortage of testing capacity leading to rationing of kits. This jeopardised attempts to accurately trace the spread of the pandemic. The SOPs released by the Ministry of Health have relied heavily on disease symptoms as a measure of the spread of the infection. The insistence to initially test only symptomatic patients, allowed a large base of potentially infectious individuals to further spread the virus.
A study by the Indian Council of Medical Research (ICMR) for the period of January-April 2020 shows that the contact tracing history was unknown for 56.7% of the tests. The Indian Statistical Institute in Bengaluru found that between March and July 2020, 93% of confirmed positive cases did not have a known infection source. This data strongly suggests that testing without contact tracing did not help contain the pandemic despite the high number of tests that India now conducts daily.
Without fixing these issues, the increased number of tests per day offers lesser advantage since good policy decisions cannot be made with incomplete data. The testing activity must complement contact tracing efforts so that infected individuals can be effectively isolated and treated. Using mass testing as a substitute for contact tracing is poor policy since we have no idea where the next case is likely to come from.
As the pandemic has progressed and more providers of RT-PCR tests have entered the market, the cost of testing has reduced. But in order to make testing more affordable, Indian state governments have introduced price caps on multiple occasions on these tests. After a certain price point, private providers do not have sufficient margins to continue offering the tests and leave the market. The testing capacity drops and it is no longer possible to conduct more tests. If cases continue to rise, they will quickly overrun the testing capacity and India will completely lose control over the spread of the disease. This is exacerbated by the problem of limited contact tracing highlighted above.
Recommendations for improving testing
All contacts must be traced and tested irrespective of their symptomatic status. Data on how many contacts were successfully traced must be collected and analysed periodically.
Some Indian states still require a doctor’s requisition for a COVID-19 test, even though ICMR withdrew this requirement in July. The state of Gujarat removed this requirement only on December 4.
Frequent government intervention in the price of tests, while ostensibly making testing more affordable, end up pricing manufacturers out of the market and reducing the supply of tests. The market should be encouraged to instead lower prices through competition and innovation to ensure easy and affordable access to tests.
Testing must be done using RT-PCR or antigen kits with good sensitivity and specificity. In the past, ICMR validated kits did not fare well on these parameters. A higher standard needs to be set for ICMR validation to ensure that kits are of a higher quality, thus improving the quality of testing in the country.
Contact Tracing
At the epicentre of COVID-19 outbreak in Wuhan, Chinese health officials formed 1800 contact tracing teams of five members each and traced over 685,000 contacts to bring the cases under control. The population of the city is 11 million, which means they had one contact tracer for every 1200 citizens. An app was used to ease the workload of the contact tracers, but the tracing itself was done by humans. Iceland is currently using an AI-powered app for remote contact tracing. At the beginning of their outbreak, before the app was even rolled out, contact tracers had successfully quarantined more than half their cases,. Cases in Wuhan and Iceland are under control.
Even in the Indian context, contact tracing cases provided valuable information about the likely spread of the disease early on. Instances of index cases in Kerala and Telangana demonstrated the effectiveness of this approach. When India’s nationwide lockdown was announced, effective contact tracing could have brought the infection under control. However, as evident from the MoHFW and NCDC websites, staff training for contact tracing and the SOP release happened well after the lockdown was in force.
Contact tracing is a resource-intensive exercise, and lacking these resources initially, the Ministry of Health first selected Accredited Social Health Activists (ASHA) volunteers to shoulder this massive task. By the time strategy implementation began, the number of actual cases had increased. Following Singapore’s lead, India began its own experiment with a technocratic solution for contact tracing, an app called Aarogya Setu. Between April and July 2020, the government also spent over four crorerupees to promote the adoption of the app, apart from declaration of its mandatory use in many places.
However, due to the lack of a high number of smartphone users in the country and privacy concerns regarding the data gathered by the app and its usage, the active users of the app never reached the critical number of 60% that would make the app effective. The experiences of other countries who used this approach also shows that by no measure is an app an effective replacement for conventional contact tracing.
After Aarogya Setu’s failure in arresting cases, the burden of contact tracing fell back on volunteer ASHA workers, who already work in ten major areas of healthcare at a monthly honorarium of Rs. 2000 with performance-based incentives. As an added incentive during the pandemic, some states increased the honorarium to Rs. 4000. Some states tried to bring in medical students to add human resources to the exercise. However, as cases continued to swell, medical students returned to hospital settings, leaving heavily burdened, poorly incentivised volunteer workers alone to carry out the most important tasks of contact tracing.
In the view of cases surging beyond the contact tracing capacity of existing ASHA workers, most states dropped contact tracing by July. This prompted the central government to publicly ask states to trace 80% of the contacts within 72 hours. At this point, India’s case tally stood at over 760,000 confirmed positive cases. However, without an increase in capacity, and with no help from the central government, this task could not be taken up and cases continued to rise.
The lack of adequate personnel protective equipment (PPE), meagre incentives as volunteers, and the inability of the Union and state governments to prevent the deaths of ASHA workers during the pandemic resulted in them going on strike work in August and derailing existing contact tracing exercises.
As of this writing, there is no central or state-wise dashboard for the contact tracing efforts being conducted in the country. There is no measure for how many contacts have been successfully traced, how many are symptomatic, asymptomatic or infected, how many have not been successfully traced, contacted and informed or how many are not following quarantine rules.
