Andhra Pradesh is seeing a steady rise in COVID-19 cases every day, with the government massively ramping up the number of samples tested in the past few weeks. On Tuesday alone, 7,727 samples were tested. However, Chief Minister Jagan Mohan Reddy has said that the increased testing has provided a clearer picture of the situation in different zones, and has indicated that the lockdown is likely to be lifted soon in green zones - areas where no new COVID-19 cases have been reported in 28 days. PV Ramesh, Additional Chief Secretary to CM Jagan, and former Principal Secretary of Department of Health and Family Welfare (in united Andhra Pradesh), spoke to TNM about the state’s testing strategy and capacity, long-term preparedness in dealing with future spike in cases, and life after lockdown.
Andhra Pradesh is now one of the states with the highest tests per million population in the country. How was the testing capacity increased so quickly?
So far, we have tested about 75,000 samples altogether. When we started, we didn’t have a single testing laboratory in the state. We had to send the samples to Pune or to Hyderabad. Now we have 9 fully functioning PCR testing labs.
Moreover, we are using the TrueNat tests. We have 240 TrueNat machines which were set up for the Tuberculosis Control Program. The methodology is similar (to RT PCR). We extract the nucleotide, whether it is a bacillus or virus. If it is provisionally positive, that is, if it confirms that there is a nucleotide, then we go and check with the RT-PCR (real-time reverse transcription polymerase chain reaction) test.
We are also using the pooling method, where you pool 2-5 samples and test them together — particularly people who are clustered together — so that you can save on the reagents. Then if that pool is tested positive, everyone is tested separately. So it is a two-time test in that sense, if it is positive. That is how we have increased the testing rate.
It was also about setting up the labs. You need laboratories with all the biosafety protocol, you need microbiologists and virologists who understand how to interpret a test. You need samples to be transported very quickly. This is not a difficult task.
Particularly the TrueNat tests, which were already available, have been used for screening. That has added to the numbers.
So it’s been a result of opening up a large number of ICMR certified labs, faster collection of large numbers of samples, pooling methodology and TrueNat tests.
Special Chief Secretary (Health) Jawahar Reddy has indicated that about half the tests being done daily are TrueNAT tests. Recently, in Vijayawada, a man who initially tested negative for COVID-19 later tested positive. The hospital authorities have said that the initial test was performed by TrueNat, which gave a false negative result. They also said that TrueNat tests only have a 33 percent accuracy rate. Why, then, is Andhra using TrueNat for testing? Is the low accuracy rate cause for concern?
Both RT-PCR and TrueNat are antigen tests. TrueNat is a screening test which only tells you that a nucleotide is present. It does not tell you whether it is coronavirus or some other virus. Then you send it for a confirmatory test with RT-PCR. It’s not that we don’t have enough testing kits, it’s just that they (TrueNat) improve your capacity of testing.
With RT-PCR, the good thing is that it does not generate false positives. If I do not have the infection, it doesn’t say I have it. So it doesn’t cause panic.
On the other hand, RT PCR also does give false negatives. Even if I have an infection, I can be tested negative. This could be either because the sample is not collected properly, or the virus concentration is lower, or because too much time has lapsed by the time the sample reaches the laboratory. There are so many things that can contribute to a false negative.
This means the doctor or clinician who is testing, has to be conscious enough, knowledgeable enough and appreciative enough to read the test correctly. What I mean by that is, it has to be correlated with contact history, with where the person (being tested) lives, whether they are in a high risk category, whether they have symptoms or have come in contact with people who have symptoms. Then the test needs to be repeated.
So a negative does not always necessarily mean that the person does not have the virus. When a negative test comes, it has to be correlated with the symptoms.
What is our strategy then, while testing such a large number of samples, to identify these false negatives?
One of the flipsides of doing a large number of tests is we could miss out on the finer points. If I am testing 7,000 samples, I don't have as many doctors to interpret the data in realtime, and to advise that this person needs repetition and this person does not.
