Analysis

India recorded its first COVID-19 case on January 30. A student from Kerala state enrolled at university in China's Wuhan city, where the outbreak began, tested positive for the disease upon her return home.

It took about forty days from January 30 for the number of confirmed cases in India to reach 50. The figure doubled to 100 after another five days.

The health ministry today said India had recorded 724 confirmed cases, of which 17 have resulted in fatalities.

Testing shortfall

The figures released by the Indian government probably hide the true extent of community spread of COVID-19, since the country has thus far followed very conservative testing parameters.

The World Health Organization (WHO) has strongly urged that testing for COVID-19 be conducted as widely as possible. If contacts of a confirmed case are tested in addition to symptomatic individuals, authorities can detect and quarantine even asymptomatic carriers of the disease.

As of March 25, India had tested just over 25,000 samples.

South Korea, in contrast, has tested as many as 300,000 people out of a population of roughly 52 million. South Korea has recorded more than 9,000 cases of COVID-19 and 139 deaths, but its government has attracted widespread praise for "flattening the curve", ie, reducing the rate of new infections.

As cases in India have grown, the Indian Council of Medical Research (ICMR) has revised its testing parameters. It now recommends testing for "asymptomatic direct and high-risk contacts of a confirmed case" in addition to symptomatic individuals with or without travel history.

The Indian government says it has the means to conduct 60,000-70,000 tests per week, but less than 10% of that capacity has been used to date.

More facilities are being allowed to administer COVID-19 tests. Testing can now be conducted by some 119 ICMR-approved government laboratories and nearly 30 private laboratories. Some 17,000 collection centres for test samples have also now been approved.

India has been sourcing COVID-19 testing kits from abroad, but Mylab Discovery Solutions, a locally based molecular diagnostics company, has now received statutory approval for its kits. Mylab claims it can manufacture up to 15,000 kits per day. It suggests it can increase that number to 25,000 per day if required.

Mylab says its kits can give results within two and a half hours.

Other locally based firms are also seeking approval for their kits.

Lockdown confusion

Even if the government increases testing for COVID-19, the lockdown could make it harder to ensure testing is done, unless authorities resolve confusion over the restrictions now in place.

The home ministry's guidelines on the lockdown make it clear that all medical establishments and associated manufacturing and distribution units will continue to function, but manufacturers of testing kits have encountered difficulties. They are in some cases unable to transport products to different centres due to several states closing their borders. People employed in the manufacturing plants have been unable to get to work.

Manufacturing of other equipment crucial to critical care, such as blood bags, has also been affected by the lockdown.

Meanwhile, India's ban on international flights, imposed earlier this month, has made it hard to import key parts for manufacture of ventilators.

Unless obstacles to greater testing are overcome, even drastic curbs on movement across the country will only have a limited impact in combating the spread of COVID-19. In India's many slums, it will be almost impossible to ensure effective social distancing (see INTERNATIONAL: Pandemic declaration may be late - March 12, 2020).

Since many Indian households are multigenerational, it is also difficult to isolate older people who are more vulnerable to the disease.

Healthcare capacity

If India were to have a large outbreak of COVID-19, its suboptimal healthcare infrastructure would be overstretched and unable to cope (see INTERNATIONAL: Virus may overwhelm advanced systems - March 19, 2020).

The WHO currently says the disease's case fatality ratio is 3.4%. If India were to have 1 million cases by the end of May, which is possible given its current trajectory, there could within that time be more than 30,000 deaths from the disease in the country.

According to 2017 OECD data, India has 0.5 hospital beds per 1,000 people. There are no exact figures available for critical care beds in India, but it is estimated that the country has up to 70,000 of these. India probably has only around 40,000 ventilators.

The government has issued an advisory to all public and private hospitals and medical education institutions to prepare for higher volumes of COVID-19 cases in the coming days. It urges them to set aside beds, arrange for isolation facilities and procure enough high-flow oxygen masks.

Hospitals will inevitably have to mobilise additional manpower to cater for the needs of patients. They will also count on milder cases being taken care of at home, so that admissions are reserved only for critical patients.

Meanwhile, the government has attracted criticism for delays in procuring personal protective equipment (PPE) for its frontline healthcare professionals. India has a shortage of N95 face masks and body coveralls for doctors and healthcare workers. The community spread of the virus is being tracked by community health workers who are being sent into the field without protective covering.

Despite the WHO having urged all countries to increase PPE production by 40%, and other countries completely banning the export of PPE, India continued to export some protective gear until the middle of this month.

Finance Minister Nirmala Sitharaman yesterday presented a 1.7 trillion-rupee (23-billion-dollar) package of economic support for workers affected by the COVID-19 lockdown in which she provided medical insurance cover of 5 million rupees for every health sector employee at the front line of the fight against the disease.

However, this will not assuage concerns about the lack of PPE for healthcare workers.