New Delhi: India’s health infrastructure, especially in the big metro cities, has been under pressure since the Covid-19 crisis began. But even though the total number of cases across the country has crossed 15 lakh (or 1.5 million), there is one key element of health infrastructure that has seen consistent and robust growth — the number of diagnostic labs equipped to run Covid-19 tests.
In early March, when India had recorded only a handful of cases, 52 labs were authorised to carry out Covid-19 tests. Today, that number has gone up over 25 times to 1,321, of which 907 are government-owned.
The Indian Council of Medical Research hopes to have a Biosafety Level-2 (BSL-2) laboratory — one that can run the gold standard RT-PCR test — in each district in the country.
BSL-2 labs are the second of four safety levels, with BSL-4 being the most stringent and sophisticated in terms of testing lethal pathogens. BSL-2 labs are authorised to handle moderately hazardous pathogens, such as HIV, and now the SARS-CoV-2.
But until every district is equipped with a BSL-2 lab, states have also deployed CBNAAT and TrueNat tests, which were originally designed to detect tuberculosis and have been tweaked for the SARS-CoV-2 virus. While the CBNAAT requires a BSL-2 facility, TrueNat can be done in a more basic laboratory and is widely available.
“The aim is to establish BSL-2 labs in every district as soon as possible. We have already managed to increase the number of labs in a short span of time, and we’re working aggressively to push states to open more,” Dr Nivedita Gupta, senior scientist helming the lab network growth at the ICMR told ThePrint.
An analysis of the labs by ThePrint shows that, as on 27 July, only 152 districts of India’s 739 didn’t have Covid-19 testing facilities. In other words, approximately 80 per cent of the country’s districts have labs which can test for the novel coronavirus.
“Wherever there are public or private medical colleges, they are being upgraded for the establishment of BSL-2 Covid testing facilities, and in districts that don’t have a medical college, we are trying to distribute TrueNat and CBNAAT machines,” said Gupta, adding that the pandemic has forced states to prioritise healthcare infrastructure in a way that hasn’t happened before.
How the labs expanded
Although Covid-19 has brought renewed interest in public healthcare, it can’t be solely credited for the expansion of lab networks in India.
Back in 2009, when the H1N1 swine flu pandemic spread across the world, India had only two viral research labs capable of carrying out molecular virology tests — the National Institute of Virology and the National Centre for Disease Control. The gap in testing infrastructure prompted the Government of India to set up designated laboratories for the purposes of viral research and diagnosis.
What emerged was the Viral Research and Diagnostic Laboratory Network (VRLN), a scheme set in motion in 2013 with the intent of setting up 125 (initially 160) labs at the regional, district, and medical college-level “for timely diagnosis/identification of viruses during outbreaks of epidemics, generation of data about viral diseases for facilitating quick deployment of resources & measures to save the human lives”.
The project was overseen by the ICMR and headed by Dr Gupta. By the time Covid-19 hit India, 106 labs had already been set up and were functioning.
“The labs selected under the VRLN were the first to conduct testing and research into Covid-19 when it first came to India. It was also a model through which other labs could be set up,” Gupta said.
The VRLN has trained to those working in labs testing for Covid-19 today. The average one-time cost of setting up a BSL-2 lab is Rs 6 to 7 crore, though this varies from state to state and immediate context.
Dr Manoj Murhekhar, director of the National Institute of Epidemiology in Chennai, told ThePrint that if it hadn’t been for the VRLN, India’s Covid-19 management would have been a “complete mess”.
“The VRLN has made a huge contribution to India’s Covid-19 management. If we didn’t have it, we would be in a complete mess, and it would have taken us much longer to establish a credible network of labs to run diagnostic tests,” Murhekar said. “We will be able to rely on these labs for future outbreaks too. It’s a lifetime investment.”
On 7 July, the Medical Council of India passed an order saying all medical colleges needed to set up labs that were BSL-2 compliant, and that if they did not comply, they would be stripped of their recognition. Of the 540 medical colleges in the country, 293 have set up the facility.
Lab distribution trends
An analysis of the Covid-19 diagnostic labs across the country throws up surprising results. Lower income states like Jharkhand, Bihar, and Madhya Pradesh, have managed to ramp up their infrastructure and set up Covid-19 labs in all or nearly every district.
These lower-income states still suffer from high positivity and low testing per million. Bihar, for example, has testing labs in all its 38 districts but has the lowest testing per million in the country (3,900), and a positivity rate of 17.09 per cent.
“It seems like the problem is not the infrastructure. This could be happening because the labs are not receiving sufficient samples from the district administration, whose responsibility it is to collect samples,” Murhekhar said.
Wealthier states like Gujarat and Telangana haven’t set up labs in several of their districts, even though both have been pulled up by their respective high courts for not testing enough. Gujarat has labs in 19 districts out of 33, while the figure for Telangana is 12 out of 33 districts.
Even though the north-eastern states of Assam, Tripura, Manipur, Mizoram and Arunachal Pradesh have few labs across their districts, they have maintained high testing per million and low positivity. Arunachal Pradesh, which has labs in just nine of its 25 districts, tests over 44,000 people per million, and has a positivity rate of 1.8 per cent.
Similarly, 24 of Assam’s 33 districts don’t have a testing facility, but the state is testing over 22,000 people per million. Tripura has just one testing lab, but is conducting over 35,000 tests per million to track the spread of the virus.
“We’re doing our best to make sure every district has a lab, but it will take some time,” said Dr Gupta.