On Tuesday, 4 May, The Indian Council of Medical Research (ICMR) issued new guidelines for COVID testing in the country.
The advisory recommends against repeating RT-PCR tests, and lists the different scenarios where the tests may be foregone.
These guidelines have been updated keeping the ongoing COVID crisis, in an attempt to reduce the burden on laboratories due to an increase in caseload.
Is reducing RT-PCR tests at this stage of the pandemic a good idea? FIT asks Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University, and Dr Swapneil Parikh, an internal medicine specialist in Mumbai and author of ‘The Coronavirus: What You Need to Know About the Global Pandemic’.
What Do the New Guidelines Say?
First, let's go over the guidelines themselves.
In a bid to optimise the use of these tests, the ICMR has advised that one would no longer need to get an RT-PCR test done,
- When a COVID patient is being discharged.
- If a Rapid Antigen Test, or a previous RT-PCR test has found them positive.
- When a healthy individual is travelling across states.
With the last point, the advisory adds, "non-essential travel and interstate travel of symptomatic individuals (COVID-19 or flu-like symptoms) should be essentially avoided reducing the risk of infection."
ICMR also adds that COVID-appropriate behaviour must be followed by all asymptomatic travellers.
At present, the laboratories are facing challenges to meet the expected testing target due to extraordinary case load and staff getting infected with COVID-19. In view of this situation, it is imperative to optimize the RTPCR testing.Indian Council of Medical Research (ICMR)
To this, they have added that they simultaneously aim to increase the access and availability of testing to all citizens of the country.
What do Experts Think of These Guidelines?
When it comes to completely removing the need for RT-PCR tests for inter-state travel, Dr Parikh doesn't agree with the move.
There is some amount of essential travel that’s going to be needed, and for anyone that’s travelling, an RT-PCR test close to when they’re travelling is very helpful in controlling the spread of the infection.Dr Swapneil Parikh, Internal medicine specialist, Mumbai
"The rationale behind this move could be the people aren't able to get tests done or get results in time for their travels because of a backlog," says Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University.
“That being said we know asymptomatic infections occur, and we also know that travel is a major factor for infections," he adds.
So, how then can we ensure the lack of tests at the time of travel doesn't trigger another wave of infections?
According to Dr Bhan, "the lack of RT-PCR tests could be made up for with the help of other kinds of systematic checks like thermal screening (although they have low sensitivity)."
Adding to this, Dr Swapneil suggests people could follow up an initial RT-PCR test before travel with other self administered tests.
Each state will have to look at the risks and take a call on how they’re going to deal with the situation. They will have to plan out what measures they will take, like will they need to do Rapid antigen tests, will they make it mandatory for travellers to quarantine?Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics, Mangaluru’s Yenepoya University
Dr Parikh also brings up the recommendation that ‘people who have recovered don’t need to test’.
"Such blanket statements can also be problematic,” he says.
Yes, 99 out of 100 times you don’t need to test someone who’s recovered because 10 days after the symptoms have stopped as people are not really infectious then, but there are situations where it may be important to do so.Dr Swapneil Parikh, Internal medicine specialist, Mumbai
He further explains this by saying, "let's say an individual who has recovered is going home from the hospital and has elderly relatives in the house. In that situation, it's important that the person get tested even after recovery."
Its not impossible to infect someone else after ten days, it’s just very unlikely. We need to give some leeway to doctors to make some of these decisions based on individualised case criteria.Dr Swapneil Parikh, Internal medicine specialist, Mumbai
'Total Tests Should Never Go Down'
While it is true that the upsurge of cases in the country has been putting immense pressure on the laboratories and technicians, is avoiding RT-PCR tests the way to ease this?
"We are in a crisis situation right now," says Dr Parikh. “So right now we do have to preserve our RT-PCR testing capacity for where we need it the most."
But we have to be careful that it doesn't lead to a reduction in tests altogether, as has been the case of late in different parts of the country.
The idea of optimising RT-PCR tests at this point makes sense. But it doesn’t make sense if the overall tests are going down.Dr Swapneil Parikh, Internal medicine specialist, Mumbai
"The total number of tests should always go up, it should especially not be dipping," he adds. "ICMR needs to look into drastically scaling up even RT-PCR testing capacity."
Optimise, but Don't Compromise
What then can help ease the pressure on the molecular testing labs in the country?
The ICMR guidelines say that they're pushing to ramp up Rapid Antigen Testing (RAT) in the meantime.
Rapid antigen tests (RATs) were recommended in India for COVID-19 testing in June 2020. However, the use of these tests is currently limited. To meet the overwhelming testing demand, it will be prudent to upscale testing using RATs.Indian Council of Medical Research (ICMR
Dr Swapneil agrees, saying that RAT is an “underutilised resource at this point, and its use needs to be increased. "
A major advantage of RAT, as mentioned by ICMR, is that it has a short turnaround time of 15-30 minutes.
Because of this reason, it offers a huge advantage of quick detection of cases and the opportunity to isolate and treat them early for curbing transmission.
We Need to Consider Other Alternative Testing Methods
One of the drawback of the RT-PCR test, and even the RAT is the need for reagents.
Regeants in chemical-based tests are the main chemical used to trigger the chemical reaction. In COVID tests these include enzymes, probes, and primers created to match the coronavirus’s genome.
According to Dr Parikh, "this is what creates the bottleneck when it comes to these tests”.
An alternative to this is the spectral analysis test that doesn't require reagents.
We need to rapidly start looking at these. They may be less accurate but right now anything that can help us break the chain while also reducing the burden on RT-PCR testing is very useful.Dr Swapneil Parikh, Internal medicine specialist, Mumbai
Other alternative testing modalities that should be considered are Real-time loop-mediated amplification (LAMP) technology, Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) based tests, and, spectroscopy which can give instant results with satisfactory accuracy.
Speaking of reducing the pressure on RT-PCR tests, Dr Bhan says, “we might not always need to have tests carried out to assume someone has COVID, he says.
With the amount of infection we have now, we have reached a threshold where if you have had a potential exposure and are showing symptoms, it would be prudent to assume that you are likely infected, and not wait for RT-PCR tests to confirm.Dr Anant Bhan
"Hospitals shouldn’t require RT-PCR test reports to confirm covid," he adds. “If someone is showing symptoms, it should be assumed they have COVID and treated accordingly."
RT-PCRs should definitely be used for confirmation. But it shouldn’t be an exclusion criterion.Dr Anant Bhan
Home Testing Could Fill the Gaps
“Decentralising the process of testing can really help ease the burden on the labs," Dr Parikh says.
The ICMR has already green-lit home self-testing. But, what we need to do is operationalise this. The barriers that make it difficult to do must be removed.Dr Swapneil Parikh, Internal medicine specialist, Mumbai
He goes on saying, "I would even suggest various cities and states consider providing free home testing kits to people to further decrease the burden on RT-PCR testing."
(This was first published on FIT and has been republished with permission.)
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