There are two major defects that the Central team led by Dr S K Singh, director of the National Centre for Disease Control, had found in Kerala's COVID-19 response strategy.
One was what it called the disproportionate reliance on rapid antigen tests. And two, the virtual absence of contact tracing.
Health experts Onmanorama talked to had no problem with a higher number of rapid antigen tests (RATs) than RT-PCR (Reverse transcription polymerase chain reaction) tests. "It would be foolish to upset the balance of our testing tools. At a time when the case load is very high, using more RATs will improve the efficiency of our prevention strategy. It gives quick results and is a better bet to identify high viral loads," said Dr K P Aravindan, noted pathologist and a member of the Kerala Government's COVID-19 advisory group.
However, even government doctors, concede that no contact tracing worth mentioning is taking place in Kerala.
Missed contacts
"There is huge fatigue among health workers and panchayat officials. They are just not demonstrating the kind of initiative they have shown in the initial stages of COVID-19 when Asha workers and junior health nurses, and even the police, fanned out with great urgency in search of contacts. Now the daily cases are so high that the tracing of contacts is seen as even impossible," a top health department official, who doesn't want to be identified, said.
The central team has recommended a contact tracing ratio of 1:20, which means at least 20 contacts of a person declared positive should be traced. In Kerala, the ratio is a woeful 1:1.5, meaning not even two contacts of a COVID positive patient are being traced.
A place to stay
Even assuming that contacts are diligently traced, what happens after is the big question. "Where are you going to lodge them, especially the mild symptomatics and the asymptomatics," the official asked. "Most of our CFLTCs (Covid First-Line Treatment Centres) have closed down. This is the case of even our domiciliary care centres (where asymptomatics with no quarantine facilities at home are supposed to move into)," the official said.
The CFLTCs, which had in the last year opened in almost all local bodies in Kerala, have now dwindled to less than 130.
Home alone
Patients, too, are unwilling to shift to CFLTCs. "Some of the CFLTCs we still have have just three or four patients. There are demands to shut them also. We are holding discussions at the ward level on the future of these CFLTCs," said P Jameela Sreedharan, Thiruvananthapuram Corporation's health standing committee chairperson.
The other day, health minister Veena Goerge lamented that COVID transmission was happening in a big way within homes. She said over 35% of cases were accounted for by home transmission.
That contact tracing has weakened in Kerala is acknowledged. As for the other major defect pointed out by the central team, the seeming overreliance on RATs, it is widely seen as no defect at all.
Sense and sensitivity
The charge is that the RAT's sensitivity (ability to pick the viral presence) is low compared to the RT PCR test and, since over 60% of daily tests in Kerala are RATs, it is said the number of false negatives will be high. "We will have infected people going out into the society unintentionally believing they are negative," is how opposition leader V D Satheesan put it.
Experts brush aside the argument, saying a larger proportion of RAT is more sensible. "Kerala does testing in a very targeted manner. It tests people with heavy symptoms and also the most vulnerable. In other words, the tests are done on people with a very high viral load. When the viral load is high, the sensitivity of both the RT-PCR and RAT are almost the same. RAT sensitivity is relatively weak only when the viral load is low," said Rajeev Sadanandan, former health secretary.
This commendable sensitivity of RAT when the viral load is high also suits Kerala's prevention strategy. "Our objective is to isolate patients when they are infective. RAT unfailingly picks high viral load. RT-PCR tests, on the other hand, show positive even after the patient has long ceased to be infective. It is so sensitive that it picks signals from even viral litter," Dr K P Aravindan said.
In addition, RAT can be done without much fuss. "It can be done anywhere and you don't even require trained personnel to conduct a RAT," Dr Aravindan said. The RT-PCR tests are elaborate and have to be done in labs.
RT-PCR and delayed results
"At the moment, we conduct between 25,000 to 30,000 RT-PCR tests daily in the 40-odd labs that we have. This is the full utilisation of our capacity and more RT-PCR tests beyond our existing lab capacity would lead to a delay in the announcement of results," said community medicine expert Dr Aneesh T S.
"There was a time last year when we had a lesser number of labs and the results used to take four to five days to get published. And in this interval, even those who were actually positive moved around like it was normal transmitting the virus," he said.
The RAT is not just cost-effective, it gives the verdict in 15 minutes flat. "So RAT is ideal to take quick decisions," Dr Aneesh said.