Considering the number of public health experts, epidemiologists, and infectious disease professionals we have, we are positioned in difficult circumstances, where this pandemic has hit us like a tsunami. I think we are doing the best that is possible.
While testing, there are two important things — sensitivity and specificity. With RT PCR, it is specific to the particular virus SARS-CoV-2 which causes COVID-19. The sensitivity is about 67 to 70 per cent, that is the nature of the test.
So if I am testing 1,000 samples, and I get 50 positive results, it’s quite possible that I might have missed out on another 20-25 positives. The challenge is that we don’t know which of the remaining 950 samples are these 20-25 samples.
So ideally, we try to identify those 20 people who are otherwise showing signs and have not yet been identified among the positives. That is an ongoing process. It is possible that when there are 5.4 crore people, some may be slipping through the sieve. We are trying to do our best to see that false negatives are minimised.
CM Jagan has said that 70 per cent testing is being done in red and orange zones (areas where there haven’t been a case in 7 days) alone.While very few new cases have been emerging from the outside red and orange zones, what is the testing strategy for various zones? Is there a possibility of overlooking the spread in green zones by testing less?
Right now as we speak, yes, there has been strong control over the red and orange zones in the state, since people are not moving much. We need to understand that it’s a dynamic situation, but as we speak that’s how the situation is. The bulk of testing is happening here.
We are testing a large number of people, so if I am testing 10,000 samples a day and 70 per cent from red and orange zones, I am still testing 3,000 a day in green zones, which is still a large number.
While we do need numbers to measure the disease spread, how many people are recovering, serious, dying — it is important for planning and management — we also need to remember that every patient is important. Unless there is a strategic framework for testing, the numbers aren't very useful. It is important that we ramp up testing but at the same time, we have to have a strategy. Andhra Pradesh has a strategy for how to test and when to test.
What have been the challenges so far in containing the situation in the state?
Ultimately, containment of the pandemic depends not only on the measures taken by the government but also on the measures taken by the people. By and large, the people have been complying, they’re maintaining social distance. But there are also people breaking all rules, crowding, rushing, not maintaining distance and hygiene parameters. That is one big challenge, to educate people, spread awareness and to ensure that people take responsibility for their actions.
The other challenge is the government’s part. Infrastructure is easy to create, but how do we get the human resources — nurses, doctors, lab technicians, virologists — all those who are essential for treating critical care patients. That we cannot produce overnight. We are doing our best, by bringing in doctors from private and public sectors, and training them.
The third aspect is the economic challenge we are facing, with the situation in which the people, particularly the poor and those who are dependent on daily wages, are in. For this the state has made necessary arrangements in terms of providing a certain amount of cash in hand, and also providing rice and dal, and ensuring restarting of NREGS work.
CM Jagan has said that the green zones in the state must return to normalcy and resume economic activity soon. How does lifting of lockdown look for these areas?
That is specific to each of the green zones. People would still have to take all necessary precautions in terms of minimising the spread, and get back to work as the industries and services require.
We will follow the Government of India directives, but those in green zones must protect themselves.
There must be certain limited movement. Not random public transport, but selective movement. It will be a very calibrated type of movement rather than an open-for-all situation.
Given that experts are saying there could be another spike in cases once lockdown is lifted, how is Andhra Pradesh planning to contain cases in the long run?
This is a virus which will be around with us for a long time. CM has said we need to learn to live with this reality. The spirit of it is really how do we coexist.
We expect a surge in cases following relaxation of lockdown. We can't have a perpetual lockdown. There is a need for balancing lives and livelihoods. Livelihoods are equally important, at the same time we can't sacrifice lives for want of proper healthcare.
So one of the purposes of the lockdown has also been for the government to build capacity to manage critical cases. So we are certainly building that capacity, and we will continue to build it.
We expect the resumption of economic activity slowly. It may not be like what it was before. I believe that people will change their behaviour for the better — wearing masks , keeping away from each other, not attending crowded places. There will be certain COVID-19 cases, which we will be able to trace and track and test and treat.