Without this essential data, India will never be able to ‘chase the virus’ and always end up on the losing side of the pandemic. Efforts must be made to gather as much data as possible about the spread of the disease, analyse it, learn from it, correlate it with experiences of other countries, and rapidly adapt them to make our strategies more effective.
One report of contact tracing efforts in Tamil Nadu and Andhra Pradesh provides a very important insight. Through rigorous testing and contact tracing systems, the teams have arrived at the conclusion that just five per cent of infected individuals are responsible for 80% of the following cases. A similar study in Japan also arrived at a similar conclusion that 10% of the infected cases were responsible for 90% of further infections. This shows that a contact tracing system need not be perfect. Even a good system that traces most of its listed contacts can provide great benefits and help substantially curb the spread of the infection.
The current SOP dictates that contact tracing is activated after a symptomatic case is found positive. Contacts are then traced forward from the time of onset of symptoms, but no efforts are made to find out how the individual became infected. Strategies used in Japan and in Massachusetts in the US show that determining the source of the infection can help in identifying many more cases that would have been left out, if only contacts of identified positives are traced. While this strategy requires more resources, it is more useful in curbing the infection. Experiences in both these countries have shown that in most cases, backward tracing reveals a cluster where people gathered in indoor settings. This approach of tracing all individuals in that cluster is called cluster busting and provides better benefits than forward tracing of all contacts of a positive patient with an unknown source of infection.
Months after calling off their strike, the demands of ASHA workers are still unmet. Moralising this workforce again will be a key challenge that needs to be addressed at a high priority.
To prepare for the challenges ahead, the government needs to relook at its strategy of testing, tracing and isolating, with importance being given to human contact tracers, reviewing their performance and analysing the data to make improvements to this strategy. Contact tracing is not just a task to be completed by the health authorities but an objective that can be completed by building trust and engaging the community. Local participation is key.
Recommendations for improved contact tracing
Contact tracing is the most important lever in this strategy and needs fixing for short term and long term benefits.
Short Term Recommendations
The MoHFW must implement contact tracing that includes ALL contacts of a confirmed positive case, whether classified at high risk or low risk, symptomatic or asymptomatic.
Contact tracing efforts must also work to narrow down the cause of the infection.
A time-bound target to establish and trace these contacts must be established and data pertaining to these targets must be released publicly, similar to testing data being released by ICMR. Indicators such as the number of contacts of a confirmed positive case, those that were successfully contacted, those who could not be contacted, those who were contacted but remain untraceable or not quarantining etc need to be monitored to understand how and why the disease is spreading. It will also provide valuable information about the reasons for failures of contact tracing programs and help in taking steps to address them.
It is likely that failures for contact tracing will come from the following major areas
Funding: As economic activity has resumed, both state and central governments should be in a position to dedicate more funds to this effort. Contact tracing remains a low-cost intervention for containing the spread of the infection.
Trust: Experiences of contact tracers have shown that communities with high numbers of infections are averse to sharing details of their whereabouts. Efforts must be made to involve community leaders and local medical practitioners to gain trust and convey the importance of the exercise. Use of force is unlikely to bring any gains.
Capacity: There are several limits to the capacities of volunteers. A temporary workforce can increase capacity and can be quickly raised from within the local community. A work guarantee scheme on lines of the MGNREGA can be brought into force for the duration of the pandemic providing temporary wages to locals as well as added incentive to trace contacts. These can be foot soldiers who can be minimally trained by experienced ASHA workers and work under the guidance almost immediately.
Long Term Recommendations
1. Increase Incentive, Reduce Burden
Since the program was brought into force in 2005, responsibilities of ASHAs have been on the rise. Currently, their responsibilities are divided under ten different programmes/ areas ranging from sanitation to vector-borne disease control apart from maternal and child health. Recently, an added responsibility of monitoring non-communicable diseases in adults over 30 years of age was added to the list.
The ASHA program has been successful in its state goals so far. But we cannot risk a total burnout of the program by adding new responsibilities without taking anything away.
Taking into account the rise of non-communicable diseases in the country, ASHA workers could be entrusted with the task of monitoring them and working with the community to counter risks and bring about behavioural change. The task of monitoring communicable diseases can be shifted to a specialised ground force for Infectious diseases.
2. Create a Ground Force for Infectious Diseases
The World Health Organisation recommends one contract tracer per 1000 population. For a population of 1.3 billion, India needs 1.3 million contact tracers. Instead, we asked ASHA workers to double up at short notice.
1.3 million contact tracers would be responsible for contact tracing for current COVID-19 cases. In the future, they will be repurposed as a ground force for preventing all communicable diseases in the country. This will be achieved by focusing on immunizations as well as outbreaks such as Nipah that occurred in Kerala or hepatitis or even tuberculosis that has over 2 million active cases in the country.
The government could engage private sector entities through contracts; setting goals on an annual basis and rewarding performance by continuing contracts with these providers. The staff can be trained by their employers and their competency measured through audits and the ability to control outbreaks in local regions.
Central and State governments have allocated fair resources to the isolation of infected individuals. Using event venues to trains as isolation wards, the government and private sector have worked in tandem to provide isolation beds and kits to infected individuals and their close contacts. Issues with their maintenance have prompted people to isolate at home instead. These are easy to fix issues and governments must ensure that existing facilities are used to maximise benefits of isolation by alleviating people’s fears.
To conclude, the government and health authorities must use the pandemic as an opportunity to reassign the workload of handling infectious diseases to a dedicated team of workers. This will also function as an early detection system and contain outbreaks in the future.
